Patterns of allergic rhinitis among adults in Qassim region, Saudi Arabia: a cross sectional study

Introduction developing and developed countries have a high prevalence of allergic rhinitis (AR). Severe AR has negative impacts on sleep, quality of life, and work performance. The study aimed to identify the patterns of AR among patients attending the ears nose and throat Unit (ENT) clinic at King Saud Hospital, Qassim, Saudi Arabia. Methods this study was a cross-sectional study conducted at the ENT clinic of King Saudi Hospital, Unaizah City, Qassim region, Saudi Arabia. We examined outpatients diagnosed with AR using an interview questionnaire and clinical examination. Results the sample included 455 patients. Of these, 23.7% were 21-30 years old, 65.7% had a family history of AR, 57.8% had no general symptoms, 75.6% reported runny nose as the most common nasal symptom, and 35.4% reported no complications. Dust was the most common trigger of AR (82.4%), 49.2% reported allergic symptoms in all seasons, 96% of patients have inferior turbinate hypertrophy, and oral histamine was the most commonly used treatment (33.2%). Conclusion perineal AR and inferior turbinate hypertrophy were very common findings comparing to previous studies, further studies to assess the risk factors are highly recommended.


Introduction
Rhinitis is a common inflammatory disorder of the nose, which affects approximately 40% of the population [1]. There are several different types of rhinitis, but allergic rhinitis (AR) is the most common type, reported to affect approximately 10%-20% of the population [2]. Allergic rhinitis prevalence is high in both developing and developed countries [3], affecting almost 400 million individuals worldwide [4,5]. In Jazan City in Saudi Arabia, an AR incidence of approximately 44% has been reported, substantially exceeding the global average of 10%-20% [6]. Symptoms of AR typically emerge after exposure to an allergen due to IgE mediated inflammation of the membranes lining the nose [7]. The symptoms of AR result in fatigue, cognitive function decline which impairs quality of life, depressed mood and sleep disturbances [8]. There are several triggers for AR, including domestic animals, mites, allergens of plant origin or animal origin, common outdoor allergens such as mold and pollens, tobacco smoke, occupational triggers such as latex, sulfur oxide and oxides of nitrogen, aspirin, ozone, and other nonsteroid anti-inflammatory medications [7]. The major symptoms of AR include nasal obstruction, itching postnasal drip, sneezing and rhinorrhea [9]. AR can be classified into seasonal or perennial the former occurs during a specific season, whereas the later occurs throughout the year [10].
However, because this classification is not able to describe all patients, another classification system was established in which AR is classified according to symptom duration, as either intermittent (inflammation duration of less than 6 months) or persistent (symptoms continue throughout the year) and severity is classified as mild (where the patient can sleep normally), moderate or severe (where sleep and daily activity are affected) [11,12]. Because AR is commonly undetected in primary care settings, with patients suffering from the condition often being unable to recognize the impact of the disease and physicians failing to regularly ask patients about the condition, screening for AR is recommended [13]. Saudi Arabia is known for its frequent and periodic sandstorms in all seasons. Sandstorms transport many types of microorganisms and dust particles that can trigger or exacerbate respiratory diseases such as AR and asthma [14]. Qassim region is a central area in the kingdom of Saudi Arabia, and is well known agricultural zone, and has the desert climate, with frequent dust storms, and low humidity [15]. In unpublished communication, medical practitioners in various specialties have thought that a large number of people in Qassim region suffer from AR compared to other regions. However, few studies of this widespread disease have been conducted in Saudi Arabia, and the patterns of the disease remain to be clarified. To the best of our knowledge, this is the first study of AR to be conducted in Qassim region. The present study was conducted to identify patterns of AR among patients attending the ear, nose and throat (ENT) outpatient clinic at King Saud Hospital, Unaizah City, Qassim region, Saudi Arabia.

Methods
Study design and setting: we conducted a quantitative observational descriptive crosssectional study among outpatients from the ENT clinic of King Saud Hospital, which has a capacity of 294 beds and is the only governmental hospital in Unaizah city, Qassim region, between January 2019, and December 2019.
Sample size: the sample size was calculated based on assuming that the prevalence of perineal allergic rhinitis was 50% to get the maximium sample size, type I error 5%, adequate power (80%), and 15% of expected incomplete data. The minimium sample size was 443.
Sampling, data collection and analysis: a systematic sampling technique was used to enroll participants over 18 years of age. Patient's who were under 18 years of age were excluded. An interview questionnaire was used to collect data, and was given to the doctors to fill in during the interview with patients. The questionnaire focused on personal data, clinical presentation, recurrent triggers, family history, and co-morbidities according to the study objective and based on previous studies [6,[16][17][18]. Clinical examinations were performed, including a detailed ENT examination using an endoscope. The diagnosis of AR was based on clinical diagnosis when patients have a history, and physical findings which compatible with allergic cause according to American academy of otolaryngology head and neck surgery [19]. The data were entered into excel then transferred into STATA v16 for analysis. Description of data was conducted using frequency and percentages for categorical variables.
Ethical considerations: ethical approval was obtained from the regional committee of bioethics in Qassim region before we began the process of data collection. Written consent was obtained from all participants before participation in the study.

Results
The response rate was 97%, and 455 participants were recruited to the study. The most common age group was 21-30 years old (n= 108 23.7%). There were more male than female participants (n=286 62.9% vs n= 169 37.1%, respectively). The most common body mass index category was normal weight (n=203 44.6%). The sample contained 53 (11.6%) office workers, and most participants lived in the city (n= 420 72.3%). The most commonly reported type of home was villa (n=198 43.5%). More than three quarters of participants were nonsmokers (n= 363 79.8%), whereas there were 44 (9.7%) smokers. Of the 44 smokers, 24 (54.5%) participants reported smoking for more than 10 years, and 25 (65.8%) participants reported smoking ≤ 1 pack per day. Most participants (412 90.5%) reported that they did not undergo an allergy test, while 43 (9.5%) participants had undergone an allergy test. Of the 43 participants who underwent the allergy test, 15 (34.9%) participants reported that they underwent an allergy test more than 5 years earlier, and the skin test was the most common type (n= 36 83.7%). More than half of the participants reported having a family history of allergy (n= 299 65.7%), as shown in Table 1. The clinical presentations of participants are shown in Table 2. More than half of participants (n= 263 57.8%) reported no general symptoms, while 188 (41.3%) and 68 (14.9%) reported fatigue and malaise, respectively. Commonly, the onset of symptoms was ≤10 years (n= 216 47.5%). The most common nasal, throat and sinus symptoms were runny nose 344 (75.6%), frequent clearing 205 (45.1%) and headache 215 (47.3%), respectively. Among the 215 participants who reported headache characteristics, the most commonly reported location of headache was frontal (n= 106 49.3%). Most participants experiencing headache (n= 20595.3%) reported tension as the type of headache, and more than half of them (n= 124 57.7%) reported that it occurred occasionally.

Discussion
Clinically, AR is defined as a symptomatic nose disease evoked by IgE-mediated inflammation of the nasal membrane after exposure to an allergen [20]. It is the most common respiratory disease, affecting 19% and 8.8%-16% of the general population in Europe and the United States, respectively [21,22]. AR affects both young adults and teenagers frequently. However, the prevalence of AR has been found to decrease after the age of 20 years old [23]. A previous study from Jazan region in Saudi Arabia reported that the prevalence of AR was 44% among adults [6]. In the present study, the findings indicate that AR prevalence peaked at between 22-31 years old, and decreased with increasing age. A study with a similar finding in Jazan city reported that, the peak of age of AR was 22 years old, which constitutes 25.8% [6]. Also in our study, 62.9% was male and 37.1% was female which is inconsistence with study conducted in Saudi Arabia using electronic survey found more females with AR than males, however this is may be due to selection bias [24]. It was previously reported that having a parent with AR increased the risk of having AR [25], while other reported risk factors include exposure to cigarette smoke, obesity, increased blood eosinophils, amplified IgE in the serum, and environmental factors such as environmental exposure in urban areas [26,27]. In contrast, growing up in a farming environment was associated with reduced risk of AR [28]. In the current study, 65.7% of patients reported having a family history of AR. This consistent with study conducted in Saudi Arabia, in which most of AR patient have positive family history (64.1%) [24].
Regarding obesity, half of participants were overweight and obese. The percentage of normal weight is consistent with study conducted in Saudi Arabia, in which AR occurred in normal weight individual constituting 38%, while overweight and obesity constitute 58% [24]. A previous study reported association between the high body mass index and AR [29], while another study reported no association [30], suggesting that this issue may require further investigation. Moreover, 79.8% of our patients reported that they were not smokers, 9.7 % of them are smoker and 10.5 % are passive smoker indicating that smoking was not a risk factor for this study group. This consistence with study done in Al-Ahssa in which 6% of patients are smokers and 8% are passive smokers [31], but in contrast to a study done in western area of Saudi Arabia concluded that 84.8% are either smokers or ex-smokers and only 15.2% non-smoker [16]. Regarding residence area, 92.3% of participants were living in the city which is similar to the study of western area of Saudi Arabia reported that 91% are urban citizen [16].
The majority of patients reported mild symptoms 80.9%), and (74.7%) participants reported that symptoms were intermittent. This inconsistent with study done in Riyadh, where 34% of AR reporting mild symptoms and 54% reporting intermittent symptoms [24]. Skin symptoms, lung symptoms, and ear symptoms were uncommon in this study, and more than half of the participants had no general symptoms. The most common reported nasal symptoms were runny nose (75.6%), nasal obstruction (75.5%) and frequent sneezing (73.8%). This is consistence with a study where the most common present symptoms were runny nose (82%), nasal itching (70%) and nasal obstruction (69%) [32], also in the study survey conducted an Middle East in five countries Saudi Arabia one of them, the percentage of symptoms reported by the participants were runny nose (57%), nasal itching (56%), nasal congestion (55%), throat itching (52%), reduced sense of smell (51%), and postnasal drip (50%) [17]. Complications of AR included chronic and acute sinusitis, apnea or sleep disturbance, dental problems and otitis media [18]. The current results revealed that 35.4% of patients had no complications, while the most common complications were sleep disturbance, acute or chronic rhinitis and dental problems, whereas otitis media represented only 2% of cases among all complications. In present study, sleep disturbance present in 27.7% of cases with AR. In the study done in Al-Ahssa, sleep disturbance were reported in 75% of cases with AR [31], and in the study survey conducted in Middle East in five countries Saudi Arabia one of them, the percentage of sleep disturbance were reported by about 80% [31]. The goal of AR treatment is to relieve symptoms, and there are several therapeutic options, including oral histamines, leukotriene, allergen immunotherapy, avoidance measures and intranasal corticosteroids [13]. In the current study, the most common treatments were oral histamine (33.2%), intranasal steroids (31%), and nasal decongestant. Although the study was selecting a representative sample from the study population, however, there are some limitations that should be considered. First, the study design was descriptive cross sectional that providing a snapshot of the frequency of each variable and did not asses the relationship between exposure and outcome. Second, recall bias cannot be rule out as the nature of the study design.

Conclusion
Allergic rhinitis decreases with increasing age. Most patients with AR were living in urban areas and had a family history of AR. Thus, these characteristics appear to constitute risk factors for AR. The most common symptoms of AR were non-specific and mild, and nasal symptoms were the most frequent. Perineal allergic rhinitis was the common type and inferior turbinate hypertrophy with pale bluish discoloration was the most common finding during the clinical examination. Dust was the most common trigger for AR. Oral histamine and intranasal steroids were the most commonly used treatments.

What is known about this topic
 Allergic rhinitis has wide varities of presentations and complications;  Allergic rhinitis had negative impact on quality of life;  Allergic rhinitis management are avoidance, medications and immunotherapy.

What this study adds
 This is the first study to assess common presentations and patterns of allergic rhinitis in Qassim region;  Significantly, the perineal allergi rhinitis was the most common frequent type;  Interestingly, the inferior turbinate hypertrophy was common finding in physical examination.