Price: Rs.1500/- (US $35 approx)

Obstruction in the nasal passage.

• Nasal itching.
• Sneezing.

These symptoms may occur as a result of colds or environmental irritants, such as allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factors.
Infectious Rhinitis. If symptoms last less than six weeks, the condition is referred to as acute rhinitis and is usually caused by a cold or infection, temporary overexposure to environmental chemicals or pollutants.

Chronic Rhinitis. When rhinitis lasts for a longer period, the condition is called chronic rhinitis, and is most often caused by allergies but can also be caused by structural problems or chronic infections.

Causes of Chronic Rhinitis Not Related to Allergies

Aging Process
The elderly are at risk for chronic rhinitis as the mucous membranes become dry with age. In addition, the cartilage supporting the nasal passages weakens, causing changes in airflow. In such cases, therapy involves avoiding possible allergens and airborne irritants as well as measures to keep the nasal passages moist. (Decongestants, then, would not be appropriate.)

Irritative Rhinitis
Irritative rhinitis is caused by an overreaction to irritants, such as cigarette smoke, dozens of other air pollutants, strong odors, alcoholic beverages, and exposure to cold. The nasal passages become red and engorged. This reaction is not the same as allergic reaction, although both are associated with increased numbers of white blood cells called eosinophils.

Vasomotor Rhinitis
Vasomotor rhinitis, also sometimes called idiopathic or irritant rhinitis, is congestion and stuffy nose that is produced by the changes in blood vessels and nerve cells in the nasal passages. It occurs in response to irritants, including smoke, environmental toxins, changes in temperature and humidity, stress, and even sexual arousal. This over-reaction is not associated with any immune response. The biologic causes are unknown. Some research has found an association between vasomotor rhinitis and gastroesophageal reflux disorder (GERD, a common cause of heartburn), which some experts posit may be due to a common defect in the nervous system that controls muscle action. Symptoms of vasomotor rhinitis are similar to most of those caused by allergies. Usually, however, they are more severe and occur predominantly on one side of the nose.

Foreign Objects
Blockage in young children is very often caused by foreign objects that they have pushed up their nose. If they are left in place, they may eventually cause infection and nasal discharge, usually in one side of the nose, which may be yellow or green and foul smelling.

Blockage in the Nose from Polyps or Structural Abnormalities
A number of conditions may block the nasal passages. Surgery may be helpful for certain cases.
• Polyps. These are soft, gray, fluid-filled sacs that develop off stalk-like structures on the mucus membrane. They impede mucus drainage and restrict airflow. Polyps usually develop from sinus infections that cause overgrowth of the mucus membrane in the nose. They do not regress on their own and, in fact, may multiply and cause considerable obstruction.
• Deviated Septum. A common structural abnormality that causes rhinitis is a deviated septum. The septum is the inner wall of cartilage and bone that separates the two sides of the nose . When it is deviated, it is not straight but shifted to one side, usually the left.
• Other Causes of Blockage. Rarely, cleft palates, overgrowth of bones in the nose, or tumors cause rhinitis.

Nonallergic Rhinitis in Children
Chronic nasal congestion in children often accompanies a susceptibility to ear, sinus, or adenoid infections. Adenoids are spongy tissue masses located between ends of the nasal passages and the soft tissue in the back of the throat. Enlarged adenoids may also cause ear problems. The bacteria that cause these other infections, however, are not usually the cause of this chronic rhinitis.

Medications and Illegal Drugs
A number of drugs can cause rhinitis or worsen it in people with conditions such as deviated septum, allergies, or vasomotor rhinitis:
• Overuse of decongestant sprays used to treat nasal congestion can, over time (three to five days), cause inflammation in the nasal passages and worsen rhinitis.
• Many people with allergies and asthma are sensitive to some of the common painkillers known as nonsteroidal anti-inflammatory drugs (NSAIDs). They include the common drugs aspirin, ibuprofen (Motrin, Advil, Nuprin, Rufen), and naproxen (Aleve) among many others. Aspirin and products containing aspirin can even cause life-threatening asthma attacks in some highly susceptible individuals. NSAIDs vary, however, and some patients may not have a reaction to all of them. For minor pain, acetaminophen ( e.g., Tylenol), which is not an NSAID, is usually recommended for patients with intolerance to NSAIDs. A pharmacist should be consulted if the ingredients of any over-the-counter preparations are not known.
• Other medications that may cause rhinitis include oral contraceptives, hormone replacement therapy, anti-anxiety agents (particularly alprazolam), some antidepressants, and some blood pressure medications, including beta-blockers and vasodilators.
• Sniffing cocaine damages nasal passages and can cause chronic rhinitis.

Estrogen in Women
Elevated levels of estrogen appear to increase mucus production and swelling in the nasal passages and can cause congestion. This effect is most apparent in women during pregnancy. In such cases the condition usually clears up after delivery. Oral contraceptives and hormone replacement therapies that contain estrogen have also been associated with nasal congestion in some women.

Medical Conditions
Hypothyroidism is associated with chronic rhinitis. People with certain genetic or other medical conditions that specifically affect the mucous membranes are at also risk, although rhinitis in such people is apt to be only one of many more serious conditions, including chronic sinusitis and respiratory problems. Wegener's granulomatosis, for example, is a serious but very rare illness that causes long-term swelling and tumor-like masses in air passages.
Rare genetic disorders that cause chronic rhinitis include the following:
• Cystic fibrosis, in which the mucus is very thick.
• Kartagener's syndrome. With this condition the body's major internal organs are located in the mirror-image position of their normal location. In addition, the body's cilia (hair-like-projections on many body tissues that help to move mucus and other fluids) are impaired or motionless.
In both disorders, mucus build-up also produces an environment favorable to infection-causing organisms.

WHAT ARE THE CAUSES AND TRIGGERS OF ALLERGIC RHINITIS?

The Allergic Response
The allergic process, called atopy, and its connection to asthma is not completely understood. It involves various airborne allergens or other triggers that set off a cascade of events in the immune system leading to inflammation and hyperreactivity in the airways. One description is as follows:
• The conductor in an orchestra of immune factors that contribute to allergies and asthma appears to be a category of white blood cells known as helper T-cells, in particular a subgroup called TH2-cells.
• TH2-cells overproduce interleukins (ILs), immune factors that are molecular members of a family called cytokines, powerful agents of the inflammatory process.
• Interleukins 4, 9, and 13, for example, may be responsible for a first-phase asthma attack. These interleukins stimulate the production and release of antibody groups known as immunoglobulin E (IgE). (People with both asthma and allergies appear to have a genetic predisposition for overproducing IgE.)
• During an allergic attack, these IgE antibodies can bind to special cells in the immune system called mast cells, which are generally concentrated in the lungs, skin, and mucous membranes. This bond triggers the release of a number of active chemicals, importantly potent molecules known as leukotrienes. These chemicals cause airway spasms, over-produce mucus, and activate nerve endings in the airway lining.
• Another cytokine, interleukin 5, appears to contribute to a late-phase inflammatory response. This interleukin attracts white blood cells known as eosinophils. These cells accumulate and remain in the airways after the first attack. They persist for weeks and mediate the release of other damaging particles that remain in the airways.

The Hygiene Theory: Early Infections as Protection Against Allergies and Asthma
An increasingly important theory blames the dramatic increase in asthma and allergies on the reductions in childhood infections that have occurred with modern hygiene and antibiotic use. The basic theory rests on the idea that infections stimulate production of specific immune factors called TH1 cells. As these cells build up, they replace other immune factors called TH2 cells, which react to allergens--a less serious threat to the body. Without infections to stimulate the production of the TH1 infection fighters, then the TH2 allergen fighters are not replaced and they persist at high levels, making the growing child more susceptible to allergies and asthma.

A number of different studies support this theory:
• Some studies suggest that being part of a large family or attending day care increases the risk for early respiratory infections but reduces the risk of childhood asthma. The occasional cold, then, may be protective.
• In a 2002 study, researchers measured levels of bacterial byproducts called endotoxins in the mattress dust of 812 children. Those with the highest levels had an 80% lower rate in allergies and asthma.
• A 2001 Swedish study further found a strong association between allergy development and the absence of certain beneficial bacteria (called probiotics) carried in the infant's intestines. Infants who were born in more hygienic environments tended to lack these bacteria. Antibiotic over-use and modern hygiene may specifically be reducing these helpful organisms. (Probiotics can be obtained in active yogurt cultures and in supplements, which are being studied for protection.)
Of note: The standard vaccinations against serious childhood infections, according to important studies in 2002 and 2003, pose no risk for asthma. One of the studies even reported some lower risk for asthma and allergies in the second and third years after vaccinations. It should strongly be pointed out that infections killed thousands of children every year before immunization became widespread. Asthma, although serious, is rarely fatal in children. No one should stop giving their children vaccinations against childhood killers.

Overexposure to Indoor Allergens
Some evidence suggests that the increase in allergies and asthma may be due to over exposure to allergens. One study in Germany that tracked East German children after the country became unified reported that children in the areas previously under communism experienced a significant increase in allergies, particularly hay fever, when they were exposed to a Western lifestyle. Included in lifestyle changes were the following:
• Increases in wall-to-wall carpeting.
• Increases in cat ownership.
• Damper homes.
• Consumption of margarine (which has been associated with hay fever).

Some scientists believe that more children are developing allergies because they are spend hours indoors each day engaging in sedentary activities and so are overexposed to indoor allergens. This exposure is intensified by the recent trend of making homes more energy-efficient, which may result in more dust mites being trapped inside.

Triggers of Seasonal Allergic Rhinitis (Hay Fever or Rose Fever)
Seasonal allergic rhinitis occurs only during periods of intense airborne pollen or spores. It is commonly, although inaccurately, called hay fever or rose fever, depending on whether it occurs in the late summer or spring. No fever accompanies this condition, and the allergic response is not dependent on either hay or roses. In general, triggers of seasonal allergy in the US are the following:
• Ragweed. Ragweed is the most important cause of allergic rhinitis in the US, affecting about 75% of allergy sufferers. One plant can release one million pollen grains a day. Ragweed is everywhere in the US, although it is less prevalent along the West Coast, southern Florida, northern Maine, Alaska, and Hawaii. The effects of ragweed in the northern states are first felt in middle to late August and last until the first frost. Ragweed allergies tend to be most severe before midday.
• Grasses. Grasses affect people in mid-May to late June. Grass allergies are experienced more in the late afternoon.
• Tree Pollen. Small pollen grains from certain trees usually produce symptoms in late March and early April.
• Mold Spores. Mold spores that grow on dead leaves and release spores into the air are common allergens throughout the spring, summer and fall. Mold spores may peak on dry windy afternoons or on damp or rainy days in the early morning.

Major weather changes, such as El Nino, can affect the timing of allergy seasons. For example, in 1998, when the effects of El Nino were very strong, allergy attacks were markedly increased and maximum tree pollen counts occurred two to four weeks earlier and mold counts two to three months earlier than in 1997.

Triggers of Perennial (Year-Round) Allergic Rhinitis
Allergens in the House. Allergens in the house can trigger attacks in people with year-long allergic rhinitis, called perennial rhinitis. Household allergens may include the following:
• House dust and mites. Dust mites, specifically mite feces, are coated with enzymes that contain a powerful allergen.
• Cockroaches.
• Pet dander.
• Molds growing on wallpaper, house plants, carpeting, and upholstery.
It is important to note that studies are now suggesting that early exposure to some of these allergens, including dust mites and pets, may prevent allergies from developing in the first place in children.

Fossil Fuels. Although difficult to prove, a number of investigations, including European studies in 1999 and 2000, reported an association between traffic-related air pollution and allergic rhinitis. Of particular note, some experts believe that refined fossil fuels, such as diesel fuel and particularly kerosene, may be important triggers for allergic rhinitis. And, in people who already have allergies or asthma, exposure to such fossil fuels may worsen symptoms.

WHAT ARE THE SYMPTOMS OF RHINITIS?

The general symptoms of rhinitis are congestion, runny nose, and post-nasal drip, in which mucous drips into the throat from the back of the nasal passage, especially when lying on the back. Symptoms may vary depending on the cause of rhinitis. Symptoms of influenza and sinusitis must also be differentiated from allergies and colds.

Symptom Phases
Symptoms of allergic rhinitis occur in two phases, early and late.
Early Phase Symptoms. The early phase occurs within minutes of exposure to the allergens and includes the following:
• A runny nose.
• Frequent or repetitive sneezing.
• Itching in the nose, eyes, throat, or roof of the mouth.
Late-Phase Symptoms. The late phase occurs four to eight hours later and may have one or more of the following symptoms:
• Nasal congestion and possibly plugged ears. Children may push their nose upward with the palm of their hand or twitch their nose rabbit-like to clear obstruction.
• Fatigue.
• Mental changes in some cases include irritability, a slight decrease in attention span, worsened memory, and slower thinking.
• Other common physical symptoms include a decreased sense of smell, plugged ears, sinus headache, postnasal drip or some combination. In severe allergies, dark circles under the eye. The lower eyelid may be puffy and lined with creases.

WHO GETS ALLERGIC RHINITIS?

Allergic rhinitis affects between 20 and 40 million Americans of all ages. (It is difficult to determine the true prevalence since evidence often relies on people self-reporting their own symptoms, which can be highly inaccurate.) In any cases, as with asthma and many upper respiratory infections, the incidence in allergic rhinitis is increasing. Allergies most often appear first in childhood, and allergic rhinitis is the most common chronic condition in childhood. It should be noted, however, that it can first develop at any age. About 20% of cases are due to seasonal allergies, 40% to perennial (chronic) rhinitis, and the rest are mixed.

Family History
Genetic factors are the major determinants of allergies.
• If both parents have an allergy, the risk to the child is 75%.
• If one parent is allergic, the child's chances are 50%.
It should be noted that children with allergic family members are at highest risk for allergies themselves, but they can develop in anyone.

Having Other Allergies

Having other allergies increases the risk for allergic rhinitis. Here are some examples:
• Young children who have eczema (an allergic skin reaction) have a later risk for allergic rhinitis and asthma. In fact, a family history of eczema increases the risk.
• Food allergies are associated with allergic rhinitis and asthma. (Early feeding patterns, time of weaning, and introduction of solid food do not appear to affect this risk.)

Other Factors Associated with Allergies
Birth Month. Some studies report a higher risk of allergies and asthma in children both in winter months and lower risk in those born during the summer.
Breastfeeding. Some researchers suggest that the dramatic increase in asthma and allergies may be due to fewer women breastfeeding their infants. In a number of studies, including some in 2002 and 2003, breastfeeding has been associated with a lower risk for allergies and asthma--at least until age two. The effects of breastfeeding on allergy risk are unclear, however. Other studies found no effect, and some have even suggested a higher risk for allergies and asthma in children who have been breastfed. (Breastfeeding is very beneficial, in any case, for preventing early respiratory infections and is the best nutritional source in infants.)

HOW SERIOUS IS ALLERGIC RHINITIS?

Long-Term Outlook of Seasonal Allergies
Seasonal allergic rhinitis tends to diminish as a person ages. The earlier the symptoms start the greater the chances for improvement. People who develop hay fever in early childhood are likely not to have the allergy in adulthood. In one study, over half of allergic subjects reported that by 40 years of age their symptoms had decreased, and 23% were symptom-free. In some cases, allergies go into remission for years and then return later in life. Those who develop it after age 20, however, tend to continue to have hay fever at least into middle age.
People with allergic rhinitis may be at higher risk for other allergies, including potentially serious food or latex allergies.

Effect On Quality of Life
Although allergic rhinitis is certainly not considered a serious condition, it nonetheless can interfere with many important aspects of life. People with allergic rhinitis, particularly those with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. Often they attribute this to medication, but studies suggest congestion may be the culprit in these symptoms. In addition, a 2002 study indicated that patients with seasonal allergies experience hundreds of brief, subtle awakenings, called "microarousals", each night. In such cases, people are not aware that they wake up, but such events can cause fatigue the next day.

Higher Risk for Asthma
Asthma and allergies often coexist, and the allergic response plays a strong role in childhood asthma. About 70% to 85% of children with asthma have allergies, with the risk being higher from seasonal allergies (e.g., hay fever) than perennial allergies ( e.g., indoor allergies). It should noted, however, that, allergies are very common, and studies report that only 1% to 20% of children with allergic rhinitis actually develop asthma.
Aggressive treatment of allergies in children with asthma can lower the risk for asthma attacks in patients with both conditions. Treating seasonal allergies may even help prevent the onset of asthma in children with only allergies.

Chronic Swelling In the Nasal Passages (Turbinate Hypertrophy)
Any chronic rhinitis, whether allergic or nonallergic, can cause swelling in the turbinate, which may become persistent (turbinate hypertrophy). The turbinate is a tiny shelf-like bony structure that protrudes in the nasal passageways. It helps warm, humidify, and clean the air as it passes over. If turbinate hypertrophy develops, it causes persistent nasal congestion and in some cases pressure and headache in the middle of the face and forehead. It is not reversible without surgery.

Complications of Chronic Rhinitis in Children
• Children with severe allergies may have a higher risk for behavioral problems than those without allergies. Some research suggests that allergic rhinitis is responsible for two million missed school days each year.
• There have been reports that 30% to 45% of people with allergic rhinitis also suffer from ear infections (otitis media).
• Chronic nasal obstruction from year-round allergies can affect a child's appearance. If a child can only breathe through the mouth, the continual force of air passing through the oral cavity can change facial development. Such changes may include an elongated face and an overbite from teeth coming in at an abnormal angle.
• Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growth.

Associations with Other Disorders
Depression. Some evidence has linked some cases of depression with allergies. A 2002 study, for example, found that people with depression reported a higher rate of allergic disorders (71%) compared to nondepressed individuals (43%). And during allergy season, allergic individuals were more likely to experience mood changes, including sadness, lethargy, and mental fatigue, than at other times. Some evidence suggests that specific immune factors in the allergic response can cause depressive symptoms. Other research indicates that both may have a common cause.
Chronic Fatigue Syndrome (CFS). Some, although not all, studies have reported that a majority of CFS patients have allergies to foods, pollen, metals (such as nickel or mercury), or other substances. One theory is that allergens, like viral infections, may trigger a harmful overreaction of the immune system that can cause fatigue, joint aches, and fever as well as hormone and brain chemical disturbances. (Most allergic people, in any case, do not have CFS.)