History:

Ask about triggers (e.g., pets) and if symptoms are intermittent or all year round (perennial).

Signs and Symptoms include:

• Bilateral nasal itching
• congestion and rhinorrhoea
• sneezing
• bilateral conjunctivitis.

Differential diagnosis include:

• Seasonal rhinitis (symptoms only in pollen season spring/summer)
• Perennial rhinitis (all year round)
• Infective rhinosinusitis
• Non-allergic (e.g., hormonal, drug-induced, vasomotor) rhinitis

Urgent referral via the suspected Head and Neck Cancer pathway should be considered if there are:

• unilateral symptoms (persistent purulent discharge or nasal obstruction with epistaxis)

or

• clinical findings suggestive of cancer (unilateral nasal mass or polyp)

No investigations required prior to referral.

1. For seasonal allergic rhinitis, treatment should be initiated at least 2 weeks before the anticipated start of the pollen season.

2. Allergen avoidance where possible (e.g., house dust mite reduction measures or pet avoidance).

3. Mild symptoms should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dosing

4. Moderate-severe symptoms should be treated with intranasal corticosteroid (in addition to non-sedating antihistamines)

5. Consistent daily use of intranasal use is vital, given maximal effect may not be apparent for at least two weeks.

6. Training in appropriate nasal spray technique essential. Guidance can be found here.

7. Systemic corticosteroids (in addition to intranasal corticosteroid and non-sedating antihistamines) at doses of 15-20mg for a maximum of 5 days as a one-off course can be used for severe symptoms uncontrolled on conventional therapy e.g., to control symptoms during important periods (e.g. exams or other major events).

8. Topical anti-inflammatory eye drops are useful to manage allergic conjunctivitis

Consider a concomitant diagnosis of asthma and manage according to guidelines.

Avoid sedating antihistamines, depot corticosteroids, and chronic use of decongestants.
Treatment failure should prompt a review of the diagnosis, compliance with therapy (regular therapy is more effective than “as required” treatment), and intranasal corticosteroid technique.

Experience from Peninsula Immunology and Allergy Service suggests that 70% of patients referred with severe symptoms achieve satisfactory symptom control using non-sedating antihistamines and regular intranasal corticosteroids alone.

For more information see:

South and West Devon Formulary: 12.2.1 Drugs used in nasal allergy, 12.2.2 Topical nasal decongestants

BSACI - Rhinitis management guidelines

Onlinelibrary.wiley - guidelines for the management of allergic and non-allergic rhinitis

The information essential for clinical triage is outlined on the referral form.

For efficiency and to minimise returned referrals, use of the referral form is recommended.

Referrals not on the referral form will be accepted as long as all the essential information is included in a referral letter.

Referral Criteria

• Perennial or seasonal symptoms that are severe and resistant to treatment (when combination treatment of antihistamines and nasal spray (used correctly) at maximum doses have been attempted for at least 3 months)
• For consideration for Grass & Tree Pollen / House Dust Mite desensitisation if people remain significantly symptomatic despite at least 3 months of maximal treatment (as outlined above)

Referral Instructions

Red Flags – refer to ENT

• Refer using e-Referral Service
  • Specialty: ENT
  • Clinic type: Not otherwise specified
  • Service: DRSS-South Devon & Torbay-Ear Nose and Throat- Devon ICB -15N

Refer to Peninsula Immunology and Allergy Service

• Refer using e-Referral Service
  • Specialty: Allergy
  • Clinic type: Allergy
  • Service: DRSS-South Devon & Torbay-Allergy- Devon ICB - 15N

Referral Form

Evidence

Onlinelibrary.wiley - guidelines for the management of allergic and non-allergic rhinitis

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: March 2016

Updated: December 24