Clinical continued...

Physical

The physical examination should focus on the nose, but examination of facial features, eyes, ears, oropharynx, neck, lungs, and skin is also important. Look for physical findings that may be consistent with a systemic disease that is associated with rhinitis.

• General facial features
• • "Allergic shiners" are dark circles around the eyes and are related to vasodilation or nasal congestion.

     

  • "Nasal crease" is a horizontal crease across the lower half of the bridge of the nose that is caused by repeated upward rubbing of the tip of the nose by the palm of the hand (ie, the "allergic salute").

     

   

• Nose
• • The nasal examination is best accomplished with a nasal speculum or an otoscope with nasal adapter. In the specialist's office, a rigid or flexible rhinolaryngoscope may be used.

     

  • The mucosa of the nasal turbinates may be swollen (boggy) and have a pale, bluish-gray color. Some patients may have predominant erythema of the mucosa, which can also be observed with rhinitis medicamentosa, infection, or vasomotor rhinitis. While pale, boggy, blue-gray mucosa is typical for allergic rhinitis, mucosal examination findings cannot definitively distinguish between allergic and nonallergic causes of rhinitis.

     

  • Assess the character and quantity of nasal mucus. Thin and watery secretions are frequently associated with allergic rhinitis, while thick and purulent secretions are usually associated with sinusitis; however, thicker, purulent, colored mucus can also occur with allergic rhinitis.

     

  • Examine the nasal septum to look for any deviation or septal perforation, which may be present due to chronic rhinitis, granulomatous disease, cocaine abuse, prior surgery, topical decongestant abuse, or, rarely, topical steroid overuse.

     

  • Examine the nasal cavity for other masses such as polyps or tumors. Polyps are firm gray masses that are often attached by a stalk, which may not be visible. After spraying a topical decongestant, polyps do not shrink, while the surrounding nasal mucosa does shrink.

     

   

• Ears, eyes, and oropharynx
• • Perform otoscopy to look for tympanic membrane retraction, air-fluid levels, or bubbles. Performing pneumatic otoscopy can be considered to look for abnormal tympanic membrane mobility. These findings can be associated with allergic rhinitis, particularly if eustachian tube dysfunction or secondary otitis media is present.

     

  • Ocular examination may reveal findings of injection and swelling of the palpebral conjunctivae, with excess tear production. Dennie-Morgan lines (prominent creases below the inferior eyelid) are associated with allergic rhinitis.

     

  • The term "cobblestoning" is used to describe streaks of lymphoid tissue on the posterior pharynx, which is commonly observed with allergic rhinitis. Tonsillar hypertrophy can also be observed. Malocclusion (overbite) and a high-arched palate can be observed in patients who breathe from their mouths excessively.

     

   

• Neck: Look for evidence of lymphadenopathy or thyroid disease.

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• Lungs: Look for the characteristic findings of asthma.

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• Skin: Evaluate for possible atopic dermatitis.

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• Other: Look for any evidence of systemic diseases that may cause rhinitis (eg, sarcoidosis, hypothyroidism, immunodeficiency, ciliary dyskinesia syndrome, other connective tissue diseases).