Diagnosis of allergic rhinitis

The diagnosis of allergic rhinitis is established based on the history of the disease, the characteristic clinical symptoms and the detection of cause-significant allergens (for skin testing or the determination of the titer of allergen-specific IgE in vitro in the event that it is impossible to carry out skin tests).

Anamnesis and physical examination

When collecting anamnesis, it is necessary to clarify the presence of allergic diseases in relatives, the nature, frequency, duration, severity of symptoms, seasonality, response to treatment, the presence of other allergic diseases in the patient, provoking factors. Conduct a rhinoscopy (examination of nasal passages, mucous membrane of the nasal cavity, secretion, nasal concha and septum). In patients with allergic rhinitis, the mucous membrane is usually pale, cyanotic-gray, edematous. The nature of the secretion is mucous and watery. In chronic or severe acute allergic rhinitis, a transverse fold is found on the back of the nose, which is formed in children as a result of an "allergic salute" (rubbing the tip of the nose). Chronic nasal obstruction leads to the formation of a characteristic "allergic face" (dark circles under the eyes, a violation of the development of the facial skull, including an incorrect bite, arch-shaped palate, flattening of molars).

Laboratory and instrumental methods

Skin testing and allergosorbent test are used for differential diagnosis of allergic and non-allergic rhinitis; these methods also allow you to determine the cause-significant allergens.

Skin Testing

Correctly performed skin testing allows to assess the presence of IgE in vivo; the study is shown to patients who:

• poorly controlled symptoms [persistent nasal symptoms and / or inadequate clinical response to intranasal glucocorticoid agents];
• the diagnosis based on the data of the anamnesis and physical inspection is not specified;
• there is concomitant persistent bronchial asthma and / or recurrent sinusitis or otitis media.

Skin testing is a fast, safe and inexpensive test method that confirms the presence of IgE. When setting skin tests with domestic, pollen and epidermal allergens, the reaction is evaluated after 20 minutes according to the size of the papule and hyperemia. For 7-10 days before this, it is necessary to cancel antihistamines. Skin testing should be carried out by specially trained medical personnel. A specific set of allergens varies depending on the suspected sensitivity to them and the geographical area.

Immunoallergosorbent test

Immunoallergosorbent test - less sensitive and more expensive (in comparison with skin tests) method of detecting specific IgE in serum. In 25% of patients with positive skin tests, the results of an allergic sorbent test are negative. In connection with this, this method has limited application in the diagnosis of allergic rhinitis. It is not necessary to cancel antihistamines before the study.

RAST - radioallergosorbent test (proposed by WIDE in 1967) - detection of increased concentration of class E immunoglobulins in blood serum in patients with atopic allergy. By results, it coincides with the reliability of skin reactions, but it can be carried out not only during remission, but also during exacerbation. It should be noted that the total level of IgE in children with AR is not more than 50%, it is lower than in adults. At birth, it is 0-1 kE / l and increases gradually.

PRIST - radioimmunosorbent test - a similar technique, the differences consist in the ability to take into account the formed radioactive complexes with the help of a y-radiation counter.

Rhinoscopic picture

During the period of exacerbation, it differs little from that of adults: the edema of the inferior nasal concha is characteristic; in this connection they acquire a whitish color. Less common are the so-called spots Voyachek and cyanosis of the mucous membrane, the discharge is mostly serous-mucous. Often during the period of exacerbation, we observed mucous membrane swelling in the middle nasal passage, resembling a small polyp, soft when probed. During the period without exacerbation the rhinoscopic picture became completely normal, and the middle nasal passage was completely released from the edematous tissue. This symptom is called edematous etiomyitis, in all probability, it is a harbinger of polyposis etmoiditis in adults and the main cause of violation of the clearance of the paranasal sinuses. When this symptom appears, especially if it is combined with abundant mucous secretions, differential diagnosis is performed with cystic fibrosis.

New possibilities for examination of the nasal cavity appeared in recent years in connection with the use of modern endoscopic technologies. Conventionally, two main methods can be distinguished. The first - an examination using an operating microscope - has been used for more than 20 years. You can use a different magnification. The main disadvantage of the method is the limitation of the lateral view, therefore it is preferable to use straight rigid or flexible endoscopes that allow not only to get an idea of the entire mosaic of the lateral wall of the nose, but also for a certain art to perform a direct examination of some paranasal sinuses through natural anastomoses. Using a fibroscope, it is easy to examine the posterior part of the nasal cavity, to get an idea of the condition of the opener. Much less often than in adults, in childhood, hypertrophic changes in nasal concha are found. Anemization almost always leads to a decrease in the size of the shells. Traumatic curvature of the septum of the nose is encountered in childhood rarely. However, congenital disorders in the form of spines, especially closer to the bottom of the nasal cavity, are often detected in allergic rhinitis, but, unfortunately, are left unaddressed. Particular care should be taken to examine the posterior part of the septum in the vomer region, in this area, in the allergic rhinitis, pillow-shaped thickenings are revealed by the growth of cavernous tissue. These pathological changes often remain unrecognized in connection with the difficulties of a posterior rhinoscopy in a child. When examining the nasopharynx, usually draws attention to a large amount of mucus in its dome, edematous ridges of the mouths of the auditory tubes. The size and color of the adenoid vegetation depends on the time of examination, during the period of exacerbation they are whitish or cyanotic, covered with viscous mucus. The child tries to truncate it, but without success. With pharyngoscopy during an exacerbation of allergic rhinitis, the swelling of the soft palate and tongue is often revealed, this leads not only to closed but also open nasal. All these changes in childhood very quickly pass. This must be remembered when analyzing the x-ray of the nasopharynx and paranasal sinuses. Decrease in pneumonitis of sinuses, and also the increased shadow of adenoids during this period should be evaluated critically. X-ray data are valuable only in cases when pictures are taken during the remission period. In childhood, organic changes (parieto-hyperplastic form of sinusitis, not to mention polypous-purulent processes) are less common than in adults.

The most common diseases of ENT organs, associated with allergic rhinitis, include rhinosinusitis, adenoiditis, pharyngeal tonsillitis, recurrent and exudative otitis media, nasal polyposis, nasal septum spines, granulosis pharyngitis, liningitic lining. In general, it can be said that in approximately 70% of cases only nasal and paranasal sinus lesions are observed, 20% - inflammation in the nasopharynx and 10% - in the larynx. Treatment and elimination of this pathology are indispensable conditions for successful treatment of allergic rhinitis, however the approach in each case should be differentiated. Of particular interest are the allergic rhinitis associated with allergic diseases of other organs. Most often, in about 50% of cases, its combination with exudative diathesis is observed, in 30% - with conjunctivitis. Approximately 25% of children have allergic rhinitis combined with bronchial asthma. A special place is taken by the combination of allergic diseases of the nose and paranasal sinuses with the pathology of bronchi and lungs. As early as 1929, Wasson introduced the concept of sinobronchitis. Further, this pathology was given different names: sinusopneumonia, sinusobronchopneumonia syndrome, adenosine intronumopneumonia. The most popular name at present is respiratory allergies. They are more common in children aged 4 to 9 years. This question is very complicated, but, no doubt, it is determined by the mutual influence of pathological foci in the nasal cavity, paranasal sinuses, bronchi and lungs. The mechanism of this influence can be different: reflexogenic, topical, allergenic or otherwise, but the principle does not change from this. Left without treatment of allergic rhinitis in 40% of cases go to bronchial asthma. It is generally believed that allergic rhinosinusitis is regarded as a pre-asthmatic condition, although in certain cases a simultaneous debut of rhinosinusitis and bronchial asthma is also observed.

Local methods of research

The secret of the nasal cavity:

• determination of the number and location of eosinophils;
• determination of goblet cells content;
• determination of the content of mast cells (target cells);
• determination of IgE level. Serum of nasal concha:
• determination of the number of eosinophils;
• determination of IgE level. Fabrics:
• examination of the mucosa of the shells and paranasal sinuses;
• The study of polyps of the nose and its adnexal sinuses.

RAST and PRIST tests are also used to determine the level of IgE in the blood of the nasal concha and in the secretion of the nasal cavity. Recently, the determination of IgE level in polyp fluids is popular.

Determination of the number of eosinophils in the secretion of the nasal cavity

The secret for research is obtained by aspirating with a pear or syringe, but it is better to make prints from the surface of the nasal concha with special polished glasses. In this case, the group location of eosinophils is preserved in the smear, this confirms the diagnosis. In the smears, goblet and mast cells are also examined. The cytogram is a good method for diagnosing allergic rhinitis in children due to its complete safety and painlessness.

Additional research methods (not recommended for routine use)

• Provocative tests with allergens in children's clinical practice have limited application, they are performed only in specialized medical institutions of the allergological profile.
• Radiography (CT) of the paranasal sinuses is performed with suspicion of sinusitis.
• Endoscopic examination of the nasal cavity / nasopharynx after consultation with an ENT doctor is used to exclude other causes of difficulty in nasal breathing (foreign body, curvature of the nasal septum, etc.).

Differential diagnosis of allergic rhinitis

• Acute infectious rhinitis in acute respiratory viral infection (ARVI) is manifested by nasal congestion, rhinorrhea, sneezing. Nasal symptoms predominate on the 2nd-3rd day and die off by the 5th day of the disease. Clinical manifestations that persist for more than 2 weeks may indicate an allergic rhinitis.
• Vasomotor rhinitis is one of the most common forms of non-allergic rhinitis (idiopathic rhinitis). A constant nasal congestion is characteristic, which is aggravated by changes in temperature, humidity and sharp odors. There is a hypersecretory variant with persistent rhinorrhea, in which there is an insignificant itching of the nose, sneezing, headaches, anosmia, sinusitis. Heredity for allergic diseases is not burdened, nor is sensitization to allergens. With rhinoscopy, in contrast to allergic rhinitis, which is characterized by cyanosis, pallor, edema of the mucous membrane, reveal hyperemia, a viscous secret.

Differential diagnosis of allergic and vasomotor rhinitis

Clinical criteria	Allergic rhinitis	Vasomotor rhinitis
Features of anamnesis	Occurs in early childhood	Occurs in older age
Contact with the causal agent Allergen	Pollen of plants, house dust, etc.	Allergen does not reveal
Seasonality of the disease	Possible	Not typical
The elimination effect	Present	Absent
Other allergic diseases	Often there are	None
Hereditary predisposition	Often present	Absent
Other criteria	Anatomical defects are rarely detected; combination with conjunctivitis, asthma, atopic dermatitis, allergic urticaria	The development of vasomotor rhinitis is often preceded by long-term use of vasoconstrictive drops, curvature or defect of the nasal septum
Rhinoscopy	The mucous membrane is pale pink (outside of exacerbation), cyanotic, edematous (with exacerbation)	Mucous membrane of cyanotic, marble, Voyachek stains, mucosal hypertrophy
Skin tests	Positive with cause-significant allergens	Negative
The concentration of total IgE in the blood	Increased	Within normal limits
The effect of using antihistamines / local glucocorticosteroids	Pronounced positive	Is absent or less pronounced (SCS can be effective in this disease)
The content of eosinophils in the blood	Often increased	Usually normal

• Medicamentous rhinitis is the result of prolonged use of vasoconstrictive nasal drugs, as well as the inhalation of cocaine. Note the constant nasal obstruction, with a rinoscopy the mucous membrane of a bright red color. A positive response to the treatment with intranasal glucocorticosteroids, which are necessary for the successful withdrawal of drugs that cause the disease, is characteristic.
• Non-allergic rhinitis with eosinophilic syndrome is characterized by pronounced nasal eosinophilia, absence of a positive allergological anamnesis, negative results of skin testing. There are persistent symptoms, mild sneezing and itching, a tendency to form nasal polyps, a lack of an adequate response to antihistamine drugs, a good effect with the use of intranasal glucocorticosteroids.
• Unilateral rhinitis presupposes nasal obstruction due to foreign body, tumor, nasal polyps, which are possible with nonallergic rhinitis with eosinophilic syndrome, chronic bacterial sinusitis, allergic fungal sinusitis, aspirin asthma, cystic fibrosis and ciliated syndrome of epithelium. One-sided lesions or polyps of the nose for uncomplicated allergic rhinitis are not characteristic.

Nasal symptoms are typical for some systemic diseases, in particular for Wegener's granulomatosis, which is manifested by a permanent rhinorrhea, purulent / hemorrhagic detachable, ulcers in the mouth and / or nose, polyarthralgia, myalgia, pain in the paranasal sinuses.

[1], [2], [3], [4], [5], [6], [7]