Rhinoconjunctivitis, Allergic

Key Features

Essentials of Diagnosis

• The pathologic changes are chiefly hyperemia, edema, and increased serous and mucoid secretions caused by mediator release, all of which lead to variable degrees of nasal obstruction and conjunctival injection, nasal and ocular pruritus, or nasal and ocular discharge

• Ocular allergies can occur in isolation, but more commonly, they are in conjunction with nasal symptoms

• Inhalant allergens are primarily responsible for symptoms, but food allergens can cause symptoms as well

General Considerations

• Intermittent and persistent have replaced the prior classifications of perennial, seasonal (hay fever), or episodic

  • Intermittent: symptoms present < 4 days a week or for < 4 weeks

  • Persistent: symptoms present > 4 days a week and for > 4 weeks

• In addition, severity should be noted as

  • Mild: without impairment or disturbance of sleep, daily activities, leisure, sport, school, or work, or without troublesome symptoms

  • Moderate-severe: presence of one or more of the aforementioned

Demographics

• Allergic rhinoconjunctivitis is the most common allergic disease and significantly affects quality of life as well as school performance and attendance

• Frequently coexists with asthma, can impact asthma control, and is a risk factor for subsequent development of asthma

• Over 80% of patients with asthma have rhinitis and 10–14% of patients with rhinitis have asthma

• Symptoms develop before age 20 years in about 80% of individuals with allergic rhinitis

• An estimated that 13% of children have a physician diagnosis of allergic rhinitis.

• Prevalence of this disease increases during childhood, peaking at 15% in the postadolescent years

Clinical Findings

Symptoms and Signs

• Patients may complain of itching of the nose, eyes, palate, or pharynx and loss of smell or taste

• Nasal itching can cause paroxysmal sneezing and epistaxis

• Repeated rubbing of the nose (so-called allergic salute) may lead to a horizontal crease across the lower third of the nose

• Nasal obstruction is associated with mouth breathing, nasal speech, allergic salute, and snoring

• Nasal turbinates may appear pale blue and swollen with dimpling or injected with minimal edema

• Nasal secretions

  • Clear and thin nasal

  • Increased, with anterior rhinorrhea, sniffling, postnasal drip, and congested cough

  • Often cause poor appetite, fatigue, and pharyngeal irritation

• Conjunctival injection, tearing, periorbital edema, and infraorbital cyanosis (so-called allergic shiners) are frequently observed

• Increased pharyngeal lymphoid tissue ("cobblestoning") from chronic drainage and enlarged tonsillar and adenoidal tissue may be present

Differential Diagnosis

• Infectious rhinosinusitis

• Foreign bodies

• Structural abnormalities

  • Choanal atresia

  • Marked septal deviation

  • Nasal polyps

  • Adenoidal hypertrophy

• Rhinitis medicamentosa (rebound congestion)

Diagnosis

• Eosinophilia

  • Can be demonstrated on smears of nasal secretions or blood

  • Frequent but nonspecific finding

  • May occur in nonallergic conditions

• Serum IgE may be elevated, but measurement of total IgE is a poor screening tool because of the ...