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RHINITIS - ALLERGIC
Allergic rhinitis is a symptomatic disorder of the nose secondary to IgE-mediated inflammation of the nasal membranes induced after exposure to allergens.
Major symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Other symptoms include headache, conjunctival symptoms, eye pruritus, impaired smell and morning cough.
Symptoms can reverse spontaneous w/ or w/o treatment.

Diagnosis

  • The diagnosis of allergic rhinitis relies mainly on the clinical history, physical exam & diagnostic tests

Classification

  • Infection
    • Acute
    • Chronic
  • Irritant rhinitis
    • Physical
    • Chemical
    • Radiation
  • Hyperesthetic non-infectious rhinitis
    • Combined type (nasal hypersensitivity)
      • Allergic (perennial, seasonal)
      • Nonallergic (vasomotor or idiopathic rhinitis, rhinitis with eosinophilia syndrome)
      • Rhinorrhea type (gustatory rhinitis, cold inhalation rhinitis, senile rhinitis)
      • Congestive type (medicament rhinitis, psychogenic rhinitis, pregnant rhinopathia, hormonal rhinitis and cold rhinitis)
  • Others
    • Atopic rhinitis
    • Specific granulomatous rhinitis

Assessment

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

  • Sleep disturbance
  • Problems w/ 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 allergy & related conditions should be elicited
    • Asthma or eczema
    • Atopic dermatitis
    • Rhinitis
    • Chronic sinusitis
    • Food allergy
    • Drug sensitivity (eg Aspirin/NSAID)
  • Evaluate for asthma especially in patients diagnosed with severe &/or persistent allergic rhinitis
    • Asthmatic patients most likely (≥80%) suffer from allergic rhinitis
  • Determine onset patterns of symptoms including triggers & seasonality, & relief with certain treatments
  • History of exposure to allergens must be scrutinized
    • Occupational, home & school exposures
    • Exposure to passive or active smoking

Physical Examination

  • Complete exam of all systems potentially affected by allergies should be performed in patients w/ history of rhinitis

Nasal Exam

  • Preferably through endoscopy performed by specialist
  • May reveal the following:
    • Swollen nasal turbinates
    • Rhinorrhea w/ clear, cloudy or colored discharge 
  • Patient should be referred to a specialist if findings are more consistent w/ a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation)

Other physical findings include:

  • Conjunctivitis
  • Allergic “shiners” (dark circles under the eyes resulting from venous stasis)
  • Lower eyelid creases
  • Nasal crease
  • Periorbital edema
  • Cobblestoning of the pharynx

Laboratory Tests

Allergy Testing

  • Considered as the results would help in the management of the disease
  • Recommend expert referral

Skin Tests & Radioallergosorbent Test (RAST)/Automated Immunoassay Systems

  • Used to differentiate allergic from nonallergic rhinitis or to determine specific allergens causing allergic rhinitis
  • Skin test is preferred due to its better sensitivity, faster results, & lesser cost

Nasal Smear for Eosinophils

  • Eosinophils may be seen in both allergic & nonallergic rhinitis
  • Presence of eosinophilia predicts a good response to topical nasal corticosteroid medication
  • May be performed when allergic symptoms are present
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