Is It Just a Cold — or Could It Be an Allergy? Understanding Allergic Rhinitis in Children and Adults

• House dust mite is the dominant allergen in Singapore, causing year-round symptoms in a large proportion of patients with allergic rhinitis

• Allergy blood tests (IgE/RAST) have important limitations — some patients with florid allergy test negative, while others with high results have minimal symptoms; clinical assessment matters more than a number on a report

• When nasal blockage is severe enough to prevent medication reaching the nasal lining, surgery to reduce the turbinates can restore airflow and make medical treatment effective again

• Allergen immunotherapy can reduce symptoms significantly over time but requires a three to five year commitment, does not guarantee full resolution, and involves meaningful cost — expectations should be set carefully before starting

Persistent sneezing and a blocked nose are among the most common symptoms of allergic rhinitis — a condition frequently mistaken for a recurring cold.

By Dr Vyas M.N. Prasad, FRCS (ORL-HNS) Consultant Otolaryngologist & Head and Neck Surgeon, Camden Medical Centre, Singapore

A blocked nose, constant sneezing, itchy eyes — many people put up with these symptoms for years, assuming it is just how they are. In Singapore, where house dust mite allergens are present year-round, allergic rhinitis is one of the most common conditions I see in clinic. Yet it remains significantly underdiagnosed — and undertreated. Yet it remains significantly underdiagnosed. Many patients arrive having been treated repeatedly for colds or sinus infections, when the underlying problem is allergy that was never identified or adequately managed.

Allergic rhinitis affects a substantial proportion of the population in Singapore, in both children and adults. Many patients arrive having been treated repeatedly for colds or sinus infections, when the underlying problem is allergy that was never properly identified. Others have been managing symptoms with over-the-counter antihistamines for years without ever understanding what is driving them or whether better options exist.

Getting the diagnosis right — and understanding the full range of management options — makes a meaningful difference to quality of life.

What Is Allergic Rhinitis?

Allergic rhinitis is an immune reaction in the lining of the nose triggered by exposure to allergens — substances the immune system mistakenly identifies as harmful. The most common trigger in Singapore is the house dust mite, a microscopic organism that thrives in warm, humid climates and is found in bedding, soft furnishings, carpets, and air-conditioned spaces. Other common triggers include pet dander, mould, and — during certain periods — outdoor pollutants and haze.

When someone with allergic rhinitis is exposed to their trigger, the nasal lining becomes inflamed, producing the characteristic cluster of symptoms: sneezing, a runny or blocked nose, postnasal drip, and itching of the nose, eyes, or throat.

Allergic rhinitis can be seasonal or perennial. In Singapore's tropical climate, perennial allergic rhinitis driven by house dust mite is by far the most prevalent pattern — meaning symptoms are present most days of the year rather than at particular times.

How Does It Present Differently in Children and Adults?

In children, allergic rhinitis often presents alongside other allergic conditions — eczema, asthma, and food allergies frequently coexist as part of what is known as the atopic march. Children may not articulate their symptoms clearly. Instead, parents notice habitual nose-rubbing (the "allergic salute"), frequent sniffing, a persistently open mouth, dark circles under the eyes, or restless sleep. Disrupted sleep from nasal congestion is common and can contribute to problems with concentration and behaviour at school that are sometimes attributed to other causes.

In adults, the condition may have been present since childhood but never formally diagnosed. Many adults have simply adapted to a degree of nasal congestion they consider normal. Symptoms are more clearly described but are frequently labelled as recurrent colds or sinusitis without the underlying allergy ever being considered. Fatigue, reduced sleep quality, and impact on daily productivity are commonly reported.

When Allergy Leads to Other Problems

Allergic rhinitis rarely exists in isolation. Chronic nasal inflammation from allergy can contribute to or worsen a number of related conditions:

Sinusitis — persistent mucosal swelling obstructs the drainage pathways of the sinuses, leading to recurrent or chronic sinus infections.

Eustachian tube dysfunction and glue ear — the Eustachian tube connects the middle ear to the back of the nose, and nasal allergy can impair its function, causing ear pressure, muffled hearing, or recurrent fluid in the ears, particularly in children.

Snoring and sleep-disordered breathing — nasal obstruction from allergy increases airway resistance during sleep, contributing to snoring and in some cases obstructive sleep apnoea.

Asthma — the airway lining in the nose and lungs shares characteristics, and poorly controlled nasal allergy consistently makes asthma harder to manage.

Identifying and treating the allergy therefore has benefits that extend well beyond the nose.

How Is Allergic Rhinitis Assessed?

A thorough clinical history is the starting point — the pattern of symptoms, known triggers, family history of allergy, and any associated conditions. Nasal endoscopy allows direct visualisation of the nasal lining, the turbinates, the adenoids in children, and any structural factors that may be contributing to obstruction.

Allergy testing helps identify specific triggers. The two main methods are skin prick testing, which provides immediate results in clinic, and specific IgE blood testing (sometimes called RAST testing), which measures the level of allergy antibody to particular allergens.

It is important to understand the limitations of these tests. A high IgE result does not always mean a patient will have significant symptoms — some individuals have markedly elevated levels with relatively mild clinical allergy. Conversely, and perhaps more importantly, some patients with clearly florid allergic disease test negative or show only weakly positive results on blood testing. This is well recognised and does not mean the allergy is absent. Allergy testing is a tool to support clinical assessment, not replace it. The history, examination findings, and response to treatment all carry equal or greater weight than a number on a blood test report. Patients should not be falsely reassured by a negative test if their symptoms and clinical picture are consistent with allergy.

Management: A Layered Approach

Management is tailored to the individual and involves a combination of approaches depending on symptom severity, triggers, and the presence of structural factors.

Allergen avoidance is a useful foundation. For house dust mite allergy this includes allergen-impermeable mattress and pillow covers, regular hot washing of bedding, reducing soft furnishings, and maintaining good ventilation. Avoidance alone is rarely sufficient to control symptoms but reduces the allergen load and improves the effectiveness of other treatments.

Nasal saline irrigation helps clear allergens and inflammatory mediators from the nasal lining and can meaningfully improve mucosal function when used consistently.

Nasal corticosteroid sprays remain the most effective medical treatment for allergic rhinitis and work best when used regularly rather than on an as-needed basis. Correct technique matters significantly — many patients who report that sprays "don't work" have been using them incorrectly.

Antihistamines address sneezing and itch effectively but have limited effect on nasal blockage. Non-sedating options are preferred for daytime use.

Combination treatment — a nasal corticosteroid spray together with an antihistamine — is appropriate for moderate to severe symptoms and is more effective than either agent alone.

When Medication Is Not Enough: The Role of Surgery

There is an important practical limitation with nasal sprays that is often overlooked: if the nasal passages are so severely blocked that the spray cannot physically penetrate the nasal lining, it will not work regardless of how correctly it is applied. This is more common than it might sound, particularly in patients with significantly enlarged inferior turbinates — the structures along the floor and sides of the nose that swell in response to allergic inflammation.

In these cases, surgery has an important role, and there are several options depending on what is driving the problem.

Turbinate reduction addresses the enlarged inferior turbinates directly, reducing their size to restore nasal airflow. The procedure is minimally invasive, performed endoscopically, and has a good evidence base for improving nasal obstruction in allergic rhinitis. In many patients it makes a dramatic difference to nasal breathing and allows topical medication to work effectively for the first time.

Septoplasty is relevant where a deviated nasal septum is contributing to obstruction alongside the allergy. In many patients with chronic allergic disease the problem is both inflammatory and structural — and addressing only one component produces a limited result.

Vidian nerve cryotherapy is a more targeted surgical option for patients whose predominant symptoms are persistent watery rhinorrhoea, sneezing, and nasal hyperreactivity that are difficult to control with medication. The vidian nerve carries the parasympathetic nerve supply to the nasal mucosa — the nerve pathway responsible for driving the excessive mucus production and hypersensitivity response. Cryotherapy using liquid nitrogen to the vidian nerve interrupts this pathway, reducing the hyperreactivity of the nasal lining at its source. It is particularly useful in patients with allergic rhinitis, vasomotor rhinitis, and chronic rhinosinusitis where the runny, overreactive nose is the dominant and most debilitating feature. It can be performed as a day procedure and is an option worth discussing for patients who have not achieved adequate control with conventional medical and surgical management.

Where structural factors such as nasal polyps or sinus disease are also present, these may need to be addressed as part of a more comprehensive surgical plan.

Allergen Immunotherapy — What It Is and What to Expect

For patients with persistent, significant allergic rhinitis that does not respond adequately to medication, allergen immunotherapy is the only treatment that addresses the underlying immune mechanism rather than just managing symptoms. It works by gradually exposing the immune system to increasing amounts of the allergen, retraining it to tolerate rather than overreact to the trigger.

Immunotherapy is available in two forms — subcutaneous injections (SCIT), administered in clinic on a regular schedule, and sublingual drops or tablets (SLIT), which can be taken at home. Both have a reasonable evidence base for house dust mite allergy, which is the most relevant in Singapore.

There are several important points patients should understand before committing to immunotherapy:

It is a long-term commitment. A full course typically takes three to five years. Stopping early reduces the likelihood of a durable response.

Results vary. Many patients experience significant and lasting improvement in symptoms. Some achieve complete or near-complete resolution. Others see partial benefit. A proportion of patients do not respond meaningfully. It is not possible to predict with certainty how an individual will respond before starting.

It does not always produce full resolution. This is perhaps the most important expectation to set correctly. Immunotherapy is not a cure in every case — for many patients it is a significant reduction in symptom burden and medication dependence, which is a meaningful outcome but not the same as being symptom-free.

Cost is a consideration. Immunotherapy is an ongoing treatment over several years and involves regular clinic visits for injections or consistent daily use of sublingual preparations. The cumulative cost is significant and should be factored into the decision alongside the potential benefit.

For the right patient — someone with clearly identified triggers, significant impact on quality of life, and the commitment to a multi-year treatment programme — immunotherapy is a worthwhile option to discuss. For others, optimised medical management and surgical correction of any structural obstruction may be the more practical path.

When Should You Seek an Assessment?

If you or your child has had symptoms of nasal congestion, sneezing, or a runny nose for more than a few weeks — particularly if they recur or are present most of the time — it is worth seeking a specialist opinion. Similarly, if symptoms have been labelled as recurrent colds or sinusitis without improvement, underlying allergy may not have been adequately investigated.

Early assessment allows the full picture to be understood — including whether structural factors are contributing, what the allergy triggers are, and which management approach is most appropriate for the individual.

This article is for general informational purposes and does not constitute medical advice. If you are concerned about your symptoms or your child's health, please consult a qualified healthcare professional.

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