561600
ryngology—Head and Neck SurgerySeidman et al
2014© The Author(s) 2010
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OTOXXX10.1177/0194599814561600Otola
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Guideline
Otolaryngology–
Clinical Practice Guideline: Allergic Rhinitis Head and Neck Surgery
2015, Vol. 152(1S) S1–S43
© American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2014
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Michael D. Seidman, MD1, Richard K. Gurgel, MD2, Sandra Y. Lin, MD3, DOI: 10.1177/0194599814561600
Seth R. Schwartz, MD, MPH4, Fuad M. Baroody, MD5, http://otojournal.org
James R. Bonner, MD6, Douglas E. Dawson, MD7, Mark S. Dykewicz, MD8,
Jesse M. Hackell, MD9, Joseph K. Han, MD10,
Stacey L. Ishman, MD, MPH11, Helene J. Krouse, PhD, ANP-BC, CORLN12,
Sonya Malekzadeh, MD13, James (Whit) W. Mims, MD14,
Folashade S. Omole, MD15, William D. Reddy, LAc, DiplAc16,
Dana V. Wallace, MD17, Sandra A. Walsh18,
Barbara E. Warren, PsyD, MEd18, Meghan N. Wilson, MD19,
and Lorraine C. Nnacheta, MPH20
Sponsorships or competing interests that may be relevant to content are guideline are not intended to represent the standard of care for
disclosed at the end of this article. patient management, nor are the recommendations intended
to limit treatment or care provided to individual patients.
Abstract Action Statements. The development group made a strong rec-
ommendation that clinicians recommend intranasal steroids
Objective. Allergic rhinitis (AR) is one of the most common for patients with a clinical diagnosis of AR whose symptoms
diseases affecting adults. It is the most common chronic dis- affect their quality of life. The development group also made
ease in children in the United States today and the fifth most a strong recommendation that clinicians recommend oral
common chronic disease in the United States overall. AR is second-generation/less sedating antihistamines for patients
estimated to affect nearly 1 in every 6 Americans and gener- with AR and primary complaints of sneezing and itching. The
ates $2 to $5 billion in direct health expenditures annually. It panel made the following recommendations: (1) Clinicians
can impair quality of life and, through loss of work and school should make the clinical diagnosis of AR when patients pres-
attendance, is responsible for as much as $2 to $4 billion in ent with a history and physical examination consistent with an
lost productivity annually. Not surprisingly, myriad diagnos- allergic cause and 1 or more of the following symptoms: nasal
tic tests and treatments are used in managing this disorder, congestion, runny nose, itchy nose, or sneezing. Findings of AR
yet there is considerable variation in their use. This clinical consistent with an allergic cause include, but are not limited
practice guideline was undertaken to optimize the care of to, clear rhinorrhea, nasal congestion, pale discoloration of the
patients with AR by addressing quality improvement opportu- nasal mucosa, and red and watery eyes. (2) Clinicians should
nities through an evaluation of the available evidence and an perform and interpret, or refer to a clinician who can perform
assessment of the harm-benefit balance of various diagnostic and interpret, specific IgE (skin or blood) allergy testing for
and management options. patients with a clinical diagnosis of AR who do not respond
Purpose. The primary purpose of this guideline is to address to empiric treatment, or when the diagnosis is uncertain, or
quality improvement opportunities for all clinicians, in any set- when knowledge of the specific causative allergen is needed
ting, who are likely to manage patients with AR as well as to to target therapy. (3) Clinicians should assess patients with
optimize patient care, promote effective diagnosis and thera- a clinical diagnosis of AR for, and document in the medical
py, and reduce harmful or unnecessary variations in care. The record, the presence of associated conditions such as asthma,
guideline is intended to be applicable for both pediatric and atopic dermatitis, sleep-disordered breathing, conjunctivitis,
adult patients with AR. Children under the age of 2 years were rhinosinusitis, and otitis media. (4) Clinicians should offer, or
excluded from the clinical practice guideline because rhinitis refer to a clinician who can offer, immunotherapy (sublingual
in this population may be different than in older patients and or subcutaneous) for patients with AR who have inadequate
is not informed by the same evidence base. The guideline is response to symptoms with pharmacologic therapy with or
intended to focus on a limited number of quality improvement without environmental controls.
opportunities deemed most important by the working group The panel recommended against (1) clinicians routinely perform-
and is not intended to be a comprehensive reference for diag- ing sinonasal imaging in patients presenting with symptoms
nosing and managing AR.The recommendations outlined in the consistent with a diagnosis of AR and (2) clinicians offering
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S2 Otolaryngology–Head and Neck Surgery 152(1S)
oral leukotriene receptor antagonists as primary therapy for attendance, is responsible for as much as $2 to $4 billion in
patients with AR. lost productivity annually.4,5 Not surprisingly, myriad diag-
nostic tests and treatments are used in managing patients with
The panel group made the following options: (1) Clinicians
this disorder, yet there is considerable variation in their use.
may advise avoidance of known allergens or may advise en-
This clinical practice guideline was undertaken to optimize
vironmental controls (ie, removal of pets; the use of air fil-
the care of patients with AR by addressing quality improve-
tration systems, bed covers, and acaricides [chemical agents
ment opportunities through an evaluation of the available
formulated to kill dust mites]) in patients with AR who have
evidence and an assessment of the harm-benefit balance of
identified allergens that correlate with clinical symptoms. (2)
various diagnostic and management options.
Clinicians may offer intranasal antihistamines for patients with
For the purpose of this guideline, AR is defined as an
seasonal, perennial, or episodic AR. (3) Clinicians may offer
immunoglobulin E (IgE)–mediated inflammatory response of
combination pharmacologic therapy in patients with AR who
the nasal mucous membranes after exposure to inhaled aller-
have inadequate response to pharmacologic monotherapy. (4)
gens. Symptoms include rhinorrhea (anterior or post nasal
Clinicians may offer, or refer to a surgeon who can offer, infe-
drip), nasal congestion, nasal itching, and sneezing. AR can be
rior turbinate reduction in patients with AR with nasal airway
seasonal or perennial, with symptoms being intermittent or
obstruction and enlarged inferior turbinates who have failed
persistent. Table 1 summarizes the common terms used for
medical management. (5) Clinicians may offer acupuncture, or
this guideline.
refer to a clinician who can offer acupuncture, for patients
with AR who are interested in nonpharmacologic therapy.The Defining Allergic Rhinitis
development group provided no recommendation regarding
AR is an inflammatory, IgE-mediated disease characterized
the use of herbal therapy for patients with AR.
by nasal congestion, rhinorrhea (nasal drainage), sneezing,
and/or nasal itching. It can also be defined as inflammation of
Keywords the inside lining of the nose that occurs when a person inhales
allergic rhinitis, allergic rhinitis immunotherapy, surgical man- something he or she is allergic to, such as animal dander or
agement of allergic rhinitis, medical management of allergic pollen; examples of the symptoms of AR are sneezing, stuffy
rhinitis, allergic rhinitis and steroid use/antihistamine use/ nose, runny nose, post nasal drip, and itchy nose.
decongestant use, allergic rhinitis and complementary/alter- AR may be classified by (1) the temporal pattern of exposure
native/integrative medicine, acupuncture, herbal therapies, to a triggering allergen, such as seasonal (eg, pollens), perennial/
diagnosis of allergic rhinitis, nasal allergies, hay fever, atopic year-round (eg, dust mites), or episodic (environmental from
rhinitis, atrophic rhinitis, pollinosis, catarrh exposures not normally encountered in the patient’s environment,
eg, visiting a home with pets); (2) frequency of symptoms; and
Received September 18, 2014; revised October 22, 2014; accepted (3) severity of symptoms. Classifying AR in this manner may
November 5, 2014. assist in choosing the most appropriate treatment strategies for an
individual patient.
In the United States, AR has traditionally been viewed as
Introduction either seasonal or perennial, and this is the classification sys-
Allergic rhinitis (AR) is one of the most common diseases tem that the Food and Drug Administration (FDA) uses when
affecting adults.1 It is the most common chronic disease in approving new medications for AR. However, it is recognized
children in the United States today2 and is the fifth most com- that this classification system has limitations, as the length of
mon chronic disease in the United States overall.3 AR is esti- the aeroallergen pollen season is dependent on geographic
mated to affect nearly 1 in every 6 Americans and generates location and climatic conditions. When the pollen season is
$2 to $5 billion in direct health expenditures annually.4,5 It can year-round, as in tropical locations, it can be very difficult
impair quality of life and, through loss of work and school based on history to distinguish allergic symptoms provoked
1
Department of Otolaryngology–Head and Neck Surgery, Henry Ford West Bloomfield Hospital West Bloomfield, Michigan, USA; 2Department of Surgery
Otolaryngology–Head and Neck Surgery University of Utah, Salt Lake City, Utah, USA; 3Johns Hopkins School of Medicine, Department of Otolaryngology–
Head and Neck Surgery, Baltimore, Maryland, USA; 4Virginia Mason Medical Center, Seattle, Washington, USA; 5University of Chicago Medical Center,
Department of Otolaryngology, Chicago, Illinois, USA; 6Birmingham VA Medical Center, Birmingham, Alabama, USA; 7Otolaryngology, Private Practice,
Muscatine, Iowa, USA; 8Department of Internal Medicine, St Louis University School of Medicine, St Louis, Missouri, USA; 9Pomona Pediatrics, Pomona, New
York, USA; 10Eastern Virginia Medical School, Norfolk,Virginia, USA; 11Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA; 12Wayne State
University, Philadelphia, Pennsylvania, USA; 13Georgetown University Hospital, Washington, DC, USA; 14Wake Forest Baptist Health, Winston Salem, North
Carolina, USA; 15Morehouse School of Medicine, East Point, Georgia, USA; 16Acupuncture and Oriental Medicine (AAAOM), Annandale,Virginia, USA
17
Florida Atlantic University, Boca Raton, Florida and Nova Southeastern University, Davie, Florida, USA; 18Consumers United for Evidence-based Healthcare,
Fredericton, New Brunswick, Canada; 19Louisiana State University School of Medicine, New Orleans, Louisiana, USA; 20Department of Research and Quality,
American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria,Virginia, USA.
Corresponding Author:
Michael D. Seidman, MD, Henry Ford West Bloomfield Hospital, 6777 West Maple Rd, West Bloomfield, MI 48322, USA.
Email: mseidma1@hfhs.org
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Seidman et al S3
Table 1. Abbreviations and Definitions of Common Terms.
Term Definition
Allergic rhinitis (AR) Disease caused by an IgE-mediated inflammatory response of the nasal mucous membranes after
exposure to inhaled allergens. Symptoms include rhinorrhea (anterior or posterior nasal drainage), nasal
congestion, nasal itching, and sneezing.
Seasonal allergic rhinitis (SAR) Disease caused by an IgE-mediated inflammatory response to seasonal aeroallergens. The length of
seasonal exposure to these allergens is dependent on geographic location and climatic conditions.
Perennial allergic rhinitis (PAR) Disease caused by an IgE-mediated inflammatory response to year-round environmental aeroallergens.
These may include dust mites, mold, animal allergens, or certain occupational allergens.
Intermittent allergic rhinitis Disease caused by an IgE-mediated inflammatory response and characterized by frequency of exposure or
symptoms (<4 days per week or <4 weeks per year).
Persistent allergic rhinitis Disease caused by an IgE-mediated inflammatory response and characterized by persistent symptoms (>4
days per week and >4 weeks per year).
Episodic allergic rhinitis Disease caused by an IgE-mediated inflammatory response that can occur if an individual is in contact with
an exposure that is not normally a part of the individual’s environment. (ie, a cat at a friend’s house).
by exposure to pollen from symptoms caused by exposure to The guideline is intended to focus on a select number of qual-
allergens that are perennial in temperate zones (eg, dust mites). ity improvement opportunities deemed most important by the
Mold has been considered to be both a seasonal and a peren- working group and is not intended to be a comprehensive refer-
nial allergen.6 Furthermore, it is recognized that many patients ence for diagnosing and managing AR. The recommendations
with AR have perennial AR exacerbated by seasonal pollen outlined in the guideline are not intended be an all-inclusive
exposure, and many patients are polysensitized so the clinical guide for patient management, nor are the recommendations
implications of seasonal versus perennial are not as clear.6 intended to limit treatment or care provided to individual patients.
Classifying a patient’s symptoms by frequency and sever- The guideline is not intended to replace individualized patient
ity allows for more appropriate treatment selection. AR symp- care or clinical judgment. Its goal is to create a multidisciplinary
tom frequency has been divided into intermittent (<4 days per guideline with a specific set of focused recommendations based
week or <4 weeks per year) and persistent (>4 days per week upon an established and transparent process that considers levels
and >4 weeks per year).6 However, this classification of symp- of evidence, harm-benefit balance, and expert consensus to
tom frequency has limitations. For example, the patient who resolve gaps in evidence.8 These specific recommendations may
has symptoms 3 days per week year-round would be classified then be used to develop performance measures and identify ave-
as “intermittent” even though she or he would more closely nues for quality improvement. Table 2 highlights the topics and
resemble a “persistent” patient. It may be advantageous for issues considered in the development of this guideline.
the patient and the provider to determine which frequency cat-
egory is most appropriate and would best guide the treatment Healthcare Burden
plan. Based on these definitions, it is possible that a patient
may have intermittent symptoms with perennial AR or persis- Incidence and Prevalence
tent symptoms with seasonal AR. Allergic rhinitis is a worldwide health problem that affects
AR severity can be classified as being mild (when symp- adults and children. In the United States, AR is the 16th most
toms are present but are not interfering with quality of life) or common primary diagnosis for outpatient office visits.9 Large
more severe (when symptoms are bad enough to interfere with epidemiologic studies consistently show a significantly higher
quality of life).6,7 Factors that may lead to a more severe clas- percentage of the population with rhinitis symptoms than
sification include exacerbation of coexisting asthma; sleep those with rhinitis symptoms and positive allergy tests.10 In
disturbance; impairment of daily activities, leisure, and/or the 2005-2006 National Health and Nutritional Examination
sport; and impairment of school performance or work. Survey (NHANES), a sample of 7398 people (selected to
represent the United States population age 6 years and older)
Guideline Purpose were surveyed for “hay fever,” “current allergies,” and “cur-
The primary purpose of this guideline is to address quality rent rhinitis” and tested for IgE specific to 19 inhalant aller-
improvement opportunities for all clinicians, in any setting, gens. One in 3 participants reported rhinitis symptoms within
who are likely to manage patients with AR, as well as to opti- the last 12 months not associated with an upper respiratory
mize patient care, promote effective diagnosis and therapy, infection. Of those with rhinitis, 52.7% demonstrated at least
and reduce harmful or unnecessary variations in care. The 1 positive allergy test.10 By this standard, IgE-mediated AR
guideline is intended to be applicable for both pediatric and may affect 1 in 6 persons within the United States. The United
adult patients with AR. Children under the age of 2 years were States population is most commonly sensitized to grass pol-
excluded in this clinical practice guideline because rhinitis in len, dust mites, and ragweed pollen.10
this population may be different than in older patients and is The International Study of Asthma and Allergies in
not informed by the same evidence base. Childhood (ISAAC), a worldwide study of allergies in
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S4 Otolaryngology–Head and Neck Surgery 152(1S)
Table 2. Topics and Issues Considered in Allergic Rhinitis (AR) Guideline Development.a
Prevention/Education/
Diagnosis/Testing Treatment Risk Factors Other Therapies Outcomes
•• Diagnosis of AR •• First-line therapy upon •• Methods for preventing •• Role of acupuncture •• Initial evaluation of the
•• Differentiating diagnosis the development of AR •• Role of herbal medicines patient
nonallergic nasal •• When does combining •• Role of patient •• Role of homeopathy •• Improvement in
conditions from AR 2 different classes of education •• Role of nasal rinses accuracy of diagnosis;
•• When should a patient allergy pharmacology •• When is it appropriate •• Role of capsaicin avoidance of
be referred to an allergy benefit the patient? to manage symptoms •• Role of antibiotics unnecessary testing
specialist? •• Pharmacology and the over the phone (or •• Reduction in care
•• Differentiating perennial different medication internet)? variation and
or seasonal AR classes that offer •• Role of dietary unnecessary radiation
•• Identifying and treating additive vs negative modifications exposure from sinonasal
comorbidities effects •• Value of pollen counts imaging
•• When is it acceptable •• Self-directed therapy in determining symptom •• Expenditure reduction
to test for allergic or over-the-counter severity and self- for ineffective
component(s), and what medications vs guidance environmental measures
type of test should be physician-directed or •• Role of stress •• Increased treatment
performed? prescription medications management in optimization and
•• Accuracy of self- •• Use and safety of nasal, the creation of, or reduced complications
diagnosis oral, topical steroids exacerbation of, AR from comorbidities
•• Accuracy of clinician •• When is it acceptable symptoms •• Optimization of proven
diagnosis based on to add a second or •• Identification of effective therapy
clinical assessment third medication? risk factors for the •• Avoidance of sedating
•• Children age 2 and •• Treatment of allergic development of AR antihistamine and
older with a diagnosis conjunctivitis promotion of direct
of allergies, since age •• Role of surgical therapy
2 is the earliest age to management •• Improved awareness of
consider allergy testing •• Managing chronic the different classes of
•• Role and appropriate inflammation of lung, medication for effective
use of imaging sinus, skin, and ears treatment of AR
•• Role of nasal endoscopy •• Role of immunotherapy •• Reduction in the use of
•• Accurate use of •• Efficacy of different a less effective first-line
instruments to measure antihistamines agent
symptoms/objective •• Measuring response to •• Improved symptom
testing for baseline therapy and identifying control and reduction in
•• When is it necessary to further need for therapy care variation
perform specific allergy •• Role of environmental •• Increased awareness
testing and/or IgE test? controls and appropriate use
of immunotherapy
and reduction in care
variation
•• Improved nasal
breathing and quality
of life
•• Increased awareness
of acupuncture as a
treatment option
•• Increased awareness
of herbal therapy as a
treatment option
a
This list was created by the Guideline Development Group to refine content and prioritize action statements; not all items listed were ultimately included in
the guideline.
children, found a large variation in the prevalence of AR exposure in complex ways we do not fully understand. Allergic
between countries, with the lowest rate reported at 1.5% in rhinitis is a heterogenic condition in many respects, so the epi-
Iran and the highest at 39.7% in Nigeria.11 The prevalence of demiologic variance is not unexpected. Despite the variation,
AR varies with genetics, epigenetics, and environmental the majority of centers found an increasing prevalence of AR
