rhinitis%20-%20allergic%20(pediatric)
RHINITIS - ALLERGIC (PEDIATRIC)
Rhinitis is the inflammation of the nasal lining membranes.
Allergic rhinitis is most prevalent in childhood and adolescence.
Careful elimination of nonallergic etiologies must be done in preschool children as allergic rhinitis is unusual in <3 years of age.

Rhinitis%20-%20allergic%20(pediatric) Diagnosis

Diagnosis

  • Diagnosis relies primarily on the clinical history and physical exam
  • Careful elimination of nonallergic etiologies must be done in preschool children as allergic rhinitis is unusual in <3 years

Assessment

  • Stepwise treatment approach depends on severity, duration and frequency of allergic rhinitis
Symptom Duration of Allergic Rhinitis is Classified into the Following:
Intermittent
  • Symptoms occur <4 days/week or symptoms last for <4 consecutive weeks/year
Persistent
  • Symptoms occur >4 days/week and last for >4 consecutive weeks/year
Symptom Severity of Allergic Rhinitis is Classified into the Following:
Mild
  • Normal sleep
  • Normal functioning at work and school
  • Normal conduct of routine and leisure activities
  • No bothersome symptoms
Moderate-Severe
1 or more of the following
  • Sleep disturbance
  • Problems with functioning at work or at school
  • Impairment of routine and leisure activities
  • Bothersome symptoms
Patterns of Exposure to Allergens
Seasonal
  • Dependent on a specific season
Perennial
  • Year-round allergen exposure and usually present in everyday environment
Episodic
  • Patient is exposed to allergens not normally encountered in daily activities

History

  • A family or personal history of allergic and related conditions
    • Asthma
    • Infantile eczema (atopic dermatitis)
    • Rhinitis, rhinosinusitis
    • Recurrent otitis media with or without effusion
  • Investigate onset patterns of symptoms including triggers and seasonality, and relief with certain treatments
  • Social and environmental history
    • Exposure to allergens and trigger factors

Physical Examination

  • Detect other diseases (eg asthma, atopic dermatitis, cystic fibrosis, otitis media or eustachian tube dysfunction) which may occur in relation with allergic rhinitis
Nasal Exam
  • Can be carried out using a nasal speculum or by endoscopy
    • Endoscopy is done when symptoms persist despite treatment
  • May reveal the following:
    • Swollen nasal turbinates (note size and color)
    • Rhinorrhea with clear, cloudy or colored discharge
      • Viral infection, sinusitis is considered if colored discharge is noted
  • Patient should be referred to an ENT specialist if findings are more consistent with a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation, etc)
Other Physical Findings May Include:
  • Conjunctival injection and edema
  • Allergic shiners (dark circles under the eyes)
  • Morgan-Dennie lines (lower eyelid creases)
  • Periorbital edema
  • Allergic salute which gives rise to nasal crease
  • Dental malocclusion
  • Open-mouth breathing or allergic gape
  • Cobblestoning (lymphoid hyperplasia)

Laboratory Tests

Allergy Testing
  • Skin test: Used to differentiate allergic from nonallergic rhinitis and to identify the triggering agents
  • Allergen-specific IgE identification corresponding to allergen exposure and symptomatic periods is confirmatory of allergic rhinitis
    • Has high sensitivity and specificity
  • Radioallergosorbent test (RAST) may also be used for the detection of allergen-specific IgE
    • Alternative for patients with extensive dermatitis or dermatographism, those at high-risk for anaphylaxis, patients taking drugs that may inhibit mast cell degranulation, and those who cannot tolerate skin test
Nasal Smear
  • Eosinophils in the nasal smear usually indicate allergy; it may support the diagnosis of allergic rhinitis

Evaluation

Evaluation of Disease Control

  • The following factors are considered when evaluating a patient’s response to treatment:
    • Symptom scores
    • Measures of nasal obstruction (eg peak nasal inspiratory flow, acoustic rhinometry, rhinomanometry)
    • Allergic Rhinitis and its Impact on Asthma (ARIA) severity classification
    • Quality of Life (QOL) result
    • Itemized scoring
    • Symptom-medication scoring
    • VAS
      • A low VAS score with the establishment of treatment (<5) shows an amount of improvement, as indicated in Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) as well as in terms of work efficiency, and treatment is usually maintained or continued
      • VAS score of <2 means well-controlled allergic rhinitis and treatment is usually stepped down
      • A high VAS score (≥5) shows no effect in symptom relief and treatment is usually stepped up

MACVIA-ARIA Sentinel NetworK for Allergic Rhinitis (MASK-Rhinitis)

  • A clinical approach used to diagnose and classify patients based on disease severity, as well as a tool to evaluate symptom control after initiation of treatment strategies by using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on ARIA guidelines
  • Electronic monitoring of allergic diseases include a cell phone-based VAS assessment (uses MASK aerobiology which is a simple IOS/Android app), Control of Allergic Rhinitis and Asthma Test (CARAT), an e-Allergy screening and the RhinAsthma Patient Perspective (RAPP) tool for smartphones
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