Allergic rhinitis is inflammation of the nasal lining triggered by an immune response to inhaled allergens — pollen, dust mites, pet dander, mold. The 2015 AAO-HNS guideline states the diagnosis should be made clinically when a patient presents with one or more of the following: nasal congestion, runny nose, itchy nose, or sneezing, with a history and physical exam consistent with an allergic cause. You do not need imaging to make this diagnosis — the guideline explicitly recommends against routine sinonasal imaging (like a CT scan) in patients with allergic rhinitis symptoms.

The AAO-HNS guideline makes its strongest recommendation for intranasal corticosteroid sprays — fluticasone (Flonase), mometasone (Nasonex), budesonide (Rhinocort). These are first-line for any patient whose symptoms affect quality of life. For patients whose primary symptoms are sneezing and itching, the guideline also makes a strong recommendation for second-generation oral antihistamines — cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra). Older antihistamines like diphenhydramine (Benadryl) are not recommended for routine use due to sedation and impaired cognitive function.

No — and this is one of the guideline’s most important recommendations against. The AAO-HNS guideline explicitly recommends against oral leukotriene receptor antagonists like montelukast as primary therapy for allergic rhinitis. Evidence shows they are less effective than intranasal steroids and carry neuropsychiatric side effects including mood changes, depression, and suicidal ideation that the FDA has added a black box warning for. If you are currently taking Singulair primarily for nasal allergy symptoms, that is worth a conversation with your doctor.

Not necessarily right away. The guideline recommends specific IgE testing — skin prick testing or blood testing — when: the diagnosis is uncertain, treatment has been ineffective, identifying a specific allergen would change your treatment, or you are being considered for allergy immunotherapy. Routine allergy testing for every patient with classic seasonal allergic rhinitis symptoms is not required before starting treatment. Testing becomes important when the next step is immunotherapy.

Allergy immunotherapy — subcutaneous (shots) or sublingual (under-the-tongue drops or tablets) — is the only treatment that modifies the underlying immune response rather than just managing symptoms. The AAO-HNS guideline recommends offering immunotherapy to patients who have an inadequate response to pharmacologic therapy, have significant side effects from medications, or want a long-term solution rather than indefinite daily medication. Immunotherapy typically requires 3 to 5 years of treatment but can produce lasting improvement after the treatment course ends.

Yes — and the guideline specifically recommends that every patient diagnosed with allergic rhinitis be assessed for associated conditions including asthma, eczema, conjunctivitis, rhinosinusitis, ear fluid, and sleep-disordered breathing (snoring). Untreated allergic rhinitis causes chronic nasal inflammation that blocks the Eustachian tube and sinus drainage pathways. This is why children with recurrent ear infections or adults with chronic sinusitis often have underlying allergic rhinitis driving the problem. Treating the allergy frequently reduces the frequency of secondary infections.

The guideline lists allergen avoidance as an option — not a strong recommendation — because the evidence is mixed. For dust mite allergy: mattress covers, pillow covers, and washing bedding weekly in hot water have moderate evidence. HEPA air purifiers have limited evidence for overall benefit but reasonable evidence for pet dander reduction. Removing a pet from the home, if feasible, is the most effective environmental control for pet dander allergy. The honest answer is that avoidance measures help at the margins — they are worth doing but are unlikely to eliminate symptoms on their own.

See an ENT if: symptoms are not controlled after 4 to 6 weeks of daily intranasal steroid use, you have symptoms year-round rather than seasonally, you have nasal polyps, you have recurrent sinusitis or ear infections, you are interested in allergy testing and immunotherapy, or you have nasal obstruction that may have a structural component such as a deviated septum. Many patients with allergic rhinitis have a combination of allergic inflammation and structural problems — the ENT evaluates both.