The hallmarks of allergic rhinitis are clear: thin rhinorrhea; nasal congestion; paroxysms of sneezing; and pruritus of the eyes, nose, ears, and palate. Postnasal drip may result in frequent attempts to clear the throat, nocturnal cough, and hoarseness. It is important to correlate the onset, duration, and severity of symptoms with seasonal or perennial exposures, changes in the home or school environment, and exposure to nonspecific irritants, such as tobacco smoke.
The physical examination includes a thorough nasal examination and an evaluation of the eyes, ears, throat, chest, and skin. Physical findings may be subtle. Classic physical findings include pale pink or bluish gray, swollen, boggy nasal turbinates with clear, watery secretions. Frequent nasal itching and rubbing of the nose with the palm of the hand, the allergic salute, can lead to a transverse nasal crease found across the lower bridge of the nose. Children may produce clucking sounds by rubbing the soft palate with their tongue. Oropharyngeal examination may reveal lymphoid hyperplasia of the soft palate and posterior pharynx or visible mucus or both. Orthodontic abnormalities may be seen in children with chronic mouth breathing. Allergic shiners, dark periorbital swollen areas caused by venous congestion, along with swollen eyelids or conjunctival injection, are often present in children. Retracted tympanic membranes from eustachian tube dysfunction or serous otitis media also may be present. Other atopic diseases, such as asthma or eczema, may be present, which helps lead the clinician to the correct diagnosis.
Allergy testing can be performed by in vivo skin tests or by in vitro serum tests (radioallergosorbent test [RAST], fluorescent enzyme immunoassay [FEIA], or enzyme linked immunosorbent assay [ELISA]) to pertinent allergens found in the patient’s environment (see Table 77-4). Skin tests (prick/puncture) provide immediate and accurate results. Positive tests correlate strongly with nasal and bronchial allergen provocative challenges. In vitro serum tests are useful for patients with abnormal skin conditions, for those with a tendency for anaphylaxis, or for those taking medications that interfere with skin testing. Disadvantages of serum tests include increased cost, inability to obtain immediate results, and reduced sensitivity compared with skin tests. Widespread screening with serum testing without regard to symptoms is not recommended. Measurement of total serum IgE or blood eosinophils generally is not helpful. The presence of eosinophils on the nasal smear suggests a diagnosis of allergy, but eosinophils also can be found in patients with nonallergic rhinitis with eosinophilia. Nasal smear eosinophilia is often predictive of a good clinical response to nasal corticosteroid sprays.