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Allergic rhinitis

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Updated 2024 AAO-HNSF guidelines on immunotherapy for inhalant allergy.

Background

Overview

Definition
Allergic rhinitis is an inflammatory disease of the nasal mucosa characterized by symptoms of sneezing, nasal pruritus, airflow obstruction, and clear nasal discharge.
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Pathophysiology
Common allergens that are associated with allergic rhinitis include pollen and mites (67%), animal dander and pollutants (23%), and fungal allergens (21%).
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Epidemiology
The prevalence of physician-diagnosed allergic rhinitis is estimated at 14% in the US.
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Disease course
In patients with allergic rhinitis, exposure to allergens triggers an IgE-mediated hypersensitivity reaction, leading to mucosal inflammation and associated nasal symptoms. Type 2 helper T cells play a role in maintaining persistent mucosal inflammation beyond the time of allergen exposure.
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Prognosis and risk of recurrence
Allergic rhinitis can impair QoL by interrupting sleep. It is associated with work performance impairment and missed work time.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of allergic rhinitis are prepared by our editorial team based on guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2024,2015), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2020), and the Allergic Rhinitis and its Impact on Asthma (ARIA 2017). ...
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Screening and diagnosis

Diagnostic criteria: as per AAO-HNSF 2015 guidelines, diagnose allergic rhinitis clinically when patients present with ≥ 1 typical symptoms (nasal congestion, runny nose, itchy nose, or sneezing), and history and physical examination is consistent with an allergic cause.
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Diagnostic criteria for allergic rhinitis
Presence of ≥ 1 typical symptoms (sneezing, nasal congestion, discharge or itch)
Demonstration of sensitization
Congestion of the mucosa and bilateral transparent secretions on anterior rhinoscopy
Allergic rhinitis is unlikely
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Classification and risk stratification

Severity assessment: as per AAAAI/ACAAI 2020 guidelines, consider using a validated instrument (such as scoring system, scale, or questionnaire) to help determine the severity of rhinitis and to monitor the degree of disease control.
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Diagnostic investigations

Clinical examination
As per AAAAI/ACAAI 2020 guidelines:
Elicit a complete detailed history and perform physical examination in patients presenting with symptoms of rhinitis.
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Review all current medications in patients presenting with symptoms of rhinitis to assess whether drug-induced rhinitis may be present.
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More topics in this section

  • IgE allergy testing

  • Sinonasal imaging

Medical management

Intranasal corticosteroids
As per AAAAI/ACAAI 2020 guidelines:
Prefer intranasal corticosteroids when choosing monotherapy in patients with persistent allergic rhinitis.
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Prefer intranasal corticosteroids over leukotriene receptor antagonists for the initial treatment of ≥ 15 years old patients with moderate or severe seasonal allergic rhinitis.
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More topics in this section

  • Intranasal antihistamines

  • Intranasal decongestants

  • Intranasal anticholinergics

  • Intranasal cromolyn

  • Systemic corticosteroids

  • Oral antihistamines

  • Oral leukotriene receptor antagonists

  • Oral decongestants

  • Combination therapy

  • Allergen immunotherapy

Nonpharmacologic interventions

Avoidance of allergens: as per AAO-HNSF 2015 guidelines, consider advising avoidance of known allergens or environmental control measures (such as removal of pets, air filtration systems, bed covers, and chemical agents formulated to kill dust mites) in patients with allergic rhinitis who have identified allergens that correlate with clinical symptoms.
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More topics in this section

  • Herbal products

  • Acupuncture

Surgical interventions

Inferior turbinate reduction: as per AAO-HNSF 2015 guidelines, consider performing surgical inferior turbinate reduction in patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management.
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