The diagnosis and management of rhinitis: An updated practice parameter

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology.The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “The diagnosis and Management of Rhinitis: An Updated Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “The diagnosis and Management of Rhinitis: An Updated Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. Published practice parameters of the Joint Task Force on Practice Parameters for Allergy and Immunology include the following:1.Practice parameters for the diagnosis and treatment of asthma. J Allergy Clin Immunol 1995;96(suppl):S707-S870.2.Practice parameters for allergy diagnostic testing. Ann Allergy 1995;75:543-625.3.Practice parameters for the diagnosis and management of immunodeficiency. Ann Allergy 1996;76:282-94.4.Practice parameters for allergen immunotherapy. J Allergy Clin Immunol 1996;98:1001-11.5.Disease management of atopic dermatitis: a practice parameter. Ann Allergy 1997;79:197-211.6.The diagnosis and management of anaphylaxis. J Allergy Clin Immunol 1998;101(suppl):S465-S528.7.Algorithm for the diagnosis and management of asthma: a practice parameter update. Ann Allergy 1998;81:415-20.8.Diagnosis and management of rhinitis: parameter documents of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy 1998;81(suppl):S463-S518.9.Parameters for the diagnosis and management of sinusitis. J Allergy Clin Immunol 1998;102(suppl):S107-S144.10.Stinging insect hypersensitivity: a practice parameter. J Allergy Clin Immunol 1999;103:963-80.11.Disease management of drug hypersensitivity: a practice parameter. Ann Allergy 1999;83(suppl):S665-S700.12.Diagnosis and management of urticaria: a practice parameter. Ann Allergy 2000;85(suppl):S521-S544.13.Allergen immunotherapy: a practice parameter. Ann Allergy 2003;90(suppl):S1-S540.14.Symptom severity assessment of allergic rhinitis, part I. Ann Allergy 2003;91:105-14.15.Disease management of atopic dermatitis: an updated practice parameter. Ann Allergy 2004;93(suppl):S1-S21.16.Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol 2004;114;4:869-86.17.The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol 2005;115(suppl):S483-S523.18.Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy 2005;94(suppl):S1-S63.19.Attaining optimal asthma control: a practice parameter. J Allergy Clin Immunol 2005;116(suppl):S3-S11.20.The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2006;116(suppl):S13-S47.21.Food allergy: a practice parameter. Ann Allergy 2006;96(suppl):S1-S68.22.Contact dermatitis: a practice parameter. Ann Allergy 2006;97(suppl):S1-S37.23.Allergen immunotherapy: a practice parameter second update. J Allergy Clin Immunol 2007;120(suppl):S25-S85.24.Allergy diagnostic testing: an updated practice parameter. Ann Allergy 2008;100(suppl):S1-S148.These parameters are also available on the internet at http://www.jcaai.org.ContributorsThe Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the Task Force will ensure that appropriate recognition of such contributions is made subsequently.Chief editor—joint task forceDana V. Wallace, MDAssistant Clinical ProfessorNova Southeastern UniversityDavie, FlaChief editor—parameter workgroup chairMark S. Dykewicz, MDProfessor of Internal MedicineChief, Section of Allergy and Clinical Immunology, Division of ImmunobiologyDirector, Allergy and Immunology Fellowship ProgramSaint Louis University School of MedicineSt Louis, MoTask force reviewersDavid I. Bernstein, MDProfessor of Clinical Medicine and Environmental HealthDivision of Allergy/ImmunologyUniversity of Cincinnati College of MedicineCincinnati, OhioI. Leonard Bernstein, MDClinical Professor of Medicine and Environmental HealthUniversity of Cincinnati College of MedicineCincinnati, OhioJoann Blessing-Moore, MDClinical Associate Professor of Medicine and PediatricsStanford University Medical CenterDepartment of ImmunologyPalo Alto, CalifLinda Cox, MDAssistant Clinical Professor of MedicineNova Southeastern University College of Osteopathic MedicineDavie, FlaDavid A. Khan, MDAssociate Professor of Internal MedicineUniversity of Texas Southwestern Medical CenterDallas, TexDavid M. Lang, MDHead, Allergy/Immunology SectionDivision of MedicineDirector, Allergy and Immunology Fellowship Training ProgramCleveland Clinic FoundationCleveland, OhioRichard A. Nicklas, MDClinical Professor of MedicineGeorge Washington Medical CenterWashington, DCJohn Oppenheimer, MDDepartment of Internal MedicineNew Jersey Medical SchoolPulmonary and Allergy AssociatesMorristown, NJJay M. Portnoy, MDChief, Section of Allergy, Asthma and ImmunologyChildren's Mercy HospitalProfessor of PediatricsUniversity of Missouri–Kansas City School of MedicineKansas City, MoChristopher C. Randolph, MDClinical Professor of PediatricsYale Affiliated HospitalsCenter for Allergy, Asthma, and ImmunologyWaterbury, ConnDiane E. Schuller, MDProfessor of PediatricsPennsylvania State University Milton S. Hershey Medical CollegeHershey, PaSheldon L. Spector, MDClinical Professor of MedicineUniversity of California–Los Angeles School of MedicineLos Angeles, CalifStephen A. Tilles, MDClinical Assistant Professor of MedicineUniversity of Washington School of MedicineRedmond, WashAssigned reviewersKathleen R. May, MDAllegany Allergy and AsthmaCumberland, MdTravis A. Miller, MDUniversity of MichiganCapital Allergy and Respiratory Disease CenterSacramento, CalifHoward M. Druce, MD, FAAAAIClinical Associate Professor of MedicineUniversity HospitalMorris Plains, NJParameter workgroup membersFaud M. Baroody, MDProfessor of Otolaryngology–Head and Neck Surgery and PediatricsPritzker School of MedicineUniversity of ChicagoChicago, IllJonathan A. Bernstein, MDProfessor of MedicineDivision of Immunology/Allergy SectionDepartment of Internal MedicineUniversity of Cincinnati College of MedicineCincinnati, OhioTimothy J. Craig, DOProfessor of Medicine, Pediatrics and Graduate StudiesPennsylvania State UniversityHershey, PaJohn W. Georgitis, MDLaFayette ClinicFayetteville, NCRuby Pawankar, MD, PhDProfessor of MedicineDivision of Rhinology and AllergyDepartment of OtolaryngologyNippon Medical SchoolTokyo, JapanGary S. Rachelefsky, MDClinical Professor of Allergy and ImmunologyCenter for Asthma, Allergy and Respiratory DiseasesUniversity of California–Los Angeles Medical CenterLos Angeles, CalifRussell A. Settipane, MDClinical Associate Professor of MedicineBrown University Medical SchoolProvidence, RIDavid P. Skoner, MDProfessor of PediatricsDrexel University College of MedicineDirector, Division of Allergy, Asthma and ImmunologyAllegheny General HospitalPittsburgh, PaStuart W. Stoloff, MDClinical Professor of Family and Community MedicineUniversity of Nevada School of MedicineReno, NevClassification of recommendations and evidenceCategory of evidenceIa. Evidence from meta-analysis of randomized controlled trialsIb. Evidence from at least 1 randomized controlled trialIIa. Evidence from at least 1 controlled study without randomizationIIb. Evidence from at least 1 other type of quasi-experimental studyIII. Evidence from nonexperimental descriptive studies, such as comparative studiesIV. Evidence from expert committee reports or opinions or clinical experience of respected authorities, or bothLB Evidence from laboratory-based studies.NR Not rated.Strength of RecommendationA Directly based on category I evidenceB Directly based on category II evidence or extrapolated recommendation from category I evidenceC Directly based on category III evidence or extrapolated recommendation from category I or II evidenceD Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidenceDiagnosis and management of rhinitis: An updated practice parameterPreface S3Abbreviations S4Collation of Summary Statements S4Executive Summary S9Annotations S27Summary Statements with discussion S32References S65Note: The Summary Statements that are associated with the sections of the Preface and Exective Summary are Indicated inside the brackets.Preface [summary statements 8, 9, 13]Rhinitis, as defined for the purposes of this document, is characterized by 1 or more of the following nasal symptoms: congestion, rhinorrhea (anterior and posterior), sneezing, and itching. Rhinitis is usually associated with inflammation, but some forms of rhinitis such as vasomotor rhinitis or atrophic rhinitis are not predominantly inflammatory.Rhinitis is a significant cause of widespread morbidity, medical treatment costs, reduced work productivity, and lost school days. Although sometimes mistakenly viewed as a trivial disease, symptoms of allergic and nonallergic rhinitis may significantly affect a patient's quality of life and can be associated with conditions such as fatigue, headache, cognitive impairment, and sleep disturbance. Appropriate management of rhinitis may be an important component in effective management of coexisting or complicating respiratory conditions, such as asthma, sinusitis, and sleep apnea. The financial burden to society for allergic rhinitis is substantial. The total direct ($7.3 billion) and indirect costs ($4.28 billion, including loss of productivity) estimated in the United States for 2002 were $11.58 billion.1Schoenwetter W.F. Dupclay Jr., L. Appajosyula S. Botteman M.F. Pashos C.L. Economic impact and quality-of-life burden of allergic rhinitis.Curr Med Res Opin. 2004; 20 (IV): 305-317Crossref PubMed Scopus (114) Google ScholarAllergic rhinitis affects between 10% and 30% of all adults and as many as 40% of children.2Settipane R.A. Rhinitis: a dose of epidemiological reality.Allergy Asthma Proc. 2003; 24 (IV): 147-154PubMed Google Scholar, 3Druce H. Allergic and nonallergic rhinitis.in: Middleton E. Reed C.E. Ellis E.F. Adkinson Jr., N.F. Yunginger J.W. Busse W.W. Allergy principles and practice. 5th ed. Mosby-Year Book, St Louis1998: 1005-1016Google Scholar, 4Settipane R.J. Hagy G.W. Settipane G.A. Long-term risk factors for developing asthma and allergic rhinitis: a 23-year follow-up study of college students.Allergy Proc. 1994; 15 (III): 21-25Crossref PubMed Google Scholar, 5Varjonen E. Kalimo K. Lammintausta K. Terho P. Prevalence of atopic disorders among adolescents in Turku, Finland.Allergy. 1992; 47 (III): 243-248Crossref PubMed Google Scholar, 6Smith J.M. A five-year prospective survey of rural children with asthma and hay fever.J Allergy. 1971; 47 (III): 23-30PubMed Google Scholar In most studies, the ratio of allergic to pure nonallergic rhinitis is 3:1.2Settipane R.A. Rhinitis: a dose of epidemiological reality.Allergy Asthma Proc. 2003; 24 (IV): 147-154PubMed Google Scholar Preliminary data suggest that 44% to 87% of patients with rhinitis may have mixed rhinitis, a combination of allergic and nonallergic rhinitis.2Settipane R.A. Rhinitis: a dose of epidemiological reality.Allergy Asthma Proc. 2003; 24 (IV): 147-154PubMed Google Scholar, 7Settipane R.A. Charnock D.R. Epidemiology of rhinitis: allergic and nonallergic.Clin Allergy Immunol. 2007; 19 (IV): 23-34PubMed Google Scholar Worldwide, the prevalence of allergic rhinitis continues to increase.The objective of “Diagnosis and Management of Rhinitis: An Updated Practice Parameter” is to improve the care of patients by providing the practicing physician with an evidence-based approach by reviewing data in the medical literature and incorporating this evidence into development of this guideline. While giving an overview of all categories of rhinitis, the parameter will focus on the diagnosis and treatment of allergic rhinitis. Using the 1998 practice parameter on “Diagnosis and Management of Rhinitis”8Dykewicz M.S. Fineman S. Skoner D.P. Nicklas R. Lee R. Blessing-Moore J. et al.Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology.Ann Allergy Asthma Immunol. 1998; 81 (IV): 478-518Abstract Full Text PDF PubMed Google Scholar as the basis, the working draft of this updated rhinitis practice parameter was prepared by a work group chaired by Mark S. Dykewicz, MD, and was revised and edited by the Joint Task Force on Practice Parameters under the leadership of Dana V. Wallace, MD. Preparation of this draft included a review of the recent medical literature using a variety of search engines such as PubMed. Published clinical studies were rated by category of evidence and used to establish the strength of the recommendations, as defined in the preamble to this parameter. The parameter was then reviewed by experts on rhinitis selected by the sponsoring organizations of the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma, and Immunology. Based on this process, this parameter represents an evidence-based document.Components and organization of this parameterThe “Diagnosis and Management of Rhinitis: An Updated Practice Parameter” contains an annotated algorithm that presents the major decision points for the appropriate evaluation and treatment of patients with suspected rhinitis. This is followed by a collation of Summary Statements, which represent key points in the evaluation and management of this condition. Tables that provide clinically useful information in a concise format precede the body of the practice parameter, which provides a referenced narrative discussion of each Summary Statement. The graded references and figures complete the document. The Executive Summary emphasizes the key updates since the 1998 rhinitis parameter (Box).Key updatesThe following is a list of key updates discussed in this document:•Pharmacologic products introduced since publication of the 1998 “Diagnosis and Management of Rhinitis: Complete Guidelines”•More defined positioning of agents (eg, leukotriene receptor antagonists) in management based on more recent evidence•Introduction of episodic as a term to describe rhinitis elicited by sporadic exposures to inhalant aeroallergens, and implications for treatment•Use of certain agents—that is, intranasal corticosteroids—on an as-needed basis•Emphasis on recognizing comorbidities of allergic rhinitis (AR), such as asthma, sinusitis, and obstructive sleep apnea, and conducting appropriate studies, such as pulmonary function testing and sleep apnea studies•Evidence on using combination therapy, specifically leukotriene receptor antagonists, with antihistamines•Need to consider the benefits versus recently raised safety concerns about oral decongestants before their use in children below age 6 years•Recommendation of considering second-generation antihistamines as safe agents for use during pregnancy•Use of intranasal corticosteroids for symptoms of allergic conjunctivitis associated with rhinitis•Consideration of using a Rhinitis Action Plan•Emerging diagnostic and surgical procedures, such as acoustic rhinometry and radiofrequency volumetric tissue reductionTo obtain the maximum value from this practice parameter in the most time-efficient manner, the clinician should review the Executive Summary, annotated algorithm, Summary Statements, and tables because these are created to provide the key information. The text and graded references provide the foundation on which the Joint Task Force formulated and graded the Summary Statements.AbbreviationsACE: Angiotensin-converting enzymeAERD: Aspirin-exacerbated respiratory diseaseARIA: Allergic Rhinitis and its Impact on AsthmaBHR: Bronchial hyperresponsivenessCF: Cystic fibrosisCNS: Central nervous systemCSF: Cerebral spinal fluidCT: Computed tomographycysLT: Cysteinyl leukotrieneECP: Eosinophilic cationic proteinFDA: US Food and Drug AdministrationHEPA: High-efficiency particulate airIOC: International Olympic CommitteeIOP: Intraocular pressureLT: LeukotrieneLTRA: Leukotriene receptor antagonistMRI: Magnetic resonance imagingNARES: Nonallergic rhinitis with eosinophilia syndromeNSAID: Nonsteroidal anti-inflammatory drugOA: Occupational asthmaOME: Otitis media with effusionOSAS: Obstructive sleep apnea syndromeOTC: Over-the-counterPCD: Primary ciliary dyskinesiaPRN: When necessary (from Latin pro re nata)QOL: Quality of lifeRFVTR: Radiofrequency volumetric tissue reductionRQLQ: Rhinoconjunctivitis Quality of Life QuestionnaireRUDS: Reactive upper-airways dysfunction syndromeSIT: Specific immunotherapySPT: Skin prick testUSOC: US Olympic CommitteeCollation of summary statementsDefinition and classification of rhinitis1.Rhinitis is characterized by 1 or more of the following symptoms: nasal congestion, rhinorrhea (anterior and posterior), sneezing, and itching. DDifferential diagnosis of rhinitis and associated conditions2.Rhinitis should be classified by etiology as allergic or nonallergic and differentiated from conditions that mimic symptoms of rhinitis. C3.Symptoms of allergic rhinitis may occur only during specific seasons, may be perennial without seasonal exacerbation, may be perennial with seasonal exacerbations, or may occur episodically after specific aeroallergen exposures. C4.Episodic allergic rhinitis is a new rhinitis category that denotes allergic nasal symptoms elicited by sporadic exposures to inhalant aeroallergens. D5.The severity of allergic rhinitis ranges from mild and intermittent to seriously debilitating. D6.Although there is no generally accepted method of grading the severity of rhinitis, the clinician may want to consider a graphic rating scale. D7.Mixed rhinitis (combined allergic and nonallergic rhinitis) is noted in approximately 44% to 87% of patients with allergic rhinitis and is more common than either pure allergic rhinitis or nonallergic rhinitis. CBurden and epidemiology of rhinitis8.Allergic rhinitis affects 30 to 60 million people in the United States annually, including 10% to 30% of adults and as many as 40% of children. C9.Risk factors for allergic rhinitis include (1) family history of atopy, (2) serum IgE >100 IU/mL before age 6 years, (3) higher socioeconomic class, and (4) presence of a positive allergy skin prick test (SPT). C10.The influence of early childhood exposure to infections, animals, and secondary tobacco smoke on the development of atopy and allergic rhinitis is still unknown. C11.Aeroallergen sensitization may occur within the first 2 years of life. C12.The cost of treating allergic rhinitis and indirect costs related to loss of workplace productivity resulting from the disease are substantial. Rhinitis is also a significant cause of lost work and school days. CAllergic rhinitisPathogenesis13.The symptoms of allergic rhinitis result from a complex allergen-driven mucosal inflammation caused by interplay between resident and infiltrating inflammatory cells and a number of vasoactive and proinflammatory mediators, including cytokines. Sensory nerve activation, plasma leakage, and congestion of venous sinusoids also contribute. C14.Allergic rhinitis may be characterized by early-phase and late-phase responses. Each type of response is characterized by sneezing, congestion, and rhinorrhea, but congestion predominates in the late phase. CSeasonal and perennial allergic rhinitis15.Seasonal allergic rhinitis is caused by an IgE-mediated reaction to seasonal aeroallergens. The length of seasonal exposure to these allergens is dependent on geographic location and climatic conditions. C16.Perennial allergic rhinitis is caused by an IgE-mediated reaction to perennial environmental aeroallergens. These may include dust mites, molds, animal allergens, or certain occupational allergens, as well as pollen in areas where pollen is prevalent perennially. CAssociated allergic conjunctivitis17.Allergic rhinitis is often accompanied by symptoms of allergic conjunctivitis. C18.Many treatments used for allergic rhinitis can benefit associated symptoms of allergic conjunctivitis, and a variety of topical ophthalmic agents is useful for specific treatment of associated ocular symptoms. A19.Intranasal corticosteroids, oral antihistamines, and intranasal antihistamines have similar effectiveness in relieving ocular eye symptoms associated with rhinitis. ANonallergic rhinitis syndromes20.Nonallergic rhinitis is characterized by periodic or perennial symptoms of rhinitis that are not a result of IgE-dependent events. Examples of nonallergic rhinitis are infectious rhinitis, vasomotor rhinitis, and the nonallergic rhinitis with eosinophilia syndrome (NARES). CVasomotor rhinitis21.Vasomotor rhinitis (idiopathic rhinitis) accounts for a heterogeneous group of patients with chronic nasal symptoms that are not immunologic or infectious in origin and is usually not associated with nasal eosinophilia. DRhinitis from foods and alcohol22.Rhinitis may occur after ingestion of foods or alcoholic products. This may be a result of vagally mediated mechanisms, nasal vasodilation, food allergy, and/or other undefined mechanisms. Food allergy is a rare cause of rhinitis without associated gastrointestinal, dermatologic, or systemic manifestations. BInfectious rhinitis23.Infectious rhinitis and rhinosinusitis may be acute or chronic. Acute infectious rhinitis is usually a result of 1 of a large number of viruses, but secondary bacterial infection with sinus involvement may be a complication. Symptoms of acute infectious rhinosinusitis include nasal congestion, mucopurulent nasal discharge, pain and pressure, headache, olfactory disturbance, postnasal drainage, and cough. C24.Viral infections account for as many as 98% of acute infectious rhinitis and the majority of rhinitis symptoms in the young child. Routine nasopharyngeal cultures when bacterial infections are suspected do not add diagnostic value. CNARES25.NARES is characterized by nasal eosinophils in patients who have perennial symptoms and occasionally reduced sense of smell. These patients often lack evidence of allergic disease as demonstrated by absence of positive skin tests and/or specific IgE antibodies in the serum. COccupational rhinitis26.Occupational rhinitis is rhinitis arising in response to airborne substances in the workplace, which may be mediated by allergic or nonallergic factors, such as laboratory animal antigen, grain, wood dusts, chemicals, and irritants. It often coexists with occupational asthma (OA). CHormonal rhinitis27.Causes of hormonal rhinitis include pregnancy and menstrual cycle–related rhinitis. Pregnancy rhinitis, when present, is associated with significant nasal congestion, starts after the second month of pregnancy, and usually disappears within 2 weeks after delivery. CDrug-induced rhinitis28.Drug-induced rhinitis may be caused by a number of medications, including angiotensin-converting enzyme (ACE) inhibitors, phosphodiesterase-5–selective inhibitors, phentolamine, α-receptor antagonists, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs). Rhinitis medicamentosa is a syndrome of rebound nasal congestion that follows the overuse of intranasal α-adrenergic decongestants or cocaine. CAtrophic rhinitis29.Treatment of primary and secondary atrophic rhinitis involves reducing crusting and alleviating the foul odor by continuous nasal hygiene, such as nasal lavage and crust debridement, and the use of topical and/or systemic antibiotics when purulent secretions or an acute infection is present. CConditions that mimic rhinitisNasal polyps30.Nasal polyps may occur in conjunction with chronic rhinitis or sinusitis and may contribute significantly to the patient's symptoms. Nasal polyps should always be considered in the differential diagnosis of patients who present with invariant nasal congestion and/or anosmia and its sequelae. Allergy as a cause of nasal polyps has not been established, but nasal polyps may occur in conjunction with allergic rhinitis. CAnatomic abnormalities31.Signs and symptoms suggestive of rhinitis can be produced by other conditions, including nasal septal deviation, tumors, and hypertrophy of the nasal turbinates. C32.In infants and young children, nasal congestion or obstruction can result from structural problems, such as cleft palate and adenoidal hypertrophy, or functional problems, such as laryngopharyngeal reflux. DCerebral spinal fluid rhinorrhea33.Refractory clear rhinorrhea may be a result of cerebral spinal fluid (CSF) leak, which is often caused by trauma or recent surgery. BCiliary dysfunction34.Ciliary dysfunction can be primary (primary ciliary dyskinesia; PCD) or secondary (eg, viral infection) and may contribute to recurrent rhinitis and sinus infections. CEvaluation and diagnostic studiesHistory35.An effective evaluation of the patient with rhinitis often includes the following: a determination of the pattern, chronicity, and seasonality of nasal and related symptoms (or lack thereof); response to medications; presence of coexisting conditions; occupational exposure; and a detailed environmental history and identification of precipitating factors. D36.Evaluation of rhinitis therapy should include assessment of quality of life (QOL). CPhysical examination37.A physical examination of all organ systems potentially affected by allergies with emphasis on the upper respiratory tract should be performed in patients with a history of rhinitis. The nasal examination supports but does not definitely establish the diagnosis of rhinitis. DTesting for specific IgE antibodySkin testing38.Determination of specific IgE, preferably by skin testing, is indicated to provide evidence of an allergic basis for the patient's symptoms, to confirm or exclude suspected causes of the patient's symptoms, or to assess the sensitivity to a specific allergen for avoidance measures and/or allergen immunotherapy. B39.Skin tests are the preferred tests for the diagnosis of IgE-mediated sensitivity. The number of skin tests and the allergens selected for skin testing should be determined on the basis of the patient's age, history, environment, and living situation, such as area of the country, occupation, and activities. DIn vitro assays for specific IgE40.The precise sensitivity of specific IgE immunoassays compared with skin prick/puncture tests is approximately 70% to 75%. Immunoassays have similar sensitivity to skin tests in identifying those patients with nasal symptoms elicited after natural or controlled allergen challenge tests. C41.Interpretation of specific IgE immunoassays may be confounded by variables such as potency of allergens bound to solid support systems, cross-reactive proteins and glycoepitopes, specific IgG antibodies in the test serum, and high total IgE. DSpecial diagnostic techniques42.In selected cases, special techniques such as fiber optic nasal endoscopy and/or rhinomanometry may be useful in evaluating patients presenting with rhinitis symptoms. These tests may require special expertise for performance and interpretation. Patients with nasal disease require appropriate examination for associated diseases, such as sinusitis and otitis media. B43.Nasal smears for eosinophils are not necessary for routine use in diagnosing allergic rhinitis when the diagnosis is clearly supported by the history, physical examination, and specific IgE diagnostic studies but may be a useful adjunct when the diagnosis of allergic rhinitis is in question. C44.Although the saccharin test for mucociliary clearance has been relied on as a clinical screening test, it cannot be relied on for a definitive diagnosis of mucociliary dysfunction. C45.Nasal biopsy may be indicated when determining whether a lesion is neoplastic