Step 1 of 14
Presentation & Red-Flag Triage
Rhinitis symptoms + rapid red-flag screen to exclude sinonasal malignancy before allergy workup
Allergic rhinitis presents with sneezing, nasal itch, clear rhinorrhoea, nasal obstruction, postnasal drip, hyposmia, chronic congestion, and sleep disturbance — typically bilateral and symmetrical. Before attributing these to allergy, a rapid red-flag triage excludes sinister sinonasal disease, because the cost of mislabelling a tumour as allergy is high.
Red flags — unilateral nasal obstruction, unilateral blood-stained discharge, persistent epistaxis, facial swelling, proptosis, diplopia, cranial neuropathy, a neck mass, weight loss, a persistent unilateral polyp, or severe facial pain — mandate urgent nasal endoscopy, CT/MRI, and biopsy as indicated to exclude sinonasal malignancy, inverted papilloma, fungal sinusitis, and granulomatous disease (GPA). Their absence allows the structured allergy evaluation to proceed. The discipline here is simple: allergy is bilateral and symmetrical; anything persistently unilateral, bloody, or neurological is not allergic rhinitis until proven otherwise.
- Symptoms — sneezing, itch, clear rhinorrhoea, obstruction, postnasal drip, hyposmia, congestion, sleep disturbance
- Red flags — unilateral obstruction/bleeding, epistaxis, facial swelling, proptosis, diplopia, cranial neuropathy, neck mass, weight loss, unilateral polyp, severe pain
- Red flags → urgent endoscopy + CT/MRI + biopsy (exclude malignancy, inverted papilloma, fungal sinusitis, GPA)
- Bilateral/symmetrical → proceed to allergy evaluation
★ High-yield pearls (chapter-wide)
- Unilateral nasal obstruction, blood-stained discharge, a single persistent polyp, facial swelling, proptosis, diplopia, or cranial neuropathy are red flags — endoscope and image before calling it allergy, to exclude sinonasal malignancy, inverted papilloma, fungal sinusitis, and granulomatous disease.
- Allergic rhinitis is one airway — screen every patient for asthma, conjunctivitis, eczema, chronic rhinosinusitis, nasal polyps, otitis media with effusion, and sleep-disordered breathing, because treating the nose alone misses the disease.
- ARIA classifies by duration (intermittent vs persistent) and severity (mild vs moderate-severe) — not by season — and that 2×2 drives the choice and intensity of treatment.
- The intranasal corticosteroid is the single most effective drug for moderate-severe allergic rhinitis and is first-line — more effective than an oral antihistamine for congestion, the symptom patients most want relieved.
- Spray technique is part of the prescription — head slightly forward, aim the nozzle laterally away from the septum, and breathe gently; forceful sniffing and septal aiming cause epistaxis and failure, not the drug.
- An intranasal-corticosteroid / intranasal-antihistamine combination beats either agent alone for inadequately controlled disease — escalate to combination before declaring treatment failure.
- Before escalating, run the failure checklist — right diagnosis, adherence over 80%, correct technique, adequate duration, and environmental control — because most apparent drug failures are one of these.
- Test (skin-prick or specific IgE) to confirm IgE sensitisation and guide immunotherapy, not to make the diagnosis — a positive test must correlate with the history to be clinically relevant.
- Allergen immunotherapy (SCIT or SLIT) is the only disease-modifying treatment — it is for confirmed IgE-mediated disease with a relevant allergen, persistent symptoms, or medication failure, and can reduce progression to asthma.
- A negative allergy test in a symptomatic patient points to non-allergic rhinitis — vasomotor, NARES, drug-induced (including rhinitis medicamentosa), hormonal, or occupational — each with its own management.
Evidence base
4 sources- HIGH
Seidman MD, Gurgel RK, Lin SY · Otolaryngol Head Neck Surg · 2015Clinical practice guidelinePMID 25644617
The AAO-HNS allergic-rhinitis guideline — diagnosis, INCS-first pharmacotherapy, testing, and immunotherapy; the spine of this chapter.
- HIGH
Seidman MD, Gurgel RK, Lin SY · Otolaryngol Head Neck Surg · 2015Clinical practice guideline (summary)PMID 25645524
Executive summary of the AAO-HNS allergic-rhinitis guideline action statements.
- HIGH
Fokkens WJ, Lund VJ, Hopkins C · Rhinology · 2020International position paperPMID 32077450
EPOS 2020 — the reference standard for chronic rhinosinusitis and CRSwNP diagnosis and management, including biologics and surgery.
- HIGH
Bousquet J, Khaltaev N, Cruz AA · Allergy · 2008International guidelinePMID 18331513
The ARIA framework — duration/severity classification and the stepwise approach; defines intermittent/persistent and mild/moderate-severe.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.