Hay fever and Rhinitis
Rhinitis is a very common condition and one I see frequently in ENT practice. Over many years as an ENT consultant in a tertiary unit in Oxford, I have assessed and treated a large number of patients with hay fever, allergic rhinitis, non-allergic rhinitis, persistent nasal blockage, and enlarged turbinates, both medically and surgically.
Although many people use the term hay fever to describe seasonal allergy symptoms, rhinitis is broader than that. It includes both allergic and non-allergic rhinitis, and in some patients there may also be structural factors such as enlarged turbinates, septal deviation, or associated sinus disease.
The turbinates are normal prong-like structures inside the nose. Their job is to help warm, humidify, and regulate the air as you breathe. If they become swollen or enlarged, they can contribute significantly to nasal blockage.
As a result, I do not take a one-size-fits-all approach. I assess the pattern of symptoms carefully, looking at seasonality, likely triggers, examination findings, the nasal cycle, whether there may also be sinus involvement, and how much symptoms are affecting day-to-day life before recommending the most appropriate treatment.
Many patients improve with well-targeted medical treatment. Others continue to struggle despite prolonged use of sprays or antihistamines, and in those cases I also assess whether procedures such as turbinoplasty, septoplasty, or, where sinus disease is also contributing, endoscopic sinus surgery, are likely to help.
What is the difference between hay fever, allergic rhinitis, and non-allergic rhinitis?
Hay fever is really a form of seasonal allergic rhinitis, usually triggered by pollen.
Allergic rhinitis means the nose is reacting to allergens such as pollen, house dust mite, animal dander, or mould. It may be seasonal, such as hay fever, or perennial, meaning symptoms occur all year round.
Non-allergic rhinitis causes similar symptoms, but not because of allergy. It is often more dominated by blockage and may be triggered by irritants, infection, medication, hormones, or nasal hyper-reactivity.
In general, sneezing, itching, a clear runny nose, and eye symptoms point more towards allergic rhinitis, whereas predominant blockage without much itching or sneezing points more towards non-allergic rhinitis.
What symptoms does rhinitis cause?
Typical symptoms include:
nasal blockage
clear runny nose
sneezing
itching in the nose
itchy or watery eyes
postnasal drip
reduced sense of smell
Eye symptoms are much more typical of allergic rhinitis than non-allergic rhinitis.
A particularly important symptom is alternating nasal obstruction — when one side feels more blocked, then later the other side does.
What is the nasal cycle, and why does it matter?
Everyone has a normal nasal cycle. This means the lining over the turbinates — the normal prong-like structures inside the nose that help with humidification — naturally swells a little on one side and then the other over the course of the day. Most people do not notice it.
In rhinitis, that normal cycle becomes exaggerated. The turbinates become more swollen and reactive, so instead of a subtle shift in airflow, patients notice obvious blockage that alternates from side to side.
This is one reason alternating obstruction is such a key symptom in rhinitis. It is also one reason a septal deviation is less likely to be the whole explanation when the blockage is clearly bilateral or alternating.
How do I assess rhinitis?
I usually want to know about:
seasonality
exposure to pets, dust, pollen, or work-related triggers
whether symptoms are mainly blockage or mainly itching, sneezing, and a runny nose
whether symptoms are intermittent or persistent
whether there is asthma or wheeze
whether medications may be contributing
smoking or irritant exposure
whether there may also be sinus involvement
Rhinitis and asthma often overlap, so I also think about the wider airway picture rather than treating the nose in isolation.
What is rhinitis medicamentosa?
This is a very common problem. Rhinitis medicamentosa means rebound nasal blockage caused by overuse of decongestant sprays or drops.
Examples include products such as Otrivine and Sudafed nasal sprays. These can be very helpful for a few days during a bad cold or severe congestion, but if they are used for too long the nose can become dependent on them. The blockage then comes back quickly, often worse than before, which leads to more spray use and a vicious cycle.
The key point is that if decongestants are being used long term, they need to be stopped. This can be difficult, because the nose often feels dramatically more blocked at first when they are withdrawn. However, continuing them usually keeps the problem going.
In some patients, I prescribe other treatment to make that withdrawal easier, particularly nasal steroid treatment and saline rinses while the lining recovers.
Do I need allergy testing?
Not always.
If the story is very typical for mild seasonal hay fever and symptoms respond well to antihistamines, it is often reasonable to treat on that basis.
Allergy testing becomes more useful when:
symptoms are more severe
the pattern is not clear
symptoms are resistant to first-line treatment
immunotherapy might be relevant
there is a need to clarify specific triggers
What are the main treatment options?
Treatment depends on the dominant symptom pattern, severity, and whether there are structural factors contributing to nasal obstruction.
1. Saline rinses
Saline irrigation is one of the most useful starting points, especially for congestion, mucus, irritants, and postnasal drip. It can also help steroid sprays or drops work better by clearing the nose first.
A simple home saline rinse can be made using:
240 mL previously boiled and cooled water
¼ teaspoon salt
¼ teaspoon bicarbonate of soda
The solution should be freshly made, used at room temperature, and not stored for more than 24 hours.
A good practical routine is to use the saline rinse first, then wait a few minutes, and then use the steroid spray or drops.
Commercial saline products can also be helpful. Sterimar is a reasonable option for patients who prefer a ready-made saline spray, and NeilMed can be very useful for those who prefer a bottle-based rinse system. Many pharmacies also sell their own versions of both spray and rinse systems, which can work just as well.
2. Antihistamines
For allergic-type symptoms such as sneezing, itching, a clear runny nose, and eye symptoms, antihistamines can help. This may be:
an oral non-sedating antihistamine
or an intranasal antihistamine spray
If allergic symptoms are clearly mild and intermittent, antihistamines alone may be enough.
3. Nasal steroid treatment
For more persistent or more troublesome rhinitis, nasal steroid treatment is often the most important part of management.
A key point is that treatment can be escalated depending on symptom severity. For some patients, a standard nasal spray is enough. For others with more marked blockage or inflammation, treatment may need to be stepped up for a period using higher-dose preparations such as steroid drops or nasules. In selected adults with particularly severe symptoms, marked blockage, or significant associated sinus inflammation, a short course of oral steroid tablets may occasionally be appropriate as well.
In the longer term, the aim is usually to bring treatment back down to the lowest effective steroid dose, and in most patients that means a standard nasal steroid spray. Steroid sprays and drops work well in the nose and generally have fewer side effects than steroid tablets, which is why sprays are usually the mainstay of long-term control.
Another important point is that nasal steroids are not quick fixes. They can take time to reach their full effect, so a short trial is often misleading.
Technique matters. I usually advise patients to:
blow the nose gently first
keep the head upright
use the opposite hand to the opposite nostril
aim the spray towards the ear
breathe in gently as you spray
avoid sniffing hard afterwards
That technique helps direct the spray to the right part of the nose and reduces the chance of irritation to the septum.
4. Combination sprays and other targeted treatments
If a simple steroid spray is not enough, a combination spray containing a steroid and an antihistamine can be very effective.
Other targeted treatments may help depending on the symptom pattern:
short-term decongestant sprays for severe blockage only
steroid drops or nasules for marked obstruction
ipratropium spray if a watery runny nose is a major problem
5. Allergy desensitisation
In selected patients with clearly confirmed allergic rhinitis, allergy desensitisation may sometimes be an option. This is usually directed at a single allergen and is typically managed through a specialist allergy clinic rather than as a general rhinitis treatment for everyone.
What if the nose is mainly blocked?
If obstruction is the main issue, I think carefully about whether the problem is:
inflammatory swelling from rhinitis
enlarged turbinates
a deviated septum
sinus disease
or a combination of these
Not all patients with blockage need surgery. In many cases, medical treatment works well when it is used properly and for long enough.
However, turbinoplasty can be a very good option for the right patient, especially when enlarged turbinates remain a major problem despite appropriate medical treatment. Sometimes it is combined with septoplasty, and sometimes turbinate surgery is performed alongside surgery on the sinuses where both problems are contributing.
There is a separate page on this website with more information about turbinate surgery.
Does surgery cure rhinitis?
Not completely.
Surgery can improve the physical space inside the nose and reduce the effect of swollen turbinates or structural narrowing, but it does not remove environmental triggers. That is why even after successful surgery, treatment often still needs to continue in some form, such as saline rinses, nasal steroid treatment, allergy management, or trigger avoidance.
What if there is sinus involvement as well?
Sometimes rhinitis is not the whole story.
If there is facial pressure, recurrent sinus infections, reduced smell, thick mucus, or ongoing symptoms despite appropriate rhinitis treatment, there may also be sinus involvement. In those cases, the sinuses may need to be assessed and treated as part of the wider picture rather than focusing on the nose alone.
Where significant chronic sinus disease is present and symptoms are still not well controlled despite appropriate medical treatment, endoscopic sinus surgery may sometimes be needed as part of the overall treatment plan.
When is further assessment important?
I would usually want to assess patients more carefully if there are:
symptoms not improving with well-used medical treatment
mainly one-sided symptoms
blood-stained discharge
facial or orbital pain
headache or visual symptoms
new loss of smell with unilateral symptoms
concern about structural problems
possible sinus disease
Helpful resources
Disclaimer
This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice.
I do not have any financial interest in any of the products mentioned.