IMPORTANT The information provided is of a general nature and should not be used as a substitute for professional advice. If you think you may suffer from an allergic or other disease that requires attention, you should discuss it with your family doctor. The content of the information articles and all illustrations on this website remains the intellectual property of Dr Raymond Mullins and cannot be reproduced without written permission.

Summary
Allergy is often considered a nuisance than a major disease. Yet it affects 1 in 5 Australians and has a major impact on quality of life, mood, learning and work performance. Allergy interferes with learning in children and causes significant personal distress, sleep disturbance and social embarrassment. It is also associated with a number of medical complications. The quality of life of a patient with food allergy has been equated with dealing with diabetes. An economic analysis of the impact of allergic disease in Australia was published by ASCIA in 2007.

Adults are moody and work less efficiently
Hay fever results in poor quality sleep, fatigue and daytime sleepiness. Adults find it harder to think and function at work, suffer from greater absenteeism and more work-related injury. They are more irritable and moody than their healthier friends and find it harder to make important decisions.

 

They are also more prone to injury

Treatment with sedating older antihistamines makes the situation worse. Even when sleepiness is not recognised, use of these medications slows down their reflexes and ability to drive a car safely. In one study of work-related injuries by Gilmour (1996), antihistamines increased the risk of injury by 50 %. Even taking a sedating antihistamine at bedtime can make people sleepy the next day.

 

Allergic children do less well at school
Hay fever and its treatment can cause daytime sleepiness and interfere with learning. A number of studies in children have demonstrated poor memory, examination performance, and impaired ability to recall information taught during class. Hearing loss due to eustacian tube dysfunction or middle ear infection can also interfere with academic performance.

Sinus infections are more common
An association between allergy and sinusitis is supported by the fact that the lining of sinuses is thickened in allergic subjects and the high incidence of allergy in patients suffering from chronic (ongoing) sinusitis (~40-80%) or acute (short-lived) sinusitis (75% in one paediatric study, Lombardi 1996).

 

Nasal polyps grow faster too
Even though the majority of patients with nasal polyps are not allergic, those who are allergic have polyps that grow back at a faster rate and have an increased rate of relapse after surgery. For example, the recurrence rate in one study of 140 patients was 36% in allergic patients but only 18% in non-allergic subjects (Farrell 1993).

 
Hay fever patients have a poor sense of smell and taste
Major causes include allergic rhinitis, sinusitis and nasal polyps. Approximately 20 % of patients with allergic rhinitis ((hay fever) have a reduced sense of smell and taste.

Impact of allergic rhinitis on the eustacian tube and middle ear infection
Otitis media with effusion (OME) is a non-infectious inflammatory condition of the middle ear resulting in a serous effusion ("fluid in the ears"), eustacian tube dysfunction and hearing loss. It may also predispose to acute middle ear infection. Around 20% of allergic children have OME, and 35-50% of patients with OME are allergic.

Impact of allergic rhinitis on sleep apnoea
Obstructive sleep apnoea results from collapse of the upper airways during sleep. This results in reduced airflow, a drop in oxygen levels and disturbed sleep. Factors predisposing to this condition include being over weight and having a blocked nose. Nasal blockage is associated with more severe obstructive sleep apnoea, arousals during sleep and daytime sleepiness. These abnormalities had been found to be reversible with surgical correction of anatomical abnormalities, topical nasal steroid sprays in patients with allergic rhinitis and reduced allergen exposure in patients with seasonal allergic rhinitis.

 
Impact of allergic rhinitis on facial structure
Observational studies have linked chronic mouth breathing to structural changes of the face. Nasal obstruction due to allergic rhinitis or adenoid hypertrophy (the so-called "adenoid facies") have been associated with a long and narrow face, a long narrow tongue, high arched palate, small lower jaw, over bite and cross bite and dental crowding and malocclusion. While there was initial uncertainty whether these changes were caused by nasal congestion or contributed to it, animal studies have demonstrated the development of similar abnormalities in experimental models. Furthermore, some have been shown to be reversible when the obstruction has been relieved. These observations have cosmetic and functional implications to patients with severe dental abnormalities. What is uncertain, however, is whether these changes are reversible in humans (there are only a few small studies), and if so, when treatment must be commenced to achieve this aim.

Allergic rhinitis and gum inflammation (gingivitis)
The incidence of gum inflammation (gingivitis) and severity of dental plaque is increased in patients who mouth breath, perhaps secondary to reduced protection of the mouth by open lips.

Allergic rhinitis and asthma
Asthma and allergic rhinitis frequently co-exist. For example, approximately 25 per cent of patients with allergic rhinitis have asthma, and approximately 75 per cent of asthmatic patients have allergic rhinitis. The presence of allergic rhinitis also substantially increases the cost of treatment of asthma, by approximately 50 per cent in recent studies (Yawn 1999). Pathogenic mechanisms are similar, and both disorders can respond to similar treatment strategies including allergen avoidance, use of medication and immunotherapy. Sub-clinical bronchial inflammation and hyperactivity can also be found in patients with allergic rhinitis, even in the absence of lower respiratory tract symptoms.

Allergic rhinitis often precedes the onset of asthma. For example, a follow-up study of children aged three to 17 years demonstrated the development of asthma or allergic rhinitis in 19 per cent of cases over a 10-year period. (Linna 1992). A 23-year followup study of American College students demonstrated that in those with a history of both disorders, 45 % developed hayfever first, 34 % developed asthma first, and 21 % developed both disorders at the same time. Of those with allergic rhinitis, 21 % developed asthma over a 23-year period (Greisner 1998).

There is much anecdotal evidence, and some published evidence, that the severity of allergic rhinitis influences that of asthma (Corren 1997). Proposed mechanisms include the inhalation of cool dry air due to mouth breathing, aspiration of inflammatory nasal contents, the nasobronchial reflex and subjective symptoms of chest tightness in patients with severe nasal congestion. Since allergy is a systemic disorder, it is also conceivable that local nasal inflammation might have an effect on inflammation in distal organs such as the bone marrow and lower airways via humoral mechanisms (O'Byrne 1999, Denburg 1999, Inman 1999).

Not only made these disorders co-exist, but treatment of rhinitis may actually improve asthma control. For example, antihistamines (cetirizine, loratadine and terfenadine) have been shown to improve asthma symptoms when administered at higher than routine recommended doses. Whether this relates to control of rhinitis, asthma or both is uncertain. Nasal steroid sprays have been shown to reduce bronchial hyperactivity on provocation testing and to improve asthma symptom scores. In some cases, this has been achieved more effectively by administering medication to the nose then when the same drug is inhaled into the lung (Aubier 1992). Similar changes have been observed in patients with both seasonal and perennial allergic rhinitis. Indeed in some cases, treatment can be shifted from the lower to the upper airways with greater overall disease control.

References and Further Reading
Sinusitis and Rhinitis
Lombardi E, Stein RT, Wright AL, Morgan WJ, Martinez FD. The relation between physician-diagnosed (+"MD")sinusitis, asthma, and skin test reactivity to allergens in 8-year-old children. Pediatr Pulmonol 1996 Sep;22(3):141-6.
Correlation of allergy and severity of sinus disease. Am J Rhinol 1999 Sep-Oct;13(5):345-7.
Mahakit P, Pumhirun P. A preliminary study of nasal mucociliary clearance in smokers, sinusitis and allergic rhinitis patients. Asian Pac J Allergy Immunol 1995 Dec;13(2):119-21
Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 1999 Mar;54(3):242-8.
Savolainen S. Allergy in patients presenting with acute maxillary sinusitis. Allergy 1989; 44: 116-22.
Newman LJ et al. Chronic sinusitis: relationship of computed tomographic findings to allergy, asthma and eosinophilia. JAMA 1994; 271: 363-7.
Otitis media
Ruggeri C; Barberio G; Pajno GB; Putorti A. Relations between allergic rhinitis and otitis media with effusion.The role of the Eustachian tube. Minerva Pediatr 1990 Nov;42(11):481-3
Morabito L; Pollicino A; Galletti F; Muscianisi F; Galletti B, Messina G; et al.An assessment of middle ear involvement in children with allergic rhinitis: a comparison with chronic hypertrophic adenoiditis. Pediatr Med Chir 1990 Sep-Oct;12(5):491-3
Bierman CW; Pierson WE. Diseases of the ear. J Allergy Clin Immunol 1988 May;81(5 Pt 2):1009-14
Bernstein J et al. Further observations on the role of IgE-mediated hypersensitivity in recurrent otitis media with effusion. Otolaryngol Head Neck Surg 1985; 93: 611-5.
Tomonaga K et al. The role of nasal allergy in otitis media with effusion: a clinical study. Acta Otolaryngol 1988; 458 (suppl): S41-7.
Nasal Polyps
Farrell BP. Endoscopic sinus surgery: sinonasal polyposis and allergy. ENT J 1993; 72: 389-99.
Settipane GA. Nasal polyps in asthma and rhinitis: a review of 6037 patients. J Allergy Clin Immunol 1977; 59: 17-21.
Smell
Apter AJ et al. Allergic rhinitis and olfactory loss. Ann Allergy Asthma Immunol 1995 Oct;75(4):311-6.
Cowart BJ et al. Hyposmia in allergic rhinitis. J Allergy Clin Immunol 1993 Mar;91(3):747-51.
Reviews
Spector SL. Overview of comorbid associations of allergic rhinitis. J Allergy Clin Immunol 1997 Feb;99(2):S773-80.
Settipane RA. Complications of allergic rhinitis. Allergy Asthma Proc 1999 Jul-Aug;20(4):209-13.
Slavin RG. Complications of allergic rhinitis: implications for sinusitis and asthma. J Allergy Clin Immunol 1998 Feb;101(2 Pt 2):S357-60
Antihistamines / Learning Impairement / Work Performance
Nolen TM. Sedative effects of antihistamines: safety, performance, learning, and quality of life. Clin Ther 1997 Jan-Feb;19(1):39-55; discussion 2-3
Storms WW. Treatment of allergic rhinitis: effects of allergic rhinitis and antihistamines on performance. Allergy and Asthma Proceedings 1997; 18: 59-61.
Vuurman EF et al. Seasonal allergic rhinitis and antihistamine effects on childrens' learning. Ann Allergy 1993; 71: 121-6.
Simons FE Learning impairment and allergic rhinitis. Allergy Asthma Proc 1996 Jul-Aug;17(4):185-9.
Mann RD et al. Sedation with "non-sedating" antihistamines: four prescription monitoring studies in general practice. BMJ 2000; 320: 1184-7.
McLoughlin J et al. The realtionship of allergies and allergy treatment to school performance and student behaviour. An Allergy 1983; 51: 506-10.
Reilly MC et al. Work, classroom and activity impairement instruments. Validation studies in allergic rhinitis. Clin Drug Invest 1996; 11: 278-88.
Gilmore TM et al. Occupational injuries and medication use. Am J Ind Med 1996; 30: 234-9.
O'Hanlon JF. Antihistamines and driving performance: the Netherlands. J Respir Dis 1988; 9 (supp 7A): S12-17.
Vermeeren A, O'Hanlon JF. Fexofenadine's effects, alone and with alcohol on actual driving and psychomotor test performance. J Allergy Clin Immunol 1998; 101: 306-11.
Psychological Impact
Marshall PS, Colon EA. Effects of allergy season on mood and cognitive function. Ann Allergy 1993; 71: 251-8.
Gauci M et al. A Minnesota Multiphasic Personality Inventory Profile of women with allergic rhinitis. Psychsom Med 1993; 55: 533-40.
Sleep Apnoea
Gosepath J, Amedee RG, Romantschuck S, Mann WJ Breathe Right nasal strips and the respiratory disturbance index in sleep related breathing disorders. Am J Rhinol 1999 Sep-Oct;13(5):385-9.
Craig TJ,Teets S, Lehman EB, Chinchilli VM, Zwillich C. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids. J Allergy Clin Immunol 1998 May;101(5):633-7.
Green RJ, Luyt DK. Clinical presentation of chronic non-infectious rhinitis in children. S Afr Med J 1997 Aug;87(8):987-91.
Kushida CA, Guilleminault C, Clerk AA, Dement WC. Nasal obstruction and obstructive sleep apnea: a review. Allergy Asthma Proc 1997 Mar-Apr;18(2):69-71.
The University of Wisconsin Sleep and Respiratory Research Group. Nasal obstruction as a risk factor for sleep-disordered breathing. J Allergy Clin Immunol 1997 Feb;99(2):S757-62.
McNicholas WT, Tarlo S, Cole P, Zamel N, Rutherford R, Griffin D, Phillipson EA Obstructive apneas during sleep in patients with seasonal allergic rhinitis. Am Rev Respir Dis 1982 Oct;126(4):625-8.
Zwillich CW et al.Disturbed sleep and prolonged apnoea during nasal obstruction in men. Am Rev Respir Dis 1981; 124: 158-60.
Craig TJ, Teets S, Lehman EB, Chinchilli VM, Zwillich C. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids. J Allergy Clin Immunol 1998 May;101(5):633-7.
Scharf MB, Cohen AP . Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep apnea. Ann Allergy Asthma Immunol 1998 Oct;81(4):279-87; quiz 287-90
Quality of Life
Pariente PD, LePen C, Los F, Bousquet J. Quality-of-life outcomes and the use of antihistamines in a French national population-based sample of patients with perennial rhinitis. Pharmacoeconomics 1997 Nov;12(5):585-95.
Blaiss MS. Cognitive, social, and economic costs of allergic rhinitis. Allergy Asthma Proc 2000 Jan-Feb;21(1):7-13.
Blaiss MS Quality of life in allergic rhinitis. Ann Allergy Asthma Immunol 1999 Nov;83 (5): 449-54.
Meltzer EO, Casale TB, Nathan RA, Thompson AK. Once-daily fexofenadine HCl improves quality of life and reduces work and activity impairment in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol 1999 Oct;83(4):311-7.
Juniper EF. Measuring health-related quality of life in rhinitis. J Allergy Clin Immunol 1997 Feb;99(2):S742-9.
Nolen TM Sedative effects of antihistamines: safety, performance, learning, and quality of life. Clin Ther 1997 Jan-Feb; 19(1):39-55; discussion 2-3.
Summary of a European conference. Review. The impact of allergic rhinitis on quality of life and other airway diseases. Allergy 1998;53(41 Suppl):1-31.
Bousquet J et al. Quality of life in asthma. I. Internal consistency and validity of the SF-36 questionaire. Am J Respir Crit Care Med 1994; 149: 371-5.
Craniofacial Development
Bresolin D et al. Facial charcteristics of children who breathe through the mouth. Pediatrics 1984; 73: 622-5.
Trask GM, Shapiro GG, Shapiro PA. The effects of perennial allergic rhinitis on dental and skeletal development: a comparison of sibling pairs. Am J Orthod Dentofacial Orthop 1987 Oct;92(4):286-93
Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel S Mouth breathing in allergic children: its relationship to dentofacial development. Am J Orthod 1983 Apr;83(4):334-40
Sassouni V, Friday GA, Shnorhokian H, Beery QC, Zullo TG, Miller DL, Murphey SM,Landay RA. The influence of perennial allergic rhinitis on facial type and a pilot study of the effect of allergy management on facial growth patterns. Ann Allergy 1985 Jun;54(6):493-7
Lofstrand-Tidestrom B, Thilander B, Ahlqvist-Rastad J, Jakobsson O, Hultcrantz E.Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old children. Eur J Orthod 1999 Aug;21(4):323-32
Behlfelt K. Enlarged tonsils and the effect of tonsillectomy. Characteristics of the dentition and facial skeleton. Posture of the head, hyoid bone and tongue. Mode of breathing. Swed Dent J Suppl 1990;72:1-35
Kerr WJ, McWilliam JS, Linder-Aronson S Mandibular form and position related to changed mode of breathing--a five-year longitudinal study. Angle Orthod 1989 Summer;59(2):91-6
Ferro A, Diaco P Changes in the transverse diameter of the upper arch after adenoidectomy. Arch Stomatol (Napoli) 1988 Nov;29(5):943-61
Harvold EP, Tomer BS, Vargervik K, Chierici G Primate experiments on oral respiration. Am J Orthod 1981 Apr;79(4):359-72
Harvold EP, Vargervik K, Chierici G. Primate experiments on oral sensation and dental malocclusions. Am J Orthod 1973 May;63(5):494-508.
Shapiro PA. Effects of nasal obstruction on facial development. J Allergy Clin Immunol 1988; 81: 967-71.
Shapiro GG. The role of nasal airway obstruction in sinus disease and facial development. J Allergy Clin Immunol 1988; 81: 935-40.
Linder-Aronson S. Effects of adenoidectomy on dentition and nasopharynx. Am J Orthod 1974; 65: 1-15.
Tomer BS, Harvold EP. Primate experiments on mandibular growth direction. Am J Orthod 1982; 82: 114-9.
Gingivitis
Gulati MS, Grewal N, Kaur A.A comparative study of effects of mouth breathing and normal breathing on gingival health in children. J Indian Soc Pedod Prev Dent 1998 Sep;16(3):72-83
Wagaiyu EG, Ashley FP. Mouthbreathing, lip seal and upper lip coverage and their relationship with gingival inflammation in 11-14 year-old schoolchildren. J Clin Periodontol 1991 Oct;18(9):698-702
Asthma
Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis. Ann Allergy Asthma Immunol 1997 Jul;79(1):70-4.
Inman MD, Ellis R, Wattie J, Denburg JA, O'Byrne PM. Allergen-induced increase in airway responsiveness, airway eosinophilia, and bone-marrow eosinophil progenitors in mice. Am J Respir Cell Mol Biol 1999 Oct;21(4):473-9
Denburg JA. Bone marrow in atopy and asthma: hematopoietic mechanisms in allergic inflammation. Immunol Today 1999 Mar;20(3):111-3
Denburg J . The nose, the lung and the bone marrow in allergic inflammation. Allergy 1999;54 Suppl 57:73-80
O'Byrne PM, Gauvreau GM, Wood LJ. Interaction between haemopoietic regulation and airway inflammation. Clin Exp Allergy 1999 Jun;29 Suppl 2:27-32
Greisner WA 3rd, Settipane RJ, Settipane GA Co-existence of asthma and allergic rhinitis: a 23-year follow-up study of college students. Allergy Asthma Proc 1998 Jul-Aug;19(4):185-8
Corren J. The impact of allergic rhinitis on bronchial asthma. J Allergy Clin Immunol 1998 Feb;101(2 Pt 2):S352-6
Polosa R, Ciamarra I, Mangano G, Prosperini G, Pistorio MP, Vancheri C, Crimi N. Bronchial hyperresponsiveness and airway inflammation markers in nonasthmatics with allergic rhinitis. Eur Respir J 2000 Jan;15(1):30-5
Yawn BP, Yunginger JW, Wollan PC, Reed CE, Silverstein MD, Harris AG. Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on health care charges. J Allergy Clin Immunol 1999 Jan;103(1 Pt 1):54-9
Linna O et al. A 10 year prognosis for childhood allergic rhinitis. Acta Paediatrica 1992; 81: 100-2.
Corren J. Allergic rhinitis and asthma: how important is the link? J Allergy Clin Immunol 1997; 99: S781-6.
Wade TA et al. Treatment of allergic rhinitis with intranasal corticosteroids in patienst with mild asthma: effect on lower airway responsiveness. J Allergy Clin Immunol 1993; 91: 97-101.
Aubier M. Liuking ther upper and lower airways. Ann Allergy Asthma Immunol 1999; 83: 431-4.
Pauwels R. Influence of treatment on the nose and/or the lungs. Clin Exp Allergy 1998; 28: Supplement 2: 37-40.
Aubier M et al. Different effects of nasal and bronchial glucocorticosteroid administration on bronchial hyperresponsiveness in patients with allergic rhinitis. Am Rev Respir Dis 1992; 146: 122-6.
Sotomayor H et al. Seasonal increase of carbachol airway responsiveness in patients allergic to grass pollen. Reversible by corticosteroids. American Rev Respir Dis 1984; 130: 56-8.
Welsh P W. Efficacy of beclomethasone nasal solution, flunisolide, and cromolyn in relieving symptoms of ragweed allergy. Mayo Clinic Proceedings 1987; 62: 125-34.
Foresi A et al. Once daily intranasal fluticasone reduces nasal symptoms and inflammation but also attenuates the increase in bronchial responsiveness during the pollen season in allergic rhinitis. J Allergy Clin Immunol 1996; 98: 272-82.
Nasal beclomethasone prevents the seasonal increase in bronchial responsiveness in patients with allergic rhinitis and asthma. J Allergy Clin Immunol 1992; 90: 250-6.
Grant JA. Clinical aspects of allergic disease. Cetirizine in patients with seasonal rhinitis and concomitant asthma: prospective, randomised, placebo controlled trial. J Allergy Clin Immunol 1995; 95: 923-32.
Taytard A et al. Treatment of bronchial asthma with terfenadine: a randomised controlled trial. British Journal of Clinical Pharmacology 1987; 24: 743-6
Rafferty P et al. Terfenadine, a potent H1 receptor antagonist and the Treatment of grass pollen sensitive asthma. British Journal of Clinical Pharmacology 1990; 30: 229-35

Goossens NJ, Flokstra-de Blok BM, Vlieg-Boerstra BJ, Duiverman EJ, Weiss CC, Furlong TJ, Dubois AE. Online version of the food allergy quality of life questionnaire-adult form: validity, feasibility and cross-cultural comparison. Clin Exp Allergy. 2011 Apr;41(4):574-81.

Resnick ES, Pieretti MM, Maloney J, Noone S, Muñoz-Furlong A, Sicherer SH. Development of a questionnaire to measure quality of life in adolescents with food allergy: the FAQL-teen. Ann Allergy Asthma Immunol. 2010 Nov;105(5):364-8.

Springston EE, Smith B, Shulruff J, Pongracic J, Holl J, Gupta RS. Variations  in quality of life among caregivers of food allergic children. Ann Allergy Asthma Immunol. 2010 Oct;105(4):287-294.

MacKenzie H, Dean T. Quality of life in children and teenagers with food hypersensitivity. Expert Rev Pharmacoecon Outcomes Res. 2010 Aug;10(4):397-406.

OTHER

Meltzer EO. Allergic Rhinitis: Burden of Illness, Quality of Life, Comorbidities, and Control. Immunol Allergy Clin North Am. 2016 May;36(2):235-48. doi: 10.1016/j.iac.2015.12.002.

Blaiss MS, Hammerby E, Robinson S, Kennedy-Martin T, Buchs S. The burden of allergic rhinitis and allergic rhinoconjunctivitis on adolescents: A literature review. Ann Allergy Asthma Immunol. 2018 Jul;121(1):43-52.e3. doi: 10.1016/j.anai.2018.03.028.

Speth MM, Hoehle LP, Phillips KM, Caradonna DS, Gray ST, Sedaghat AR. Treatment history and association between allergic rhinitis symptoms and quality of life. Ir J Med Sci. 2019 May;188(2):703-710. doi: 10.1007/s11845-018-1866-2.

Last reviewed 5 June 2020