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Key Features

Essentials of Diagnosis

  • Clear rhinorrhea, sneezing, tearing, eye irritation, and pruritus

  • Associated symptoms include cough, bronchospasm, eczematous dermatitis

  • Environmental allergen exposure in the presence of allergen specific IgE

General Considerations

  • Seasonal allergic rhinitis is most commonly caused by pollens and spores

  • Dust, household mites, air pollution, and pet dander may produce year-round symptoms, termed "perennial rhinitis"

Clinical Findings

Symptoms and Signs

  • Nasal symptoms are often accompanied by eye irritation, pruritus, conjunctival erythema, and excessive tearing

  • Symptoms of "hay fever" are similar to those of viral rhinitis but are usually persistent and may show seasonal variation

  • Physical examination may reveal inflamed, edematous, or even pale boggy nasal mucosa

  • The mucosa of the turbinates is usually pale or violaceous because of venous engorgement; this is in contrast to the erythema of viral rhinitis

  • Nasal polyps, which are yellowish boggy masses of hypertrophic mucosa, may be seen

Differential Diagnosis

  • Viral rhinitis (common cold)

  • Viral conjunctivitis

  • Vasomotor rhinitis (eg, cold air or irritant-induced)

  • Acute or chronic sinusitis

  • Rhinitis medicamentosa (drug-induced rhinitis)

  • Nasal polyposis

  • Foreign body

  • Granulomatosis with polyangiitis (formerly Wegener granulomatosis)

Diagnosis

Laboratory Tests

  • Usually a clinical diagnosis

  • Confirmation of IgE-mediated hypersensitivity to aeroallergens is occasionally indicated

  • Allergy skin tests or radioallergosorbent testing (RAST) or enzyme-linked immunosorbent assay (ELISA) are available to detect specific IgE

Treatment

Medications

INTRANASAL CORTICOSTEROID SPRAYS

  • More effective—and frequently less expensive—than nonsedating antihistamines

  • Available preparations include

    • Beclomethasone (42 mcg/spray twice daily per nostril)

    • Flunisolide (25 mcg/spray twice daily per nostril)

    • Mometasone furoate (200 mcg once daily per nostril)

    • Budesonide (100 mcg twice daily per nostril)

    • Fluticasone propionate (200 mcg once daily per nostril)

  • All intranasal corticosteroids sprays are considered equally effective

ANTIHISTAMINES

  • Antihistamines

    • Loratadine (10 mg orally once daily), desloratadine (5 mg once daily), and fexofenadine (60 mg twice daily or 120 mg once daily) are nonsedating

    • Cetirizine (10 mg orally once daily) is minimally sedating

    • Brompheniramine or chlorpheniramine (4 mg orally every 6–8 hours, or 8–12 mg orally every 8–12 hours as a sustained-release tablet)

    • Clemastine (1.34–2.68 mg orally twice daily) may be less expensive though usually associated with some drowsiness

  • Azelastine (two sprays per nostril, 1.1 mg/day), an H1-receptor antagonist antihistamine nasal spray is also effective, but many patients object to its bitter taste

ANTICHOLINERGIC AGENTS

  • Intranasal anticholinergic agents, such as ipratropium bromide 0.03% or 0.06% sprays (42–84 mcg per nostril three times daily), when rhinorrhea is a major symptom

  • Ipratropium nasal sprays are not as effective as intranasal corticosteroids for treating allergic rhinitis but are useful for treating vasomotor rhinitis

SYMPATHOMIMETICS
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