Diagnosis of allergic rhinitis

The diagnosis of allergic rhinitis is established on the basis of anamnesis data, characteristic clinical symptoms and identification of causative allergens (by skin testing or determination of the titer of allergen-specific IgE in vitro if skin tests are not possible).

History 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. Rhinoscopy is performed (examination of the nasal passages, mucous membrane of the nasal cavity, secretion, nasal turbinates 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 bridge of the nose, which is formed in children as a result of the "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, impaired development of the facial skull, including malocclusion, arched palate, flattening of the molars).

Laboratory and instrumental methods

Skin testing and allergosorbent testing are used for differential diagnosis of allergic and non-allergic rhinitis; these methods also allow identification of causative allergens.

Skin testing

When performed correctly, skin testing can assess the presence of IgE in vivo and is indicated in patients who:

• poorly controlled symptoms [persistent nasal symptoms and/or inadequate clinical response to intranasal glucocorticoids];
• the diagnosis based on the history and physical examination data is not clear;
• there is concomitant persistent bronchial asthma and/or recurrent sinusitis or otitis.

Skin testing is a fast, safe and inexpensive method of testing to confirm the presence of IgE. When performing skin tests with household, pollen and epidermal allergens, the reaction is assessed after 20 minutes based on the size of the papule and hyperemia. Antihistamines should be discontinued 7-10 days before this. Skin testing should be performed by specially trained medical personnel. The specific set of allergens varies depending on the expected sensitivity to them and the geographic area.

Immunoallergosorbent test

The immunoallergosorbent test is a less sensitive and more expensive (compared to skin tests) method for detecting specific IgE in blood serum. In 25% of patients with positive skin tests, the results of the allergosorbent test are negative. In this regard, this method has limited application in the diagnosis of allergic rhinitis. It is not necessary to cancel antihistamines before the test.

RAST - radioallergosorbent test (proposed by WIDE in 1967) - detection of increased concentration of immunoglobulins of class E in the blood serum of patients with atopic allergy. According to the 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 no more than 50%, which is lower than in adults. At birth, it is 0-1 kE / l and increases gradually.

PRIST - radioimmunosorbent test - a similar method, the differences are in the ability to take into account the resulting radioactive complexes using a gamma-radiation counter.

Rhinoscopic picture

During the period of exacerbation, it differs little from that in adults: swelling of the lower nasal conchae is characteristic, due to which they acquire a whitish color. Less common are the so-called Voyachek spots and cyanosis of the mucous membrane, the discharge is mainly serous-mucous. Often during the period of exacerbation, we observed swelling of the mucous membrane in the area of the middle nasal passage, resembling a small polyp, soft on probing. During the period outside of exacerbation, the rhinoscopic picture became completely normal, and the middle nasal passage was completely freed from edematous tissue. We call this symptom edematous ethmoiditis, in all likelihood, it is a harbinger of polypous ethmoiditis in adults and the main cause of impaired clearance of the paranasal sinuses. When such a symptom appears, especially if it is combined with abundant mucous discharge, differential diagnostics with cystic fibrosis is carried out.

New opportunities for examining the nasal cavity have appeared in recent years due to the use of modern endoscopic technologies. Conventionally, two main methods can be distinguished among them. The first - examination using an operating microscope - has been used for over 20 years. Different magnifications can be used. The main disadvantage of the method is the limitation of lateral view, so it is preferable to use direct rigid or flexible endoscopes, which allow not only to get an idea of the entire mosaic of the lateral wall of the nose, but also, with a certain skill, to directly examine some paranasal sinuses through natural fistulas. With the help of a fiberscope, it is easy to examine the posterior part of the nasal cavity, get an idea of the state of the vomer. Hypertrophic changes in the nasal turbinates are found in childhood much less often than in adults. Anemia almost always leads to a decrease in the size of the turbinates. Traumatic curvature of the nasal septum is rare in childhood. However, congenital abnormalities in the form of spikes, especially closer to the bottom of the nasal cavity, are detected quite often in allergic rhinitis, but, unfortunately, remain unnoticed. The posterior parts of the septum in the vomer area should be examined especially carefully, it is in this area that pillow-shaped thickenings are detected due to the growth of cavernous tissue in allergic rhinitis. These pathological changes often remain unrecognized due to the difficulties of posterior rhinoscopy in a child. When examining the nasopharynx, one usually notices a large amount of mucus in its dome, edematous ridges of the mouths of the auditory tubes. The size and color of adenoid vegetations depend on the time of examination, during an exacerbation they are whitish or bluish, covered with viscous mucus. The child tries to cough it up, but to no avail. Pharyngoscopy during an exacerbation of allergic rhinitis often reveals swelling of the soft palate and uvula, which leads not only to closed but also to open nasal speech. All these changes in childhood very quickly pass. This must be remembered when analyzing radiographs of the nasopharynx and paranasal sinuses. A decrease in pneumatization of the sinuses, as well as an enlarged adenoid shadow during this period, should be assessed critically. Radiographic data are valuable only in cases where the images are taken during remission. In childhood, organic changes (parietal-hyperplastic form of sinusitis, not to mention polypous-purulent processes) are less common than in adults.

The most common ENT diseases accompanying allergic rhinitis include rhinosinusitis, adenoiditis, hypertrophy of the pharyngeal tonsil, recurrent and exudative otitis media, nasal polyposis, nasal septum spines, granular pharyngitis, and subglottic laryngitis. In general, it can be said that in approximately 70% of cases, only the nose and paranasal sinuses are affected, in 20% - inflammation in the nasopharynx, and in 10% - in the larynx. Treatment and elimination of this pathology are essential conditions for the successful treatment of allergic rhinitis, but the approach in each case should be differentiated. Of particular interest are allergic diseases of other organs accompanying allergic rhinitis. Most often, in about 50% of cases, it is combined with exudative diathesis, in 30% - with conjunctivitis. Approximately 25% of children have allergic rhinitis combined with bronchial asthma. A special place is occupied by the combination of allergic diseases of the nose and paranasal sinuses with pathology of the bronchi and lungs. As early as 1929, Wasson introduced the concept of sinobronchitis. Later, this pathology received different names: sinusopneumonia, sinusobronchopneumonic syndrome, adenosinusobronchopneumonia. The most popular name at present is respiratory allergies. They are more often found in children aged 4 to 9 years. This issue is very complex, but, without a doubt, it is determined by the mutually negative 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 other, but the principle does not change. Allergic rhinitis left untreated develops into bronchial asthma in 40% of cases. It is generally accepted that allergic rhinosinusitis is considered a pre-asthmatic condition, although in certain cases, the simultaneous onset of rhinosinusitis and bronchial asthma is observed.

Local research methods

Secretion from the nasal cavity:

• determination of the number and location of eosinophils;
• determination of goblet cell content;
• determination of mast cell (target cell) content;
• Determination of IgE level. Blood serum of nasal turbinates:
• determination of the number of eosinophils;
• Determination of IgE levels. Tissues:
• examination of the mucous membrane of the turbinates and paranasal sinuses;
• examination of nasal polyps and paranasal sinuses.

RAST and PRIST tests are also used to determine the level of IgE in the blood of the nasal conchae and in the secretion of the nasal cavity. Recently, the determination of the level of IgE in the fluid from polyps has become popular.

Determination of the number of eosinophils in nasal secretions

The secret for examination is obtained by aspiration with a bulb or syringe, but it is better to make prints from the surface of the nasal conchae with special ground glasses. In this case, the group arrangement of eosinophils is preserved in the smear, which confirms the diagnosis. Goblet and mast cells are also examined in smears. 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 pediatric clinical practice have limited use; they are performed only in specialized allergological medical institutions.
• X-ray (CT) of the paranasal sinuses is performed if sinusitis is suspected.
• An endoscopic examination of the nasal cavity/nasopharynx after consultation with an ENT specialist 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 subside by the 5th day of the disease. Clinical manifestations that persist for more than 2 weeks may indicate allergic rhinitis.
• Vasomotor rhinitis is one of the most common forms of non-allergic rhinitis (idiopathic rhinitis). Characterized by constant nasal congestion, which intensifies with changes in temperature, air humidity and strong odors. There is a hypersecretory variant with persistent rhinorrhea, which causes slight itching of the nose, sneezing, headaches, anosmia, and sinusitis. There is no heredity for allergic diseases, and sensitization to allergens is also not characteristic. Rhinoscopy, unlike allergic rhinitis, which is characterized by cyanosis, pallor, and swelling of the mucous membrane, reveals hyperemia and viscous secretion.

Differential diagnosis of allergic and vasomotor rhinitis

Clinical criteria	Allergic rhinitis	Vasomotor rhinitis
Peculiarities of the anamnesis	Occurs in early childhood	Occurs in older age
Contact with the causal agent Allergen	Plant pollen, house dust, etc.	Allergen is not detected
Seasonality of the disease	Possible	Not typical
Elimination effect	Present	Absent
Other allergic diseases	Often present	None
Hereditary predisposition	Often present	Absent
Other criteria	Anatomical defects are rarely detected; combination with conjunctivitis, bronchial asthma, atopic dermatitis, allergic urticaria	The development of vasomotor rhinitis is often preceded by long-term use of vasoconstrictor drops, curvature or defect of the nasal septum
Rhinoscopy	The mucous membrane is pale pink (outside of exacerbation), cyanotic, edematous (during exacerbation)	The mucous membrane is cyanotic, marbled, Vojacek spots, hypertrophy of the mucous membrane
Skin tests	Positive with causative allergens	Negative
Total IgE concentration in blood	Increased	Within normal limits
Effect of antihistamines/topical glucocorticosteroids	Expressed positive	Absent or less pronounced (GCS may be effective in this disease)
Blood eosinophil content	Often elevated	Usually normal

• Drug-induced rhinitis is the result of long-term use of vasoconstrictor nasal preparations, as well as cocaine inhalation. Constant nasal obstruction is noted, and the mucous membrane is bright red during rhinoscopy. A positive response to treatment with intranasal glucocorticosteroids is characteristic, which are necessary for successful withdrawal of the drugs causing this disease.
• Nonallergic rhinitis with eosinophilic syndrome is characterized by pronounced nasal eosinophilia, absence of a positive allergy history, negative skin testing results. Persistent symptoms, mild sneezing and itching, tendency to form nasal polyps, absence of an adequate response to treatment with antihistamines, and good effect with intranasal glucocorticosteroids are noted.
• Unilateral rhinitis suggests nasal obstruction due to a foreign body, tumor, or nasal polyps, which may occur in nonallergic rhinitis with eosinophilic syndrome, chronic bacterial sinusitis, allergic fungal sinusitis, aspirin-induced asthma, cystic fibrosis, and ciliary immobility syndrome. Unilateral lesions or nasal polyps are not typical of uncomplicated allergic rhinitis.

Nasal symptoms are characteristic of some systemic diseases, in particular Wegener's granulomatosis, which is manifested by constant rhinorrhea, purulent/hemorrhagic discharge, ulcers in the mouth and/or nose, polyarthralgia, myalgia, pain in the paranasal sinuses.

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