Diagnosis and Treatment of Allergic Rhinosinusitis

Clinical Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery recommends that the clinical diagnosis of allergic rhinitis is made when patients present with one or more cardinal symptoms—nasal congestion, runny nose, itchy nose, or sneezing—combined with physical examination findings consistent with an allergic cause 1
The diagnosis is entirely clinical and does not require allergy testing initially, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends intranasal corticosteroids as first-line treatment for patients whose symptoms affect their quality of life 1, 2, 3
Oral second-generation antihistamines (loratadine, cetirizine, fexofenadine, desloratadine) should be recommended for patients whose primary complaints are sneezing and itching, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2, 3
For moderate to severe allergic rhinitis, combination therapy with intranasal corticosteroid plus intranasal antihistamine (such as azelastine) provides superior symptom reduction compared to either agent alone, with a 40% relative improvement over monotherapy 3, 5

The American Academy of Otolaryngology-Head and Neck Surgery advises against confusing allergic rhinitis with nonallergic rhinitis, which presents primarily with nasal congestion and postnasal drainage, sinus pressure, ear symptoms, and lacks the characteristic pale nasal mucosa and itching symptoms 1, 2
The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely ordering sinonasal imaging in patients with symptoms consistent with allergic rhinitis 1, 2
The American Academy of Otolaryngology-Head and Neck Surgery suggests avoiding prolonged use of topical decongestants beyond 3-5 days to prevent rhinitis medicamentosa 4