ce
allergies or NOT?
Episodic • Symptoms occur if an individual is in contact with an exposure that is not normally part of the individual’s environment (i.e., a cat at a friend’s house) • Severity can be mild, moderate, or severe (based on symptoms) It is also important to know the key differences between allergic rhinitis from nonallergic rhinitis. The cause of allergic rhinitis is allergen-driven, while the causes of nonallergic rhinitis are broader. For example, nonallergic rhinitis can be caused by hormonal imbalances (pregnancy, puberty, thyroid disorders), structural damages (septal deviation, adenoid hypertrophy), drug-induced (cocaine, beta-blockers, ACEIs, chlorpromazine, clonidine, reserpine, hydralazine, oral contraceptives, aspirin or other NSAIDs, overuse of topical decongestants), systemic inflammatory disorders (eosinophilic nonallergic rhinitis), lesions (nasal polyps, neo- plasms), traumatic experiences (recent facial or head trauma), and autonomic or vasomotor conditions (age-related, physical or chemical agent causing parasympathetic hyperactivity). The below table describes the differentiation between the two conditions.
Symptoms/Findings Allergic Rhinitis
Nonallergic Rhinitis
Bilateral symptoms that are worst upon awakening, subside during the day, then may worsen at night
Unilateral symptoms common but can be bilateral; constant day and night
Symptom Presentation
Sneezing
Frequent, paroxysmal
Little or none
Posterior, watery or thick and/or mucopu- rulent (often associated with an infection)
Rhinorrhea
Anterior, watery
Pruritus of eyes/nose/palate
Frequent
Not present
Nasal Obstruction
Variable
Usually present and often severe
Conjunctivitis (red, irritated eyes with prominent conjunctival blood vessels)
Frequent
Not present
Sinus pain due to congestion may be present; throat pain due to postnasal drip irritation may be present
Pain
Variable depending on cause
Anosmia
Rare
Frequent
Epistaxis
Rare
Recurrent
“Allergic shiners” (periorbital darkening secondary to venous congestion) “Dennie’s lines” (wrinkles beneath the lower eyelids) “Allergic crease” (horizontal crease just above bulbar portion of the nose secondary to the “allergic salute”) “Allergic salute” (patient will rub the tip of the nose upward with the palm of the hand) “Allergic gape” (open mouth breathing secondary to nasal ob- struction) Nonexudative cobblestone appearance of posterior oropharynx
Nasal polyps, nasal septal deviation, en- larged tonsils and/or adenoids
Facial, Nasal, or Throat features
Clinical manifestations of allergic rhinitis include paroxysms of sneezing, rhinorrhea, nasal obstruction, and nasal itch- ing. Postnasal drip, cough, irritability, and fatigue are other common symptoms of the condition. Some patients experi- ence itching of the palate and inner ear. Acute complications of allergic rhinitis include sinusitis and otitis media with effusion. Complications of a chronic nature include nasal polyps, sleep apnea, sinusitis, and hyposmia (diminished sense of smell). Allergic rhinitis and asthma share a common pathology, and allergic rhinitis has been implicated in the development of asthma and exacerbations of pre- existing asthma in children and adults. Depression, anxiety, delayed speech development, and facial or dental abnormalities have also been linked to allergic rhinitis.
DIAGNOSIS OF ALLERGIC RHINITIS
The diagnosis of allergic rhinitis is primarily made on clin- ical grounds based upon the presence of characteristic symptoms, such as paroxysms of sneezing, rhinorrhea, nasal obstruction, nasal itching, postnasal drip, cough, irri- tability, and fatigue. A clinical history, including the presence of patient-specific risk factors, and supportive findings on a physical exam is also useful in correctly identifying the con- dition. With a physical exam, the nose, oropharynx, tympanic membranes, and eyes should be examined as each of these structures may show findings of allergic rhinitis or associ- ated disorders. Allergy skin testing confirms that the patient
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