Allergic rhinitis Diagnosis and management Diagnostic criteria Diagnose allergic rhinitis clinically when patients present with 1 typical symptom(s) (nasal congestion, runny nose, itchy nose, or sneezing), and history and physical examination is consistent with an allergic cause. B Diagnostic criteria for allergic rhinitis Presence of 1 typical symptoms (sneezing, nasal congestion, discharge or itch) Demonstration of sensitization Congestion of the mucosa and bilateral transparent secretions on anterior rhinoscopy Allergic rhinitis is unlikely Clinical examination Assess patients with allergic rhinitis for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. B Sinonasal imaging Avoid routine sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of allergic rhinitis. D IgE allergy testing AAO-HNSF Q Is the diagnosis of allergic rhinitis uncertain? Q Is knowledge of the specific causative allergen needed to guide therapy? Yes to any Obtain specific IgE allergy testing: in patients in whom there is uncertainty regarding the diagnosis of allergic rhinitis in patients in whom knowledge of the specific causative allergen is needed to target therapy in patients with a lack of response to empiric treatment for allergic rhinitis. B No to all Avoidance of allergens Q Has the patient identified one or several allergens that correlate with the onset of clinical symptoms? Yes Consider advising avoidance of known allergens or environmental control measures (such as removal of pets, air filtration systems, bed covers, and chemical agents formulated to kill dust mites) in patients with allergic rhinitis who have identified allergens that correlate with clinical symptoms. C No Intranasal antihistamines Consider intranasal antihistamines for patients with seasonal, perennial, or episodic allergic rhinitis. C Oral leukotriene receptor antagonists Avoid leukotriene receptor antagonists as primary therapy for patients with allergic rhinitis. D Oral antihistamines AAO-HNSF Q Does the patient primary complaints include sneezing and itching? Yes Administer oral second-generation/less sedating antihistamines for patients with primary complaints of sneezing and itching. B Combination therapy AAO-HNSF Q Does the patient display an adequate response to single-agent pharmacologic therapy? Yes Continue management as clinically appropriate. Refer patients who do not respond adequately to pharmacologic therapy to a clinician who can offer immunotherapy. B Inferior turbinate reduction Q Does the patient have nasal airway obstruction and enlarged inferior turbinates? Yes Consider performing surgical inferior turbinate reduction in patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. C No Continue management as clinically appropriate.