DIAGNOSIS AND PHYSICAL EXAM FINDINGS
In terms of diagnosis of allergic rhinitis , the history and physical should yield the diagnosis with confirmation by skin prick testing or specific IgE by Immunocap methodology on serum to further identify specific allergens . Skin prick testing is considered to be more sensitive and less expensive than serum testing and has the benefit of the results being immediately available for the patient . Antihistamines , depending on their half-life , should generally be withheld for five to seven days before skin testing to avoid blocking measurement of wheal and flare response due to mast cell histamine release . The likelihood of a systemic reaction on skin prick testing ( not intradermal testing ) is rare with some estimates as low as one in 10,000 . Furthermore , skin prick testing is very accurate at predicting clinical reactivity based on exposure chamber studies and outdoor park studies and is associated with less false positives . Skin testing can provide a “ road map ” of what is to come in the future in terms of predicting patient symptoms and can better guide environmental control measures and medical management .
Physical exam findings consistent with allergic rhinitis generally include swollen boggy turbinates with pale mucosa and clear mucous . ( 3 ) Exam findings consistent with infection may include purulent mucous and erythema of the turbinates . Non-allergic rhinitis is usually characterized by an erythematous mucosal surface with clear secretions thought this is not always a reliable predictor . A nasal crease along the top of the nose suggests frequent nasal pruritus and allergic shiners under the eyes suggest underlying nasal congestion . Septal deviation , nasal polyps , nasal spurs and other anatomical abnormalities can also be detected on nasal exam . ( 3 )
DIFFERENTIAL DIAGNOSIS
It is important to note that not everyone that has congestion , rhinitis , sneezing and postnasal drainage has a positive allergy test . These skin test negative patients can have a non-IgE mediated cause of symptoms known as non-allergic rhinitis or vasomotor rhinitis with or without nasal eosinophilia . In these patients , it is important to inform them that irritants such as cleaning supplies , perfumes , cigarette smoke , air-fresheners and other noxious stimuli can trigger symptoms . Other causes of non-allergic rhinitis include cold air , weather changes and pollution . In addition , congestion may be due to medications , other medical conditions , anatomical abnormalities , or chronic rhinosinusitis with or without polyps . Table III is a classification table of rhinitis and outlines the differential diagnosis of nasal symptomatology . ( 2 , 3 )
As one considers this differential diagnosis , it becomes more apparent that your patient with chronic congestion may have a very complex diagnosis , including sinus disease . ( 3 ) Chronic rhinosinusitis includes symptoms of decreased smell , facial pain or pressure , postnasal drainage , nighttime cough , and nasal congestion of 12-weeks duration . Chronic rhinosinusitis may be associated with or without polyps . These patients often have coexisting asthma and these patients can react to aspirin or other NSAIDS with an occurrence rate as high as 20 percent . Idiosyncratic reactions are non IgE mediated and occur in these patients who previously took an aspirin or NSAID safely and then later had a severe asthmatic
TABLE III . CLASSIFICATION OF RHINITIS AND DIFFERENTIAL DIAGNOSIS
FEATURE
I . Allergic Rhinitis - Positive skin prick test and / or positive specific IgE ( Immunocap testing ) and nasal provocation
II . Non-Allergic Rhinitis with or without Eosinophilia , Vasomotor , Gustatory . Negative skin prick test and / or negative specific IgE ( Immunocap testing )
III . Local Allergic Rhinitis . Negative skin prick test and / or negative specific IgE ( Immunocap testing ) Positive Nasal provocation , local specific IgE in nasal mucosal Positive nasal allergen challenge
IV . Medication induced rhinitis and other medical conditions . Rhinitis medicamentosa : Topical Nasal Decongestants , ie , oxymetazoline , pseudoephedrine , and phenylephrine Other medications : Oral Contraceptives , Ace-I ’ s , PDE-5 inhibitors , alpha receptor antagonists , aspirin , NSAIDS ( Samter ’ s Triad ) Medical conditions : Hypothyroidism , hormonal , pregnancy
V . Anatomical Consideration - Foreign body , septal deviation , other anatomical issues , Haller cell , concha bullosa , enlarged adenoids , nasal polyps , tumor VI . Infectious . Viral ( most common ) bacterial or fungal infection VII . Chronic rhinosinusitis - Chronic rhinosinusitis without nasal polyps ( TH1 mediated ), Chronic rhinosinusitis with nasal polyps ( TH2 mediated )
reaction to the same previously tolerated medication . Treatment of these patients often includes prednisone and extensive nasal hygiene with nasal saline irrigations and chronic nasal steroids . Newer biologicals indicated for asthma including anti-IgE ( omalizumab , lowers IgE ) and anti-IL-5 ( mepolizumab , reslizumab , both lower eosinophils ) have shown some benefit in upper nasal airway disease , but thus far are not indicated for isolated chronic sinusitis with nasal polyps .( 14 ) More recently , studies have shown that anti-IL4 , anti-IL13 therapy with dupilumab ( currently indicated for adults with atopic dermatitis ) may in fact reduce polyps significantly resulting in improved airway flow , and improved sense of smell . ( 15 ) Surgery may be necessary to get control of underlying polyp burden , but polyps frequently reoccur despite surgery .
Editor ’ s note : This is a two-part series on allergic rhinitis . Part two will focus on treatment , expectant mothers and immunotherapy with references listed at the conclusion .
F . Tolis Simon , MD holds board certifications in both Allergy & Immunology and Internal Medicine . He is a third generation allergist in Louisville , KY , and has been practicing for 20 years . He is in private practice at Bluegrass Allergy and Asthma in Jeffersontown , KY , and also works part-time at the Family Health Centers , Inc . Dr . Simon is an associate faculty member at both the University of Louisville and the University of Kentucky .
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