What are the pertinent positive findings and initial treatment recommendations for allergic rhinosinusitis?

Pertinent Positive Findings for Allergic Rhinosinusitis

The clinical diagnosis of allergic rhinitis is made when patients present with one or more cardinal symptoms—nasal congestion, runny nose, itchy nose, or sneezing—combined with physical examination findings consistent with an allergic cause. 1

Cardinal Symptoms (At Least One Required)

• Nasal congestion (present in 94.23% of patients) 2
• Rhinorrhea/runny nose (present in 90.38% of patients) 2
• Sneezing 1
• Nasal itching 1

Physical Examination Findings Consistent with Allergic Cause

Nasal Findings

• Clear rhinorrhea (watery, not purulent) 1
• Pale discoloration of the nasal mucosa (characteristic of allergic inflammation) 1
• Edematous and pale turbinates (especially in seasonal allergic rhinitis) 2
• Erythematous and inflamed turbinates with serous secretions (more common in perennial allergic rhinitis) 2
• Swollen nasal turbinates 3

Ocular Findings

• Red and watery eyes 1
• Watery eye discharge 3
• Conjunctival swelling 3

Other Supportive Findings

• Allergic shiners (dark circles under the eyes) 3
• Postnasal drainage 2

Important Clinical Context

The diagnosis is entirely clinical and does not require allergy testing initially. 1 Allergy testing (skin or blood IgE) should only be performed when patients fail empiric treatment, when the diagnosis is uncertain, or when specific allergen identification is needed to guide immunotherapy. 1

Common Pitfalls to Avoid

• Do not confuse with nonallergic rhinitis, which presents primarily with nasal congestion and postnasal drainage, sinus pressure, ear symptoms, and lacks the characteristic pale nasal mucosa and itching symptoms. 2
• Do not routinely order sinonasal imaging in patients with symptoms consistent with allergic rhinitis, as this is not recommended. 1
• Always assess for associated comorbid conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and document these in the medical record. 1

Initial Treatment Recommendations

First-Line Therapy

Intranasal corticosteroids should be recommended as first-line treatment for patients whose symptoms affect their quality of life. 1, 4 These are the most effective medication class for controlling all four major symptoms of allergic rhinitis. 4, 5

• Start fluticasone propionate 200 mcg once daily or equivalent intranasal corticosteroid 5
• Symptom improvement expected within 12 hours 5

Second-Line Therapy for Specific Symptoms

Oral second-generation antihistamines (loratadine, cetirizine, fexofenadine, desloratadine) should be recommended for patients whose primary complaints are sneezing and itching. 1, 4

Moderate to Severe Disease

For moderate to severe allergic rhinitis, combination therapy with intranasal corticosteroid plus intranasal antihistamine (such as azelastine) provides superior symptom reduction compared to either agent alone, with a 40% relative improvement over monotherapy. 4, 6

What NOT to Do

• Do not offer oral leukotriene receptor antagonists (montelukast) as primary therapy, as they are significantly less effective than intranasal corticosteroids. 1, 4
• Do not routinely add oral antihistamines to intranasal corticosteroids, as this provides no additional benefit for initial treatment. 1, 4
• Avoid prolonged use of topical decongestants beyond 3-5 days to prevent rhinitis medicamentosa. 5