Dec
2018
25
F
Cr
Feature Review
Clinical
Table 1. History-taking in allergic rhinitis (AR)
Important feature of the history
Significance
General
When did the symptoms first start? Persistent (previously perennial), AR is more common in preschool-aged children.
Intermittent AR with a seasonal variance is more common in school-aged children and
young adults.
Onset in later life should prompt consideration of a non-allergic cause of rhinitis.
Do the symptoms occur predominantly at certain times
of the year or all year round? In general, grasses pollinate late-spring to early-summer and trees do so from late-
winter to early spring.
What indoor allergens is the patient exposed to? Understanding a patient’s housing and workplace conditions will reveal potential
offending allergens.
What is the patient’s occupation? Understanding a patient’s housing and workplace conditions will reveal potential
offending allergens.
Is there a family history of atopy? A family history of atopy and in particular AR is the best-established risk factor for the
development of AR.
What is the impact of symptoms? AR can have a significant, negative impact on sleep quality and other quality of life
domains.
What medications have been tried to date?
How regularly and for how long? Failure of response to particular medications helps direct initial pharmacotherapy.
Failure of response to an optimal regimen of medications may suggest an alternative
cause.Prolonged use of nasal decongestants can lead to rebound rhinitis (see rhinitis
medicamentosa).
What other medications does the patient take regularly? Drug-induced rhinitis (see differential diagnosis) may mimic allergic rhinitis.
Symptoms
Classification Classifying AR helps direct initial pharmacotherapy.
What is the most troublesome symptom? The predominant symptom may potentially direct treatment.
What is the character and source of nasal discharge? Consider ‘red flags’.
Is there a diurnal variation to symptoms? Sneezing and nasal obstruction are worse in the morning in 70% of patients with AR.
Is there hyposmia or anosmia? Mild hyposmia is not rare in symptomatic AR; however, anosmia or more severe hyposmia
should prompt consideration of alternative diagnosis.
Is post-nasal drip or chronic cough a feature? This question may reveal acute or chronic sinusitis as a concomitant or alternative
diagnosis (see differential diagnosis).
Are there symptoms consistent with asthma or
bronchial hypersensitivity? The close relationship between AR and asthma is discussed later. History-taking in
a patient presenting with AR should aim to determine the presence and degree of
concomitant asthma.
Source: AIHW and Hu W, et al. Allergic rhinitis: practical management strategies. Australian Family Physician 2008; 37:214-20.
The nose
Rhinorrhoea is often appreciable during
examination and the character of the discharge
should be noted. Examination of the nose much
beyond the nares is difficult without specialised
equipment, and adequate lighting from a simple
head lamp, at the very least, is essential.
A Thudichum or other nasal speculum will
open the nare and aid in examination. Enlarged,
red-to-purple inferior turbinates with vascular
dilatation and obvious limitation of the nasal
airway is characteristic of allergic rhinitis.
Nasal polyps are not usually appreciated on
anterior rhinoscopy.
Further examination of the nose requires
flexible or rigid nasendoscopy, which allows
a full examination of the nasal cavity, the
adenoids and beyond.
Nasal airflow should be assessed during
examination. Ask the patient to breathe
in and out through the nose, and repeat
the exercise with the left then right nare
occluded. During this assessment, ask the
patient if any manoeuvres or manipulation
of the nose improves breathing, which may
give clues to alternative or exacerbating
causes of nasal obstruction such as nasal
valve collapse.
The head and neck
Examine the head and neck for any evidence
of regional infection that may direct further
examination and investigation.
The chest
Given the close relationship between allergic rhinitis
and asthma, examination is incomplete without
inspection of the chest for evidence of obstructive
airways disease and auscultation for wheeze.
Differential diagnosis
There are myriad conditions that mimic one
or more of the symptoms of allergic rhinitis,