• The connection and interrelatedness between rhinitis and asthma must be borne in mind, and whenever possible the investigations and treatment should include both conditions.
• Instead of trying to avoid allergens, the patient’s tolerance to allergens should be enhanced in different ways. The avoidance of allergens is needed when the symptoms are severe, but as soon as the situation has calmed down, methods that strengthen tolerance should preferably be applied.
• Investigations performed by an ENT specialist are required if the symptoms are severe and unresponsive to treatment, if allergen-specific immunotherapy (desensitisation) is considered or if there is a suspicion of occupational rhinitis.

• See table T1

• It is estimated that up to 30% of the population suffer from hypersensitivity rhinitis. 20–30% of it is allergic rhinitis, half non-allergic rhinitis and the remaining 20–30% have both forms, i.e. so-called mixed rhinitis.
• In the majority of cases allergic rhinitis is caused by pollen allergy (deciduous trees, grasses, mugwort). Other common causes of allergic rhinitis include animal and cereal allergens and other organic dusts, often from occupational exposure.

• Carefully compiled patient history
  • Previous history of atopy
  • The character of symptoms (seasonal or all year round; intermittent or persistent according to ARIA [Allergic Rhinitis and its Impact on Asthma] classification, picture (ARIA-classification of allergic rhinitis))
  • Symptoms (clear nasal secretions, stuffy and itching nose, rhinorrhoea, sneezing)
    • About 70% of patients with allergic rhinitis have concurrent conjunctival symptoms in the eyes (redness, tearing, itching).
  • Associated diseases (sinusitis, otitis media, asthma)
  • Exposure data (particularly if an occupational disease is suspected)
• Rhinoscopy, preferably using a headlight and topical nasal decongestant (a complete ENT examination is indicated during the first visit), if the patient complains of nasal congestion.
  • The aim is to identify nasal polyps (Nasal polyps).
  • Livid pale grey or bluish mucous membranes (suggestive of an allergic reaction, but other types of findings do not exclude allergy)
  • Secretions may vary from clear watery to mucous.
• Serum IgE studies and/or skin prick tests are indicated for the planning of treatment, for consideration of allergen-specific immunotherapy (desensitisation) and for diagnosing possible occupational rhinitis (Investigation of atopy).

• Referral to an ENT specialist is warranted when
  • the patient has severe, treatment-resistant rhinitis
  • occupational rhinitis is suspected.

• ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines http://www.euforea.eu/about-us/aria.html, which have been drafted by an expert panel together in collaboration with the WHO, are research and treatment guidelines for general practitioners and specialists. The emphasis is on the concept "one airway, one disease". The connection and inter-relatedness of rhinitis and asthma must be borne in mind and whenever possible the investigations and treatment should include both conditions.

• Pharmacotherapy should include a combination of drugs from different pharmaceutical groups administered individually according to the symptoms and treatment response.
• In allergic rhinitis, antihistamines Dynamed are the most effective drugs to control sneezing and the production of mucus.
• Antihistamines are also available as nasal sprays and eye drops.
• Combination products (antihistamine + sympathomimetic) have a good effect on nasal congestion. They should not be used continuously for more than 10 days.
• Nasal glucocorticoids Dynamed are effective against all symptoms of allergic rhinitis. In children, products with low systemic bioavailability should be preferred.
• Nasal sprays combining an antihistamine and a nasal glucocorticoid is also available for patients over 12 years of age.
• Sodium cromoglicate Dynamed shows some effect against all symptoms of rhinitis, but its efficacy is only modest.
• Leukotriene receptor antagonists may be suitable for the treatment of allergic rhinitis in patients with asthma Dynamed.
• Desensitisation therapy (hyposensitisation, allergen immunotherapy) Dynamed: see (Allergen-specific immunotherapy)
• The management of other symptoms associated with allergic rhinitis:
  • eye drops for allergic ocular symptoms (mast cell stabilisers, antihistamines)
  • nasal sprays and solutions (water or oil based) to condition and moisten mucous membranes if the use of antihistamines or nasal glucocorticoids causes dryness or irritation
  • short-term use of sprays containing a sympathomimetic drug (no longer than for 7–10 days) if relief from nasal congestion is required before treatment with nasal glucocorticoids is started.

Seasonal allergic rhinitis

• For mild symptoms, antihistamines may be sufficient for symptomatic treatment.
• In moderate or severe symptoms, nasal glucocorticoids alone or in combination with antihistamine tablets are the basis of treatment.
• Nasal glucocorticoids are most effective against nasal congestion when treatment is started before the onset of symptoms. Regular treatment should continue throughout the season. The patient can regulate the dosage depending on exposure (pollen count) and symptoms.
• A combination product containing both an antihistamine and a nasal glucocorticoid is possibly a quicker and more effective treatment option than a glucocorticoid or antihistamine as monotherapy.
• Cromoglicates are commenced before the start of the pollen season and the onset of symptoms. Treatment should continue throughout the pollen season.
• Allergen immunotherapy (desensitization therapy) (Allergen immunotherapy) should be considered in motivated patients with severe symptoms or symptoms despite optimal medication.

Perennial allergic rhinitis

• Nasal glucocorticoids are the first-line drug that can be used continuously.
• Antihistamines may be used to control sneezing and excessive mucus production. They may also be used for a short period of time concomitantly with a sympathomimetic drug in mild nasal congestion.
• A combination product containing both an antihistamine and a nasal glucocorticoid is possibly a quicker and more effective treatment option than a glucocorticoid or antihistamine as monotherapy.
• Cromoglicate can be used all year round.
• Leukotriene receptor antagonists may be also suitable in perennial rhinitis associated with asthma.

Non-allergic rhinitis

• The most important thing is to find out the symptom picture and the cause of non-allergic rhinitis.
• As a symptomatic treatment, medications for allergic rhinitis can be tried.
• The excessive mucus production is best managed with ipratropium nasal spray. The contraindications to anticholinergic medication should be remembered when treating elderly patients.
• Irrigating the nose with a neti pot (nasal irrigation device) can also be helpful.