Allergic Rhinitis and Sinusitis: Diagnosis

Allergic Rhinitis

The diagnosis of allergic rhinitis is based on consistent findings in the history and physical examination, and may be confirmed by finding an allergen–induced IgE response during skin testing. Allergic rhinitis can be intermittent (seasonal) or persistent (perennial) and may be described as mild, moderate, or severe, to the extent that it interferes with sleep or daily activities.

Pale or bluish nasal mucosa, edematous turbinates with or without drainage, and “cobblestoning” of the oropharynx may be visible on examination. Fiberoptic rhinoscopy can allow visualization of polyps, septal deviation, foreign bodies, and tumors.

A transverse nasal crease, subcutaneous venodilation under the eyes, and mouth breathing may be signs of allergic rhinitis. Young children may make a clicking sound while rubbing their soft palates with their tongues.

Immediate hypersensitivity skin testing may help establish the diagnosis or the possible role of occupational factors. When the condition is refractory to treatment, such testing may be useful in planning immunotherapy. Negative skin tests do not preclude empiric use of nasal corticosteroids in patients with a high probability of disease based on history and physical examination. However, response to antihistamines and anti–inflammatory medications is not diagnostic of allergic rhinitis; nonallergic rhinitis commonly responds to these medications.

Other tests such as blood eosinophils, serum IgE, and the radioallergosorbent test (RAST) are used in selected situations to assist in diagnosis and treatment planning.

Sinusitis

Along with possible symptoms of rhinitis, sinusitis may include purulent nasal discharge, postnasal drip, cough, headache, and teeth or facial pain at sinus sites. Allergic rhinitis may predispose the patient to acute bacterial sinusitis, which may become chronic. Chronic sinusitis may be asymptomatic, but may also affect the sense of smell (anosmia), cause halitosis, and exacerbate asthma. With both acute and chronic rhinosinusitis, mucosal inflammation of the nasal and paranasal sinus cavities is the underlying issue.

In cases of complicated acute, refractory (chronic), or recurrent sinusitis, a sinus CT scan may help determine the presence of an anatomic sinus defect or abscess, or define the extent of mucosal disease.