AKT · ENT/Nose & sinuseslow yield

Allergic rhinitis

IgE-mediated nasal mucosal hypersensitivity

Overview

An IgE-mediated hypersensitivity of the nasal mucosa to allergens (pollen, house-dust mite, animals), seasonal or perennial. Sneezing, itch, clear rhinorrhoea and congestion — distinct from infective rhinosinusitis by the itch, sneezing and lack of fever/purulence. Part of the atopic triad.

Recognise

Sneezing, nasal ITCH, watery (clear) rhinorrhoea and congestion; itchy/watery eyes (allergic conjunctivitis)
Seasonal (pollen — "hay fever") or perennial (house-dust mite, pets); the "allergic salute" and "allergic shiners" in children
Personal/family history of atopy (asthma, eczema)

Red flags

Unilateral symptoms/bleeding → exclude a structural or neoplastic cause; poorly controlled rhinitis worsens asthma

Differentials & how to tell them apart

Acute rhinosinusitis (viral)facial pain/pressure, purulent discharge, no itch/sneezing, often febrile

Nasal polypspale mobile masses + anosmia

Vasomotor (non-allergic) rhinitistriggered by temperature/odours, no allergic itch or IgE

Investigations

Clinical. Allergy testing (skin-prick/specific IgE) if the trigger is unclear or immunotherapy is considered.

Management

Allergen avoidance + antihistamine; intranasal corticosteroid for persistent/moderate symptoms

1Allergen avoidance + a non-sedating antihistamine for mild/intermittent symptoms; an intranasal corticosteroid is most effective for moderate/persistent disease (especially congestion).Gate: The itch + sneezing + CLEAR rhinorrhoea (and no fever/purulence) distinguish allergic rhinitis from infective rhinosinusitis — the treatment is antihistamine/intranasal steroid, not antibiotics
2Inadequate control → combine intranasal steroid + antihistamine, add a leukotriene antagonist; refractory/single-allergen → specialist immunotherapy. Treat coexisting asthma ("one airway").

Allergen avoidance — first-line where feasible

Non-sedating oral or intranasal antihistamine — for mild/intermittent symptoms

Intranasal corticosteroid — most effective for moderate/persistent symptoms (esp. congestion)

Leukotriene receptor antagonist; immunotherapy — add-on/refractory (immunotherapy is specialist)

Key points

Itch + sneeze + clear discharge + atopy = allergic rhinitis. Intranasal steroids beat antihistamines for congestion. It and asthma are "one airway" — control both.

Monitor & prognosis

Symptom control; asthma control.

Chronic but well controlled; immunotherapy can modify it.

Source: NICE CKS Allergic rhinitis; BSACI