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.

Diagnosis

  • Diagnosis relies primarily on the clinical history & 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 & 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 week/year
Persistent
  • Symptoms occur >4 days/week & last for >4 consecutive week/year
Symptom severity of allergic rhinitis is classified into the following:
Mild
  • Normal sleep
  • Normal functioning at work & school
  • Normal conduct of routine & 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 & leisure activities
  • Bothersome symptoms
Patterns of exposure to allergens:
Seasonal
  • Dependent on a specific season
Perennial
  • Year-round allergen exposure & 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 & related conditions
    • Asthma
    • Infantile eczema (atopic dermatitis)
    • Rhinitis, rhinosinusitis
    • Recurrent otitis media with or without effusion
  • Investigate onset patterns of symptoms including triggers & seasonality, & relief with certain treatments
  • Social & environmental history
    • Exposure to allergens & 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 & 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 & to identify the triggering agents
  • Allergen-specific IgE identification corresponding to allergen exposure & symptomatic periods is confirmatory of allergic rhinitis
    • Has high sensitivity & 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, & those who cannot tolerate skin test
Nasal Smear
  • Eosinophils in the nasal smear usually indicate allergy; it may support the diagnosis of allergic rhinitis
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