Rhinitis & nasal congestion

Pre-referral guidelines for primary care providers

Rhinitis or rhinosinusitis is common in childhood and involves inflammation of the mucosa of the nasal passages and nasal sinuses. It is commonly caused by allergy (hay fever), infection, obstruction or chemical irritation.

Allergic rhinitis (hay fever) is commonly familial and is seen in children with atopy, which includes asthma, eczema, rhinitis and food allergies.

Sinusitis on its own is commonly infective, either viral or bacterial.

Nasal congestion may be caused by rhinosinusitis, however may be purely obstructive, as in the case of adenoid hypertrophy.

For further details on rhinosinusitis, specifically bacterial sinusitis, please refer to the Royal Children’s Hospital clinical practice guidelines.

Also see the Royal Children's Hospital pre-referral guidelines for allergic rhinitis hay fever.


Rhinitis is a clinical diagnosis, previously classified as seasonal or perennial, although now considered either intermittent (symptoms < 4 days/week or < 4 weeks at a time) or persistent. It is characterised by:

  • sneezing paroxysms
  • rhinorrhoea
  • nasal obstruction
  • pruritis to the nose, pharynx, palate & ears
  • ocular pruritis, redness & tearing
  • 'bags' under the eyes
  • often a strong past or family history of atopy.

Sinusitis often presents with the additional signs of

  • maxillary toothache
  • unilateral facial pain
  • headache
  • fever

No investigations are required for the diagnosis of rhinitis, whereas sinusitis can be assisted by a CT scan (however one must weigh up the radiation dose).

Practice points

  • Rhinitis is a clinical diagnosis, no investigations are required.
  • Management is generally with intranasal steroids and/or oral antihistamines for breakthrough symptoms as needed.
  • Skin prick testing is only useful when other management strategies have failed.
  • Antibiotics are only required when sinusitis is present.
  • Most cases of rhinosinusitis can be managed by the general practitioner.
  • ENT referral is generally only required when all other management steps have failed and there is ongoing severe obstructive symptoms.


Rhinitis can be managed with the following steps:

  • wait and watch - most cases of rhinosinusitis in children is self limiting.
  • allergy avoidance (when practical).
  • intranasal steroids (e.g. Nasonex, Avamys) one spray each day for 4-6 weeks as a preventer.
  • oral antihistamines for breakthrough symptoms.
  • it is also important to manage any concomitant asthma, eczema or food allergies given one atopic manifestation may trigger the other.
  • skin prick testing is indicated when symptom management as above has failed and in atopic children who also have moderate asthma.
  • immunotherapy can be considered when all of the above has failed and there is a history indicating a clear allergic sensitisation.

Sinusitis can be managed with the above steps, as well as:

Nasal obstruction

  • Most cases of nasal obstruction will respond to management of rhinitis in younger children, and again a wait and watch approach is often sensible.
  • Consideration of adeniodectomy for nasal obstruction should only be undertaken when other management strategies have failed and the symptoms are severe, including impacting on quality of sleep.

Referral pathways