Allergic Rhinitis in Otolaryngology and Facial Plastic Surgery Clinical Presentation

• Allergy history

  • For the clinician who treats patients with allergic rhinitis, nothing is more crucial than the allergy history. It is important not only in identifying an allergy but also in guiding the treatment plan.
  • Although history taking begins at the initial encounter, it should not be completed at a single sitting, and it should be continued during subsequent visits, as needed.
  • Details about the presenting symptoms (eg, onset, fluctuation, severity) should be obtained. In addition, the interviewer should note any recent changes in the patient's life (eg, at home, in the workplace, in leisure activities, in diet).
• Family history

  • Children of individuals with allergies have been shown to have a higher incidence of allergies than that of other children.
  • If both parents have allergies, their child has a 50% chance of having the same problem.
• Past medical history

  • In children, a history of recurrent otitis media, upper respiratory tract infection, asthma, chronic rashes, and formula intolerance are suggestive of allergies.
  • Other pertinent medical problems (eg, asthma, aspirin hypersensitivity) and the use of medications (eg, beta-blockers, tranquilizers) that could interfere with the treatment for allergies should be evaluated.
  • Inquire about the results of previous allergy tests and treatment.

Patients with allergies frequently have a characteristic physical appearance.

• Face

  • Patients with allergic rhinitis frequently grimace and twitch their face, in general, and nose, in particular, because of itchy mucus membranes.
  • Chronic mouth breathing secondary to nasal congestion can result in the typical adenoid facies.
• Eyes

  • Patients may have injected conjunctiva; increased lacrimation; and long, silky eyelashes.
  • Dennie-Morgan lines (creases in the lower eyelid skin) and allergic shiners (dark discoloration below the lower eyelids) caused by venous stasis may be present.
• Ears

  • Ears are frequently unremarkable.
  • Eczematoid otitis externa and middle ear effusion may be present.
• Nose

  • A transverse nasal crease may be present because of the patient's repeated lifting of the nasal tip to relieve itching and open the nasal airway.
  • The turbinates are frequently hypertrophic and covered with a boggy pale or bluish mucosa.
  • Nasal secretions can range from clear and profuse to stringy and mucoid.
  • The presence of polyps does not necessarily indicate that the affected individual has allergic rhinitis.
• Mouth

  • A high arched palate, narrow premaxilla, and receding chin may be present secondary to long-term mouth breathing.
  • The posterior oropharynx may be granular because of irritation from persistent postnasal discharge.

For practical purposes, allergens can be divided into seasonal and perennial groups.

Seasonal allergens are primarily pollens. In general, trees bloom in the spring; grasses, in the summer; and weeds, in the fall. Information about regional allergens can be obtained from manufacturers of allergy-treatment supplies, local botanic gardens, universities, and newspapers.

Perennial allergens of importance are molds, house dust, and animal danders. Although these allergens are present throughout the year, they tend to be more problematic during the winter, when people spend most of their time indoors.

• Molds can be either indoor or outdoor allergens. Perennial symptoms that worsen in cool, humid weather suggest mold sensitivity. The major manufacturers of allergy-treatment supplies have lists of predominant molds in each region. Significant reservoirs of molds include indoor plants, refrigerator drip pans, areas under sinks, and compost piles.
• House dust is a mixture of approximately 28 allergenic components. The actual major allergen appears to be a collection of degrading lysine residues.

  • For practical reasons, the component of house dust that most closely resembles the overall extract consists of dust mites (although they are much less immunologically potent than the overall extract).
  • The 2 major dust mites in the United States are Dermatophagoides pteronyssinus and Dermatophagoides farina. These mites thrive in warm (65-80°F), humid (>70% relative humidity) environments. They are abundant in mattresses, pillows, upholstered furniture, and carpets.
  • Another significant ingredient of house dust is decomposing cockroach body parts, which can be a problem even in buildings that appear to be free of the live insect.
• A person does not need to own a pet to be exposed to dander, such as cat dander, which can cling to clothing and be brought into classrooms and homes. Dog dander, however, tends to be primarily a problem for its owner. The dander of other pets such as rabbits and hamsters is also highly allergenic.