Clinical continued...

Symptoms that can be associated with allergic rhinitis include sneezing, itching (of nose, eyes, ears, palate), rhinorrhea, postnasal drip, congestion, anosmia, headache, earache, tearing, red eyes, eye swelling, fatigue, drowsiness, and malaise.

• Symptoms and chronicity
• • Determine the age of onset of symptoms and whether symptoms have been present continuously since onset. While the onset of allergic rhinitis can occur well into adulthood, most patients develop symptoms by age 20 years.

     

  • Determine the time pattern of symptoms and whether symptoms occur at a consistent level throughout the year (ie, perennial rhinitis), only occur in specific seasons (ie, seasonal rhinitis), or a combination of the two. During periods of exacerbation, determine whether symptoms occur on a daily basis or only on an episodic basis. Determine whether the symptoms are present all day or only at specific times during the day. This information can help suggest the diagnosis and determine possible triggers.

     

  • Determine which organ systems are affected and the specific symptoms. Some patients have exclusive involvement of the nose, while others have involvement of multiple organs. Some patients primarily have sneezing, itching, tearing, and watery rhinorrhea (the classic hayfever presentation), while others may only complain of congestion. Significant complaints of congestion, particularly if unilateral, might suggest the possibility of structural obstruction, such as a polyp, foreign body, or deviated septum.

     

   

• Trigger factors
• • Determine whether symptoms are related temporally to specific trigger factors. This might include exposure to pollens outdoors, mold spores while doing yard work, specific animals, or dust while cleaning the house.

     

  • Irritant triggers such as smoke, pollution, and strong smells can aggravate symptoms in a patient with allergic rhinitis. These are also common triggers of vasomotor rhinitis. Many patients have both allergic rhinitis and vasomotor rhinitis.

     

  • Other patients may describe year-round symptoms that do not appear to be associated with specific triggers. This could be consistent with nonallergic rhinitis, but perennial allergens, such as dust mite or animal exposure, should also be considered in this situation. With chronic exposure and chronic symptoms, the patient may not be able to associate symptoms with a particular trigger.

     

   

• Response to treatment
• • Response to treatment with antihistamines supports the diagnosis of allergic rhinitis, although sneezing, itching, and rhinorrhea associated with nonallergic rhinitis can also improve with antihistamines.

     

  • Response to intranasal corticosteroids supports the diagnosis of allergic rhinitis, although some cases of nonallergic rhinitis (particularly the nonallergic rhinitis with eosinophils syndrome [NARES]) also improve with nasal steroids.

     

   

• Comorbid conditions
• • Patients with allergic rhinitis may have other atopic conditions such as asthma or atopic dermatitis. Of patients with allergic rhinitis, 20% also have symptoms of asthma. Uncontrolled allergic rhinitis may cause worsening of asthma or even atopic dermatitis. Explore this possibility when obtaining the patient history.

     

  • Look for conditions that can occur as complications of allergic rhinitis. Sinusitis occurs quite frequently. Other possible complications include otitis media, sleep disturbance or apnea, dental problems (overbite), and palatal abnormalities. The treatment plan might be different if one of these complications is present. Nasal polyps occur in association with allergic rhinitis, although whether allergic rhinitis actually causes polyps remains unclear. Polyps may not respond to medical treatment and might predispose a patient to sinusitis or sleep disturbance (due to congestion).

     

  • Investigate past medical history, including other current medical conditions. Diseases such as hypothyroidism or sarcoidosis can cause nonallergic rhinitis. Concomitant medical conditions might influence the choice of medication.

     

   

• Family history
• • Because allergic rhinitis has a significant genetic component, a positive family history for atopy makes the diagnosis more likely.

     

  • In fact, a greater risk of allergic rhinitis exists if both parents are atopic than if one parent is atopic. However, the cause of allergic rhinitis appears to be multifactorial, and a person with no family history of allergic rhinitis can develop allergic rhinitis.

     

   

• Environmental and occupational exposure
• • A thorough history of environmental exposures helps to identify specific allergic triggers. This should include investigation of risk factors for exposure to perennial allergens (eg, dust mites, mold, pets). Risk factors for dust mite exposure include carpeting, heat, humidity, and bedding that does not have dust mite–proof covers. Chronic dampness in the home is a risk factor for mold exposure. A history of hobbies and recreational activities helps determine risk and a time pattern of pollen exposure.

     

  • Ask about the environment of the workplace or school. This might include exposure to ordinary perennial allergens (eg, mites, mold, pet dander) or unique occupational allergens (eg, laboratory animals, animal products, grains and organic materials, wood dust, latex, enzymes).

     

   

• Effects on quality of life
• • An accurate assessment of the morbidity of allergic rhinitis cannot be obtained without asking about the effects on the patient's quality of life. Specific validated questionnaires are available to help determine effects on quality of life.

     

  • Determine the presence of symptoms such as fatigue, malaise, drowsiness (which may or may not be related to medication), and headache.

     

  • Investigate sleep quality and ability to function at work.