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llergic rhinitis (AR) is one of the most common dis- symptoms of AR are sneezing, stuffy nose, runny nose, post-
eases affecting adults.1 It is the most common chronic nasal drip and/or itchy nose.
disease in children in the United States today2 and is Allergic rhinitis may be classified by (1) the temporal pat-
the fifth most chronic disease in the United States overall.3 tern of exposure to a triggering allergen as seasonal (eg, pol-
Allergic rhinitis is estimated to affect nearly 1 in every 6 lens), perennial/year round (eg, dust mites), or episodic
Americans and generates $2 to $5 billion in direct health (environmental from exposures not normally encountered in
expenditures annually.4,5 It can impair quality of life and, the patient’s environment, eg, visiting a home with pets); (2)
through loss of work and school, is responsible for as much as frequency of symptoms; and (3) severity of symptoms.
Term Definition
Allergic rhinitis (AR) Allergic rhinitis is an IgE-mediated inflammatory response of the nasal mucous membranes after
exposure to inhaled allergens. Symptoms include rhinorrhea (anterior or posterior nasal
drainage), nasal congestion, nasal itching, and sneezing.
Seasonal allergic rhinitis (SAR) Caused by an IgE-mediated inflammatory response to seasonal aeroallergens. The length of
seasonal exposure to these allergens is dependent on geographic location and climatic
conditions.
Perennial allergic rhinitis (PAR) Caused by an IgE-mediated inflammatory response to year-round environmental aeroallergens.
These may include dust mites, mold, animal allergens, or certain occupational allergens.
Intermittent allergic rhinitis Caused by an IgE-mediated inflammatory response and is characterized by frequency of exposure/
symptoms (<4 days/week or <4 weeks/year).
Persistent allergic rhinitis Caused by an IgE-mediated inflammatory response and is characterized by persistent symptoms
(>4 days/week and >4 weeks/year).
Episodic allergic rhinitis Caused by an IgE-mediated inflammatory response and can occur if an individual is in contact with
an exposure that is not normally a part of the individual’s environment (ie, a cat at your friend’s
house).
Classifying AR in this manner may assist in choosing the most who has symptoms 3 days/week year round would be classi-
appropriate treatment strategies for an individual patient. fied as “intermittent” even though he or she would more
In the United States, AR has traditionally been viewed as closely resemble a “persistent” patient. It may be best for the
either seasonal or perennial, and it is this classification system patient and the provider to determine which frequency cate-
that the Food and Drug Administration (FDA) uses when gory is most appropriate and would best guide the treatment
approving new medications for AR. However, it is recognized plan. Based on these definitions, it is possible that a patient
that this classification system has limitations, as the length of may have intermittent symptoms with perennial AR or persis-
the aeroallergen pollen season is dependent on geographic tent symptoms with seasonal AR.
location and climatic conditions. When the pollen season is Allergic rhinitis severity can be classified as mild (when
year round (eg, tropical locations), it can be very difficult symptoms are present but are not interfering with quality of
based on history to distinguish allergic symptoms provoked life) or more severe (when symptoms are bad enough to inter-
by exposure to pollen from symptoms caused by exposure to fere with quality of life).6,7 Factors that may lead to a more
allergens that are perennial in temperate zones (eg, dust mites). severe classification include exacerbation of coexisting
Mold has been considered both a seasonal and a perennial asthma; sleep disturbance; impairment of daily activities, lei-
allergen.6 Furthermore, it is recognized that many patients sure, and/or sport; and impairment of school or work.
with AR have perennial AR exacerbated by seasonal pollen
exposure, and many patients are polysensitized so the clinical Purpose
implications of seasonal vs perennial are not as clear.6 The primary purpose of this guideline is to address quality
Classifying a patient’s symptoms by frequency and sever- improvement opportunities for all clinicians, in any setting,
ity allows for more appropriate treatment selection. Allergic who are likely to manage patients with AR, as well as to opti-
rhinitis symptom frequency has been divided into intermittent mize patient care, promote effective diagnosis and therapy,
(<4 days/week or <4 weeks/year) and persistent (>4 days/ and reduce harmful or unnecessary variations in care. The
week and >4 weeks/year).6 However, this classification of guideline is intended to be applicable for both pediatric and
symptom frequency has limitations. For example, the patient adult patients with AR. Children younger than 2 years were
1
Department of Otolaryngology–Head and Neck Surgery, Henry Ford West Bloomfield Hospital, West Bloomfield, Michigan, USA; 2Department of Surgery
Otolaryngology–Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA; 3Department of Otolaryngology–Head and Neck Surgery, Johns
Hopkins School of Medicine, Baltimore, Maryland, USA; 4Virginia Mason Medical Center, Seattle, Washington, USA; 5Department of Otolaryngology, University
of Chicago Medical Center, Chicago, Illinois, USA; 6Birmingham VA Medical Center, Birmingham, Alabama, USA; 7Otolaryngology–Private Practice, Muscatine,
Iowa, USA; 8Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Missouri, USA; 9Pomona Pediatrics, Pomona, New York, USA;
10
Eastern Virginia Medical School, Norfolk,Virginia, USA; 11Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA; 12Wayne State University,
Philadelphia, Pennsylvania, USA; 13Georgetown University Hospital, Washington, DC, USA; 14Wake Forest Baptist Health, Winston Salem, North Carolina,
USA; 15Morehouse School of Medicine, East Point, Georgia, USA; 16Acupuncture and Oriental Medicine (AAAOM), Annandale,Virginia, USA; 17Florida Atlantic
University, Boca Raton, Florida, and Nova Southeastern University, Davie, Florida, USA; 18Consumers United for Evidence-based Healthcare, Fredericton, New
Brunswick, Canada; 19Louisiana State University School of Medicine, New Orleans, Louisiana, USA; 20Department of Research and Quality, American Academy
of Otolaryngology—Head and Neck Surgery Foundation, Alexandria,Virginia, USA.
Corresponding Author:
Michael D. Seidman, MD, Henry Ford West Bloomfield Hospital, 6777 West Maple Rd, West Bloomfield, MI 48322, USA.
Email: mseidma1@hfhs.org
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Seidman et al 199
Prevention/Education/Risk
Diagnosis/Testing Treatment Factors Other Therapies Outcomes
• Diagnosis of allergic • First-line therapy on • Methods for preventing • Role of acupuncture • Initial evaluation of the
rhinitis diagnosis the development of patient
allergic rhinitis
• Differentiating • When does combining • Role of patient • R
ole of herbal • Improve accurate
nonallergic nasal 2 different classes of education medicines diagnosis; avoidance of
conditions from allergy pharmacology unnecessary testing
allergic rhinitis benefit the patient
• When should a patient • Pharmacology and the • When is it appropriate • Role of homeopathy • Reduction in care
be referred to an allergy different medication to manage symptoms variation and
specialist classes that offer over the phone (or unnecessary radiation
additive vs negative Internet) exposure from sinonasal
effects imaging
• Differentiating perennial • Self-directed therapy • Role of dietary • Role of nasal rinses • Expenditure reduction
or seasonal allergic or over-the-counter modifications for ineffective
rhinitis medications vs physician- environmental measures
directed or prescription
medications
a
This list was created by the Guideline Development Group to refine content and prioritize action statements; not all items listed were ultimately included in
the guideline.
excluded in this CPG because rhinitis in this population may summarized in Table 3, with the corresponding action state-
be different than in older patients and is not informed by the ments and profiles reproduced below. Supporting text and
same evidence base. complete citations can be found in the guideline proper.10
The guideline is intended to focus on a select number of
quality improvement opportunities deemed most important by Key Action Statements
the working group and is not intended to be a comprehensive STATEMENT 1. PATIENT HISTORY AND PHYSICAL
reference for diagnosing and managing AR. The recommen- EXAMINATION: Clinicians should make the clinical
dations outlined in the guideline are not intended to be an all- diagnosis of AR when patients present with a history and
inclusive guide for patient management, nor are the physical exam consistent with an allergic cause and one or
recommendations intended to limit treatment or care provided more of the following symptoms: nasal congestion, runny
to individual patients. The guideline is not intended to replace nose, itchy nose, or sneezing. Findings of AR consistent
individualized patient care or clinical judgment. Its goal is to with an allergic cause include, but are not limited to, clear
create a multidisciplinary guideline with a specific set of rhinorrhea, nasal congestion, pale discoloration of the
focused recommendations based on an established and trans- nasal mucosa, and red and watery eyes. Recommendation
parent process that considers levels of evidence, harm-benefit based on observational studies, with a preponderance of ben-
balance, and expert consensus to resolve gaps in evidence.8 efit over harm.
These specific recommendations may then be used to develop
performance measures and identify avenues for quality
Action Statement Profile
improvement. Table 2 highlights the topics and issues con-
•• Quality improvement opportunity: To promote a con-
sidered in the development of this guideline.
sistent and systematic approach to initial evaluation
of the patient with allergic rhinitis
Methods •• Aggregate evidence quality: Grade C, based on
This guideline was developed using an explicit and transpar- observational studies
ent a priori protocol for creating actionable statements based •• Level of confidence in evidence: High
on supporting evidence and the associated balance of benefit •• Benefits: Avoid unnecessary treatment or testing,
and harm.9 The Guideline Development Group (GDG) con- have appropriately timed referral, institute a specific
sisted of 20 panel members representing experts in otolaryn- therapy, improve quality of life (QOL) and produc-
gology, allergy and immunology, internal medicine, family tivity, improve accurate diagnosis
medicine, pediatrics, sleep medicine, advanced practice nurs- •• Risks, harms, costs: Inappropriate treatment, poten-
ing, complementary and alternative medicine (acupuncture tial misdiagnosis from using history and physical
and herbal therapies), and consumer advocacy. For additional alone
details on methodology, please refer to the complete text •• Benefit-harm assessment: Preponderance of benefit
of the guideline.10 The 14 guideline recommendations are over harm
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200 Otolaryngology–Head and Neck Surgery 152(2)
•• Value judgments: Although the GDG recognized that and physical exam consistent with an allergic cause”
a conclusive diagnosis of allergic rhinitis is difficult assumes that a clinician will know how to make an
without diagnostic testing, making a presumptive appropriate diagnosis of allergic rhinitis. Specifics of
diagnosis of allergic rhinitis based on history and what constitutes a history and physical exam consistent
physical examination alone is reasonable with an allergic cause are provided in the supporting
•• Intentional vagueness: The use of the words “clini- text.
cal diagnosis” acknowledges that this is a presump- •• Role of patient preferences: Limited—patient may
tive diagnosis not confirmed with testing. The use of request additional testing be conducted before decid-
the words “when patients present with a history ing on initiation of treatment
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Seidman et al 201
•• Intentional vagueness: None •• Risks, harms, costs: Topical side effects, epitaxis,
•• Role of patient preferences: Large—shared decision drug side effects, potential growth concerns in chil-
making in discussion of evidence for effectiveness dren, septal perforation, and the cost of medication
of possible controls and the need to weigh the costs •• Benefit-harm assessment: Preponderance of benefit
and benefits over harm
•• Exclusions: None •• Value judgments: None
•• Policy level: Option •• Intentional vagueness: None
•• Difference of opinion: None •• Role of patient preferences: Large—there are mul-
tiple classes of effective therapy with differing risks,
STATEMENT 5. CHRONIC CONDITIONS AND adverse effects, costs, and benefits. The clinician
COMORBIDITIES: Clinicians should assess patients with should use his or her expertise in assisting patients
a clinical diagnosis of allergic rhinitis for, and document in to evaluate the best treatment and to ensure patient
the medical record, the presence of associated conditions compliance.
such as asthma, atopic dermatitis, sleep-disordered breath- •• Exclusions: None
ing, conjunctivitis, rhinosinusitis, and otitis media. •• Policy level: Strong Recommendation
Recommendation based on randomized trials with some hetero- •• Differences of opinions: Minor. There were some dif-
geneity and a preponderance of benefit over harm. ferences of opinion as to what the best therapies for
mild or intermittent symptoms are, as oral or nasal anti-
Action Statement Profile histamines may be adequate therapy for those patients
•• Quality improvement opportunity: Identification of
significant comorbid conditions or complications. STATEMENT 7. ORAL ANTIHISTAMINES: Clinicians
Potential for treatment optimization should recommend oral second-generation/less sedating
•• Aggregate evidence quality: Grade B, based on ran- antihistamines for patients with allergic rhinitis and pri-
domized trials with some heterogeneity mary complaints of sneezing and itching. Strong
•• Level of confidence in the evidence: High Recommendation based on randomized controlled trials with
•• Benefits: Increased awareness of these conditions, minor limitations and a preponderance of benefit over harm.
identification of treatable conditions, and knowledge
of these conditions may alter recommendations for Action Statement Profile
allergic rhinitis treatment as comorbid conditions can •• Quality improvement opportunity: Avoidance of
alter response to treatment sedating antihistamine use and promotion of use of
•• Risks, harms, costs: Potential erroneous diagnosis of effective symptom-directed therapy
comorbid conditions •• Aggregate evidence quality: Grade A, based on ran-
•• Benefit-harm assessment: Preponderance of benefit domized controlled trials with minor limitations
over harm •• Level of confidence in evidence: High
•• Value judgments: None •• Benefits: Rapid onset of action, oral administration,
•• Intentional vagueness: None relief of symptoms, over-the-counter availability,
•• Role of patient preferences: None potentially cost saving (generic brand), relief of eye
•• Exclusions: None symptoms
•• Policy level: Recommendation •• Risks, harms, costs: Systemic side effects (sedation),
•• Differences of opinion: None dry eyes, urinary retention
•• Benefit-harm assessment: Preponderance of benefit
STATEMENT 6. TOPICAL STEROIDS: Clinicians over harm
should recommend intranasal steroids for patients with a •• Value judgments: None
clinical diagnosis of allergic rhinitis whose symptoms •• Intentional vagueness: None
affect their quality of life (QOL). Strong Recommendation •• Role of patient preferences: Large—shared decision
based on randomized controlled trials with minor limitations making in considering the benefits, harms, costs,
and a preponderance of benefit over harm. and evaluation of the best treatment options. Clini-
cians should offer a comparison of evidence for the
Action Statement Profile effectiveness of oral vs nasal administration of anti-
•• Quality improvement opportunity: Optimizing the histamines and nasal steroids that will provide good
use of proven effective therapy patient adherence and treatment efficacy
•• Aggregate evidence quality: Grade A, based on ran- •• Exclusions: None
domized controlled trials with minor limitations •• Policy level: Strong Recommendation
•• Level of confidence in the evidence: High •• Differences of opinions: None
•• Benefits: Improved symptom control, improved
QOL, better sleep, potential cost saving with mono- STATEMENT 8. INTRANASAL ANTIHISTAMINES:
therapy, targeted local effect Clinicians may offer intranasal antihistamines for patients
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Seidman et al 203
with seasonal, perennial, or episodic allergic rhinitis. •• Benefits: Avoid ineffective or less effective therapy,
Option based on randomized controlled trials with minor cost saving, decreased variations in care
limitations and observational studies, with equilibrium of •• Risks, harms, costs: There may be a subset of patients
benefit and harm. who would benefit from this medication (ie, patient
with both AR and asthma)
Action Statement Profile •• Benefit-harm assessment: Preponderance of benefit
•• Quality improvement opportunity: Improve aware- over harm
ness of this class of medications as another effective •• Value judgments: The panel was concerned with
treatment for allergic rhinitis that may be an alterna- the cost of this medication in combination with
tive to other medication classes the evidence that it is less effective than first-line
•• Aggregate evidence quality: Grade A, based on ran- medications
domized controlled trials with minor limitations and •• Intentional vagueness: None
observational studies •• Role of patient preferences: Low—rare patients
•• Level of confidence in evidence: High, but most of with intolerance of intranasal therapy and concerns
the trials were of short duration regarding somnolence may benefit from consider-
•• Benefits: Rapid onset, increased effectiveness over ation of use of this class of medicine
oral antihistamines for nasal congestion •• Exclusions: Patient with concurrent diagnosis of
•• Risks, harms, costs: Increased cost relative to oral asthma. These patients may benefit from oral leukot-
antihistamines, poor taste, sedation, more frequent riene receptor antagonists as a first-line therapy
dosing, epistaxis, local side effects •• Policy level: Recommendation
•• Benefit-harm assessment: Equilibrium •• Differences of opinion: None
•• Value judgments: The GDG felt that in general, this
class of medications would represent second-line STATEMENT 10. COMBINATION THERAPY:
therapy after failure of nasal steroids or oral antihis- Clinicians may offer combination pharmacologic therapy
tamines due to poor acceptance due to taste and cost in patients with allergic rhinitis who have inadequate
but that there may be specific patients in whom this response to pharmacologic monotherapy. Option based on
class would be an appropriate first-line therapy randomized controlled trials with minor limitations and
•• Intentional vagueness: None observational studies, with equilibrium of benefit and harm.
•• Role of patient preferences: Large—there is equilib-
rium of benefits to risks when using intranasal anti- Action Statement Profile
histamine. Shared decision making may help ensure •• Quality improvement opportunity: Reduce variations
that the patient understands the potential benefits vs in care, improve symptom control
harms of undergoing this treatment, while also pro- •• Aggregate evidence quality: Grade A, based on ran-
moting patient compliance with medication domized controlled trials with limitations, observa-
•• Exclusions: Not approved for children younger than tional studies
age 5 years •• Level of confidence in evidence: High. There is
•• Policy level: Option strong evidence supporting the use of some combi-
•• Differences of opinion: Minor; there are reasonable data nations and the ineffectiveness of other combinations
supporting their use, but there was some debate regard- •• Benefits: Improved effectiveness and symptom con-
ing the harm-benefit ratio leading this to be an option. trol of combined therapy
Several panel members thought these should be recom- •• Risks, harms, costs: Increased cost, overuse of medi-
mended at the same level as oral antihistamines cation, use of ineffective combinations, multiple
medication side effects, drug interactions
STATEMENT 9. ORAL LEUKOTRIENE RECEPTOR •• Benefit-harm assessment: Equilibrium
ANTAGONISTS (LTRAs): Clinicians should not offer •• Value judgments: None
oral leukotriene receptor antagonists as primary therapy •• Intentional vagueness: The term “combination
for patients with allergic rhinitis. Recommendation against therapy” is nonspecific as there are multiple differ-
based on randomized controlled trials and systematic reviews, ent combinations. The details are elaborated in the
with a preponderance of benefit over harm. supporting text. The term “inadequate response to
monotherapy” also allows for some interpretation by
Action Statement Profile clinicians and patients
•• Quality improvement opportunity: Reduced use of a •• Role of patient preferences: Moderate—shared deci-
less effective agent for initial therapy sion making in consideration of evidence for benefits,
•• Aggregate evidence quality: Grade A, based on ran- harms and cost of combinations, effective dosing,
domized controlled trials and systematic reviews and potential medication interactions to assist the
•• Level of confidence in evidence: High patient in more effective treatment compliance
•• Exclusions: Decongestants that are part of some inferior turbinate reduction in patients with allergic rhinitis
combined products are not approved for children with nasal airway obstruction and enlarged inferior turbi-
younger than age 4 years nates who have failed medical management. Option based on
•• Policy level: Option observational studies, with a preponderance of benefit over harm.
•• Differences of opinion: None
Action Statement Profile
STATEMENT 11. IMMUNOTHERAPY: Clinicians •• Quality improvement opportunity: Improved nasal
should offer or refer to a clinician who can offer immuno- breathing and QOL
therapy (sublingual or subcutaneous) for patients with •• Aggregate evidence quality: Grade C, based on
allergic rhinitis who have inadequate response to symp- observational studies
toms with pharmacologic therapy with or without envi- •• Level of confidence in the evidence: Moderate
ronmental controls. Recommendation based on randomized •• Benefits: Improved symptoms, improved QOL,
controlled trials and systematic reviews, with a preponder- improved medication delivery, reduced medication
ance of benefit over harm. use, better sleep
•• Risks, harms, costs: Unnecessary surgery, cost of
Action Statement Profile surgery, risks of surgery, atrophic rhinitis
•• Opportunity for quality improvement: Increased •• Benefit-harm assessment: Balance of benefit and harm
appropriate use of immunotherapy and reduce varia- •• Value judgments: The panel felt that despite the lack
tion in care, increased awareness of immunotherapy of head-to-head trials between medical and surgical
•• Aggregate evidence quality: Grade A, based on ran- therapy, surgery should be reserved for patients fail-
domized controlled trials and systematic reviews ing medical therapy due to the higher risk of any sur-
•• Level of confidence in evidence: High gical management
•• Benefits: Altered natural history, improved symptom •• Intentional vagueness: The panel elected to use the
control, decreased need for medical therapy, long- term “failure of medical therapy” as there are cir-
term cost effectiveness, may improve or prevent cumstances where inferior turbinate reduction may
asthma or other comorbidities, and may prevent new be beneficial for symptom control even if there is
sensitizations some response to medical therapy
•• Risks, harms, costs: Local reactions, and systemic •• Role of patient preferences: Large—clinicians should
reactions including anaphylaxis, increased initial use a shared decision-making process about the risks,
cost, frequency of treatment (logistics), pain of injec- benefits, and costs of undergoing surgery and associ-
tion, delayed onset of symptom control (months) ated use of anesthesia
•• Benefit-harm assessment: Preponderance of benefit •• Exclusions: Patients who are not surgical candidates
over harm •• Policy level: Option
•• Value judgments: None •• Differences of opinion: Minor difference of opinion
•• Intentional vagueness: We elected to use the term whether allergic rhinitis is an independent risk factor
“inadequate response” to medical therapy as there for turbinate hypertrophy
are circumstances where immunotherapy may be
beneficial for symptom control even if there is some STATEMENT 13. ACUPUNCTURE: Clinicians may offer
response to medical therapy since immunotherapy acupuncture, or refer to a clinician who can offer acupunc-
addresses the underlying pathophysiology of atopy ture, for patients with allergic rhinitis who are interested in
•• Role of patient preferences: Large—there are poten- nonpharmacologic therapy. Option based on randomized con-
tial risks, harms, and costs associated with the use of trolled trials with limitations, observational studies with consis-
immunotherapy and a delayed onset. Shared decision tent effects, and a preponderance of benefit over harm.
making may help the patient understand the potential
harms of undergoing this treatment. In addition, the Action Statement Profile
efficacy of using this mode of therapy also depends •• Quality improvement opportunity: Increased aware-
on patient compliance with frequency and duration ness of acupuncture as a treatment option for allergic
of treatment, as well as delay in onset of effect with rhinitis
immunotherapy •• Aggregate evidence quality: Grade B, based on ran-
•• Exclusions: Uncontrolled asthma domized controlled trials with limitations, observa-
•• Policy level: Recommendation tional studies with consistent effects
•• Differences of opinion: Minor; some panel members felt •• Level of confidence in evidence: Low; the random-
that immunotherapy could be offered as first-line treat- ized trials did not show comparison to traditional
ment to patients who elect not to use medical therapy medical therapy for allergic rhinitis and had meth-
odological flaws
STATEMENT 12. Inferior Turbinate Reduction: •• Benefits: Effective alternative to medical therapies,
Clinicians may offer, or refer to a surgeon who can offer, reduction of symptoms, may more closely align with
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Seidman et al 205
patient values, improved quality of life, avoidance of clinical indicators and guidelines are promoted as conditional and
medication use and potential side effects provisional proposals of what is recommended under specific con-
•• Risks, harms, costs: Logistics of multiple treatments, ditions but are not absolute. Guidelines are not mandates; these do
need for multiple needle sticks, cost of treatment, not and should not purport to be a legal standard of care. The
responsible physician, in light of all circumstances presented by
rare infections
the individual patient, must determine the appropriate treatment.
•• Benefit-harm assessment: Equilibrium of benefit and Adherence to these guidelines will not ensure successful patient
harm outcomes in every situation. The American Academy of
•• Value judgments: Panel members varied in their pre- Otolaryngology—Head and Neck Surgery Foundation emphasizes
conceived bias for or against acupuncture that these clinical guidelines should not be deemed to include all
•• Intentional vagueness: None proper treatment decisions or methods of care, or to exclude other
•• Role of patient preferences: Limited—potential for treatment decisions or methods of care reasonably directed to
shared decision making obtaining the same results.
•• Exclusions: None
•• Policy level: Option Author Contributions
•• Differences of opinions: None Michael D. Seidman, writer, chair; Richard K. Gurgel, writer,
assistant chair; Sandra Y. Lin, writer, assistant chair; Seth R.
STATEMENT 14. HERBAL THERAPY: No recommen- Schwartz, methodologist; Fuad M. Baroody, writer; James R.
dation regarding the use of herbal therapy for patients Bonner, writer; Douglas E. Dawson, writer; Mark S. Dykewicz,
with allergic rhinitis. No recommendation based on limited writer; Jesse M. Hackell, writer; Joseph K. Han, writer; Stacey L.
knowledge of herbal medicines, concern about the quality of Ishman, writer; Helene J. Krouse, writer; Sonya Malekzadeh,
writer; James (Whit) W. Mims, writer; Folashade S. Omole, writer;
standardization, and safety.
William D. Reddy, writer; Dana V. Wallace, writer; Sandra A.
Walsh, writer; Barbara E. Warren, writer; Meghan N. Wilson,
Action Statement Profile writer; Lorraine C. Nnacheta, writer and AAO-HNSF staff
•• Quality improvement opportunity: Not applicable liaison.
•• Aggregate evidence quality: Uncertain
•• Level of confidence in evidence: Low. Many of the Disclosures
studies were small and of questionable methodology.
Competing interests: Michael D. Seidman, medical director on
The meta-analyses were done in English but looked Scientific Advisory Board–Visalus; founder of Body Language
at articles from the Chinese literature, which are not Vitamin Co; National Institutes of Health grant on simulation; 6
available for assessment by the panel patents but related to supplements, aircraft, and the middle ear and
•• Benefits: Improved awareness of alternative treat- brain implant; Sandra Y. Lin, consultant for Wellpoint; Fuad M.
ments, improved education of side effects of herbal Baroody, speaker for Merck, Inc; speaker for GlaxoSmithKline and
therapy speaker/consultant for Acclarent/Johnson/Johnson; Mark S.
•• Risks, harms, costs: Not applicable Dykewicz, consultant for Merck and research contract support to
•• Benefit-harm assessment: Not applicable Saint Louis University for Novartis; Jesse M. Hackell,
•• Value judgments: There are many herbal therapies, GlaxoSmithKline (speakers bureau); Sunovion Pharmaceuticals, Inc
but there is only evidence for a few that have appro- (advisory board) and has had discussions regarding nasal corticoste-
riods; Transit of Venus (advisory board); Joseph K. Han, Medtronic
priate studies. There is limited knowledge about
research grant; principal investigator and consultant on clinical study
these products among most of the panel members, with Intersect; speaker for Merck; Stacey L. Ishman, consultant for
and accordingly there was a bias against their use. First Line Medical; Dana V. Wallace, TEVA (speakers bureau);
There is concern about the quality of standardization Sanofi (advisory panel and speakers bureau); Mylan (advisory board
of herbal medicines and their safety and speakers bureau); Sunovian (speakers bureau); MEDA (advisory
•• Intentional vagueness: None panel and speakers bureau); ACAAI Executive Committee Chair and
•• Role of patient preferences: None Board of Regents, Rhinitis/Sinusitis Committee; AAAAI/ACAAI/
•• Exclusions: None JCAAI Practice Parameter Joint Task Force.
•• Policy level: No recommendation Sponsorships: American Academy of Otolaryngology—Head and
•• Differences of opinion: None Neck Surgery Foundation.
Funding Source: American Academy of Otolaryngology—Head
Disclaimer and Neck Surgery Foundation.
The clinical practice guideline is not intended as the sole source of
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