What are the diagnostic criteria for rhinitis?

Diagnostic Criteria for Rhinitis

Rhinitis is diagnosed primarily through a comprehensive clinical history combined with targeted physical examination, with the diagnosis of allergic rhinitis specifically requiring correlation between symptom history after allergen exposure and positive specific IgE testing (skin tests or in vitro tests). 1

Core Clinical Presentation

The cardinal symptoms that define rhinitis include: 1

• Rhinorrhea (nasal discharge)
• Nasal congestion
• Sneezing
• Nasal pruritus (itching)
• Postnasal drainage
• Associated ocular symptoms (particularly in allergic rhinitis)

Essential History Components

A thorough allergic history remains the best diagnostic tool available. 1 The history must systematically address: 1

• Pattern and chronicity: Duration, frequency, and temporal characteristics of symptoms
• Seasonality: Specific seasons versus perennial symptoms, with or without seasonal exacerbations
• Triggers and precipitating factors: Specific allergen exposures, irritants, strong odors, eating, medications
• Occupational and environmental exposures: Detailed assessment of home, work, and recreational environments
• Response to previous treatments: Medications tried, duration, effectiveness, and adverse events
• Impact on quality of life: Sleep disturbances, fatigue, learning/attention problems, work/school absenteeism or presenteeism
• Comorbid conditions: Asthma, sinusitis, otitis media, atopic dermatitis
• Family history: Allergic rhinitis, asthma, atopic dermatitis in relatives
• Current medications: Both for rhinitis and other conditions that may affect symptoms

Pediatric-Specific History Elements

In children, inquire about: 1

• Sniffing, snorting, throat clearing
• Chronic mouth breathing and gaping mouth
• Halitosis and cough
• Dark circles under eyes ("allergic shiners") and eye rubbing
• Poor appetite, learning or attention problems
• Sleep disturbances, malaise, irritability

Physical Examination Requirements

The physical examination should focus on the nose but include evaluation of ears, eyes, throat, and lungs. 1 Key examination elements include: 1

Nasal Examination

• Nasal mucosa appearance: Edema, pallor, erythema, crusting
• Turbinate assessment: Hypertrophy, color changes
• Nasal discharge: Amount, color, consistency
• Patency of nasal passages: Unilateral versus bilateral findings
• Anatomical abnormalities: Septal deviation, spurs, perforations, nasal polyps, foreign bodies, tumors
• External findings: Transverse nasal crease, alar collapse

Associated Findings

• Eyes: Excessive lacrimation, conjunctival erythema/swelling, cobblestoning, periorbital venous stasis ("allergic shiners"), Dennie-Morgan lines
• Ears: Tympanic membrane abnormalities, eustachian tube dysfunction
• Oropharynx: Tonsillar/adenoidal hypertrophy, cobblestoning of posterior pharynx, postnasal discharge, high arched palate, dental malocclusion
• Chest: Signs of asthma (wheezing, abnormal breath sounds)
• Skin: Atopic dermatitis, urticaria, dermatographism

Distinguishing Allergic from Nonallergic Rhinitis

History and physical examination alone can often suggest allergic versus nonallergic rhinitis, though definitive diagnosis of allergic rhinitis requires specific IgE confirmation. 1 Key differentiating features: 1

Features Suggesting Allergic Rhinitis

• Pruritus and sneezing (much more common than in nonallergic rhinitis)
• Seasonal exacerbations
• Onset before age 20 years (typical)
• Associated conjunctival symptoms
• Family history of atopy

Features Suggesting Nonallergic Rhinitis

• Isolated postnasal drainage (less likely allergic)
• Symptoms triggered by strong odors (perfume, tobacco smoke) suggests vasomotor rhinitis
• Isolated rhinorrhea with eating suggests gustatory rhinitis
• Chronic topical decongestant use suggests rhinitis medicamentosa
• Unilateral symptoms suggest structural problems (polyp, foreign body, septal deformity, tumor)

Confirmatory Testing for Allergic Rhinitis

A diagnosis of allergic rhinitis depends on the history of nasal symptoms after exposure to suspected allergens, which are confirmed with positive skin or in vitro tests for specific IgE. 1 Testing requirements: 1

• Skin testing is the preferred method for diagnosing IgE-mediated sensitivity
• In vitro specific IgE immunoassays have approximately 70-75% sensitivity compared to skin prick/puncture tests
• Test selection should be based on: Patient's age, history, geographic location, occupation, and activities
• Correlation is essential: Positive tests without correlation between allergen exposure and symptoms indicate nonallergic rhinitis, even with positive IgE testing

Critical Pitfall

Patients may have positive specific IgE tests but still have nonallergic rhinitis if there is poor correlation between allergen exposures and symptoms. 1 For example, a patient with perennial rhinitis and an isolated positive test to ragweed would not have ragweed-induced allergic rhinitis as the cause of perennial symptoms.

Additional Diagnostic Considerations

When Specialist Evaluation is Indicated

Referral to an allergist/immunologist should be considered when: 1

• Prolonged manifestations despite appropriate treatment
• Complications (otitis media, sinusitis, nasal polyposis)
• Comorbid asthma
• Need for systemic corticosteroids
• Symptoms significantly impair quality of life or function
• Treatment ineffective or produces adverse events
• Rhinitis medicamentosa diagnosed
• Need for allergen identification or immunotherapy consideration

Advanced Diagnostic Tools (Specialist Setting)

In specialist evaluation: 1

• Rhinoscopy or rhinolaryngoscopy allows better visualization of middle meatus, posterior septum, sinus ostia, nasopharynx, and nasal polyps
• Nasal cytology may be valuable in select cases
• Specialized tests rarely needed (β-transferrin for CSF leak, ciliary function tests)

Diagnostic Algorithm Summary

The diagnostic approach follows this sequence: 1

1. Obtain detailed history focusing on symptom pattern, triggers, seasonality, and quality of life impact
2. Perform focused physical examination emphasizing nasal cavity, with attention to associated findings
3. Determine if history/examination suggests allergic versus nonallergic rhinitis based on distinguishing features
4. For suspected allergic rhinitis: Confirm with specific IgE testing (preferably skin tests) that correlates with symptom triggers
5. For negative IgE testing or poor correlation: Diagnose as nonallergic rhinitis
6. Consider specialist referral when indicated by severity, complications, or treatment failure