Rhinitis GUIDELINES Pocket Guide

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American Academy of Allergy, Asthma and Immunology

American College of Allergy, Asthma and Immunology

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The Rhinitis GUIDELINES Pocket Guide is endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the American Academy of Allergy, Asthma & Immunology (AAAI) and based on the latest ACAAI/AAAI guidelines. This practical quick-reference tool contains screening, diagnostic, treatment algorithm, drug therapy, dosing information, patient monitoring and counseling points. The Rhinitis Guidelines Pocket Guide provides all that is needed to make accurate clinical decisions at the point of care.

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Key Points
Classification and Differential Diagnosis
Physical Examination
Rhinitis Management Algorithm
Management of Rhinitis
Pharmacologic Therapy
Principal Medication Options for Rhinitis
Oral and Intranasal Antihistamines
Intranasal Corticosteroid Sprays
Topical Ophthalmic Preparations for Ocular Allergy Symptoms
Sample Rhinitis Medication Action Plan
Detailed drug information: strengths, formulations, comments

The American Academy of Allergy, Asthma & Immunology (AAAAI) is a professional organization with more than 6,700 members in the United States, Canada and 72 other countries.

The American College of Allergy, Asthma and Immunology (ACAAI) is a professional association of more than 5,700 Allergists/Immunologists and allied health professionals.

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Rhinitis GUIDELINES Pocket Guide

Approved By

American Academy of Allergy, Asthma and Immunology

American College of Allergy, Asthma and Immunology

$6.99 Digital
$9.95 Print

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Key Points

Rhinitis is classified as allergic or nonallergic, but not all types of rhinitis can be easily separated into one of these categories (eg, occupational rhinitis has been classified separately from allergic and nonallergic because it may have components of both) (refer to Table 1).¹
Conditions that mimic symptoms of rhinitis include nasal polyps, cerebrospinal fluid rhinorrhea, ciliary dyskinesia syndrome, and structural/mechanical factors that include¹:
- Cleft palate
- Foreign bodies
- Deviated septum/septal wall anomalies
- Pharyngonasal reflux
- Nasal tumors
- Adenoidal hypertrophy
- Trauma
- Choanal atresia
- Acromegaly (excess growth hormone)
Rhinitis is characterized ≥ 1 of the following nasal symptoms¹:
- Congestion
- Rhinorrhea (anterior and posterior)
- Sneezing
- Itching
Rhinitis is usually associated with inflammation, but some forms of rhinitis such as vasomotor rhinitis or atrophic rhinitis are not predominantly inflammatory.¹
Rhinitis frequently is accompanied by symptoms involving the eyes, ears, and throat.¹
Rhinitis is a significant cause of widespread morbidity, medical treatment costs, reduced work productivity, and lost school days.¹
Although sometimes mistakenly viewed as a trivial disease, symptoms of allergic and nonallergic rhinitis may significantly affect a patient’s quality of life and can be associated with conditions such as fatigue, headache, cognitive impairment, and sleep disturbance.¹
Appropriate management of rhinitis may be an important component in effective management of coexisting or complicating respiratory conditions, such as asthma, sinusitis, and sleep apnea.¹
The financial burden to society for allergic rhinitis is substantial and results from both direct costs and indirect costs (including loss of productivity).¹
Allergic rhinitis affects between 10% and 30% of all adults and as many as 40% of children.¹
- In most studies, the ratio of allergic to pure nonallergic rhinitis is 3:1.¹
- Preliminary data suggest that 44% to 87% of patients with rhinitis may have mixed rhinitis, a combination of allergic and nonallergic rhinitis.¹

Classification and Differential Diagnosis

Table 1. Types of Rhinitis¹

I. Allergic rhinitis
A. Seasonal
B. Perennial
C. Episodic
II. Nonallergic rhinitis
A. Vasomotor rhinitis
Irritant triggered (eg, chlorine) Undetermined or poorly defined triggers Exercise (eg, running) Cold Air
B. Gustatory rhinitis
C. Infectious
Acute Chronic
D. NARES (Nonallergic rhinitis with eosinophilia syndrome)
III. Occupational rhinitis
A. Caused by protein and chemical allergens, IgE-mediated
B. Caused by chemical respiratory sensitizers, immune mechanism uncertain
C. Work-aggravated rhinitis
IV. Other rhinitis syndromes
A. Hormonally induced
Pregnancy rhinitis Menstrual cycle related
B. Drug-induced
Rhinitis medicamentosa Antihypertensives and cardiovascular agents Oral contraceptives Aspirin/NSAIDs Other drugs
C. Atrophic rhinitis
D. Rhinitis associated with inflammatory-immunologic disorders
Granulomatous infections Wegener granulomatosis Relapsing polychondritis Midline granuloma Churg-Strauss Sarcoidosis Amyloidosis

Physical Examination

The physical examination of all organ systems potentially affected by allergies should be performed in all patients with a history of rhinitis (refer to Table 2).¹
Emphasis should be on the upper respiratory tract, but the examiner should carefully look for accompanying otitis or eustachian tube dysfunction, chronic sinusitis, nasal polyps, conjunctivitis, asthma, and atopic dermatitis.¹

Table 2. Physical Examination of Patient Presenting With Symptoms Compatible With Rhinitis¹

Vital signs	Weight and height should be recorded in all patients
General observations	Facial pallor, elongated facies, preferred mouth breathing, and any evidence of systemic disease
Eyes	Excessive lacrimation, erythema and swelling of the bulbar and/or palpebral conjunctiva, cobblestoning of the tarsal conjunctiva, swelling or dermatitis of outer eyelids, Dennie-Morgan lines, or venous stasis below the lower eyelids ("allergic shiners")
Nose	Reduced patency of nasal valve; alar collapse; transverse external crease; external deformity such as saddle nose; sepal deviation or perforation, spurs, ulcers, perforation, prominent vessels, or excoriation; nasal turbinate hypertrophy, edema, pallor or erythema, and crusting; discharge (amount, color, consistency), and nasal polyps Presence of tumors or foreign bodies should be noted
Ears	Tympanic membrane dullness, erythema, retraction, perforation, reduced or increased mobility, and air-fluid levels
Oropharynx	Halitosis, dental malocclusion, high arched palate, tonsillar or adenoidal hypertrophy Observe for malocclusion or high arched palate associated with chronic mouth breathing, tonsillar hypertrophy, cobblestoning of the oropharyngeal wall, pharyngeal postnasal discharge, temporomandibular joint pain or clicking with occlusion, furrowing, coating, or ulceration of tongue or buccal mucosa
Neck	Lymphadenopathy, thyroid enlargement, or tenderness
Chest	Signs of asthma Chest wall deformity or tenderness, abnormal percussion, egophony, audible wheezing, abnormal or diminished sounds by auscultation
Abdomen	Tenderness, distension, masses, or enlargement of liver or spleen
Skin	Rashes, especially eczematous or urticarial (distribution and description), or dermatographism
Other organ systems	When history or general observation indicate these should be included

Note: This list is not intended to be totally inclusive. Elements of the examination that will assist in the differential diagnosis of rhinitis or that may indicate complications of treatment are included. Documentation of presence or absence of these elements should be considered.

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Rhinitis GUIDELINES Pocket Guide

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Key Points

Classification and Differential Diagnosis

Table 1. Types of Rhinitis1

Physical Examination

Table 2. Physical Examination of Patient Presenting With Symptoms Compatible With Rhinitis1

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Table 1. Types of Rhinitis¹

Table 2. Physical Examination of Patient Presenting With Symptoms Compatible With Rhinitis¹