Allergic rhinitis represents a global health challenge, currently affecting between 10% and 40% of the world’s population, with a steadily rising incidence in both industrialised and developing nations [1,2]. It is an immunoglobulin E (IgE)‑mediated hypersensitivity reaction of the nasal mucosa to aeroallergens such as house dust mites, pollens, animal dander and fungal spores. The classical symptoms of sneezing, rhinorrhoea, nasal obstruction and itching are the result of a biphasic inflammatory cascade involving mast cell degranulation and the subsequent recruitment of eosinophils, basophils and T‑helper 2 lymphocytes [3]. Although often trivialised as a minor nuisance, AR is far from a benign condition; it is intimately associated with comorbidities including asthma, rhinosinusitis, conjunctivitis and otitis media, and it shares common pathophysiological pathways with these disorders [4]. The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative has redefined AR as a systemic disease with considerable repercussions on both individual health and societal productivity [5].

The traditional clinical classification of AR has evolved from a simple seasonal‑perennial dichotomy to the more dynamic ARIA scheme, which distinguishes intermittent from persistent disease and mild from moderate‑severe disease on the basis of symptom frequency and impact on daily activities, sleep, and work or school performance [5,6]. This paradigm shift underscores the importance of patient‑reported outcomes and quality of life as key determinants of disease control. Generic and disease‑specific instruments, most notably the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and its abbreviated version (Mini‑RQLQ), have been validated across cultures and are now considered essential tools for capturing the multidimensional burden of AR [7].

In India, the prevalence of AR has been estimated to range from 11% to 27% in different age groups and geographic zones, with a higher burden in urban and semi‑urban areas due to increasing environmental pollution, changing lifestyles and greater exposure to indoor allergens [8,9]. Despite this high prevalence, AR frequently remains underdiagnosed and undertreated in primary care, leading to unnecessary suffering, sleep disturbance, fatigue, poor academic and occupational performance, and a substantial economic drain. Patients often resort to over‑the‑counter antihistamines or home remedies, delaying definitive management until symptoms become intolerable [10]. The chronic, relapsing nature of the disease fosters frustration, anxiety and social withdrawal, significantly eroding overall well‑being.

While several Indian studies have documented the clinical profile and allergen sensitisation patterns of AR, very few have simultaneously assessed clinical severity and disease‑specific quality of life using validated instruments in a systematic manner. Moreover, the majority of existing data stem from northern and western India; information from the southern state of Tamil Nadu, and particularly from tier‑2 cities like Perambalur, is scarce. Tertiary care hospitals in such regions cater to a mixed rural‑urban population with distinct environmental exposures, socioeconomic constraints and healthcare‑seeking behaviours. Understanding the interplay between objective severity parameters and subjective health perceptions in this setting can guide clinicians in delivering holistic care and can inform public health strategies for allergy management. Therefore, the present study was designed to fill this knowledge gap by evaluating clinical severity and quality of life among patients with allergic rhinitis attending the outpatient department of a tertiary care teaching hospital in Perambalur, Tamil Nadu.

OBJECTIVE

The primary objective of the study was to assess the clinical severity of allergic rhinitis in adult patients presenting to a tertiary care hospital, using two complementary approaches: the ARIA classification system and the Total Nasal Symptom Score (TNSS). By employing both categorical and continuous measures, the investigation aimed to capture not only the frequency and duration of symptoms but also their subjective intensity. The secondary objective was to evaluate health‑related quality of life using the Mini Rhinoconjunctivitis Quality of Life Questionnaire (Mini‑RQLQ), a disease‑specific instrument that measures impairment across seven distinct domains: activities, sleep, non‑nose/eye symptoms, practical problems, nasal symptoms, eye symptoms and emotional function.

A further objective was to explore the relationship between objective disease severity and subjective quality of life impairment. Specifically, the study sought to determine whether the TNSS and ARIA severity grades correlate significantly with the overall Mini‑RQLQ score and with each of its individual domains. In addition, the influence of demographic variables such as age, gender and residential background on both severity and QoL was examined. By simultaneously analysing clinical and patient‑reported outcomes, the study intended to underscore the importance of incorporating validated QoL assessments into routine clinical practice, thereby enabling a more comprehensive and personalised therapeutic approach for AR patients in resource‑constrained tertiary settings.

Study Design and Setting This was a hospital based, cross sectional, observational study conducted in the Department of Otorhinolaryngology at Dhanalakshmi Srinivasan Institute of Medical Sciences and Hospital, Perambalur, Tamil Nadu, a tertiary care teaching institution serving a predominantly semi urban and rural population. The study protocol was approved by the Institutional Ethics Committee (IEC/DIMS/2025/ENT/12) prior to commencement, and all procedures adhered to the ethical principles laid down in the Declaration of Helsinki. The study was carried out over a period of seven months, from 1 September 2025 to 25 March 2026, encompassing two distinct climatic seasons (post monsoon and winter) to capture seasonal variability in symptom presentation. Sample Size and Sampling A convenience sample of 50 adult patients was recruited from the ENT outpatient department. Although formal sample size calculation was not performed due to the exploratory nature of the investigation, a minimum of 50 participants was deemed adequate to detect moderate to large effect sizes (Cohen’s d ≥0.8) with 80% power at a two tailed alpha of 0.05 for correlational and comparative analyses, as per previous similar QoL studies. Consecutive eligible patients who fulfilled the inclusion criteria and provided written informed consent were enrolled until the target sample was reached. Inclusion Criteria: • Adult patients aged between 18 and 65 years. • Clinically diagnosed with allergic rhinitis based on ARIA guidelines (history of two or more nasal symptoms occurring on most days during a symptomatic period, with evidence of IgE mediated hypersensitivity confirmed either by positive skin prick test to common aeroallergens or by elevated serum allergen specific IgE). • Willing to participate and able to comprehend the study questionnaires in Tamil or English. Exclusion Criteria: • Acute upper respiratory tract infection or febrile illness within the preceding four weeks. • Anatomical nasal abnormalities such as severe deviated nasal septum (grade III or IV), nasal polyposis or sinonasal tumours. • History of nasal or sinus surgery within the past six months. • Current exacerbation of concomitant asthma requiring systemic corticosteroids or emergency visit. • Use of systemic corticosteroids, leukotriene receptor antagonists, antihistamines or decongestants within one week, or immunotherapy within the preceding three months. • Pregnancy, lactation or any severe psychiatric illness that would impede reliable completion of questionnaires. • Chronic rhinosinusitis with or without nasal polyps as per EPOS 2020 criteria. Data Collection Procedure After obtaining written informed consent, a detailed proforma was administered to each participant. Demographic data including age, gender, residential area (rural/urban), occupation and duration of symptoms were recorded. A thorough nasal examination, including anterior rhinoscopy and nasal endoscopy where indicated, was performed by a single experienced otorhinolaryngologist to rule out alternative diagnoses. The diagnosis and classification of AR were based on the ARIA 2016 revision: patients were categorised as having intermittent (<4 days per week or <4 consecutive weeks) or persistent (≥4 days per week and ≥4 weeks) symptoms, and mild (none of the following: sleep disturbance, impairment of daily activities/leisure/sport, impairment of school or work, troublesome symptoms) or moderate severe (one or more of the above items present) disease [5]. The Total Nasal Symptom Score (TNSS) was assessed by asking the patient to rate the severity of four cardinal symptoms nasal congestion, sneezing, rhinorrhoea and nasal itching over the past week on a 4 point scale (0=absent, 1=mild, 2=moderate, 3=severe), yielding a total score ranging from 0 to 12. TNSS was categorised as mild (0 4), moderate (5 8) or severe (9 12). Quality of life was measured using the self administered Mini RQLQ, a validated 14 item instrument with a 2 week recall period. It evaluates seven domains (activities, sleep, non nose/eye symptoms, practical problems, nasal symptoms, eye symptoms, emotional) on a 7 point Likert scale (0=not troubled, 6=extremely troubled). The overall score is the mean of the 14 responses. The questionnaire was translated into Tamil and back translated to ensure conceptual equivalence, and it was pilot tested on 10 patients who were not part of the final sample. Statistical Data Analysis All data were entered into Microsoft Excel and analysed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range depending on normality; categorical variables were presented as frequencies and percentages. Normality was tested using the Shapiro Wilk test. The independent samples t test (or Mann Whitney U test for non normal data) was used to compare Mini RQLQ scores between mild and moderate severe AR groups and between genders. Chi square test was employed to examine associations between categorical variables such as ARIA severity category and demographic characteristics. Pearson correlation coefficient (or Spearman’s rho) was calculated to assess the strength and direction of the relationship between TNSS and Mini RQLQ domain and overall scores. A p value less than 0.05 was considered statistically significant for all tests.

A total of 50 adult patients with allergic rhinitis were included in the final analysis. The mean age was 34.2 ± 11.5 years, with a range of 18 to 62 years. There were 28 (56%) females and 22 (44%) males, giving a female‑to‑male ratio of 1.27:1. The majority hailed from a rural background (60%), and the mean duration of illness was 4.8 ± 3.2 years. House dust mite was the most commonly reported trigger (68%), followed by pollen (24%) and animal dander (8%). According to the ARIA classification, more than half of the patients (52%) suffered from moderate‑severe persistent AR, while 20% had moderate‑severe intermittent, 16% had mild persistent and only 12% had mild intermittent disease. The mean TNSS was 7.2 ± 2.4, with 20% classified as mild, 56% as moderate and 24% as severe based on the score tertiles. Demographic and baseline clinical characteristics are summarised in Table 1.

Regarding quality of life, the overall Mini‑RQLQ score was 2.8 ± 1.1. Among the seven domains, the highest (worst) mean scores were recorded for nasal symptoms (3.8 ± 1.1) and practical problems (3.4 ± 1.3), whereas emotional function (1.9 ± 1.5) and eye symptoms (2.2 ± 1.4) were relatively less affected. Sleep disturbance (2.5 ± 1.5) and non‑nose/eye symptoms (2.9 ± 1.2) occupied intermediate positions. Females reported slightly higher overall QoL impairment than males (3.0 ± 1.0 vs. 2.6 ± 1.2), but the difference was not statistically significant (p=0.19). Domain‑wise mean scores are presented in Table 4 and illustrated graphically in Figure 1, a bar chart that depicts the descending order of impairment.

The correlation analysis revealed a strong positive relationship between TNSS and the overall Mini‑RQLQ score (r = 0.72, p < 0.001). When individual domains were examined, TNSS correlated most robustly with nasal symptoms (r = 0.78), practical problems (r = 0.71) and sleep (r = 0.64), and moderately with non‑nose/eye symptoms (r = 0.59), activities (r = 0.52) and emotional function (r = 0.47); all correlations were statistically significant at p < 0.01 (Table 5). Furthermore, when patients were stratified by ARIA severity, those in the moderate‑severe group had a significantly higher overall Mini‑RQLQ score (3.3 ± 0.8) compared with the mild group (1.7 ± 0.6) (t = 8.43, p < 0.001). The pie chart (Figure 2) illustrates the distribution of the four ARIA classes, with persistent moderate‑severe AR occupying the largest segment. No significant association was found between ARIA severity and gender (χ² = 1.22, p = 0.75) or residential status (χ² = 0.93, p = 0.82).

Table 1: Demographic and Clinical Characteristics of Study Participants (N=50)

Table 2: Distribution of Patients According to ARIA Classification

Table 3: Categorisation of TNSS and Mean Scores

Table 4: Mini‑RQLQ Domain Scores and Overall Score (Mean ± SD)

Table 5: Pearson Correlation Between TNSS and Mini‑RQLQ Domains

Figure 1: Bar chart showing mean Mini‑RQLQ domain scores. Nasal symptoms and practical problems exhibit the highest impairment, while emotional and eye symptoms are least affected.

Figure 2: Pie chart depicting the percentage distribution of patients according to ARIA classification: Persistent Moderate‑Severe 52%, Intermittent Moderate‑Severe 20%, Persistent Mild 16%, Intermittent Mild 12%.

The present study offers a comprehensive snapshot of the clinical severity and quality of life burden experienced by allergic rhinitis patients attending a tertiary care hospital in a semi urban region of Tamil Nadu. The demographic profile, with a slight female preponderance (56%) and a mean age in the mid thirties, mirrors the pattern reported in several Indian and international cohorts, where AR peaks in young and middle aged adults, significantly impacting the most productive years of life [8,11]. The high proportion of patients reporting house dust mite as the principal trigger (68%) is consistent with aerobiological data from peninsular India, where warm, humid indoor environments favour mite proliferation throughout the year [12]. This finding reinforces the importance of environmental control measures as a first line intervention, a strategy that is often overlooked in busy outpatient settings. A striking observation was the predominance of the moderate severe persistent phenotype (52% by ARIA classification), which far exceeds the proportions typically reported in community based surveys (20 30%) [13,14]. This discrepancy is readily explained by the tertiary care setting, which selectively attracts patients with refractory, long standing or more distressing symptoms that have failed primary care remedies. The mean TNSS of 7.2 ± 2.4, with only 20% of patients falling in the mild category, corroborates this notion and underscores the substantial symptom burden carried by this population. When compared with a multicentre Indian study that reported a mean TNSS of 5.9 in a mixed primary secondary care cohort [9], our figures are noticeably higher, further emphasising referral bias. Nonetheless, these data highlight the unfortunate reality that many AR patients in India continue to suffer inadequately controlled disease, likely due to under utilisation of guideline directed pharmacotherapy and immunotherapy. Quality of life impairment, as measured by the Mini RQLQ, was pervasive. The overall score of 2.8 ± 1.1 is comparable to that documented in other Indian tertiary care studies (range 2.5 3.2) and represents a clinically meaningful detraction from optimal well being [15,16]. The domain wise analysis revealed that nasal symptoms and practical problems were the most severely affected dimensions. The practical problems domain encompasses the inconvenience of carrying tissues, needing to blow the nose repeatedly and the embarrassment associated with nasal discharge issues that are intimately linked to social and occupational dysfunction. It is noteworthy that emotional function, while the least impaired domain in absolute terms, still scored 1.9, indicating that a substantial subset of patients experience frustration, irritability and social embarrassment. These psychological ramifications, although subtle, can perpetuate a vicious cycle of stress and symptom exacerbation. The strong positive correlation between TNSS and overall Mini RQLQ (r=0.72) aligns with the hypothesis that symptom intensity is the primary driver of QoL deterioration in AR. The correlation was particularly robust for the nasal symptom domain (r=0.78), confirming the construct validity of the tools, and was also strong for practical problems and sleep. Sleep disturbance, which scored 2.5 in our study, deserves special attention because fragmented sleep due to nasal congestion leads to daytime somnolence, cognitive impairment and reduced work efficiency consequences that extend far beyond the nose [17]. These inter domain correlations support the ARIA concept that AR is a systemic disorder requiring a holistic therapeutic approach, rather than mere symptom suppression with antihistamines. When patients were stratified by ARIA severity, a clear dose response relationship emerged: moderate severe patients reported QoL scores nearly twice as high (worse) as those with mild disease. This finding is in line with the European and North American literature, which consistently demonstrates that patients with persistent, uncontrolled AR experience the greatest decrements in daily functioning [18,19]. Importantly, no significant gender or urban rural differences were detected in QoL or ARIA severity, suggesting that once the disease is established to a degree warranting tertiary consultation, the burden is uniformly distributed across demographic subgroups. However, the absence of a statistically significant gender difference should be interpreted cautiously given the small sample size, as some larger studies have reported slightly greater QoL impairment among women, possibly due to differences in symptom perception or healthcare seeking behaviour [20]. The clinical implications of these findings are manifold. First, the routine incorporation of a simple, validated QoL instrument such as the Mini RQLQ into outpatient assessment can unmask hidden disability that severity scores alone may not capture, enabling a more patient centred therapeutic plan. Second, the high prevalence of moderate severe persistent disease in the tertiary care queue calls for a lower threshold to escalate treatment beyond oral antihistamines intranasal corticosteroids, leukotriene receptor antagonists and, in eligible patients, allergen specific immunotherapy should be offered early. Third, the substantial impact on practical problems and sleep highlights the need for multidisciplinary management encompassing nursing education on nasal hygiene, psychological support and, where appropriate, occupational counselling. Finally, the data underscore the pressing requirement for community based screening and early referral pathways to prevent the progression of mild intermittent AR into a persistent, QoL devouring chronic condition. Limitations of the Study Several limitations must be acknowledged. Firstly, the cross sectional design precludes causal inference regarding the relationship between disease severity and quality of life; temporal fluctuations in symptoms and QoL could not be captured. Secondly, the small sample size of 50, while adequate for the exploratory objectives, limits the generalisability of the findings and the statistical power to detect subtle subgroup differences, such as gender specific effects or interactions with socioeconomic status. Thirdly, recruitment from a single tertiary care centre introduces selection bias; patients with milder disease who are managed at primary care level were underrepresented, which may have inflated the observed severity and QoL scores. Additionally, the diagnosis of AR relied primarily on clinical history and examination; although skin prick testing or specific IgE measurement was performed in a subset, it was not available for all participants due to resource constraints, potentially including patients with non allergic rhinitis phenotypes. The Mini RQLQ, despite being validated, remains a self reported measure susceptible to recall bias and social desirability bias. The study period of seven months covered post monsoon and winter seasons but did not include the peak pollen season of early spring, which may have influenced the recorded severity. Finally, concomitant medications and adherence were not rigorously controlled, though recent use was an exclusion criterion. Future studies should adopt a multicentre, longitudinal design with objective allergen sensitisation testing and larger, more diverse cohorts to overcome these limitations. Acknowledgment The authors express sincere gratitude to the administration of Dhanalakshmi Srinivasan Institute of Medical Sciences and Hospital, Perambalur, for granting permission and providing the necessary infrastructure to conduct this study. We thank the nursing staff and paramedical personnel of the ENT outpatient department for their unwavering support during patient recruitment and data collection. Our heartfelt appreciation goes to the patients who willingly participated and shared their experiences, without whom this research would not have been possible. We also acknowledge the institutional ethics committee for its timely review and constructive recommendations. Special thanks are due to the statistician for assistance with data analysis and interpretation.

This study demonstrates that allergic rhinitis among patients attending a tertiary care hospital in Perambalur, Tamil Nadu, is predominantly of the moderate‑severe persistent variety, with symptoms imposing a profound and multifaceted reduction in quality of life. The highest degree of impairment was observed in the domains of nasal symptoms and practical problems, although sleep, daily activities and emotional well‑being were also significantly affected. The strong correlation between objective nasal symptom scores and QoL decrements validates the notion that effective symptom control is the cornerstone of restoring functional status and psychological health. The disproportionate representation of severe phenotypes reinforces the urgency of strengthening primary and secondary care allergy services so that timely, guideline‑based interventions ranging from allergen avoidance and pharmacotherapy to immunotherapy can be instituted before disease progression necessitates tertiary referral.

Moving forward, clinicians must embrace a holistic, patient‑centred paradigm that incorporates validated QoL instruments into routine practice, allowing the invisible burden of AR to be made visible and addressed. This approach aligns with the ARIA‑recommended integrated care pathways that couple pharmacological treatment with patient education, environmental control and regular monitoring. For the Tamil Nadu region and analogous settings, public health strategies should focus on raising awareness about allergic disorders, training primary care physicians in the use of simple diagnostic algorithms and ensuring the availability of affordable, evidence‑based therapies. Ultimately, the goal is to transform allergic rhinitis from a neglected, quality‑of‑life‑eroding condition into a well‑controlled, minimally intrusive aspect of patients’ lives, thereby enhancing both individual well‑being and societal productivity.

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