Doctors Revision

ENT (Ear, Nose, Throat Conditions)

Allergic Rhinitis

An IgE-mediated inflammation of the nasal mucous membranes triggered by exposure to allergens, characterized by rhinorrhoea, sneezing, nasal itching, and obstruction.

Also known as: Nasal Allergy, Hay Fever

Open in the interactive guide
On this page

Referral and warning signs

When to refer

Refer to ENT Specialist/Allergist if: Diagnosis uncertain. Symptoms severe or unresponsive to standard treatment (INCS + antihistamine). Complications suspected (sinusitis, polyps). Consideration for immunotherapy.

Red flags

  • Unilateral symptoms (consider tumour, foreign body, CSF leak).
  • Purulent discharge / Facial pain (Sinusitis).
  • Epistaxis (significant/recurrent).
  • Anosmia (loss of smell).

Signs and symptoms

  • Paroxysmal (sudden) sneezing.
  • Watery nasal discharge (rhinorrhoea).
  • Nasal itching (pruritus).
  • Nasal obstruction / congestion.
  • Itchy eyes, throat, palate.
  • Postnasal drip.
  • Associated symptoms: Allergic conjunctivitis, cough (due to postnasal drip), fatigue, headache.
  • Symptoms may be seasonal (pollens) or perennial (dust mites, moulds, pet dander).
  • Examination: Pale, boggy, swollen nasal turbinates; clear nasal discharge; allergic shiners (dark circles under eyes); allergic salute (transverse nasal crease).

Risk factors

  • Family history of atopy (asthma, eczema, allergic rhinitis).
  • Exposure to specific allergens (pollens, dust mites, animal dander, moulds, cockroaches).
  • Environmental factors (pollution).

Diagnosis

Clinical assessment

Diagnosis primarily based on characteristic history of symptoms triggered by specific exposures or seasonal patterns, and clinical examination findings (pale/boggy turbinates).

Investigations

  • Usually clinical diagnosis.
  • Allergy testing (Skin prick tests or specific IgE blood tests) - Specialist level, to identify specific allergens.

Diagnostic criteria

Clinical diagnosis based on history and examination suggestive of allergy-mediated nasal inflammation.

Differential diagnosis

  • Viral Rhinitis (Common Cold) (usually shorter duration, fever/malaise more common, thicker discharge later).
  • Vasomotor Rhinitis (non-allergic, triggered by irritants/temperature changes).
  • Infectious Sinusitis (purulent discharge, facial pain/pressure).
  • Nasal polyps.
  • Foreign body (unilateral foul discharge).
  • Rhinitis medicamentosa (rebound congestion from decongestant spray overuse).

Management

Non-pharmacological management

  • Allergen Avoidance: Most important step. Identify and avoid triggers (dust mite control measures, keep windows closed during pollen season, air purifiers, avoid pets if allergic).
  • Nasal Saline Irrigation: Helps wash out allergens and mucus.

Pharmacological treatment

  • Intranasal Corticosteroids (INCS): Most effective treatment for moderate-severe or persistent symptoms. (e.g., Fluticasone, Budesonide, Mometasone, Beclomethasone sprays). Require regular daily use for full effect. (LOC: HC3/4)
  • Oral Antihistamines (Second Generation preferred): Effective for sneezing, itching, rhinorrhoea. Less effective for congestion. (e.g., Cetirizine, Loratadine, Fexofenadine). Less sedating than first-gen. (LOC: HC2+)
  • - First Generation Antihistamines (e.g., Chlorphenamine): Effective but cause sedation. UCG recommends 4mg BID for up to 21 days. (LOC: HC2)
  • Leukotriene Receptor Antagonists (LTRAs): (e.g., Montelukast). Alternative or add-on therapy, especially if co-existing asthma. (Specialist)
  • Topical Nasal Decongestants: (e.g., Oxymetazoline, Xylometazoline). Provide rapid relief of congestion but use STRICTLY limited to 3-5 days due to risk of rebound congestion (rhinitis medicamentosa). (LOC: HC2/3)
  • Topical Nasal Antihistamine Sprays: (e.g., Azelastine). Rapid onset, good for sneezing/itching/rhinorrhoea.
  • Topical Nasal Cromolyn: Mast cell stabilizer, less effective, needs frequent dosing, good safety profile.
  • Allergen Immunotherapy (AIT): Desensitization via injections or sublingual tablets. Specialist treatment for severe, refractory allergies.

Monitoring

Assess symptom control and medication tolerance. Adjust treatment based on response. Re-evaluate if symptoms persist despite treatment.

Complications

  • Poor sleep quality.
  • Fatigue / Impaired concentration.
  • Sinusitis.
  • Otitis Media with Effusion.
  • Nasal polyps.
  • Exacerbation of asthma.

Prevention

  • Allergen avoidance.
  • Pharmacotherapy to control symptoms.

Patient education

  • Explanation of allergic rhinitis as an allergic reaction.
  • Identification and avoidance of personal triggers.
  • Correct technique for using nasal sprays (INCS).
  • Importance of regular use of INCS for optimal effect.
  • Role of antihistamines.
  • Limited use of decongestant sprays.
  • Nasal saline irrigation technique.

Uganda-specific notes

Allergic rhinitis is common. Dust mites and pollens are frequent triggers. Oral antihistamines (especially chlorphenamine) are widely available. Access to intranasal corticosteroids and allergy testing is limited outside larger centres/private sector.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.2.3

Scroll to Top