Allergic Rhinitis

Author: Javed Sheikh, MD; Chief Editor: Michael A Kaliner, MD

Background
Rhinitis is defined as inflammation of the nasal membranes[1] and is characterized by a symptom complex that consists of any combination of the following: sneezing, nasal congestion, nasal itching, and rhinorrhea. [2] The eyes, ears, sin ses, and throat can also be in!ol!ed. "llergic rhinitis is the most common ca se of rhinitis. #t is an extremely common condition, affecting approximately 2$% of the pop lation. "ltho gh allergic rhinitis is not a life&threatening condition, complications can occ r and the condition can significantly impair ' ality of life,[(, )] which leads to a n mber of indirect costs. The total direct and indirect cost of allergic rhinitis was recently estimated to be *+.( billion per year.[+] " 2$11 analysis determined that patients with allergic rhinitis a!eraged ( additional office !isits, , more prescriptions filled, and *1+$$ in incremental healthcare costs in 1 year than similar patients witho t allergic rhinitis.[-]

Pathophysiology
"llergic rhinitis in!ol!es inflammation of the m co s membranes of the nose, eyes, e stachian t bes, middle ear, sin ses, and pharynx. The nose in!ariably is in!ol!ed, and the other organs are affected in certain indi!id als. #nflammation of the m co s membranes is characterized by a complex interaction of inflammatory mediators b t ltimately is triggered by an imm noglob lin . /#g.01mediated response to an extrinsic protein.[2] The tendency to de!elop allergic, or #g.&mediated, reactions to extrinsic allergens /proteins capable of ca sing an allergic reaction0 has a genetic component. #n s sceptible indi!id als, expos re to certain foreign proteins leads to allergic sensitization, which is characterized by the prod ction of specific #g. directed against these proteins. This specific #g. coats the s rface of mast cells, which are present in the nasal m cosa. 3hen the specific protein /eg, a specific pollen grain0 is inhaled into the nose, it can bind to the #g. on the mast cells, leading to immediate and delayed release of a n mber of mediators.[2, 4, ,] The mediators that are immediately released incl de histamine, tryptase, chymase, 5inins, and heparin.[4, ,] The mast cells ' ic5ly synthesize other mediators, incl ding le 5otrienes and prostaglandin 62.[1$, 11, 12] These mediators, !ia !ario s interactions, ltimately lead to the symptoms of rhinorrhea /ie, nasal congestion, sneezing, itching, redness, tearing, swelling, ear press re, postnasal drip0. 7 co s glands are stim lated, leading to increased secretions. 8asc lar permeability is increased, leading to plasma ex dation. 8asodilation occ rs, leading to congestion and press re. 9ensory ner!es are stim lated, leading to sneezing and itching. "ll of these e!ents can occ r in min tes: hence, this reaction is called the early, or immediate, phase of the reaction. ;!er )&4 ho rs, these mediators, thro gh a complex interplay of e!ents, lead to the recr itment of other inflammatory cells to the m cosa, s ch as ne trophils, eosinophils, lymphocytes, and macrophages.[1(] This res lts in contin ed inflammation, termed the late&phase response. The symptoms of the late&phase response are similar to those of the early phase, b t less sneezing and itching and more congestion and m c s prod ction tend to occ r.[1(] The late phase may persist for ho rs or days. 9ystemic effects, incl ding fatig e, sleepiness, and malaise, can occ r from the inflammatory response. These symptoms often contrib te to impaired ' ality of life.

Epidemiology
Frequency
United States "llergic rhinitis affects approximately )$ million people in the <nited 9tates.[1)] Recent <9 fig res s ggest a 2$% c m lati!e pre!alence rate.[1+, 1-] International 9candina!ian st dies ha!e demonstrated a c m lati!e pre!alence rate of 1+% in men and 1)% in women.[12] The pre!alence of allergic rhinitis may !ary within and among co ntries.[14, 1,, 2$, 21] This may be d e to geographic differences in the types and potency of different allergens and the o!erall aeroallergen b rden.

Mortality/Morbidity
3hile allergic rhinitis itself is not life&threatening / nless accompanied by se!ere asthma or anaphylaxis0, morbidity from the condition can be significant. "llergic rhinitis often coexists with other disorders, s ch as asthma, and may be associated with asthma exacerbations.[22, 2(, 2)] "llergic rhinitis is also associated with otitis media, e stachian t be dysf nction, sin sitis, nasal polyps, allergic con= ncti!itis, and atopic dermatitis.[1, 2, 2+] #t may also contrib te to learning diffic lties, sleep disorders, and fatig e.[2-, 22, 24]

> mero s complications that can lead to increased morbidity or e!en mortality can occ r secondary to allergic rhinitis. ?ossible complications incl de otitis media, e stachian t be dysf nction, ac te sin sitis, and chronic sin sitis. "llergic rhinitis can be associated with a n mber of comorbid conditions, incl ding asthma, atopic dermatitis, and nasal polyps. .!idence now s ggests that ncontrolled allergic rhinitis can act ally worsen the inflammation associated with asthma[22, 2(, 2)] or atopic dermatitis.[2+] This co ld lead to f rther morbidity and e!en mortality. "llergic rhinitis can fre' ently lead to significant impairment of ' ality of life. 9ymptoms s ch as fatig e, drowsiness /d e to the disease or to medications0, and malaise can lead to impaired wor5 and school performance, missed school or wor5 days, and traffic accidents. The o!erall cost /direct and indirect0 of allergic rhinitis was recently estimated to be *+.( billion per year.[+]

Race
"llergic rhinitis occ rs in persons of all races. ?re!alence of allergic rhinitis seems to !ary among different pop lations and c lt res, which may be d e to genetic differences, geographic factors or en!ironmental differences, or other pop lation&based factors.

Se
#n childhood, allergic rhinitis is more common in boys than in girls, b t in ad lthood, the pre!alence is approximately e' al between men and women.

!ge
;nset of allergic rhinitis is common in childhood, adolescence, and early ad lt years, with a mean age of onset 4&11 years, b t allergic rhinitis may occ r in persons of any age. #n 4$% of cases, allergic rhinitis de!elops by age 2$ years.[2,] The pre!alence of allergic rhinitis has been reported to be as high as )$% in

children, s bse' ently decreasing with age.[1+, 1-] #n the geriatric pop lation, rhinitis is less commonly allergic in nat re.

"istory
;btaining a detailed history is important in the e!al ation of allergic rhinitis. #mportant elements incl de an e!al ation of the nat re, d ration, and time co rse of symptoms: possible triggers for symptoms: response to medications: comorbid conditions: family history of allergic diseases: en!ironmental expos res: occ pational expos res: and effects on ' ality of life. " thoro gh history may help identify specific triggers, s ggesting an allergic etiology for the rhinitis. 9ymptoms that can be associated with allergic rhinitis incl de sneezing, itching /of nose, eyes, ears, palate0, rhinorrhea, postnasal drip, congestion, anosmia, headache, earache, tearing, red eyes, eye swelling, fatig e, drowsiness, and malaise.[2]

Symptoms and chronicity

6etermine the age of onset of symptoms and whether symptoms ha!e been present contin o sly since onset. 3hile the onset of allergic rhinitis can occ r well into ad lthood, most patients de!elop symptoms by age 2$ years.[2,] 6etermine the time pattern of symptoms and whether symptoms occ r at a consistent le!el thro gho t the year /ie, perennial rhinitis0, only occ r in specific seasons /ie, seasonal rhinitis0, or a combination of the two. 6 ring periods of exacerbation, determine whether symptoms occ r on a daily basis or only on an episodic basis. 6etermine whether the symptoms are present all day or only at specific times d ring the day. This information can help s ggest the diagnosis and determine possible triggers. 6etermine which organ systems are affected and the specific symptoms. 9ome patients ha!e excl si!e in!ol!ement of the nose, while others ha!e in!ol!ement of m ltiple organs. 9ome patients primarily ha!e sneezing, itching, tearing, and watery rhinorrhea /the classic hayfe!er presentation0, while others may only complain of congestion. 9ignificant complaints of congestion, partic larly if nilateral, might s ggest the possibility of str ct ral obstr ction, s ch as a polyp, foreign body, or de!iated sept m.

#rigger $actors
6etermine whether symptoms are related temporally to specific trigger factors. This might incl de expos re to pollens o tdoors, mold spores while doing yard wor5, specific animals, or d st while cleaning the ho se. #rritant triggers s ch as smo5e, poll tion, and strong smells can aggra!ate symptoms in a patient with allergic rhinitis. These are also common triggers of !asomotor rhinitis. 7any patients ha!e both allergic rhinitis and !asomotor rhinitis. ;ther patients may describe year&ro nd symptoms that do not appear to be associated with specific triggers. This co ld be consistent with nonallergic rhinitis, b t perennial allergens, s ch as d st mite or animal expos re, sho ld also be considered in this sit ation. 3ith chronic expos re and chronic symptoms, the patient may not be able to associate symptoms with a partic lar trigger.

Response to treatment
Response to treatment with antihistamines s pports the diagnosis of allergic rhinitis, altho gh sneezing, itching, and rhinorrhea associated with nonallergic rhinitis can also impro!e with antihistamines.[($]

Response to intranasal corticosteroids s pports the diagnosis of allergic rhinitis, altho gh some cases of nonallergic rhinitis /partic larly the nonallergic rhinitis with eosinophils syndrome [>"R.9]0 also impro!e with nasal steroids.

%omorbid conditions
?atients with allergic rhinitis may ha!e other atopic conditions s ch as asthma[22, 2(] or atopic dermatitis.[2+] ;f patients with allergic rhinitis, 2$% also ha!e symptoms of asthma. <ncontrolled allergic rhinitis may ca se worsening of asthma[2)] or e!en atopic dermatitis.[2+] .xplore this possibility when obtaining the patient history. @oo5 for conditions that can occ r as complications of allergic rhinitis. 9in sitis occ rs ' ite fre' ently. ;ther possible complications incl de otitis media, sleep dist rbance or apnea, dental problems /o!erbite0, and palatal abnormalities.[(1] The treatment plan might be different if one of these complications is present. >asal polyps occ r in association with allergic rhinitis, altho gh whether allergic rhinitis act ally ca ses polyps remains nclear. ?olyps may not respond to medical treatment and might predispose a patient to sin sitis or sleep dist rbance /d e to congestion0. #n!estigate past medical history, incl ding other c rrent medical conditions. 6iseases s ch as hypothyroidism or sarcoidosis can ca se nonallergic rhinitis. Aoncomitant medical conditions might infl ence the choice of medication.

Family history
Beca se allergic rhinitis has a significant genetic component,[(2] a positi!e family history for atopy ma5es the diagnosis more li5ely. #n fact, a greater ris5 of allergic rhinitis exists if both parents are atopic than if one parent is atopic. Cowe!er, the ca se of allergic rhinitis appears to be m ltifactorial, and a person with no family history of allergic rhinitis can de!elop allergic rhinitis.

En&ironmental and occupational e posure

" thoro gh history of en!ironmental expos res helps to identify specific allergic triggers. This sho ld incl de in!estigation of ris5 factors for expos re to perennial allergens /eg, d st mites, mold, pets0.[((, ()] Ris5 factors for d st mite expos re incl de carpeting, heat, h midity, and bedding that does not ha!e d st mite1 proof co!ers. Ahronic dampness in the home is a ris5 factor for mold expos re. " history of hobbies and recreational acti!ities helps determine ris5 and a time pattern of pollen expos re. "s5 abo t the en!ironment of the wor5place or school. This might incl de expos re to ordinary perennial allergens /eg, mites, mold, pet dander0 or ni' e occ pational allergens /eg, laboratory animals, animal prod cts, grains and organic materials, wood d st, latex, enzymes0.

E$$ects on quality o$ li$e

"n acc rate assessment of the morbidity of allergic rhinitis cannot be obtained witho t as5ing abo t the effects on the patientDs ' ality of life. 9pecific !alidated ' estionnaires are a!ailable to help determine effects on ' ality of life.[(, )] 6etermine the presence of symptoms s ch as fatig e, malaise, drowsiness /which may or may not be related to medication0, and headache. #n!estigate sleep ' ality and ability to f nction at wor5.

Physical
The physical examination sho ld foc s on the nose, b t examination of facial feat res, eyes, ears, oropharynx, nec5, l ngs, and s5in is also important. @oo5 for physical findings that may be consistent with a systemic disease that is associated with rhinitis.

'eneral $acial $eatures

E"llergic shinersE are dar5 circles aro nd the eyes and are related to !asodilation or nasal congestion.[2, (+] E>asal creaseE is a horizontal crease across the lower half of the bridge of the nose that is ca sed by repeated pward r bbing of the tip of the nose by the palm of the hand /ie, the Eallergic sal teE0.[2, (+]

(ose
The nasal examination is best accomplished with a nasal spec l m or an otoscope with nasal adapter. #n the specialistDs office, a rigid or flexible rhinolaryngoscope may be sed. The m cosa of the nasal t rbinates may be swollen /boggy0 and ha!e a pale, bl ish&gray color. 9ome patients may ha!e predominant erythema of the m cosa, which can also be obser!ed with rhinitis medicamentosa, infection, or !asomotor rhinitis. 3hile pale, boggy, bl e&gray m cosa is typical for allergic rhinitis, m cosal examination findings cannot definiti!ely disting ish between allergic and nonallergic ca ses of rhinitis. "ssess the character and ' antity of nasal m c s. Thin and watery secretions are fre' ently associated with allergic rhinitis, while thic5 and p r lent secretions are s ally associated with sin sitis: howe!er, thic5er, p r lent, colored m c s can also occ r with allergic rhinitis. .xamine the nasal sept m to loo5 for any de!iation or septal perforation, which may be present d e to chronic rhinitis, gran lomato s disease, cocaine ab se, prior s rgery, topical decongestant ab se, or, rarely, topical steroid o!er se. .xamine the nasal ca!ity for other masses s ch as polyps or t mors. ?olyps are firm gray masses that are often attached by a stal5, which may not be !isible. "fter spraying a topical decongestant, polyps do not shrin5, while the s rro nding nasal m cosa does shrin5.

Ears) eyes) and oropharyn

?erform otoscopy to loo5 for tympanic membrane retraction, air&fl id le!els, or b bbles. ?erforming pne matic otoscopy can be considered to loo5 for abnormal tympanic membrane mobility. These findings can be associated with allergic rhinitis, partic larly if e stachian t be dysf nction or secondary otitis media is present. ;c lar examination may re!eal findings of in=ection and swelling of the palpebral con= ncti!ae, with excess tear prod ction. 6ennie&7organ lines /prominent creases below the inferior eyelid0 are associated with allergic rhinitis.[(-] The term EcobblestoningE is sed to describe strea5s of lymphoid tiss e on the posterior pharynx, which is commonly obser!ed with allergic rhinitis. Tonsillar hypertrophy can also be obser!ed. 7aloccl sion /o!erbite0 and a high&arched palate can be obser!ed in patients who breathe from their mo ths excessi!ely.
[(2]

(eck

@oo5 for e!idence of lymphadenopathy or thyroid disease.

*ungs
@oo5 for the characteristic findings of asthma.

Skin
.!al ate for possible atopic dermatitis.

+ther
@oo5 for any e!idence of systemic diseases that may ca se rhinitis /eg, sarcoidosis, hypothyroidism, imm nodeficiency, ciliary dys5inesia syndrome, other connecti!e tiss e diseases0.

%auses
The ca ses of allergic rhinitis may differ depending on whether the symptoms are seasonal, perennial, or sporadicFepisodic. 9ome patients are sensiti!e to m ltiple allergens and can ha!e perennial allergic rhinitis with seasonal exacerbations. 3hile food allergy can ca se rhinitis, partic larly in children, it is rarely a ca se of allergic rhinitis in the absence of gastrointestinal or s5in symptoms. 9easonal allergic rhinitis is commonly ca sed by allergy to seasonal pollens and o tdoor molds.

Pollens ,tree) grass) and -eed.

Tree pollens, which !ary by geographic location, are typically present in high co nts d ring the spring, altho gh some species prod ce their pollens in the fall. Aommon tree families associated with allergic rhinitis incl de birch, oa5, maple, cedar, oli!e, and elm. Grass pollens also !ary by geographic location. 7ost of the common grass species are associated with allergic rhinitis, incl ding Hent c5y bl egrass, orchard, redtop, timothy, !ernal, meadow fesc e, Berm da, and perennial rye. " n mber of these grasses are cross&reacti!e, meaning that they ha!e similar antigenic str ct res /ie, proteins recognized by specific #g. in allergic sensitization0. Aonse' ently, a person who is allergic to one species is also li5ely to be sensiti!e to a n mber of other species. The grass pollens are most prominent from the late spring thro gh the fall b t can be present year&ro nd in warmer climates. 3eed pollens also !ary geographically. 7any of the weeds, s ch as short ragweed, which is a common ca se of allergic rhinitis in m ch of the <nited 9tates, are most prominent in the late s mmer and fall. ;ther weed pollens are present year&ro nd, partic larly in warmer climates. Aommon weeds associated with allergic rhinitis incl de short ragweed, western ragweed, pigweed, sage, m gwort, yellow doc5, sheep sorrel, .nglish plantain, lambDs ' arters, and R ssian thistle.

+utdoor molds
"tmospheric conditions can affect the growth and dispersion of a n mber of molds: therefore, their airborne pre!alence may !ary depending on climate and season. Ior example, Alternaria and Cladosporium are partic larly pre!alent in the dry and windy conditions of the Great ?lains states, where they grow on grasses and grains. Their dispersion often pea5s on s nny afternoons. They are !irt ally absent when snow is on the gro nd in winter, and they pea5 in the s mmer months and early fall.

Aspergillus and Penicillium can be fo nd both o tdoors and indoors /partic larly in h mid ho seholds0, with !ariable growth depending on the season or climate. Their spores can also be dispersed in dry conditions. ?erennial allergic rhinitis is typically ca sed by allergens within the home b t can also be ca sed by o tdoor allergens that are present year&ro nd.[(4] #n warmer climates, grass pollens can be present thro gho t the year. #n some climates, indi!id als may be symptomatic d e to trees and grasses in the warmer months and molds and weeds in the winter.

"ouse dust mites

#n the <nited 9tates, 2 ma=or ho se d st mite species are associated with allergic rhinitis. These are Dermatophagoides farinae and Dermatophagoides pteronyssinus.[((] These mites feed on organic material in ho seholds, partic larly the s5in that is shed from h mans and pets. They can be fo nd in carpets, pholstered f rnit re, pillows, mattresses, comforters, and st ffed toys. 3hile they thri!e in warmer temperat res and high h midity, they can be fo nd year&ro nd in many ho seholds. ;n the other hand, d st mites are rare in arid climates.

Pets
"llergy to indoor pets is a common ca se of perennial allergic rhinitis.[((, ()] Aat and dog allergies are enco ntered most commonly in allergy practice, altho gh allergy has been reported to occ r with most of the f rry animals and birds that are 5ept as indoor pets.

%ockroaches
3hile coc5roach allergy is most fre' ently considered a ca se of asthma, partic larly in the inner city, it can also ca se perennial allergic rhinitis in infested ho seholds.[(,, )$]

Rodents
Rodent infestation may be associated with allergic sensitization.[)1, )2, )(]

Sporadic allergic rhinitis causes

9poradic allergic rhinitis, intermittent brief episodes of allergic rhinitis, is ca sed by intermittent expos re to an allergen. ;ften, this is d e to pets or animals to which a person is not s ally exposed. 9poradic allergic rhinitis can also be d e to pollens, molds, or indoor allergens to which a person is not s ally exposed. 3hile allergy to specific foods can ca se rhinitis, an indi!id al affected by food allergy also s ally has some combination of gastrointestinal, s5in, and l ng in!ol!ement. #n this sit ation, the history findings s ally s ggest an association with a partic lar food. 3atery rhinorrhea occ rring shortly after eating may be !asomotor /and not allergic0 in nat re, mediated !ia the !ag s ner!e. This often is called g statory rhinitis.

+ccupational allergic rhinitis

;cc pational allergic rhinitis, which is ca sed by expos re to allergens in the wor5place, can be sporadic, seasonal, or perennial. ?eople who wor5 near animals /eg, !eterinarians, laboratory researchers, farm wor5ers0 might ha!e episodic symptoms when exposed to certain animals, daily symptoms while at the wor5place, or e!en contin al symptoms /which can persist in the e!enings and wee5ends with se!ere sensiti!ity d e to persistent late&phase inflammation0. 9ome wor5ers who may ha!e seasonal symptoms

incl de farmers, agric lt ral wor5ers /expos re to pollens, animals, mold spores, and grains0, and other o tdoor wor5ers. ;ther significant occ pational allergens that may ca se allergic rhinitis incl de wood d st, latex /d e to inhalation of powder from glo!es0, acid anhydrides, gl es, and psylli m /eg, n rsing home wor5ers who administer it as medication0.

/i$$erential /iagnoses

9in sitis, "c te 9in sitis, Ahronic

*aboratory Studies
Testing for reaction to specific allergens can be helpf l to confirm the diagnosis of allergic rhinitis and to determine specific allergic triggers. #f specific allergic triggers are 5nown, then appropriate a!oidance meas res can be recommended. #t is essential to 5now which allergens a patient is sensiti!e to in order to perform allergen imm notherapy /desensitization treatment0. To an extent, allergy testing pro!ides 5nowledge of the degree of sensiti!ity to a partic lar allergen. The most commonly sed methods of determining allergy to a partic lar s bstance are allergy s5in testing /testing for immediate hypersensiti!ity reactions0 and in !itro diagnostic tests, s ch as the radioallergosorbent test /R"9T0, which indirectly meas res the ' antity of specific #g. to a partic lar antigen. "llergy s5in tests /immediate hypersensiti!ity testing0 are an in !i!o method of determining immediate /#g.&mediated0 hypersensiti!ity to specific allergens. 9ensiti!ity to !irt ally all of the allergens that ca se allergic rhinitis /see Aa ses0 can be determined with s5in testing. By introd cing an extract of a s spected allergen perc taneo sly, an immediate /early&phase0 wheal&and& flare reaction can be prod ced. ?erc taneo s introd ction can be accomplished by placing a drop of extract on the s5in and scratching or pric5ing a needle thro gh the epidermis nder the drop. 6epending on the exact techni' e sed, this testing is referred to as scratch, pric5, or p nct re testing. The antigen in the extract binds to #g. on s5in mast cells, leading to the early&phase /immediate&type0 reaction, which res lts in the release of mediators s ch as histamine /see ?athophysiology0. This generally occ rs within 1+&2$ min tes. The released histamine ca ses the wheal&and&flare reaction /" central wheal is prod ced by infiltrating fl id, and s rro nding erythema is prod ced d e to !asodilation, with concomitant itching.0. The size of the wheal&and&flare reaction ro ghly correlates with the degree of sensiti!ity to the allergen. The extract can also be introd ced intradermally /ie, in=ected into the dermis with an intradermal [TB] needle0. 3ith this techni' e, the extract is allowed to contact the nderlying dermal tiss es, incl ding s5in mast cells. #ntradermal testing is approximately 1$$$&fold more sensiti!e than perc taneo s testing. This sho ld be performed with care by ' alified specialists. The rate of false&positi!e res lts may be high. #n !itro allergy tests, ie, R"9T, allow meas rement of the amo nt of specific #g. to indi!id al allergens in a sample of blood. The amo nt of specific #g. prod ced to a partic lar allergen approximately correlates with the allergic sensiti!ity to that s bstance. These tests allow determination of specific #g. to a n mber of different allergens from one blood sample, b t the sensiti!ity and specificity are not always as good as acc rate s5in testing /depending on the laboratory and assay sed for the R"9T0. "s with s5in testing, !irt ally all of the allergens that ca se allergic rhinitis /see Aa ses0 can be determined sing the R"9T, altho gh testing for some allergens is less well established compared to others. Testing e!ery patient for sensiti!ity to e!ery allergen 5nown is not practical. Therefore, select a limited n mber of allergens for testing /this applies to both s5in testing and R"9T0. 3hen selecting allergens, select from among the allergens that are present locally and are 5nown to ca se clinically significant allergic disease. " clinician who is specifically trained in allergy testing sho ld select allergens for testing.

#otal serum IgE

This is a meas rement of the total le!el of #g. in the blood /regardless of specificity0. 3hile patients with allergic rhinitis are more li5ely to ha!e an ele!ated total #g. le!el than the normal pop lation, this test is neither sensiti!e nor specific for allergic rhinitis. "s many as +$% of patients with allergic rhinitis ha!e normal le!els of total #g., while 2$% of nonaffected indi!id als can ha!e ele!ated total #g. le!els. Therefore, this test is generally not sed alone to establish the diagnosis of allergic rhinitis, b t the res lts can be helpf l in some cases when combined with other factors.

#otal blood eosinophil count

"s with the total ser m #g., an ele!ated eosinophil co nt s pports the diagnosis of allergic rhinitis, b t it is neither sensiti!e nor specific for the diagnosis. The res lts can sometimes be helpf l when combined with other factors.

Imaging Studies
Radiography
3hile radiographic st dies are not needed to establish the diagnosis of allergic rhinitis, they can be helpf l for e!al ating possible str ct ral abnormalities or to help detect complications or comorbid conditions, s ch as sin sitis or adenoid hypertrophy. " (&!iew sin s series /Aaldwell, 3aters, and lateral !iews0 can be helpf l in e!al ating for sin sitis of the maxillary, frontal, and sphenoid sin ses. The ethmoid sin ses are diffic lt to !is alize clearly on x&ray films. ?lain x&ray films can be helpf l for diagnosing ac te sin sitis, b t AT scanning of the sin ses is more sensiti!e and specific. Ior chronic sin sitis, plain x&ray films are often inconcl si!e, and AT scan is m ch preferred. " lateral !iew of the nec5 can be helpf l when e!al ating for soft tiss e abnormalities of the nasopharynx, s ch as adenoid hypertrophy.

%# scanning
Aoronal AT scan images of the sin ses can be !ery helpf l for e!al ating ac te or chronic sin sitis. #n partic lar, obstr ction of the ostiomeatal complex /a confl ence of drainage channels from the sin ses0 can be seen ' ite clearly. AT scanning may also help delineate polyps, t rbinate swelling, septal abnormalities /eg, de!iation0, and bony abnormalities /eg, concha b llosa0.

MRI
Ior e!al ating sin sitis, 7R# images are generally less helpf l than AT scan images, largely beca se the bony str ct res are not seen as clearly on 7R# images. Cowe!er, soft tiss es are !is alized ' ite well, ma5ing 7R# images helpf l for diagnosing malignancies of the pper airway.

+ther #ests

>asal cytology: " nasal smear can sometimes be helpf l for establishing the diagnosis of allergic rhinitis. " sample of secretions and cells is scraped from the s rface of the nasal m cosa sing a special sampling probe. 9ecretions that are blown from the nose are not ade' ate. The presence of eosinophils is consistent with allergic rhinitis b t also can be obser!ed with >"R.9. Res lts are neither sensiti!e nor specific for allergic rhinitis and sho ld not be sed excl si!ely for establishing the diagnosis.

Procedures

Rhinoscopy: 3hile not ro tinely indicated, pper airway endoscopy /rhinolaryngoscopy0 can be performed if a complication or comorbid condition may be present. #t can be helpf l for e!al ating str ct ral abnormalities /eg, polyps, adenoid hypertrophy, septal de!iation, masses, foreign bodies0 and chronic sin sitis /by !is alizing the areas of sin s drainage0. >asal pro!ocation /allergen challenge0 testing: This proced re is essentially a research tool and is rarely indicated in the ro tine e!al ation of allergic rhinitis. The possible allergen is inhaled or otherwise inoc lated into the nose. The patient can then be monitored for de!elopment of symptoms or prod ction of secretions, or ob=ecti!e meas rements of nasal congestion can be ta5en. 9ome consider this test the criterion standard test for the diagnosis of allergic rhinitis.[))] Cowe!er, it is not a practical test to perform ro tinely, and only an appropriately trained specialist sho ld perform this test.

"istologic Findings
9ee ;ther Tests.

Medical %are
The management of allergic rhinitis consists of ( ma=or categories of treatment, /10 en!ironmental control meas res and allergen a!oidance, /20 pharmacological management, and /(0 imm notherapy. .n!ironmental control meas res and allergen a!oidance in!ol!e both the a!oidance of 5nown allergens /s bstances to which the patient has #g.&mediated hypersensiti!ity0 and a!oidance of nonspecific, or irritant, triggers. Aonsider en!ironmental control meas res, when practical, in all cases of allergic rhinitis.[)+] Cowe!er, global en!ironmental control witho t identification of specific triggers is inappropriate.

Pollens and outdoor molds

Beca se of their widespread presence in the o tdoor air, pollens can be diffic lt to a!oid. Red ction of o tdoor expos re d ring the season in which a partic lar type of pollen is present can be somewhat helpf l. #n general, tree pollens are present in the spring, grass pollens from the late spring thro gh s mmer, and weed pollens from late s mmer thro gh fall, b t exceptions to these seasonal patterns exist /see Aa ses0. ?ollen co nts tend to be higher on dry, s nny, windy days. ; tdoor expos re can be limited d ring this time, b t this may not be reliable beca se pollen co nts can also be infl enced by a n mber of other factors. Heeping the windows and doors of the ho se and car closed as m ch as possible d ring the pollen season /with air conditioning, if necessary, on recirc lating mode0 can be helpf l. Ta5ing a shower after o tdoor expos re can be helpf l by remo!ing pollen that is st c5 to the hair and s5in. 6espite all of these meas res, patients who are allergic to pollens s ally contin e to be symptomatic d ring the pollen season and s ally re' ire some other form of management. "s with pollens, a!oidance of o tdoorFseasonal molds may be diffic lt.

Indoor allergens
6epending on the allergen, en!ironmental control meas res for indoor allergens can be ' ite helpf l. Ior d st mites, co!ering the mattress and pillows with impermeable co!ers helps red ce expos re.[)-] Bed linens sho ld be washed e!ery 2 wee5s in hot /at least 1($JI0 water to 5ill any mites present.[)2, )4] Thoro gh and efficient !ac m cleaning of carpets and r gs can help, b t, ltimately, carpeting sho ld be remo!ed. The carpet can be treated with one of a n mber of chemical agents that 5ill the mites or denat re the protein, b t

the efficacy of these agents does not appear to be dramatic. 6 st mites thri!e when indoor h midity is abo!e +$%, so deh midification, air conditioning, or both is helpf l.[),] #ndoor en!ironmental control meas res for mold allergy foc s on red ction of excessi!e h midity and remo!al of standing water. The en!ironmental control meas res for d st mites can also help red ce mold spores. Ior animal allergy, complete a!oidance is the best option. Ior patients who cannot, or who do not want to, completely a!oid an animal or pet, confinement of the animal to a noncarpeted room and 5eeping it entirely o t of the bedroom can be of some benefit.[+$] Aat allergen le!els in the home can be red ced with high& efficiency partic late air /C.?"0 filters and by bathing the cat e!ery wee5 /altho gh this may be impractical0. Aoc5roach extermination may be helpf l for cases of coc5roach sensiti!ity.

+ccupational allergens
"s with indoor allergens, a!oidance is the best meas re. 3hen this is not possible, a mas5 or respirator might be needed.

(onspeci$ic triggers
.xpos re to smo5e, strong perf mes and scents, f mes, rapid changes in temperat re, and o tdoor poll tion can be nonspecific triggers in patients with allergic rhinitis. Aonsider a!oidance of these sit ations or triggers if they seem to aggra!ate symptoms.

Pharmacotherapy
9ee 7edication.

Immunotherapy ,desensiti0ation.
" considerable body of clinical research has established the effecti!eness of high&dose allergy shots in red cing symptoms and medication re' irements.[+1] 9 ccess rates ha!e been demonstrated to be as high as 4$&,$% for certain allergens. #t is a long&term process: noticeable impro!ement is often not obser!ed for -& 12 months, and, if helpf l, therapy sho ld be contin ed for (&+ years. #mm notherapy is not witho t ris5 beca se se!ere systemic allergic reactions can sometimes occ r. Ior these reasons, caref lly consider the ris5s and benefits of imm notherapy in each patient and weigh the ris5s and benefits of imm notherapy against the ris5s and benefits of the other management options. 9 bling al imm notherapy /9@#T0 is c rrently increasing in se, partic larly in . rope. #t is not yet appro!ed in the <nited 9tates b t clinical trials are nderway, with plans for application for I6" appro!al. 6ifferences between 9@#T and s bc taneo s imm notherapy /9A#T0 need f rther st dy, incl ding research on differences in efficacy, d rability, and safety. Th s far, the data on 9@#T has foc sed largely on pollen allergens. 3hether 9@#T will be effecti!e for non&pollen allergens as well as pollens also needs additional st dy. " 2$12 meta&analysis of existing st dies of 9@#T for grass pollen reported that 9A#T is more effecti!e than 9@#T in controlling symptoms and in red cing the se of allergy medications in patients with seasonal allergic rhinocon= nti!itis to grass pollen.[+2]

#ndications: #mm notherapy may be considered more strongly with se!ere disease, poor response to other management options, and the presence of comorbid conditions or complications. #mm notherapy is often combined with pharmacotherapy and en!ironmental control. "dministration: "dminister imm notherapy with allergens to which the patient is 5nown to be sensiti!e and that are present in the patientDs en!ironment /and cannot be easily a!oided0. The !al e of imm notherapy for pollens, d st mites, and cats is well established.[+(, +), ++, +-, +2] The !al e of imm notherapy for dogs and mold is less well established.[+1, +(]

Aontraindication: " n mber of potential contraindications to imm notherapy exist and need to be considered. #mm notherapy sho ld only be performed by indi!id als who ha!e been appropriately trained, who instit te appropriate preca tions, and who are e' ipped for potential ad!erse e!ents.

Surgical %are
9 rgical care is not indicated for allergic rhinitis b t may be indicated for comorbid or complicating conditions, s ch as chronic sin sitis, se!ere septal de!iation /ca sing se!ere obstr ction0, nasal polyps, or other anatomical abnormalities. The !al e of t rbinectomy is not established.

%onsultations
3hile the general practitioner can effecti!ely treat most cases of straightforward allergic rhinitis, consider cons ltation with an allergist or imm nologist for se!ere disease, poor response to pharmacotherapy, and the presence of comorbid conditions or complications. Aons ltation with other specialists also might be needed for comorbid conditions or complications. Aons lt with an allergy specialist when identification or clarification of specific allergic triggers is needed, when detailed co nseling regarding en!ironmental control meas res is needed, when ' ality of life is significantly impaired, or when imm notherapy may be a consideration.

Medication Summary
7ost cases of allergic rhinitis respond to pharmacotherapy. ?atients with intermittent symptoms are often treated ade' ately with oral antihistamines, decongestants, or both as needed. Reg lar se of an intranasal steroid spray may be more appropriate for patients with chronic symptoms. 6aily se of an antihistamine, decongestant, or both can be considered either instead of or in addition to nasal steroids. The newer, second& generation /ie, nonsedating0 antihistamines are s ally preferable to a!oid sedation and other ad!erse effects associated with the older, first&generation antihistamines. ;c lar antihistamine drops /for eye symptoms0, intranasal antihistamine sprays, intranasal cromolyn, intranasal anticholinergic sprays, and short co rses of oral corticosteroids /reser!ed for se!ere, ac te episodes only0 may also pro!ide relief.

Second1generation antihistamines
%lass Summary
;ften referred to as the nonsedating antihistamines. They compete with histamine for histamine receptor type 1 /C10 receptor sites in the blood !essels, G# tract, and respiratory tract, which, in t rn, inhibits physiologic effects that histamine normally ind ces at the C1 receptor sites. 9ome do not appear to prod ce clinically significant sedation at s al doses, while others ha!e a low rate of sedation.[+4, +,, -$] ;ther ad!erse effects /eg, anticholinergic symptoms0 are generally not obser!ed. "ll are efficacio s in controlling symptoms of allergic rhinitis /ie, sneezing, rhinorrhea, itching0 b t do not significantly impro!e nasal congestion. Ior this reason, some second&generation antihistamines are a!ailable as combination preparations containing a decongestant. They are often preferred for first&line therapy of allergic rhinitis, especially for seasonal or episodic symptoms, beca se of their excellent efficacy and safety profile. They can be sed prn or daily. Topical azelastine and olopatadine are nasal sprays antihistamines that effecti!ely red ce sneezing, itching, and rhinorrhea b t also effecti!ely red ces congestion.[-1, -2, -(] <sed twice per day, especially when combined with a topical nasal corticosteroid, azelastine is effecti!e at managing both allergic and nonallergic rhinitis. The second&generation oral antihistamines c rrently a!ailable in the <nited 9tates are cetirizine, le!ocetirizine, desloratadine, fexofenadine, and loratadine. " limited n mber of st dies comparing these

agents s ggest no ma=or differences in efficacy. ;nly cetirizine ca ses drowsiness more fre' ently than placebo.[-$] Aetirizine, fexofenadine, and loratadine are also a!ailable in decongestant&containing preparations. 8iew f ll dr g information

%etiri0ine ,2yrtec.

Aompetes with histamine for C1 receptors in G# tract, blood !essels, and respiratory tract, red cing hypersensiti!ity reactions. ;nce&daily dosing is con!enient. Bedtime dosing may be sef l if sedation is a problem. 8iew f ll dr g information

*e&ocetiri0ine ,3y0al.

Cistamine1&receptor antagonist. "cti!e enantiomer of cetirizine. ?ea5 plasma le!els reached within 1 h and half&life is abo t 4 h. "!ailable as a +&mg brea5able /scored0 tab. #ndicated for seasonal and perennial allergic rhinitis. 8iew f ll dr g information

Pseudoephedrine/$e o$enadine ,!llegra.

9econd&generation agent with a rate of sedation not significantly different from that of placebo. Aompetes with histamine for C1 receptors in G# tract, blood !essels, and respiratory tract, red cing hypersensiti!ity reactions. "!ailable in 'd and bid preparations. 8iew f ll dr g information

*oratadine ,%laritin.

9electi!ely inhibits peripheral histamine C1 receptors. Tolerated well, with rate of sedation not significantly different from placebo. 8iew f ll dr g information

Pseudoephedrine/loratadine ,%laritin1/ 45 "our) %laritin1/ 64 "our.

Tolerated well, with rate of sedation not significantly different from that of placebo. 9ome patients may notice anxiety or insomnia owing to pse doephedrine component. 8iew f ll dr g information

Pseudoephedrine/$e o$enadine ,!llegra1/.

Iexofenadine is a nonsedating second&generation medication with fewer ad!erse effects than first&generation medications. Aompetes with histamine for C1 receptors on G# tract, blood !essels, and respiratory tract, red cing hypersensiti!ity reactions. 6oes not sedate. ?se doephedrine stim lates !asoconstriction by directly acti!ating alpha&adrenergic receptors of the respiratory m cosa. #nd ces also bronchial relaxation and increases heart rate and contractility by stim lating beta&adrenergic receptors. 8iew f ll dr g information

/esloratadine ,%larine .

Relie!es nasal congestion and systemic effects of seasonal allergy. @ong&acting tricyclic histamine antagonist selecti!e for C1&receptor. 7a=or metabolite of loratadine, which after ingestion is extensi!ely metabolized to acti!e metabolite (&hydroxydesloratadine.

*eukotriene receptor antagonists

%lass Summary
"lternati!e to oral antihistamine to treat allergic rhinitis. ;ne of the le 5otriene receptor antagonists, montel 5ast /9ing lair0, has been appro!ed in the <nited 9tates for treatment of seasonal and perennial allergic rhinitis.[-), -+, --] 3hen sed as single agent, prod ces modest impro!ement in allergic rhinitis symptoms.[-2] 8iew f ll dr g information

Montelukast ,Singulair.

9electi!e le 5otriene receptor antagonist that inhibits the cysteinyl le 5otriene /Ays@T 10 receptor. 9electi!ely pre!ents action of le 5otrienes released by mast cells and eosinophils. 3hen sed as a single agent, has been shown to res lt in a red ction of seasonal allergic rhinitis symptoms, similar in degree to that of loratadine.

First1generation antihistamines
%lass Summary
The older, first&generation C1 antagonists /eg, diphenhydramine, hydroxyzine0 are effecti!e in red cing most symptoms of allergic rhinitis, b t they prod ce a n mber of ad!erse effects /eg, drowsiness, anticholinergic effects0. They can be sed prn, b t ad!erse effects may limit their sef lness when ta5en on a daily basis. 9ome patients tolerate the ad!erse effects with prolonged se, b t they may experience cogniti!e impairment, and dri!ing s5ills may be affected.[-4, -,, 2$, 21, 22] "dministration at bedtime may help with drowsiness, b t sedation and impairment of cognition may contin e ntil the next day.

The second&generation antihistamines are nonsedating in most patients and are preferred as first&line therapy. Iew ad!erse effects are reported /cetirizine may ca se drowsiness in as many as 1$% of patients0: therefore, many specialists prefer the se of second&generation agents for allergic rhinitis. Aa tion patients ta5ing medications with sedati!e effects abo t dri!ing and operating hea!y machinery.[21, 22] 8iew f ll dr g information

%hlorpheniramine ,%hlor1#rimeton.

Iirst&generation agent, a!ailable ;TA in the <nited 9tates. ;ne of the safest antihistamines to se d ring pregnancy. Aompetes with histamine on C1&receptor sites on effector cells in blood !essels and respiratory tract. 8iew f ll dr g information

/iphenhydramine ,Benadryl) Benylin.

Aommon first&generation agent a!ailable ;TA in the <nited 9tates. Aompetes with histamine on C1& receptor sites on effector cells in blood !essels and respiratory tract. Ior symptomatic relief of symptoms ca sed by release of histamine in allergic reactions. 8iew f ll dr g information

"ydro y0ine ,!tara ) 7istaril) 7ista0ine.

.ffecti!e first&generation agent b t fre' ently prod ces sedation. Aonsiderable sedation may occ r with higher doses. "ntagonizes C1 receptors in periphery. 7ay s ppress histamine acti!ity in s bcortical region of A>9.

/econgestants
%lass Summary
9tim late !asoconstriction by directly acti!ating alpha&adrenergic receptors of the respiratory m cosa. ?se doephedrine prod ces wea5 bronchial relaxation / nli5e epinephrine or ephedrine0 and is not effecti!e for treating asthma. #ncreases heart rate and contractility by stim lating beta&adrenergic receptors. <sed alone or in combination with antihistamines to treat nasal congestion. "nxiety and insomnia may occ r. .xpectorants may thin and loosen secretions, altho gh experimental e!idence for their efficacy is limited. > mero s preparations are a!ailable containing combinations of !ario s decongestants, expectorants, or antihistamines. "lternati!ely, a separate decongestant and antihistamine can be administered to allow for indi!id al dose titration of each dr g. 8iew f ll dr g information

Pseudoephedrine ,Suda$ed.

9tim lates !asoconstriction by directly acti!ating alpha&adrenergic receptors of the respiratory m cosa. "!ailable ;TA in the <nited 9tates. Celpf l for nasal and sin s congestion.

(asal corticosteroids
%lass Summary
>asal steroid sprays are highly efficacio s in treating allergic rhinitis.[2(, 2), 2+, 2-, 22] They control the ) ma=or symptoms of rhinitis /ie, sneezing, itching, rhinorrhea, congestion0. They are effecti!e as monotherapy, altho gh they do not significantly affect oc lar symptoms. 9t dies ha!e shown nasal steroids to be more effecti!e than monotherapy with nasal cromolyn or antihistamines.[2), 2+] Greater benefit may occ r when nasal steroids are sed with other classes of medication. They are safe to se and not associated with significant systemic ad!erse effects in ad lts /this may also be tr e for children, b t the data are less clear0. @ocal ad!erse effects are limited to minor irritation or nasal bleeding, which resol!e with temporary discontin ation of the medication. >asal septal perforations are rarely reported and are less common with the newer corticosteroids and deli!ery systems. 9afety d ring pregnancy has not been established: howe!er, clinical experience s ggests nasal corticosteroids /partic larly beclomethasone, which has most experience in se0 are not associated with ad!erse fetal effects. The nasal steroids can be sed prn, b t seem to be maximally effecti!e when sed on a daily basis as maintenance therapy. They may also be helpf l for !asomotor rhinitis or mixed rhinitis /a combination of !asomotor and allergic rhinitis0 and can help to control nasal polyps. 8iew f ll dr g information

Mometasone ,(asone .

>asal spray: may decrease n mber and acti!ity of inflammatory cells, res lting in decreased nasal inflammation.[24] 6emonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic acti!ity in preclinical trials. 6ecreases rhino!ir s&ind ced p&reg lation in respiratory epithelial cells and mod late pretranscriptional mechanisms. Red ces intraepithelial eosinophilia and inflammatory cell infiltration /eg, eosinophils, lymphocytes, monocytes, ne trophils, plasma cells0. 8iew f ll dr g information

Beclomethasone ,Beconase !8) 8(!S*.

#ntranasal steroid. 7ost reliable d ring pregnancy, as it has been in se for many years with no significant problems obser!ed. 7ay decrease n mber and acti!ity of inflammatory cells, res lting in decreased nasal inflammation. K>"9@ a!ailable as intranasal dry powder. 8iew f ll dr g information

Budesonide inhaled ,Rhinocort !qua.

>ewer topical steroid considered efficacio s and safe for allergic rhinitis. 7ay decrease n mber and acti!ity of inflammatory cells, res lting in decreased nasal inflammation.

8iew f ll dr g information

Fluticasone ,Flonase.

>ewer topical steroid considered efficacio s and safe for allergic rhinitis. 7ay decrease n mber and acti!ity of inflammatory cells, res lting in decreased nasal inflammation. 8iew f ll dr g information

%iclesonide ,+mnaris.

Aorticosteroid nasal spray indicated for allergic rhinitis. ?rodr g that is enzymatically hydrolyzed to pharmacologic acti!e metabolite A21&desisob tyryl&ciclesonide following intranasal application. Aorticosteroids ha!e a wide range of effects on m ltiple cell types /eg, mast cells, eosinophils, ne trophils, macrophages, lymphocytes0 and mediators /eg, histamines, eicosanoids, le 5otrienes, cyto5ines0 in!ol!ed in allergic inflammation. .ach spray deli!ers +$ mcg. 8iew f ll dr g information

Fluticasone $uroate ,7eramyst.

#ntranasal corticosteroid. #ndicated for seasonal and perennial allergic rhinitis. Relie!es nasal symptoms associated with allergic rhinitis. Cas also demonstrated impro!ement in allergic eye symptoms. Aontains 22.+ mcgFspray. 8iew f ll dr g information

#riamcinolone ,(asacort !8.

#n=ectable corticosteroid sed to treat inflammatory dermatosis responsi!e to steroids: decreases inflammation by s ppressing migration of polymorphon clear le 5ocytes and re!ersing capillary permeability.

Intranasal antihistamines
%lass Summary
"lternati!e to oral antihistamines to treat allergic rhinitis. 8iew f ll dr g information

!0elastine ,!stelin.

<se prn or on a reg lar basis. <se alone or in combination with other medications. <nli5e oral antihistamines, has some effect on nasal congestion. Celpf l for !asomotor rhinitis. 9ome patients experience a bitter taste. 9ystemic absorption may occ r, res lting in sedation /reported in approximately 11% of patients0. 8iew f ll dr g information

+lopatadine intranasal ,Patanase.

Ior relief of symptoms of seasonal allergic rhinitis. Before initial se, prime prod ct by releasing + sprays or ntil fine mist appears. 3hen prod ct has not been sed for more than 2 days, re&prime by releasing 2 sprays. "!oid spraying into eyes.

Intranasal cromolyns
%lass Summary
?rod ce mast cell stabilization and antiallergic effects that inhibit degran lation of mast cells.[2,] Ca!e no direct anti&inflammatory or antihistaminic effects. .ffecti!e for prophylaxis. 7ay be sed = st before expos re to a 5nown allergen /eg, animal, occ pational0. Begin treatment 1&2 w5 before pollen season and contin e daily to pre!ent seasonal allergic rhinitis. .ffect is modest compared with that of intranasal corticosteroids. .xcellent safety profile and are tho ght to be safe for se in children and pregnancy. 8iew f ll dr g information

%romolyn sodium ,(asalcrom.

"!ailable ;TA in the <nited 9tates. <sed daily for seasonal or perennial allergic rhinitis. 9ignificant effect may not be obser!ed for )&2 d. Ior patients with isolated and predictable periods of expos re /eg, animal allergy, occ pational allergy0, administer = st before expos re. Generally less effecti!e than nasal corticosteroids. ?rotecti!e effect lasts )&4 h, fre' ent dosing is necessary.

Intranasal anticholinergic agents

%lass Summary
<sed for red cing rhinorrhea in patients with allergic or !asomotor rhinitis. >o significant effect on other symptoms. Aan be sed alone or in con= nction with other medications. #n the <nited 9tates, ipratropi m bromide /"tro!ent >asal 9pray0 is a!ailable in a concentration of $.$(% /officially indicated for treatment of allergic and nonallergic rhinitis0 and $.$-% /officially indicated for the treatment of rhinorrhea associated with common cold0. The $.$(% strength is disc ssed. 8iew f ll dr g information

Ipratropium ,!tro&ent (asal Spray 9:9;<.

Ahemically related to atropine. Cas anti&secretory properties, and when applied locally, inhibits secretions from sero s and serom co s glands lining the nasal m cosa. ?oor absorption by nasal m cosa: therefore, not associated with ad!erse systemic effects. @ocal ad!erse effects /eg, dryness, epistaxis, irritation0 may occ r.

Further +utpatient %are

#mm notherapy /desensitization0 is a long&term process: noticeable impro!ement is often not obser!ed for -&12 months, and, if helpf l, therapy sho ld be contin ed for (&+ years.

/eterrence/Pre&ention

?atients sho ld a!oid factors that may ca se or exacerbate allergic rhinitis /see 7edical Aare0.

%omplications

?ossible complications incl de otitis media, e stachian t be dysf nction, ac te sin sitis, and chronic sin sitis.[)]

Patient Education

.d cate patients on en!ironmental control meas res, which in!ol!e both the a!oidance of 5nown allergens /s bstances to which the patient has #g.&mediated hypersensiti!ity0 and the a!oidance of nonspecific, or irritant, triggers /see 7edical Aare0. Ior excellent patient ed cation reso rces !isit e7edicineDs "llergy Aenter. "lso, see e7edicineDs patient ed cation articles Cay Ie!er, #ndoor "llergens, and "llergy 9hots.