Allergic Rhinitis

Mitchell R. Lester
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Complications and comorbidities of allergic rhinitis
Of great importance, many patients with AR suffer from complications and co-morbidities that are not always recognized as direct effects of nasal disease. AR is a risk factor for recurrent otitis media and sinusitis. Nasal congestion may result in anosmia, altered taste, and decreased appetite. Chronic mouth breathing may result in halitosis, pharyngitis, and in the long-term a high arched palate and orthodontic disturbances. Post-nasal drip is the most common cause of chronic cough, but patients with AR who cough should also be assessed for possible concurrent asthma.

Perhaps the most underappreciated effects of AR lie in its impact on quality of life. Nasal congestion is the most bothersome symptom of which patients with AR complain, but the disease has more systemic effects. A very high proportion of patients with AR have constitutional symptoms including fatigue, irritability, and difficulty concentrating. Many are embarrassed by their symptoms and some even become depressed.

About a quarter of patients with AR miss school or work because of their symptoms, but AR is an even greater cause of “presenteeism” with the great majority reporting lost productivity at work or school.

The physical exam
Physical findings in AR may include boggy, pale, bluish hued inferior turbinates, infra-orbital darkening (“allergic shiners”), conjunctival redness, and extra folds of the lower eye lids (Dennie-Morgan folds). The allergic salute commonly results in a transverse nasal crease as a result of the tip of the nose constantly being pushed upward. Post-nasal drip may be visible on physical exam and posterior pharyngeal lymphoid hyperplasia (“cobblestoning”) may be the result of post-nasal drip. Because asthma is common in AR, the lungs should also be examined routinely.

Testing for specific IgE
Allergy skin testing is the preferred method for identification of allergen specific IgE. It is less expensive and takes less time to get results than in vitro tests (colloquially called “RASTs”) and in many ways is much easier to interpret. However, I recognize that skin testing is not practical in a primary care office, requiring referral to an allergist.

Most in vitro tests today use similar methods as the older paper disk RASTs, but with a different solid medium. They are more sensitive and specific than true RASTs, although they might not quite approach the statistical value of skin tests. One advantage of in vitro tests is that they do not require that oral antihistamines be withheld beforehand.

Whatever method of testing is chosen, it is important to only test for allergens thought to be relevant to and potential triggers of the symptoms. The choice of tests and their interpretation must be done in the context of the history. It is important to understand that a positive test merely indicates sensitization (the presence of allergen-specific IgE). The diagnosis of allergy relies on the presence of specific IgE AND symptoms with exposure. For that reason, tests for irrelevant allergens should not be requested. Flora varies depending on geographic region. The results of testing for allergen specific IgE allow for focused recommendations for allergen avoidance (see below).


References
Allergic Rhinitis Allergic Rhinitis 09/06/2018
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