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Oral loratadine
42%
24/57
Intranasal corticosteroids
47%
27/57
Intravenous diphenhydramine
4%
2/57
Sublingual oseltamivir
2%
1/57
Oral montelukast
Select Answer to see Preferred Response
This woman presents with cough, nasal congestion, and rhinorrhea in the setting of new environmental exposures, which is concerning for allergic rhinitis. The best initial step in management is administration of intranasal corticosteroids. Allergic rhinitis (hay fever) is an IgE-mediated immune response to episodic, seasonal, or perennial exposures to specific allergens, including dust mites, mold, pollen, or animal dander. The concentration of the allergen in the ambient air correlates directly with the rhinitis symptoms, which include sneezing, clear rhinorrhea, itching of the eyes with tearing, and boggy mucosa. Initial acute management involves avoidance of the allergen, nasal irrigation with saline, and intranasal corticosteroids such as fluticasone to immediately decrease local inflammation. Figure A shows allergic shiners, which are areas of infraorbital skin darkening due to sinus congestion. Figure B shows allergic salutes, or transverse nasal creases, which are created by physical upward rubbing of the nose. Figure C shows cobblestoning from inflammation of the posterior pharynx. Incorrect Answers: Answer 1: Oral loratadine is a non-sedating antihistamine that is used for maintenance suppression of symptoms of allergies. Intranasal antihistamines can be used for more immediate relief. Answer 3: Intravenous diphenhydramine is a sedating antihistamine that can be offered for immediate relief, but it is not recommended for patients who will need to operate heavy machinery (such as vehicles) immediately after administration. Answer 4: Oseltamivir is an oral antiviral medication against influenza A and B that inhibits neuraminidases. It is not indicated for allergic rhinitis. Answer 5: Montelukast is a leukotriene receptor antagonist that has been shown to be as effective as antihistamines for management of allergic rhinitis. However, it is not indicated for acute management of symptoms. Bullet Summary: Initial acute management of allergic rhinitis should include avoidance of the allergen, nasal irrigation with saline, and intranasal corticosteroids or antihistamines to immediately decrease local inflammation.
4.5
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