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

• Stepwise treatment approach depends on severity, duration and frequency of allergic rhinitis

• 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

• Normal sleep
• Normal functioning at work and school
• Normal conduct of routine and leisure activities
• No bothersome symptoms

• Sleep disturbance
• Problems with functioning at work or at school
• Impairment of routine and leisure activities
• Bothersome symptoms

• 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

• 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

• 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)

• 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 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