Differential Diagnosis

The patient presents with nose pain, difficulty breathing through the nose, headache, and a history of allergic rhinitis. Based on the symptoms and examination findings, the differential diagnoses can be categorized as follows:

• Single Most Likely Diagnosis

  • Chronic Rhinosinusitis: This is the most likely diagnosis given the patient's symptoms of nose pain, difficulty breathing through the nose, and headache, which have been gradually building up over 6 months. The presence of bilateral turbinate enlargement and crusting on nasal exam further supports this diagnosis. The patient's history of allergic rhinitis and lack of response to loratadine also points towards a chronic condition.

• Other Likely Diagnoses

  • Allergic Rhinitis Exacerbation: Although the patient is already on loratadine, an exacerbation of allergic rhinitis could explain the worsening symptoms, especially with the presence of itching and burning sensation in the nose.
  • Vasomotor Rhinitis: This condition could be considered given the patient's symptoms of nasal congestion and rhinorrhea (implied by difficulty breathing through the nose), especially if triggered by strong smells.
  • Sinusitis: Although the patient does not have sinus tenderness, the symptoms of headache and difficulty breathing through the nose could still suggest sinusitis, especially if the infection is not fully developed or is chronic.

• Do Not Miss Diagnoses

  • Nasal Tumor or Cancer: Although rare, it is crucial to consider nasal tumors or cancer in patients with persistent, unexplained nasal symptoms, especially if there is a significant change in symptoms or if standard treatments are not effective.
  • Invasive Fungal Sinusitis: This is a rare but potentially deadly condition, especially in immunocompromised patients. The presence of crusting and the patient's worsening symptoms could warrant further investigation to rule out this condition.
  • Granulomatosis with Polyangiitis (GPA): Formerly known as Wegener's granulomatosis, GPA is a rare autoimmune disorder that can cause chronic inflammation of the nasal passages and sinuses, leading to symptoms similar to those presented by the patient.

• Rare Diagnoses

  • Sarcoidosis: This is a systemic disease that can affect the nasal passages and sinuses, causing symptoms such as nasal congestion and pain. However, it is less likely given the patient's presentation and lack of other systemic symptoms.
  • Eosinophilic Granuloma with Polyangiitis (EGPA): Formerly known as Churg-Strauss syndrome, EGPA is a rare autoimmune condition that can cause asthma, nasal congestion, and sinusitis, among other symptoms. It is less likely in this case due to the lack of asthma symptoms and other systemic involvement.