In addition to the symptoms listed above, up to 40% of patients with allergic rhinitis also manifest lower respiratory symptoms: cough, wheezing, chest tightness, or dyspnea. The physical examination may reveal edematous or inflamed nasal mucosa. In severe cases, the affected mucosa may be pale, boggy, or bluetinged from vascular engorgement and
venous congestion. Nasal symptoms can be nonspecific, however, and the differential diagnosis can include viral rhinitis, bacterial sinusitis, vasomotor rhinitis, nasal polyposis, drug-induced rhinitis, hormonal rhinitis, rhinitis medicamentosa, atrophic rhinitis, gastroesophageal reflux, and systemic disorders such as thyroid disease or Wegener's granulomatosis. Even a basic understanding of regional aeroallergen patterns and seasons can aid the clinician during the evaluation of patients presenting with acute or chronic rhinitis.
Patients with moderate to severe disease, those who are potential candidates for allergen immunotherapy, and those with strong predisposing factors for atopic diatheses (eg, a strong family history of atopy or ongoing exposure to potential sources of allergen) should undergo testing. Since the development of rhinitis precedes the presentation of asthma in over 50% of cases, early intervention may decrease the risk of more severe clinical allergic disease. Patients with comorbidities or associated complications such as allergic asthma, allergic conjunctivitis, chronic cough, sinusitis, polyposis, eczema, or otitis media may also benefit from evaluation by a subspecialist.
The three basic principles of allergy management are avoidance of the allergen, symptomatic pharmacologic therapy, and specific allergen immunotherapy. Patients with suboptimal responses to reasonable therapeutic interventions benefit from diagnostic allergy skin testing.
Effectiveness of agents used in treatment of allergic disorders.