Allergic Rhinitis in Otolaryngology and Facial Plastic Surgery Guidelines

Updated: Nov 14, 2017
  • Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
  • Print
Guidelines

Guidelines Summary

AAO-HNSF

In 2015 the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) released clinical practice guidelines for the diagnosis and management of allergic rhinitis. The recommendations are summarized below. [13]

Diagnosis

A clinical diagnosis of allergic rhinitis should be made in patients with a history and physical examination consistent with an allergic cause and one or more of the following symptoms: (Recommendation)

  • Nasal congestion
  • Runny nose
  • Itchy nose
  • Sneezing

Findings consistent with an allergic cause include: (Recommendation)

  • Clear rhinorrhea
  • Nasal congestion
  • Pale discoloration of the nasal mucosa
  • Red and watery eyes

For patients with a clinical diagnosis of allergic rhinitis who do not respond to empiric treatment, or in situations in which the diagnosis is uncertain or the specific allergen is needed to target therapy, immunoglobulin E (IgE) (skin or blood) testing should be carried out by clinicians who can perform and interpret the testing. (Recommendation)

Sinonasal imaging should not be routinely performed in patients with symptoms consistent with a diagnosis of allergic rhinitis. (Recommendation)

Management

Avoidance of known allergens or environmental controls (eg, removal of pets; the use of air filtration systems, bed covers, and acaricides) may be advised for patients who have identified allergens that correlate with clinical symptoms. (Option)

The presence of any of the following associated conditions should be documented in medical records: (Recommendation)

  • Asthma
  • Atopic dermatitis
  • Sleep-disordered breathing
  • Conjunctivitis
  • Rhinosinusitis
  • Otitis media

Management recommendations also include the following:

  • Clinicians should treat allergic rhinitis with intranasal steroids when patients' symptoms impair their quality of life (Strong recommendation)
  • Clinicians should recommend second-generation oral antihistamines, which are less likely to cause drowsiness, for patients complaining primarily of sneezing and itching (Strong recommendation)
  • For patients with seasonal, perennial, or episodic allergic rhinitis, intranasal antihistamines may be offered (Option)
  • Oral leukotriene receptor antagonists (LTRAs) should not be offered as primary therapy (Recommendation against)
  • Combination pharmacologic therapy may be offered to patients who do not have an adequate response to monotherapy (Option)
  • If patients have an inadequate response to pharmacologic therapy, with or without environmental controls, immunotherapy (sublingual or subcutaneous) should be offered (Recommendation)
  • For patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management, inferior turbinate reduction may be offered (Option)
  • For patients who prefer nonpharmacologic therapy, acupuncture may be offered (Option)

As a result of limited knowledge of herbal medicines and concern about the quality of standardization and safety, no recommendation was made on the use of herbal therapy.

JTFPP

In November 2017, the Joint Task Force on Practice Parameters (JTFPP), of the American Academy of Allergy, Asthma, & Immunology; the American College of Allergy, Asthma & Immunology; and the Joint Council of Allergy, Asthma & Immunology, issued an update to its 2008 guidelines for the treatment of seasonal allergic rhinitis. The revised guidelines state that, at least initially, an intranasal corticosteroid should be used alone rather than in combination with an oral antihistamine, to treat nasal symptoms in patients aged 12 years or older. [14]

The revision also states that in patients aged 15 years or older with moderate to severe seasonal allergic rhinitis, an intranasal corticosteroid is preferable over an LTRA for initial treatment. [14]

Thirdly, according to the revised guidelines, clinicians can recommend seasonal allergic rhinitis treatment with a combination of intranasal corticosteroid and intranasal antihistamine as preferable to therapy with either agent alone, although the cost and side-effects risk will be greater. [14]