Table 2 Diagnosis of multi-morbidities associated with allergic rhinitis (AR)
Multi-morbidities of AR | Definitive medical history, symptoms and signs |
|---|---|
Asthma | Ask about any history of cough, wheeze, shortness of breath, exercise-induced bronchospasm |
Examine the chest for wheeze, hyperexpansion | |
Assess peak expiratory flows and spirometry in older children preferably with reversibility testing with beta-2 agonists | |
If in doubt, undertake an exercise, mannitol or methacholine challenge test or measure exhaled nitric oxide (FENO) | |
Conjunctivitis | Ask about a history of red, itchy, watery eyes, eye rubbing |
Examine eyes | |
Rhinosinusitis | Ask about a history of nasal obstruction or discharge (purulent) with or without hyposmia, headache, facial pain or cough |
Undertake nasendoscopy in older children | |
CT scan/sinus X-rays not recommended unless there are complications or failed therapy, unilateral symptoms or severe disease unresponsive to medical therapy | |
Otitis media with effusion (OME)/impaired hearing | Ask questions related to immune deficiency and/or recurrent infections |
Ask about any speech and language delay, increasing volume of TV, shouting, poor concentration, failing performance at school, frustration, irritability | |
Examine the ears using a pneumatic otoscope if possible, and Weber and Rinne tests | |
Use tympanoscopy for evaluation of tympanic membrane and middle ear | |
Undertake tympanometry | |
Use a whisper test to screen otitis media with effusion and hearing loss | |
Use audiometry in older children—pure tones, speech | |
Obstructive sleep apnea and sleep problems | Enquire about any history of disturbed sleep, snoring, apnoea, tiredness, irritability |
Assess nasal airway using spatula misting, nasal inspiratory peak flow, visual examination of nostrils and nasendoscopy in older children to view nasal airway and adenoids | |
Consider sleep study | |
Atopic dermatitis | Ask about skin symptoms of itching, redness, rash |
Food allergy | Ask about symptoms related to food intake |
Ask for oral allergy syndrome (OAS): Allergic reaction that occurs upon contact of the mouth and throat with raw fruits or vegetables which may be tolerated when cooked | |
Eosinophilic oesophagitis | Ask for symptoms related to esophageal dysfunction as solid food dysphagia, chest pain, heartburn and upper abdominal pain |
Assess esophageal biopsies | |
Adenoid hypertrophy | Ask about nasal obstruction, open mouth breathing and snoring |
Examine the face | |
Perform posterior rhinoscopy; nasal and nasopharyngeal rigid/flexible endoscopy | |
Olfactory dysfunction | Ask for olfactory dysfunction, hyposmia, anosmia |
Evaluate nasal airway and smell function tests | |
Laryngitis, cough and vocal problems | Ask for symptoms including irritation in the throat, the sensation of difficult to shift mucus and cough |
Examine throat and larynx, see vocal cords and arytenoids | |
Gastro esophageal reflux | Ask for symptoms of indigestion, regurgitation, cough |
Examine throat and larynx | |
Fatigue and learning impairment | Ask about fatigue and learning impairment, school success |
Ask about sleep quality, nasal obstruction and nasal discharge | |
Turbinate hypertrophy | Ask about nasal obstruction |
Perform anterior rhinoscopy and nasal endoscopy, acoustic rhinometry pre and post decongestant shows whether mucosal lining or bony structure is responsible |