Approach

AR is mediated by an immunoglobulin (Ig)E-associated response to indoor and outdoor environmental allergens. However, none of these individual findings are very sensitive or specific, so their presence does not distinguish between allergic and nonallergic nasal disease. Similarly, the absence of pertinent findings does not rule out allergic disease, so determination of specific IgE reactivity using skin-prick testing or in vitro specific IgE determination represents the only confirmed means of diagnosing AR.

Signs and symptoms

Nasal signs and symptoms:

  • Pruritus

  • Sneezing

  • Rhinorrhea

  • Nasal congestion, often the most bothersome.

Associated signs and symptoms:

  • Palate, throat, ear, and eye itching

  • Eye redness, puffiness, and watery discharge.

Constitutional signs and symptoms:

  • Fatigue

  • Irritability.

The diagnosis of AR may be made presumptively based on the types of signs and symptoms and the history of allergen triggers. Patients should also be asked about the presence of chest symptoms, food allergies, and atopic dermatitis (eczema).

Unilateral rhinorrhea should prompt evaluation for cerebrospinal fluid leak. Unilateral disease, with the exception of unilateral nasal congestion due to a deviated septum, should warrant referral to an ear, nose, and throat physician.

Physical exam

Physical exam of the nose is supportive. Findings may include swelling of the turbinates and nasal mucosa, the presence of clear nasal mucus and/or a pale nasal mucosa, and nasal crease (a transverse crease resulting from repetitive nose rubbing and manipulation).

Physical exam of the face may identify allergic shiners (bluish discoloration in the infraorbital region), conjunctival injection, ocular mucoid discharge, and, less commonly, Dennie-Morgan lines (creases present under the lower eyelids).

Do not routinely perform sinonasal imaging in patients with symptoms suggesting a diagnosis of allergic rhinitis alone. The use of imaging for allergic rhinitis is unproven.[50][51][52]​[53]​​

Trial of therapy

A trial of symptom-driven pharmacotherapy with intranasal corticosteroids, or oral or intranasal antihistamine, may be a pragmatic and reasonable first step. A trial of intranasal corticosteroids should be considered a preferred first choice in moderate or severe AR, especially if symptoms are persistent or nasal obstruction is an issue. A sufficient response to the chosen medication should be assessed after 1 to 2 weeks of therapy (at least 2 weeks for an intranasal corticosteroid).

Because symptoms of AR are often very subjective, the patient's perceived improvement in symptoms and quality of life is paramount in determining whether there has been an adequate response or whether further investigation is required. Validated quality of life questionnaires specific for AR can be used to assess therapy response (e.g., Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] and Rhinitis Control Assessment Test [RCAT]).[54][55][56]

Allergy testing

Determination of specific IgE reactivity using skin-prick testing or in vitro specific IgE determination is advisable if there is an inadequate response to a trial of therapy.[57]

  • Skin prick testing or in vitro IgE determination usually suffice, although on some occasions both tests are used for optimal management.

  • The choice of test often depends on availability. In vitro IgE determination tends to be more readily available but is more expensive, and provides less sensitivity and specificity than skin testing. However, in vitro IgE determination may be preferable in patients with severe eczema affecting the testing area, in patients with significant dermatographism, or for those unwilling or unable to stop their antihistamines or medications with antihistamine properties (e.g., tricyclic antidepressants).

  • Most medical laboratories offer a variety of allergen panels that should incorporate the most important perennial allergens such as animal danders and dust mites as well as geographically important local pollens such as grasses, weeds, and trees. However, tests should be ordered judiciously in the context of the patient's symptoms and exposures (e.g., do not order tests for tropical grasses in northern climates where these grasses do not grow); the "shotgun approach" - ordering numerous tests to see if any come back positive - is inappropriate.

  • Panels including foods have no role in the diagnosis of AR in the absence of systemic symptoms (e.g., urticaria or anaphylaxis) that occur in conjunction with the consumption of certain foods.

  • Results may not only confirm the presence of allergic disease but also help in directing environmental control interventions and determining whether a patient may be suitable for immunotherapy.

  • Approximately 26% of patients previously considered nonallergic based on negative tests for specific IgE may have positive nasal allergen provocation tests.[58] Although cumbersome, nasal allergen provocation tests might be an option for confirming the diagnosis in patients who have symptoms of AR, and negative specific IgE in vivo or in vitro tests, and who fail empiric therapy for AR based on the characteristics of their symptoms.

Do not perform any unproven diagnostic tests, such as immunoglobulin G (lgG) or a battery of nonspecific IgE tests, in the evaluation of allergy. IgG and indiscriminate IgE testing is unproven and can lead to inappropriate diagnosis and treatment.[44]

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