How Can I Differentiate Between Allergic Rhinitis and Chronic Sinusitis?

Judith Shannon Lynch, MS, MA, APRN-BC, FAANP

Disclosures

January 31, 2002

Question

I see many patients with chronic nasal congestion. I am often confused: Do they have allergic rhinitis or chronic sinusitis? How can I tell the difference?

Response From the Expert  

Judith Shannon Lynch, MS, MA, APRN, FAANP

Chronic nasal congestion is one of the most common complaints seen in primary care settings. Etiologies include bacterial and viral infections, allergy, abuse of decongestant nasal sprays, certain hormonal disorders (pregnancy and hypothyroid states), various anatomic abnormalities (deviated septum), and rarely neoplasia. Often symptoms are so similar that there is a real possibility of error in diagnosis and, thus, inappropriate treatment.

The most common causes of chronic nasal congestion are allergic rhinitis, from environmental allergens or irritants, and chronic rhinosinusitis. Chronic rhinosinusitis is defined as a sinus infection of greater than 12 weeks' duration that includes 2 or more major sinus symptoms or at least 1 major and 2 minor symptoms.[1]

Major symptoms include:

 

  • facial pain or pressure

  • nasal congestion or fullness

  • nasal obstruction or blockage from a deviated septum or nasal polyps

  • nasal discharge/purulence/discolored postnasal discharge

  • hyposmia/anosmia (impairment or loss of the sense of smell)

  • purulence in the nasal cavity

    Minor symptoms include:

  • headache

  • fever

  • halitosis

  • fatigue

  • dental pain

  • cough

  • ear pain/pressure/fullness

 

Complications of untreated chronic rhinosinusitis include persistent chronic airway obstruction, obstructive sleep apnea and snoring, exacerbation of lower respiratory problems, anterior headache, diminished sense of smell and taste, orbital problems, meningitis, mucocele, premalignant inverted nasal papilloma, and nasal or sinus malignancy.[2]

In recent years, it has gradually become accepted that there is a significant correlation between allergic rhinitis and chronic rhinosinusitis. Results of many studies support the notion that environmental allergies must be investigated in any patient shown to have chronic rhinosinusitis.[3] To omit such a consideration at present might even appear to be medically questionable.

The patient with allergic rhinitis may give a different history than the patient with chronic rhinosinusitis. Most patients with allergies complain of nasal stuffiness or congestion with associated clear rhinorrhea and episodes of sneezing. Severe degrees of nasal obstruction may be associated with hyposmia or anosmia. The presence of ocular irritation or burning is strongly suggestive of an allergic etiology.

Conversely, the patient with chronic rhinosinusitis is likely to give a history of frequent upper respiratory infections that fail to respond to medical therapy. There is an associated thick postnasal drip, nasal congestion, and a foreign-body sensation in the posterior pharynx. There also may be chronic anterior headache, hyposmia/anosmia, and the known presence of nasal polyps.

A thorough head and neck examination is essential to diagnosis. The nose must be fully assessed during physical examination. It is optimal to use a nasal speculum and headlight (a gooseneck lamp can also be used).

The presence of any lateral deformity of the nasal dorsum on external inspection suggests an associated intranasal abnormality.[4] In children, constant rubbing will lead to the appearance of a horizontal nasal crease that denotes the presence of allergies. Internal structure should also be thoroughly assessed. Careful attention must be paid to the nasal septum, which may be deviated. Septal perforations, ulcers, and tumors should be identified. Size and shape of turbinates should be noted: pale blue or boggy turbinates are common in allergic rhinitis.

Examination of the nasal vault should include the following:

• Presence of polyps, cysts, or foreign bodies

• Quality of mucous secretions

 

  1. Amount

  2. Location

  3. Thickness

  4. Presence of purulence, blood, or discoloration

 

• Nasal mucosa

 

  1. Edema

  2. Inflammation

  3. Ulceration or excoriation

  4. Erosion, dryness (frequently found in winter months), or atrophy

 

Normal mucosal color is pink to slightly erythematous with minimal edema. The presence of severe inflammation and irritation with thickened discolored or purulent discharge is indicative of chronic rhinosinusitis. Pale mucosa with clear discharge is suggestive of allergic rhinitis.

Diagnostic testing should include both allergy testing and a CT scan of the sinuses. Allergy testing, done by either an allergist or an ENT specialist, consists of skin-prick testing or intradermal testing.[5] The CT scan offers an excellent illustration of sinus anatomy and physiology and should be ordered as a screening scan (axial and coronal slices) for diagnostic purposes. In allergic rhinitis, the CT scan will be normal. In chronic rhinosinusitis, mucoperiosteal thickening, opacities, air-fluid levels, and bone erosions may be noted.

Once the diagnosis is confirmed, treatment is aimed at control of environmental allergies if present. Strategies include avoidance of allergens, use of intranasal steroid sprays and nonsedating antihistamines, and the emerging use of leukotriene antagonists such as montelukast (Singulair) and zafirlukast (Accolate). Management can easily remain in the primary care setting, although precise diagnosis remains the purview of specialty practice. If these efforts fail, desensitization may be explored.

The patient with chronic rhinosinusitis has a different health problem from the patient with acute bacterial rhinosinusitis, but will often have comorbid environmental allergies. Thus, treatment must include management of allergy as discussed. In addition, goals of treatment include infection control, reduction of mucosal edema, promotion of drainage from sinuses via nasal ostia, and breaking the cycle of recurrence. Because many courses of antibiotics and, often, surgery are indicated, the patient with chronic rhinosinusitis should be referred to an ENT specialist. While awaiting this referral into specialty care, patients can be started on therapy with amoxicillin-clavulanate (Augmentin) 875 mg orally twice a day or a similar broad-spectrum antibiotic. Topical nasal steroids and saline nasal sprays may also be used.

Through a careful assessment and diagnostic work-up, patients with allergic rhinitis and/or chronic rhinosinusitis can be evaluated and quickly treated and/or referred to the appropriate provider. The team approach between primary care provider and specialty practitioner ensures quality of life for patients as well as a cost-effective healthcare delivery system.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....