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Initial presentation awaiting clinical dx
Hx/exam: sneezing, itchy nose/palate,1,2 cough,3 onset <20 yo, seasonality, pollen/animal trigger,2 FHx1-3 support dx; presumptive clinical dx is adequate to initiate tx, per AAO;2 but AAI-JFT & BSACI recommend testing @ time of clinical dx1,3 - Sx. Rhinitis: sneezing, itching, rhinorrhea, or nasal congestion (AAI-JTF,3 AAO,2 BSACI1). Assoc sx may include itchy eyes, itchy throat/palate,1,2 cough,3 throat clearing,2,3 sinus pressure, ear fullness/popping;3 conjunctivitis (itching, redness, chemosis, tearing).1,3 Children may present w/ other sx2,3
- Severity, triggers, FHx: Assess severity/QOL, duration, seasonality/timing, triggers, environment (eg, animals), occupation, meds, comorbid dz; FHx allergy, asthma, rhinitis, atopic dermatitis1-3
- Classify by seasonal (pollens, outdoor molds), perennial (animals, mites, indoor molds), or episodic;1,3 by intermittent vs persistent; by mild vs mod-severe1,2
- Exam: pale/bluish nasal mucosa, transverse nasal crease, “allergic shiner,” etc may support dx, but no findings are diagnostic1-3
- Consider DDx: Nonallergic rhinitis (eg, vasomotor, infectious, pregnancy/hormonal, drug-induced), mimics (eg, nasal polyps, septal deformity, adenoid hypertrophy).1,3 Nonallergic more likely if sx primarily triggered by irritants (eg, odors, smoke) or eating; or w/ isolated postnasal drip; unilateral s/sx; epistaxis; severe HA; anosmia3
- Perform testing to confirm AR:1,3 aeroallergen skin prick testing or allergen-specific IgE; don’t check food allergens3
Footnotes 1 BSACI 2017. BSACI 2017. Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis. (Revised Edition 2017; First Edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856-889. PDF
Classification of sx:
• Intermittent: <4 days/wk or <4wk at a time
• Persistent: ≥4 days/wk and ≥4wk at a time
• Mild: Normal sleep, activities, work, school; no troublesome sx
• Mod-severe if any: abnormal sleep, impaired activities, problems at work/school, troublesome sx
Drug-induced rhinitis: α-blockers, ACE inhibitors, chlorpromazine, cocaine, ASA/NSAIDs, topical decong (w/ prolonged use)
Hormonal causes: pregnancy, puberty, HRT, contraceptive pills, possibly hypothyroidism, acromegaly.
Comorbidities assoc w/ rhinitis:
• NARES: 50% later develop ASA sensitivity, asthma, nasal polyps
• Child w/ nasal polyp should be screened for CF
2 AAO 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 Suppl):S1-43. PDF
Children may present w/ cough, malaise, fatigue, irritability, sleep problems.
AR dx supported by: clear rhinorrhea, pale/bluish swollen nasal mucosa, red watery eyes, “allergic shiners,” transverse nasal crease, conjunctival swelling. Evaluate adenoids, which may contribute to nasal obstruction (esp in children).
3 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. Joint Task Force on Practice Parameters (American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology.) J Allergy Clin Immunol. 2020. Oct;146(4):721-767. PDF
Suggestive sx: throat clearing, sniffing/snorting, eye rubbing, halitosis, mouth breathing.
Evaluate QOL, other elements of hx. Consider visual-analog severity scale or generic or rhinitis-spec QOL questionnaire (although only validated for research).
Perennial AR may have seasonal flares. Pollen seasons in temperate N. America: Trees (early-mid spring), grasses (late spring to early summer), weeds (late summer to early fall).
Examine nose (mucosal appearance, secretions, patency, anatomy, bilaterality), upper resp tract, other potentially affected organs (eg, ears, lungs); exam may support dx (eg, pale mucosa, “allergic shiners”), but not diagnostic; exam may be NL.
Rhinitis DDx also includes NARES (nonallergic rhinitis w/ eos), gustatory rhinitis, atrophic rhinitis, systemic inflam dz (eg, Wegener, Churg-Strauss), med induced (anti-HTN/CVD, ASA/NSAIDs, topical decong, others). Mimics also include foreign body, trauma, tumor, CSF leak, pharyngonasal reflux, choanal atresia, cleft palate, ciliary dyskinesia, acromegaly.
Other diagnostic tips:
• Mixed AR/nonallergic more common (44%-87%) than pure AR or pure nonallergic.
• Vasomotor (idiopathic) is mixed group w/o eos, infxn, immunologic cause; triggered by temp/humidity change, odors, smoke, fumes.
• Response to irritants may be ↑ in seasonal AR.
• Food allergy rarely causes AR w/o assoc GI, skin, systemic sx. Foods/alcohol may cause sx by vagal or undefined mechanisms.
• Hypo-/anosmia assoc w/ nasal polyposis.
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S/P clinical dx: suboptimal response to empiric tx; or allergen identification will guide tx
Review hx/exam. Test for specific IgE (AAI-JTF,1 AAO,2 BSACI3 & correlate to sx - Test if: lack of response to empiric tx, dx uncertain, or need to know allergen to guide trigger avoidance or immuno-tx, per AAI-JTF,1 AAO.2 However, BSACI recommends testing @ time of clinical dx3
- Skin prick/puncture tests preferred vs serum immunoassay, per AAI-JTF,1 BSACI;3 however, AAO considers these equivalent options.2 Skin tests suppressed by some meds (eg, antihistamines, tricyclics), which should be d/c’d prior to testing.1-3 Immunoassay preferred if unable to d/c suppressive med, extensive skin dz (eg, eczema, dermographism), uncooperative, anaphylaxis risk;1,2 or if skin tests equivocal in light of sx hx3
- Allergen selection. Adult: Test inhalant allergens but not foods. Child: OK to consider limited selection of foods, since hx may be less clear, food allergy more common1
- If (+) tests: Correlate to sx upon exposure, since (+) test alone doesn’t dx allergy1-3
- If (-) tests: Pts generally considered nonallergic, but local AR can cause sx in pts w/ (-) skin tests/immunoassay; these pts may have (+) nasal allergen provocation test1
- Don’t routinely order nasal smears for eos, total IgE, IgG, imaging studies.1,2 Don’t order tests that haven't been validated: cytotoxic tests, provocation-neutralization, electrodermal tests, applied kinesiology, iridology, hair analysis1
Footnotes 1 AAAAI 2020. Dykewicz MS, et al. Rhinitis 2020: A Practice Parameter Update. Joint Task Force on Practice Parameters (American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology.) J Allergy Clin Immunol. 2020. Oct;146(4):721-767. PDF
Skin tests are preferred for ease, rapidity, and cost. Immunoassays and skin prick/puncture tests have similar sensitivity in identifying pts w/ sx after natural or controlled exposure.
Nasal smear for eos may be helpful when dx uncertain. Total IgE, IgG subclasses of ltd value. Imaging of no use in uncomp AR.
2 AAO 2015. Seidman MD, et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 Suppl):S1-43. PDF
Evidence of superiority lacking; decide based on pt preference, availability. Consider use of skin prick/puncture tests +/or intradermal skin tests.
Severe adverse events extremely rare; no fatalities reported w/ inhalant-allergen skin prick/puncture tests but have occurred w/ intradermal skin testing.
Tests for non-IgE antibodies (eg, IgG) not beneficial. Total IgE of limited value. Rec against imaging.
3 BSACI 2017. BSACI 2017. Scadding GK, et al. BSACI Guideline for the Diagnosis and Management of Allergic and Non-allergic Rhinitis. (Revised Edition 2017; First Edition 2007). Clin Exp Allergy. 2017. Jul;47(7):856-889. PDF
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