Allergic inflammation of the nasal mucosa caused by an IgE-mediated reaction to environmental allergens (e.g., pollen, dust mites), leading to sneezing, nasal congestion, and rhinorrhea.
Very common (~10–30% of the population) and often coexists with other atopic conditions like asthma (unified airway concept). Often trivialized as 'hay fever', it can still cause significant quality-of-life and productivity loss (sleep disruption, missed work/school), and ~1 in 10 patients with allergic rhinitis develop asthma.
Episodes of sneezing, clear rhinorrhea, nasal congestion, and itchy nose/eyes (often with allergic conjunctivitis). Symptoms may be intermittent or persistent, depending on exposure.
Seasonal pattern (hay fever): symptoms flare during specific pollen seasons (spring trees, summer grasses, fall weeds). Perennial pattern: year-round mild symptoms triggered by indoor allergens like dust mites, pet dander, mold, or cockroaches.
Physical exam: swollen, boggy (pale bluish) nasal turbinates with clear discharge. May see allergic shiners (dark circles under eyes) and a transverse nasal crease from frequent nose rubbing (allergic salute). Patients often have other atopic diseases (asthma, eczema).
Differentiate allergic from other rhinitis: allergies usually have itching and sneezing with identifiable triggers and positive tests, whereas viral rhinitis (common cold) is acute (<10 days) with fever, and vasomotor rhinitis has irritant triggers and no itching.
Diagnosis is typically clinical. If history and exam strongly suggest AR, start empiric therapy without extensive testing. If patient doesn't improve or diagnosis is unclear, perform allergy testing: skin prick tests (preferred for quick results and sensitivity) or serum IgE immunoassays.
Always inspect the nasal cavity for polyps or anomalies. Multiple polyps in a child → think cystic fibrosis. Unilateral congestion or bleeding is not typical for allergies – consider a foreign body or tumor.
Imaging (sinus X-ray/CT) isn't routinely indicated for uncomplicated AR. Reserve imaging for suspected sinusitis or structural issues.
Condition
Distinguishing Feature
Viral rhinitis (common cold)
acute <10-day URI with fever, malaise, purulent discharge (if bacterial superinfection)
Facial pain, headaches, and purulent nasal drainage; often post-viral or in setting of uncontrolled allergic rhinitis
Allergen avoidance: reduce exposure (use dust mite–proof covers, keep pets out of bedroom, monitor pollen counts and keep windows closed during high pollen days).
First-line: daily intranasal corticosteroid spray (e.g., fluticasone) for maximal relief of nasal inflammation and congestion.
Adjuncts: oral or intranasal antihistamines (e.g., cetirizine or azelastine) for sneezing/itching; decongestants (pseudoephedrine, or oxymetazoline <3 days) for congestion; add montelukast (leukotriene modifier) in refractory cases or if coexisting asthma.
Immunotherapy (allergy shots or SLIT tablets) for severe or refractory cases – desensitizes the immune system to specific allergens over time and can markedly reduce symptoms.
Kids with allergies often develop a horizontal nasal crease from the habitual allergic salute (frequently rubbing the itchy nose upward).
Pale, boggy nasal mucosa = allergy (IgE) rhinitis, whereas red, inflamed nasal mucosa is more suggestive of viral infection.
Atopic triad: patients with allergic rhinitis often also have asthma and eczema (atopic dermatitis).
Nasal polyps: in children, strongly consider cystic fibrosis if multiple polyps are present; in adults, nasal polyps + asthma + aspirin sensitivity suggests aspirin-exacerbated respiratory disease.
Unilateral symptoms (one-sided obstruction, chronic bloody discharge, foul odor) are atypical for allergies – evaluate for a structural lesion or foreign body.
Chronic uncontrolled AR can lead to sinusitis (e.g., facial pain, purulent discharge) or otitis media due to eustachian tube dysfunction. New fever or sinus tenderness should prompt evaluation for infection.
Recurrent sneezing, clear runny nose, and nasal congestion especially with specific exposures or seasons → suspect allergic rhinitis.
Evaluate history & exam: note any seasonal patterns, identifiable triggers, or personal/family history of atopy (asthma, eczema). On exam, look for pale boggy turbinates or allergic shiners. Rule out viral URI (short duration, fever) and non-allergic rhinitis (irritant triggers, no itching).
If AR is likely, begin empiric management: intranasal steroid spray and allergen avoidance measures. Improvement of symptoms with therapy supports the diagnosis.
If poor response or uncertain diagnosis, perform allergy testing: skin prick testing (immediate results, high sensitivity) or serum allergen-specific IgE levels.
Use results to guide treatment: reinforce avoidance of identified allergens; consider allergen immunotherapy for long-term relief in moderate-severe cases; and monitor for complications (sinusitis, asthma) requiring additional care.
Young adult with watery eyes, repetitive sneezing each spring, and pale boggy nasal turbinates → seasonal allergic rhinitis (pollen allergy).
Child with year-round stuffy nose, mouth breathing, allergic shiners, and a nasal crease on exam → perennial allergic rhinitis (dust mite allergy).
Case 1
A 19-year-old college student with a history of eczema has 'cold-like' symptoms every spring and fall.
Illustration of allergic rhinitis (nasal mucosal inflammation due to allergens).
