Allergic Rhinitis Management: questions and answers

In detail

Allergic rhinitis is an IgE-mediated inflammatory disease of the nasal mucosa. The ARIA guidelines classify it as intermittent or persistent and mild or moderate-to-severe. First-line pharmacotherapy is intranasal corticosteroids for persistent disease. Second-generation antihistamines help with sneezing and itching.

Combination sprays may be used when monotherapy is insufficient. Allergen immunotherapy (sublingual or subcutaneous) is the only disease-modifying option and is offered when symptoms remain uncontrolled despite medicines and avoidance, or when a patient wishes to reduce long-term medication use.

Environmental controls target identified allergens such as dust mites, pollen, mould or pet dander. Saline irrigation is recommended for all patients. Surgery is not a treatment for the allergy itself but may be considered for structural problems like turbinate hypertrophy or polyps.

In detail

Allergic rhinitis commonly presents with sneezing, anterior rhinorrhoea, nasal congestion, nasal itching and itchy, watery eyes. These symptoms can impair quality of life, causing sleep disturbance, fatigue, irritability and poor concentration.

The ARIA guidelines recommend assessment for associated conditions such as asthma, conjunctivitis, sinusitis, otitis media and sleep-disordered breathing. If symptoms persist despite empiric treatment, or if the diagnosis is uncertain, specific IgE testing is indicated.

Red flags include unilateral symptoms, blood-stained discharge, facial pain, or symptoms that do not respond to standard therapy, which may suggest structural or other pathology requiring ENT evaluation.

In detail

Allergic rhinitis develops when the immune system produces IgE antibodies against specific inhaled allergens.

On re-exposure, these antibodies trigger mast cells and basophils to release histamine, leukotrienes and cytokines, causing the early phase (sneezing, itching, runny nose within minutes) and the late phase (nasal congestion, hyperresponsiveness over hours).

Common triggers in India include house dust mites, pollen, moulds and animal dander. The ARIA classification distinguishes seasonal (pollens) from perennial (dust mites, mould, dander) triggers. Risk factors include family history of atopy, early-life indoor allergen exposure, air pollution and occupational allergens.

Priming from repeated exposure or pollution can lower the threshold for symptoms. Identifying your specific triggers through history and testing guides targeted avoidance and immunotherapy.

In detail

Guidelines recommend referral to an allergist or immunologist for severe or refractory disease, uncertainty about clinically relevant allergens, consideration of allergen immunotherapy, or substantial impairment in quality of life.

Referral to an otolaryngologist is appropriate when structural abnormalities, chronic rhinosinusitis, nasal polyps, recurrent epistaxis or other conditions requiring endoscopic evaluation or surgical management are suspected.

At Jaipur Hospital, the ENT team works with allergy-trained clinicians to provide comprehensive care including skin prick testing, intranasal corticosteroid and antihistamine prescriptions, and both sublingual and subcutaneous immunotherapy.

The choice of specialist depends on whether the primary need is medical management, allergy testing and immunotherapy, or assessment for surgical issues like turbinate hypertrophy or septal deviation.

In detail

Guidelines state the clinical diagnosis of allergic rhinitis is based on history and physical findings consistent with an allergic cause: nasal congestion, runny nose, itchy nose or sneezing. Examination findings include clear rhinorrhoea, nasal congestion, pale discoloration of the nasal mucosa and red, watery eyes.

The doctor will assess for associated conditions such as asthma, atopic dermatitis, conjunctivitis, sinusitis, otitis media and sleep-disordered breathing.

If the diagnosis is uncertain, or if symptoms do not respond to empiric treatment, or if specific allergens need identification for targeted therapy or immunotherapy, specific IgE testing (skin prick or blood test) will be recommended. Routine sinonasal imaging is not recommended for straightforward allergic rhinitis.

In detail

Guidelines recommend specific IgE testing (skin prick or serum) when the diagnosis is uncertain, when empiric treatment fails, or when knowledge of the specific allergen is needed to target therapy or plan immunotherapy.

Skin prick testing is reliable, gives results in 15 to 20 minutes and allows testing multiple allergens in one session. Serum-specific IgE is an alternative when skin testing is not feasible.

Routine sinonasal imaging is not recommended for patients presenting with symptoms consistent with allergic rhinitis. It may be considered in patients who do not respond to therapy or when structural abnormalities like septal deviation, polyps or chronic sinusitis are suspected on examination. Nasal endoscopy may be performed in the clinic to evaluate the nasal cavity directly.

In detail

The ARIA and international guidelines recommend a stepwise approach. Intranasal corticosteroids are the most effective monotherapy for persistent or moderate-to-severe disease. Second-generation antihistamines are preferred for mild or intermittent symptoms. Fixed-dose combination sprays (corticosteroid plus antihistamine) offer greater control for moderate-to-severe cases.

Saline irrigation is suggested for all patients. Short-term decongestants may be used for severe congestion but not beyond a few days to avoid rebound.

Allergen immunotherapy (SLIT or SCIT) is the only disease-modifying treatment and is indicated when symptoms remain inadequately controlled despite pharmacotherapy and avoidance, or when the patient wishes to reduce long-term medication use.

SLIT is given as daily drops under the tongue at home after the first supervised dose. SCIT involves weekly then monthly injections in a clinical setting over three to five years. Both routes are effective for pollen, dust mite and certain animal allergens.

Surgery such as inferior turbinate reduction is only for refractory nasal obstruction due to structural enlargement after medical therapy fails.

In detail

Pharmacotherapy is the mainstay of treatment. Intranasal corticosteroids effectively control inflammation in the early and late phases of the allergic response. Antihistamines relieve sneezing, itching and runny nose. Combination sprays provide added benefit for moderate-to-severe disease. Saline irrigation helps clear allergens and mucus.

Allergen immunotherapy (SLIT or SCIT) can reduce symptoms, decrease medication needs and modify the long-term course of the disease. In studies, appropriate treatment results in significant symptom relief and improved quality of life.

Surgery does not treat the underlying allergic inflammation; it only addresses anatomical obstruction. Guidelines recommend inferior turbinate reduction only when nasal airway obstruction and enlarged turbinates have failed medical management. Even after surgery, medical therapy and avoidance measures are usually continued.

In detail

Allergic rhinitis is a chronic inflammatory condition. Without treatment, ongoing inflammation causes nasal hyperresponsiveness, making the nose react more strongly to irritants like smoke or pollution.

Studies show allergic rhinitis affects 20 to 30 percent of people in India, and 15 percent of them go on to develop asthma. Persistent symptoms lead to sleep disturbance, fatigue, irritability, and work absenteeism.

The ARIA guidelines recommend early initiation of appropriate drugs to control disease progression and prevent complications such as chronic rhinosinusitis, nasal polyps, and lower respiratory tract infections.

Pharmacotherapy and allergen avoidance can control symptoms, but many patients continue to have impaired quality of life without structured management.

In detail

The doctor takes a detailed history and performs a nasal examination. If needed, skin prick testing or blood tests for specific IgE identify clinically relevant allergens. Patients are often grouped as sneeze-runners with sneezing and runny nose, or blockers with severe congestion.

Sneeze-runners typically respond well to antihistamines, while blockers need intranasal corticosteroids. For moderate-to-severe or persistent symptoms, combination therapy with an intranasal corticosteroid and intranasal antihistamine is more effective than either alone. Fixed-dose combination sprays are available.

If pharmacotherapy and allergen avoidance do not control symptoms, or if you wish to reduce long-term medication use, the doctor may discuss sublingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT).

SLIT is often preferred for single allergens like grass pollen or dust mite, while SCIT suits polysensitised patients. The choice also considers your age, pregnancy status, other medications, and ability to attend regular visits.

In detail

Intranasal corticosteroids may cause nasal dryness, irritation, or nosebleeds. Second-generation antihistamines have minimal sedation. First-generation antihistamines are avoided due to drowsiness and anticholinergic effects. Decongestant sprays must not be used beyond three to five days due to rebound congestion.

For subcutaneous immunotherapy (SCIT), redness and warmth at the injection site are common. Systemic reactions like hives or breathing difficulty are rare but possible, so shots are given under observation. Sublingual immunotherapy (SLIT) may cause mouth itching or mild swelling.

Patients on beta-blockers, ACE inhibitors, or with uncontrolled asthma, autoimmune disease, or pregnancy need special consideration. The doctor will review your medications and conditions to minimise risks. Evidence shows appropriate treatment significantly improves quality of life and reduces medication needs over time.

In detail

Environmental control measures should target clinically relevant allergens identified through your history and allergy testing. For seasonal allergens, limiting outdoor exposure during high pollen counts, keeping windows closed, using air conditioning, and showering after outdoor activities may help.

For indoor allergens, a comprehensive approach works better than single steps: allergen-impermeable mattress and pillow covers, regular hot-water washing of bedding, and low indoor humidity for dust mites; moisture control for mould; and pet avoidance or HEPA filtration for animal dander.

Avoiding tobacco smoke, strong odours, and rapid temperature changes also helps. Isotonic intranasal saline is suggested for all patients with allergic rhinitis. Adherence to prescribed pharmacotherapy before and during anticipated allergen exposure may prevent symptom exacerbations.

In detail

Evidence does not support dietary restrictions for allergic rhinitis unless you have a confirmed food allergy. Smoking and secondhand smoke worsen nasal inflammation and reduce treatment response. Alcohol can cause nasal congestion in some people.

Outdoor exercise during high pollen counts may increase symptoms; indoor exercise or timing workouts when pollen is lower is better. Showering and changing clothes after outdoor activity removes pollen. Stress management may reduce symptom perception.

The most important habit is adherence to daily intranasal corticosteroids or antihistamines as prescribed, even when you feel well. Inconsistent use leads to poor control. Environmental controls for dust mites, mould, and pets should be maintained year-round for perennial allergies. Herbal remedies lack consistent evidence and are not recommended as primary treatment.

In detail

Intranasal corticosteroids and second-generation antihistamines are non-sedating and allow normal activities. For SCIT, the buildup phase requires weekly or fortnightly visits for up to six months, then monthly for three to five years.

SLIT is taken daily at home after the first supervised dose, offering more flexibility. Exercise is beneficial; if pollen triggers symptoms, exercise indoors on high-count days or use pre-treatment with antihistamine.

When travelling, carry medicines in hand luggage, bring a copy of your prescription, and maintain your dosing schedule across time zones. For SCIT, coordinate with your doctor for missed doses during extended travel. Saline irrigation helps during flights where air is dry. Good symptom control improves work productivity and reduces absenteeism, which evidence shows are significantly affected by untreated allergic rhinitis.

In detail

In patients with open-angle glaucoma, caution is advised with intranasal corticosteroids due to potential intraocular pressure changes. In closed-angle glaucoma, first-generation oral antihistamines, oral and intranasal decongestants, and intranasal ipratropium should be avoided; caution is needed with certain second-generation antihistamines.

During pregnancy and lactation, preferred options include oral antihistamines such as loratadine, cetirizine, or fexofenadine, intranasal corticosteroids such as budesonide or fluticasone, intranasal cromolyn, and nasal saline. Intranasal fluticasone and budesonide are contraindicated with protease inhibitors that inhibit CYP3A4.

For immunotherapy, asthma must be well controlled before starting; autoimmune diseases, beta-blockers, ACE inhibitors, and inability to communicate reactions are relative contraindications. Allergy shots are not started during pregnancy but can be continued if pregnancy occurs during treatment.

The doctor also assesses for comorbid conditions such as chronic rhinosinusitis, nasal polyps, or septal deviation that may need separate management.

In detail

Saline rinses are safe and recommended for all patients. Second-generation oral antihistamines like cetirizine or fexofenadine are available over the counter and may be used as directed, but duplicating the same drug class increases side effects.

Intranasal decongestants like oxymetazoline cause rebound congestion (rhinitis medicamentosa) if used longer than three to five days. Oral decongestants can raise blood pressure and disturb sleep. First-generation antihistamines cause drowsiness and are not recommended.

Herbal products are widely used but evidence is limited and quality varies; they are not recommended as primary treatment. Some may interact with corticosteroids or antihistamines. Montelukast carries a boxed warning for neuropsychiatric effects and is reserved for specific cases.

The doctor will review what you are taking to avoid duplication or interactions. Adherence to prescribed intranasal corticosteroids remains the cornerstone of control.

In detail

The term hay fever describes allergic rhinitis that occurs during pollen seasons. Evidence shows that intranasal corticosteroids are the most effective first-line treatment for persistent or moderate-to-severe symptoms. Second-generation antihistamines help with sneezing and itching.

For patients whose symptoms remain inadequately controlled despite pharmacotherapy and allergen avoidance, allergen immunotherapy (sublingual or subcutaneous) may modify the long-term course of the disease. Environmental controls such as keeping windows closed during high pollen counts and showering after outdoor activities can reduce exposure.

In detail

Nasal allergy refers to the same condition described in guidelines as allergic rhinitis. Diagnosis is based on clinical history, examination findings such as pale nasal mucosa and clear rhinorrhoea, and confirmatory testing with skin prick tests or serum-specific IgE when needed.

First-line treatment for persistent or moderate-to-severe disease is intranasal corticosteroids. Second-generation oral or intranasal antihistamines are used for mild or intermittent symptoms. Combination therapy may be offered for inadequate response to monotherapy.

Allergen immunotherapy is considered for patients with confirmed IgE-mediated disease whose symptoms remain uncontrolled despite optimised pharmacotherapy and avoidance measures, or who wish to reduce long-term medication use.

In detail

Allergic rhinitis causes blockage through mucosal swelling and inflammation. Chronic rhinosinusitis adds thick secretions and mucosal oedema. Nasal polyps, often associated with allergy, create physical obstruction. A deviated septum narrows the airway structurally. Guidelines recommend against routine sinonasal imaging for uncomplicated allergic rhinitis.

Imaging may be considered when symptoms persist despite optimised medical therapy or when structural abnormalities are suspected. Inferior turbinate reduction may be offered for enlarged turbinates that fail medical management. The clinical history, pattern of symptoms, and endoscopic findings help differentiate these causes.

In detail

Guidelines recommend against routine sinonasal imaging in patients with symptoms consistent with allergic rhinitis. Diagnosis is primarily clinical, supported by allergy testing when needed.

Diagnostic nasal endoscopy allows the specialist to visualise the nasal mucosa, turbinates, septum, and any polyps or pus in the middle meatus. This office procedure takes a few minutes and does not require anaesthesia.

CT scanning involves radiation and is reserved for cases where surgical planning is needed, or when the diagnosis remains uncertain after endoscopy and medical treatment failure. Your surgeon will decide based on your specific findings.

In detail

Evidence shows intranasal corticosteroids are the most effective monotherapy for persistent or moderate-to-severe allergic rhinitis. Saline irrigation is recommended for all patients to clear allergens and mucus. Combination therapy with intranasal corticosteroid and intranasal antihistamine provides greater symptom control than either alone for moderate-to-severe disease.

Allergen immunotherapy (sublingual or subcutaneous) is the only disease-modifying treatment and may reduce long-term medication need. Surgery such as inferior turbinate reduction is considered only when nasal obstruction persists despite optimised medical therapy. Guidelines emphasise early initiation of appropriate medical treatment to control disease progression and prevent complications.

In detail

Nasal obstruction from allergic rhinitis forces mouth breathing, which can alter speech resonance and cause dry throat. Eustachian tube dysfunction secondary to nasal inflammation may lead to middle ear effusion, causing hearing reduction or a sensation of fullness. This is more common in children.

Balance is not typically affected unless inner ear involvement occurs, which is rare in isolated allergic rhinitis. Swallowing is not directly impaired, though postnasal drip may cause throat clearing or cough. Chronic rhinosinusitis or nasal polyps, which can coexist with allergy, may worsen these effects. Guidelines recommend assessing for associated conditions such as otitis media and sleep-disordered breathing in all patients with allergic rhinitis.

In detail

Guidelines recommend referral to an otolaryngologist when structural abnormalities, chronic rhinosinusitis, nasal polyps, recurrent epistaxis, or other conditions requiring endoscopic evaluation or surgical management are suspected. Unilateral nasal symptoms, blood-stained discharge, or facial pain warrant timely evaluation to exclude other pathology.

Patients with severe or refractory allergic rhinitis despite optimised pharmacotherapy should also be assessed for immunotherapy candidacy or surgical options. Associated conditions such as asthma, sleep-disordered breathing, and conjunctivitis should be documented and managed. Early specialist review helps prevent complications and ensures appropriate escalation of therapy.

In detail

Medical management includes intranasal corticosteroids, antihistamines, saline rinses, and occasional short courses of other medications. These are ongoing expenses. Immunotherapy, offered as sublingual drops or subcutaneous injections, involves a build-up phase and a maintenance phase over 3 to 5 years.

The total immunotherapy cost reflects the allergen extracts, administration visits, and monitoring. Allergy testing such as skin prick tests or serum-specific IgE adds to the initial cost. Nasal endoscopy, if performed, is a separate charge. Hospital stay is not required as treatment is outpatient.

The final estimate varies based on the number of allergens treated, the route of immunotherapy chosen, and medication brands prescribed.

In detail

Our usual protocols show treatment is outpatient with symptom control in two to four weeks and immunotherapy lasting three to five years. The typical price range is ₹2,000 to ₹15,000 per year for medical therapy and ₹50,000 to ₹1,00,000 for a full immunotherapy course.

Evidence indicates treatment includes allergen avoidance, pharmacotherapy with intranasal corticosteroids and antihistamines, and immunotherapy for selected patients. Costs for medicines, allergy extracts, and administration visits are part of the ongoing plan. Any surgical intervention for structural issues would be a separate estimate.