Reference: April 2024 | Issue 4 | Vol 10 | Page 17
Rhinitis refers to inflammation of the nasal passages which results in symptoms such as sneezing, nasal congestion, and blockage. Rhinitis that is caused by an allergic trigger is known as allergic rhinitis (AR). AR accounts for about 75 per cent of rhinitis cases, while the remaining 25 per cent are caused by non-allergic rhinitis.
It is estimated that over 80 per cent of people with asthma have AR – which is itself also a risk factor for asthma, with 10-to-40 per cent of people who have AR also having asthma. AR is more likely to develop initially, with asthma developing later.
Therefore, people with AR should be assessed for asthma due to the increased risk of developing the disorder. Similarly, patients with persistent asthma should be assessed for AR. As spring and summer emerge, this can be a challenging time as various pollen levels start to increase.
AR and asthma often co-exist as ‘united airway disease’ or ‘one airway disease’. Both conditions are chronic inflammatory diseases affecting the upper and lower airways. Both can be triggered by allergic or non-allergic triggers and may present as several phenotypes.
Assessment and management of AR and asthma should be jointly carried out, leading to better control of both conditions. Non-allergic rhinitis can be caused by structural nasal problems such as septal deviation and through exposure to environmental pollution, chlorinated pools, and even fragrances. Hormonal changes that occur during puberty, pregnancy, and menopause can also act as triggers.
Pathophysiology of AR
Phase one, or the early allergic response, occurs when an atopic individual is first exposed to the allergen. The allergen is taken up by antigen-presenting cells – dendritic cells in particular – and processed into peptide fragments. The dendritic cell moves through the lymphatic system towards the lymph node where it presents this peptide fragment to a naive T-lymphocyte. The naive T-cell becomes activated to express cytokines, such as interleukin (IL) 4, which drive the differentiation of these cells to T-helper 2 (Th2) cells.
An environment rich in cytokines IL-4 and IL-13 is created and is responsible for inducing immunoglobulin E (IgE) production from B-lymphocytes. In addition, IL-5 is responsible for eosinophil recruitment and activation. The cytokine profile is vital as it determines a Th2 immune response.
In the meantime, T-cell dependent activation of B-cells stimulates further cytokine production, particularly IL-4, and promotes irreversible immunoglobulin class switching to allergen specific IgE antibodies. These antibodies will attach to mast cells and basophils. This is referred to as primary sensitisation. In addition, memory B-cells are generated and a small number of memory T-cells remain.
Phase two, or the late allergic response, occurs on subsequent exposure to this allergen. The allergen binds to the sensitised mast cells, triggering degranulation of the mast cell, and releasing pre-stored and newly synthesised inflammatory mediators such as histamine, leukotrienes, and prostaglandins. These contribute to vascular permeability, eosinophil infiltration, and increased mucus production.
With repetitive allergen exposure, nasal priming occurs. This appears to cause an accumulation of effector cells in the nasal mucosa and results in a hyper-responsiveness to the allergen and prolongation of symptoms. In addition, there appears to be a neural component to this hyper-responsiveness. Changes to the sensory nerves of the nose have been demonstrated in those with AR. In addition, innate immune responses can be initiated in the nasal epithelium by allergens directly compromising the epithelium and resulting in the release of alarmins, such as IL-33, which further potentiates the inflammatory response.

FIGURE 1: Symptom chart
Drug Therapy Options | Symptoms |
---|---|
Oral H1 antagonists | Sneezing, rhinorrhoea, nasal itch, eye symptoms |
Intranasal H1 antagonist | Sneezing, rhinorrhoea, nasal itch |
Intraocular H1 antagonist | Eye symptoms |
Intraocular cromones | Eye symptoms |
Intranasal decongestants | Nasal blockage |
Oral decongestants | Nasal blockage |
Leukotriene receptor antagonists | Rhinorrhoea, nasal blockage, eye symptoms |
Intranasal corticosteroids | All symptoms |
Oral corticosteroids | All symptoms |
Immunotherapy | All symptoms |
TABLE 1: Pharmacological options for managing AR

FIGURE 2: Classification of AR¹
Symptoms of AR
Typical symptoms of seasonal (hayfever) and perennial AR are:
- Sneezing;
- Itchy, blocked, or runny nose;
- Red, itchy, or watery eyes;
- Itchy throat, inner ear, or mouth;
- Postnasal drip;
- Headaches;
- Loss of concentration and generally feeling unwell;
- Reduced sensation of taste and smell.
Patients may experience all or some of the above. Symptoms of AR may also be confused with symptoms of Covid-19 and other illnesses. Figure 1 illustrates the differences between AR, asthma, chronic obstructive pulmonary disease (COPD), Covid-19, the common cold, and influenza.
Classification of AR
In 2019, the classification of seasonal and perennial rhinitis was changed to ‘intermittent’ and ‘persistent’ rhinitis. Intermittent rhinitis occurs less than four days per week or for less than four weeks. Persistent rhinitis lasts more than four days and longer than four weeks. Both intermittent and persistent AR can be
mild, moderate, or severe (Figure 2).
Pharmacological interventions
There are several treatment options available to the patient, and a combination of these options may be required for optimal relief of symptoms. These are outlined in Table 1.
Saline douching/nasal irrigation should also be encouraged and is available either as a saline rinse or saline spray. Saline rinsing involves high volume at a low pressure, whereas saline spray is a low volume delivered at high pressure. The advantages of saline douching include:
- Direct cleansing;
- Removal of mucous and inflammatory mediators;
- Reduces bacterial burden;
- Reduces mucus thickness;
- Improves mucocillary function by increasing ciliary beat frequency.
Directions for using a nasal spray include:
- If the nasal spray is being used for the first time, priming is required;
- Blow the nose prior to use;
- Tilt the head forward;
- Use right hand to left nostril, left hand to right nostril;
- Aim the nozzle of the spray away from the nasal septum and towards the outer aspect of the nose;
- Avoid sniffing deeply;
- If the nasal spray can be tasted, the patient is probably sniffing too deeply;
- Repeat if a second dose is required;
- Repeat the procedure on the other nostril;
- Wipe the nozzle of the spray with a tissue before replacing the cap.
Smoking and vaping cessation should be encouraged at every opportunity. Smoking and vaping increase the likelihood of chronic nasal symptoms and may be associated with the development of nasal polyposis. Passive smoking and environmental exposure also increase the likelihood of chronic nasal symptoms and nasal polyposis.
Mild intermittent AR treatment options include oral and nasal decongestants which can be used as a rescue medication. These medications will reduce nasal congestion and should be used for no longer than seven days, and avoided in pregnancy and breastfeeding. Oral H1 antagonists block the physiological effects from mast cell-derived histamine. Second generation antihistamines are preferred due to their less sedating effect and are available over-the-counter. Antihistamines are also available intranasally or intraocularly.
Intranasal corticosteroid (INCS) is the first-line treatment for moderate-to-severe intermittent and persistent AR. These medications are used once or twice daily to each nostril and good technique is essential. Patient technique should be checked at every opportunity. If the nasal cavity is very obstructed, a nasal spray may not be effective. Nasal drops may be more effective in this scenario. Nasal spray technique can be viewed on Asthma + Lung UK at: www.youtube.com/watch?v=S31maomo1xQ.
The efficacy of INCS is not improved when used with oral corticosteroids. Figure 3 provides a stepwise approach to the management of AR.
Sublingual immunotherapy (SLIT)/allergen immunotherapy (AIT) is now recommended by the Global Initiative for Asthma (GINA) as a treatment option for patients with asthma who are sensitised and have AR. Immunotherapy is also recommended by Allergic Rhinitis and its Impact on Asthma (ARIA) – an integrated part of EURFOREA (European Forum for Research and Education in Allergy and Airway Diseases) – for patients with AR who do not achieve an optimal response from oral H1 or INCS therapies.
There are three SLIT/AIT products available in Ireland to treat allergies – grass pollen, tree pollen, and house dust mite allergy. A limited number of these medications are available on the General Medical Service Scheme and can be prescribed by GPs.
Endonasal phototherapy
Endonasal phototherapy has an immunosuppressive effect by inhibiting allergen-induced histamine released from mast cells. It also induces apoptosis in the T-lymphocytes and eosinophils. The procedure directs a combination of ultraviolet (UV) B, UVA, and visible light into the nasal cavity. Endonasal phototherapy is generally well tolerated and effective, and is a treatment option when pharmacological treatment is insufficient or contraindicated.

FIGURE 3: AR treatment algorithm2,3
Surgical intervention
It is considered that AR is a medical condition that requires medical intervention. However, if symptoms are unilateral or if there is a septal deviation, nasal polyps, or a tumour present, surgery should be considered. Patients will still need to have an AR plan in place post-surgical intervention.
Lifestyle interventions
- Keep windows closed at night or when the pollen count is high.
- Monitor the pollen levels on www.met.ie/forecasts/pollen and minimise time spent outdoors when the pollen count is high.
- Apply vaseline around nostrils when outdoors to trap pollen.
- Wear wraparound sunglasses to minimise levels of pollen irritating the eyes. Splash the eyes with cold water to help flush out pollen and soothe and cool the eyes.
- Shower, wash your hair, and change clothes if you have been outdoors for an extended period of time.
- Exercise in the morning rather than the evening when there are higher rates of pollen falling.
- Avoid drying clothes outdoors and shake clothes outside before bringing them inside, particularly bedclothes.
- Minimise contact with pets that have been outdoors and are likely to carry pollen.

FIGURE 4: The allergic march in children
Special considerations in AR
Students
Walker et al showed that AR can have a significant impact on exam performance and results, with students dropping a grade in the state exams compared with their mock exams.4 Students should be advised to have their AR assessed and treatment started well in advance of sitting exams, usually around Easter time. Some other useful tips during exam time include:
- Use non-sedating antihistamines;
- Students should tell the adjudicator if their seasonal AR is bothering them;
- Splash the eyes with cold water before going into the exam room;
- Try not to sit near an open window;
- Keep a supply of tissues and effective, quick-acting treatments close at hand just in case.
Children under four years
Figure 4 illustrates the typical age of onset of allergies in children. Outdoor allergens are unusual in children under two years of age. Type 2 sub-endotype IL-4/IL-13 are associated with AR in children. IL-5 is associated with asthma. Treatment of children under four should focus on allergen avoidance and saline spray. Cetirizine is the oral H1 antagonist of choice.
Cetirizine is licensed from two years, but good safety is reported from six months of age. For moderate-to-severe persistent AR, intranasal corticosteroids such as fluticasone or mometasone should be considered first-line treatment. Long-term follow-up studies suggest no growth retardation if used as a once-daily dose. Caution should be taken in children who are also using inhaled or topical corticosteroids for asthma or dermatitis. In children with resistant symptoms and those with co-existing asthma, leukotriene receptor antagonists should be considered. Parents should be educated about possible side-effects of sleep disturbance and mood disorders.
Pregnancy
AR affects 20 per cent of pregnancies, and women with pre-existing AR can experience an increase in symptoms. Medications should be avoided where possible and should be used if benefits to the mother are greater than the risk to the foetus. Medication should be avoided in the first trimester if possible, and topical administration should be the first-line approach.
Conclusion
This article has explored the assessment and management of AR. Pharmacological and non-pharmacological interventions have been discussed. Special considerations in children and pregnancy have also been addressed. The impact of AR on health and wellbeing is significant, with many people experiencing impairment of daily activities, learning and cognitive function, as well as reduced productivity at work and school. Optimal control of symptoms through pharmacological and non-pharmacological treatment regimes, in combination with education, self-management, and empowerment, is paramount to managing this distressing condition.
References
- Bousquet JJ, Schünemann HJ, Togias A, et al. Next-generation ARIA care pathways for rhinitis and asthma: A model for multimorbid chronic diseases. Clin Transl Allergy. 2019;9:44.
- Hellings PW, Scadding G, Bachert C, et al. EUFOREA treatment algorithm for allergic rhinitis. Rhinology. 2020;58(6):618-622.
- Scadding GK, Hellings PW, Bachert C, et al. Allergic respiratory disease care in the Covid-19 era: A EUFOREA statement. World Allergy Organ J. 2020;13(5):100124.
- Walker S, Khan-Wasti S, Fletcher M, et al. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: Case-control study. J Allergy Clin Immunol. 2007;120(2):381-387.
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