rhinitis%20-%20allergic
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 spontaneously with or without treatment.

Rhinitis%20-%20allergic Diagnosis

Diagnosis

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

Classification

Classification According to Severity of Symptoms 

  • Mild: Symptoms do not interfere with quality of life as manifested by normal sleep, ability to perform normal daily activities, sport and leisure, normal performance at work or in school and without troublesome symptoms
  • Moderate-severe: Symptoms interfere with quality of life as manifested by 1 or more of the following:
    • Impaired daily activities, leisure, and/or sport activities
    • Impaired school or work performance
    • Sleep disturbance
    • Troublesome symptoms

Classification According to Frequency or Duration of Symptoms

  • Intermittent: Symptoms occur <4 days/week or <4 weeks/year
  • Persistent: Symptoms occur >4 days/week and >4 weeks/year

Assessment

  • Assessment will be based on the following:
    • Patient's symptomatology
    • Patient's exposure to allergens
    • Visual analogue scales (VAS)
  • Assess pattern of symptoms: (See classification based on frequency and severity of symptoms)
    • Mild intermittent allergic rhinitis
    • Moderate-severe intermittent allergic rhinitis
    • Mild persistent allergic rhinitis
    • Moderate-severe persistent allergic rhinitis

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

Visual Analogue Scales (VAS)

  • A psychometric response scale for subjective characteristics or attitudes of disease-related symptom severity in each patient that is used to classify symptom severity and disease control
  • Control of allergic rhinitis is graded as follows:  
    • ≥5 = Uncontrolled
      • VAS score of 5 suggests moderate-severe allergic rhinitis  
    • ≥2 to <5 = Partially controlled
    • <2 = Well-controlled

Evaluation

Evaluation of Disease Control

  • The following factors are considered when evaluating a patient’s response to treatment:
    • Symptom score
    • 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
    • Visual analogue scales (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

History

  • A family or personal history of allergy and related conditions should be elicited
    • Asthma or eczema
    • Atopic dermatitis
    • Rhinitis
    • Chronic sinusitis
    • Food allergy
    • Drug sensitivity [eg Aspirin/Nonsteroidal anti-inflammatory drugs (NSAIDs)]
  • Evaluate for asthma especially in patients diagnosed with severe and/or persistent allergic rhinitis
    • Asthmatic patients most likely (≥80%) suffer from allergic rhinitis
  • Determine onset patterns of symptoms including triggers and seasonality, and relief with certain treatments
  • History of exposure to allergens must be scrutinized
    • Occupational, home and school exposures
    • Exposure to passive or active smoking

Physical Examination

  • Complete examination of all systems potentially affected by allergies should be performed in patients with history of rhinitis

Nasal Examination

  • Preferably through endoscopy performed by specialist
  • May reveal the following:
    • Swollen nasal turbinates
    • Rhinorrhea with clear, watery, cloudy or colored discharge; colored discharge may indicate a comorbid condition with allergic rhinitis 
  • Patient should be referred to a specialist if findings are more consistent with 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
    • Some patients may present with geographic tongue

Laboratory Tests

Allergy Testing

  • Considered as the results would help in the management of the disease and identification of allergen to facilitate avoidance
  • Recommend expert referral

Skin Tests and Specific IgE Tests

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

Nasal Smear for Eosinophils

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

Differential Diagnosis

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