Allergic Rhinitis Guidelines

Allergic rhinitis is allergic inflammation of nasal airways. The Ministry of Health and Family Welfare, Government of India, has released Standard Treatment Guidelines for the Diagnosis and Treatment of Allergic Rhinitis. Following are its major recommendations.

When to Suspect/Recognize

Introduction: When a foreign protein (allergen) is inhaled by a previously sensitized individual, a reaction between the allergen and the antibodies takes place on the nasal mucosa. This inflammatory reaction presents as itching in the nose, sneezing, and nose block. Allergic rhinitis may be seasonal or perennial. It is found to coexist with bronchial asthma, nasal polyps, sinusitis, adenoid hypertrophy, Eustachian tube dysfunction, and otitis media.

Incidence in Our Country

No exact data are available in our country.

Differential Diagnosis

The diagnosis is clinical. The differential diagnosis would include:

• Vasomotor rhinitis
• Hormonal rhinitis in pregnancy, hypothyroidism, etc.
• Nasal block due to deviated nasal septum
• Immotile cilia syndrome
• Specific rhinitis caused by granulomatous diseases like Wegener's and sarcoidosis.

Prevention and Counselling

Allergic rhinitis can be prevented by environmental control measures and allergen avoidance by reducing outdoor exposure during pollen season. For indoor allergens, prevention would include:

• Covering mattresses with impermeable covers
• Washing of bed linen every two weeks in hot water
• Avoidance of exposure to pets

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

At Secondary Hospital/Non-Metro Situation

Clinical Diagnosis

The diagnosis is essentially based on history. The basic evaluation should include:

• Complete ENT examination
• Nasal examination for condition of nasal mucosa and polyps if any
• Evaluation of respiratory system to exclude asthma

Investigations

• Complete blood count
• Absolute eosinophil count
• X-Ray of paranasal sinuses
• Other investigations based on associated conditions

Treatment

Out Patient

• Nasal decongestants: Avil, Cetrizine, Fexofenadine, etc.
• Nasal steroid sprays: Fluticasone, Mometasone, Budesonide, etc.
• Oral steroids: for refractory cases and those with asthma.

Day Care

Nil

Inpatient

• Surgical procedures like septoplasty, adenoidectomy with or without grommet insertion, polypectomy may be required.
• Management of comorbidities.

Referral Criteria

• Extensive nasal polyposis
• Associated complications not manageable in the centre.

At Tertiary Hospital/Metro Situation

Clinical Diagnosis

Nasal examination is complemented with nasal endoscopy under local anaesthesia.

Investigations

• Allergy skin testing
• IgE estimation if available
• CT Scan of paranasal sinuses

Treatment

Out Patient

• Antihistamines, nasal steroid sprays, leukotriene antagonists, and oral steroids.

Day Care/Inpatient

• Septoplasty
• Endoscopic sinus surgery
• Management of comorbidities.

Referral Criteria

• Inadequate facilities for any of the above.

Deviated Nasal Septum

The above guideline has been developed by the Ministry of Health & Family Welfare, Govt. of India. Group Head Coordinator of Development Team: Dr. J M Hans, Ex-HOD Dept. of Otorhinolaryngology, Dr. RML Hospital, New Delhi.