Background

Definition

IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitised to allergens.

Classification:

• Seasonal rhinitis (hay fever) – symptoms occur at the same time each year in response to a seasonal allergen
  • Most typically occurs in the summer but also depends on the pollen

• Perennial rhinitis – symptoms occur throughout the year

Causes

Common environmental triggers:

• House dust mites 
• Grass, tree, and weed pollens
• Moulds
• Cat and dog hair

Clinical Features

Typical features:

• Classic bilateral symptoms: sneezing, nasal itching, rhinorrhoea, nasal congestion
• Postnasal drip
• Associated eye symptoms (e.g. bilateral itching, redness, tearing)

Other suggestive features:

• Personal / family history of atopy (asthma / eczema / allergic rhinitis)
• Symptoms occur following exposure to a known causative allergen
  • Tree pollens — intermittent or chronic symptoms occur from early to late spring.
  • Grass pollens — intermittent or chronic symptoms occur from late spring to early summer.
  • Weed pollens — intermittent or chronic symptoms may occur from early spring to early autumn.
  • House dust mites — symptoms are worse on waking and are present all year-round, but may peak in autumn and spring.
  • Animal dander — symptoms follow exposure to animal dander, and may be all year-round or occasional, depending on exposure.
  • Occupational — intermittent or chronic symptoms tend to improve when the person is away from work, such as weekends and holidays.

Guidelines

Referral Criteria

Consider referral if:

• Unilateral red-flag symptoms (blood-stained nasal discharge / recurrent epistaxis / nasal pain) → 2 week wait referral to ENT
• Structural abnormality / predominant nasal obstruction that makes intranasal drug treatment difficult
• Persistent symptoms despite optimal management in primary care
• Uncertain diagnosis

Investigation and Diagnosis

Clinical diagnosis based on a combination of:

• History
• Clinical exam 
• Response to 1st line treatment

Specialist may perform allergy testing but not required for diagnosis:

• Skin prick testing
• RAST (measure level of serum-specific IgE to allergens)

Management

General Advice / Conservative Management 

• Allergic avoidance technique    
• Consider nasal irrigation with saline solution 

Pharmacological management 

1st Line Therapy

• Intranasal corticosteroids (e.g. mometasone, fluticasone),
  • Most effective treatment
  • But may take several hours to days to become effective

AND/OR

• Intranasal antihistamine / oral non-sedating antihistamines
  • Fastest onset of action (within minutes)
  • But less effective than intranasal corticosteroids

Additional treatment:

• Presence of eye symptoms → antihistamine eye drops / chromone eye drops (sodium cromoglycate, nedocromil)

2nd Line Therapy

If 1st line options are ineffective → consider adding:

• Intranasal anticholinergic (e.g. ipratropium bromide)
• Intranasal decongestant (e.g. xylometazoline) for up to 5-7 days – especially if congestion is a problem

Also consider

• Changing 'as needed' oral antihistamine into regular oral antihistamine.
• Short course of oral corticosteroid for 5-10 days if there are severe uncontrolled symptoms that are affecting quality of life.

References

Original Guideline