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
Intermittent
- Symptoms occur <4 days/week or symptoms last for <4 consecutive weeks/year
- Symptoms occur ≥4 days/week and last for ≥4 consecutive weeks/year
Mild
- Normal sleep
- Normal functioning at work and school
- Normal conduct of routine and leisure activities
- No bothersome symptoms
1 or more of the following
- Sleep disturbance
- Problems with functioning at work or at school
- Impairment of routine and leisure activities
- Bothersome symptoms
Seasonal
- Dependent on a specific season
- Year-round allergen exposure and usually present in everyday environment
- 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
- 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)
- 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
- 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 includes 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