ORIGINAL ARTICLE
AAOA allergy primer: history and physical examination Christine B. Franzese, MD, FAAOA
Background: Allergic disease is very common in the general population and makes a significant impact on the quality of life of patients. Immunoglobulin E (IgE)-mediated allergic disease manifests throughout the body, but many signs and symptoms of inhalant allergy are centered in the head and neck region.
Conclusion: Many times, history alone can serve to make the diagnosis, but physical examination also demonstrates specific findings that confirm the practitioner’s presumptive diagnosis of allergic disease. However, should medical treatment fail or the diagnosis be in doubt, further diagnostic investigation with allergy testing should be pursued. C 2014 ARS-AAOA, LLC.
Methods: A thorough yet focused history of allergic symptoms and potential physical examination findings of inhalant allergy are described. Results: History should include types and timing of symptoms, environmental and occupational exposures, family history, associated diseases, and prior treatment, if any. Physical examination should include the skin and structures of the head and neck region. Nasal endoscopy can be helpful in visualization of nasal polyps.
A
llergy is a hypersensitivity reaction, an immunologic response to an otherwise harmless agent resulting in undesirable clinical manifestations. Allergic disease is very common in the general population and is found throughout all age groups, ethnicities, and socioeconomic classes. This section focuses on making the diagnosis of the best-understood hypersensitivity reaction, type 1 or immunoglobulin E (IgE)-mediated hypersensitivity. IgE-mediated allergic disorders are caused by a wide variety of agents, including foods and pharmaceuticals. This section addresses allergic rhinitis caused by inhalant allergens, 1 of the most common types of allergic diseases. Although a definitive diagnosis of IgE-mediated allergic disease includes allergy testing, a strong presumptive diagnosis can be made from history alone.1 Physical examination findings may be present to provide further evidence
DePaul/EVMS Department of Otolaryngology, Eastern Virginia Medical School (EVMS), Norfolk, VA Correspondence to: Christine B. Franzese, MD, FAAOA, DePaul/EVMS Department of Otolaryngology, 100 Kingsley Lane, Suite 404, Norfolk, VA 23505; e-mail: [email protected] Potential conflict of interest: None provided. Received: 25 June 2014; Revised: 30 June 2014; Accepted: 30 June 2014 DOI: 10.1002/alr.21390 View this article online at wileyonlinelibrary.com.
Key Words: allergies; allergic rhinitis; history; physical examination; allergic conjunctivitis; inhalant allergy
How to Cite this Article: Franzese CB. AAOA allergy primer: history and physical examination. Int Forum Allergy Rhinol. 2014;4: S28–S31.
of allergic disease and reassurance that medical therapy can proceed, unless further testing is warranted. Patients may state, “I have allergies,” or “I have sinus problems, but not allergies.” This self-diagnosis is frequently inaccurate and should not be passively accepted. Irritant triggers of nonallergic disorders often manifest symptoms identical to inhalant allergy, and inhalant allergy is frequently an underlying pathology complicating another disorder, such as chronic sinusitis.2 History and physical examination are important steps in the diagnosis of allergic disease.3
History The patient’s history is the single most important source of information in making the diagnosis.1 Allergy is a contributing factor in many inflammatory conditions in the head and neck region and information regarding those conditions can be helpful. If all things are considered, the number and types of potential questions to ask the patient during an allergy history become immensely impractical. Rather than an exhaustive list of questions (or extensive questionnaire), the most common and important aspects of the history should be covered, remembering that not all relevant information is likely to be obtained at the initial visit.3 The history of the allergic patient is an ongoing process continuing over the course of the patient-physician
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
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Allergy primer: history and physical examination
relationship, becoming very important if new or recurrent symptoms develop.1 The history of present illness contains 3 essential components: symptoms, timing, and location.3 Well-known allergy symptoms include sneezing; itchy, red, or watery eyes; clear rhinorrhea; and itchy nose. Urticaria, angioedema, complaints of increased mucus, and wheezing (particularly expiratory wheezing) are other potential allergic symptoms. Other, less well-known, less specific symptoms that may indicate allergy include complaints of chronic nasal congestion; postnasal drainage; coughing; frequent sinus infections; change in hearing, ear pressure, or pain; the feeling of ears being stopped up or congested; itchy throat; hoarseness; heartburn; gastrointestinal upset; snoring; and tiredness or fatigue.4, 5 These symptoms include other disease processes, such as asthma, chronic rhinosinusitis, Eustachian tube dysfunction, obstructive sleep apnea, and otitis media, which can be exacerbated by allergies.4, 5 Timing of symptoms includes onset of symptoms (age of onset, duration), fluctuation, or seasonality, and symptom pattern. The age of onset is important because allergic rhinitis is most common in the teen and young adult ages and is rare in the infant and geriatric populations.1 Duration of symptoms includes the timeframe of onset (ie, How many years have you had this complaint?) and time course of symptoms (ie, “My eyes itch for a week,” or “I’m congested most of the year”). Questions about time course overlap with questions about seasonality or fluctuations with exposure. The key thing is to identify if the symptom occurs year-round (perennial), occurs during a specific time of year (seasonal), or with a particular exposure or location (episodic). Establishing symptom patterns is important if multiple symptoms are elicited. Do all elicited symptoms occur together or just certain ones and with what exposures? This aids the physician in identifying potential offending allergens. Location and environment complete the critical elements of the history of present illness. The current geographic location helps establish potential allergen exposure, but prior locations in which the patient has lived may also be important. The list of possible environmental exposures is daunting when considering home, outdoor, and occupational environments, but key things to inquire about include the presence of pets (indoor or outdoor); laboratory animals or livestock; tobacco use; hobbies; stuffed animals; carpeting or draperies in the dwelling; type of heating or air conditioning; indications of mold or humidity; and nearby landscaping. If allergic symptoms do not improve or reoccur, reviewing additional environmental exposures is extremely helpful. Past medical history includes a review of any previous treatments or testing, surgeries, and medication usage. Previous treatment includes prescription medications, as well as self-administered pharmaceuticals, such as over-thecounter antihistamines, cold preparations, and intranasal corticosteroids. The effectiveness of any prior treatment
S29
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
TABLE 1. Possible physical examination findings in the
typical allergic patient Physical examination findings
Skin and general findings “Allergic salute” Supratip nasal crease or “allergic nasal crease” Urticarial lesions Eczema or atopic dermatitis Facial grimacing Ocular findings Conjunctivitis “Allergic shiner” Dennie-Morgan lines Lower eyelid edema Ear findings Serous otitis media External auditory canal dermatitis Nose and nasopharyngeal findings Clear, watery rhinorrhea Pale or bluish and boggy inferior turbinates Nasal polyps or polypoid mucosal changes Adenoid hypertrophy Oral cavity and oropharyngeal findings Tonsillar hypertrophy Lateral pharyngeal bands Posterior pharyngeal “cobblestoning” Laryngeal findings Thick, “bridging” mucus Mild vocal fold edema Pale arytenoids with mild edema
should be noted. Past surgical history, particularly sinus surgery, sleep surgery, or ear surgery, is indicative of associated disease processes. Medication review, including herbal preparations, is important because certain medications may impact the diagnosis, testing, and treatment options available to the patient. Allergic disease is hereditary and family history should include questions about other family members suffering from allergies, asthma, or eczema, or with similar complaints to the patient.
Physical examination Physical examination findings aid in making the diagnosis of inhalant allergic disease. Table 1 lists common findings
Franzese
associated with allergic disease, separated by area of examination. The following sections expand on specific findings in the corresponding area.
the skin from digital trauma or instrumentation to relieve itching may lead to repeated bouts of otitis externa.10
Skin and general findings
Although rhinorrhea can be colored or clear, allergic rhinitis is classically associated with clear, watery rhinorrhea. Venous congestion in the inferior turbinates typically results in edema (“boggy” edema) with a pale bluish or purplish discoloration.11 Nasal polyps can have infectious and inflammatory causes, and can have an association with allergic disease.12 Although extremely large nasal polyps can be visualized on anterior rhinoscopy, nasal endoscopy is necessary for the evaluation of nasal polyposis. Polypoid changes to the nasal mucosa may occur independently, particularly along the inferior turbinate. Large polypoid changes at the posterior aspect of the inferior turbinate are referred to as a “mulberry” turbinate. Adenoid hypertrophy may result from inflammatory mediators present in nasal secretions, and is more commonly seen in children, but it does occur in adults. This enlargement can contribute to nasal obstruction, sleep disordered breathing, and chronic rhinosinusitis in children.13
Nose and nasopharyngeal findings The “allergic salute” refers to a characteristic maneuver patients develop to manage rhinorrhea that involves wiping their nose with the palm of their hand or a tissue in a vertical direction that displaces the nasal tip superiorly. Over time, this creates a crease above the nasal tip (supratip), also known as the “allergic nasal crease.”2 Facial grimacing is another compensatory measure patients develop in response to nasal itchiness. Rather than a hand or finger, patients will use various facial contortions to relieve nasal itching. Patients with pharyngeal itchiness may exhibit nasal snorting or palatal “clicking” as a way to relieve their symptoms. Urticaria, or hives, is a rash of reddish, itchy wheals occurring anywhere on the body. It is associated with allergy, but may have nonallergic causes.6 Eczema or atopic dermatitis is an itchy, scaly rash of variable appearance with a tendency to involve flexural surfaces.7 It is part of the allergic triad, and 1 of the simplified criteria for its diagnosis is a history of allergic rhinitis.8
Ocular findings Allergic conjunctivitis includes findings of periorbital, lid, and conjunctival erythema/hyperemia, chemosis (clear conjunctival swelling), and watery discharge or excessive tearing.9 Venous congestion in the periorbital region resulting from nasal congestion can lead to the appearance of lower eyelid edema and dark discoloration below the lower eyelid, termed an “allergic shiner.”1 Hemosiderin leakage from congested vessels may cause permanent discoloration. Local hypoxia resulting from this congestion may cause spasms of Muller’s muscle, which manifest as DennieMorgan lines.2
Oral cavity and oropharyngeal findings Inflammatory mediators in nasal drainage flowing posteriorly affect lymphatic tissue in the oropharyngeal region. Tonsillar hypertrophy, hypertrophy of lateral pharyngeal lymphoid tissue (lateral pharyngeal bands), and hypertrophy of submucosal pharyngeal lymphoid tissue (“cobblestoning”) may all occur in the allergic patient.14
Laryngeal findings Allergic laryngitis is a less recognized cause of hoarseness, likely because its signs and symptoms are similar to laryngopharyngeal reflux. However, certain findings on mirror examination or flexible laryngoscopy suggest allergic disease, particularly thick, viscous mucoid secretions that tend to span from 1 vocal fold to the other (“bridging” mucus).15
Ear findings Nasopharyngeal edema around the Eustachian tube (ET) from inhalant allergies that results in ET dysfunction is thought to contribute to the development of serous, noninfected fluid in the middle ear space.4 The middle ear mucosa is also thought to be a target end-organ for allergic inflammation and is associated with the development of serous effusions.5 Atopic dermatitis in the external auditory canal is important to recognize. Buildup of chronic debris and breaches in
Conclusion A thorough yet focused history is important in making the diagnosis of allergic inhalant disease. Physical examination findings provide evidence of inhalant allergies, as well as other associated disease conditions. The diagnosis of allergic rhinitis can be made on history and physical examination alone, but if medical therapy fails or the diagnosis is questioned, further evaluation with diagnostic testing is warranted.
References 1.
King HC, Mabry RL, Mabry CS, Gordon BR, Marple BF, eds. Interaction with the patient. In: Allergy in ENT Practice: The Basic Guide. 2nd ed. New York: Thieme Medical Publishers; 2005:67– 104.
2. 3.
Franzese CB, Burkhalter NW. The patient with allergies. Med Clin North Am. 2010;94:891–902. Franzese CB. Diagnosis of inhalant allergies: patient history and testing. Otolaryngol Clin North Am. 2011;44:611–623.
4.
5.
Martines F, Bentivegna D. Audiological investigation of otitis media in children with atopy. Curr Allergy Asthma Rep. 2011;11:513–520. Martines F, Martines E, Sciacca V, et al. Otitis media with effusion with or without atopy: audiological
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
S30
Allergy primer: history and physical examination
6.
7.
8.
S31
findings on primary schoolchildren. Am J Otolaryngol. 2011;32:601–606. Viegas LP, Ferreira MB, Kaplan AP. The maddening itch: an approach to chronic urticaria. J Investig Allergol Clin Immunol. 2014;24:1–5. Spergel JM. Epidemiology of atopic dermatitis and atopic march in children. Immunol Allergy Clin North Am. 2010;30:269–280. Brenninkmeijer EE, Schram ME, Leeflang MM, et al. Diagnostic criteria for atopic dermatitis: a
systematic review. Br J Dermatol. 2008;158:754– 765. 9. Miraldi Utz V, Kaufman AR. Allergic eye disease. Pediatr Clin North Am. 2014;61:607–620. 10. Niebuhr M, Werfel T. Innate immunity, allergy, and atopic dermatitis. Curr Opin Allergy Clin Immunol. 2010;10:463–468. 11. Chhabra N, Houser SM. The surgical management of allergic rhinitis. Otolaryngol Clin North Am. 2011;44:779–795.
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
12. DeMarcantonio MA, Han JK. Nasal polyps: pathogenesis and treatment implications. Otolaryngol Clin North Am. 2011;44:685–696. 13. Sih T, Mion O. Allergic rhinitis in the child and associated comorbidities. Pediatr Allergy Immunol. 2010;21:e107–e113. 14. Woodbury K, Ferguson BJ. Physical findings in allergy. Otolarngol Clin North Am. 2011;44:603–610. 15. Stachler RJ, Al-khudari S. Differential diagnosis in allergy. Otolaryngol Clin North Am. 2011;44:561–590.
AAOA allergy primer: history and physical examination Christine B. Franzese, MD, FAAOA
Background: Allergic disease is very common in the general population and makes a significant impact on the quality of life of patients. Immunoglobulin E (IgE)-mediated allergic disease manifests throughout the body, but many signs and symptoms of inhalant allergy are centered in the head and neck region.
Conclusion: Many times, history alone can serve to make the diagnosis, but physical examination also demonstrates specific findings that confirm the practitioner’s presumptive diagnosis of allergic disease. However, should medical treatment fail or the diagnosis be in doubt, further diagnostic investigation with allergy testing should be pursued. C 2014 ARS-AAOA, LLC.
Methods: A thorough yet focused history of allergic symptoms and potential physical examination findings of inhalant allergy are described. Results: History should include types and timing of symptoms, environmental and occupational exposures, family history, associated diseases, and prior treatment, if any. Physical examination should include the skin and structures of the head and neck region. Nasal endoscopy can be helpful in visualization of nasal polyps.
A
llergy is a hypersensitivity reaction, an immunologic response to an otherwise harmless agent resulting in undesirable clinical manifestations. Allergic disease is very common in the general population and is found throughout all age groups, ethnicities, and socioeconomic classes. This section focuses on making the diagnosis of the best-understood hypersensitivity reaction, type 1 or immunoglobulin E (IgE)-mediated hypersensitivity. IgE-mediated allergic disorders are caused by a wide variety of agents, including foods and pharmaceuticals. This section addresses allergic rhinitis caused by inhalant allergens, 1 of the most common types of allergic diseases. Although a definitive diagnosis of IgE-mediated allergic disease includes allergy testing, a strong presumptive diagnosis can be made from history alone.1 Physical examination findings may be present to provide further evidence
DePaul/EVMS Department of Otolaryngology, Eastern Virginia Medical School (EVMS), Norfolk, VA Correspondence to: Christine B. Franzese, MD, FAAOA, DePaul/EVMS Department of Otolaryngology, 100 Kingsley Lane, Suite 404, Norfolk, VA 23505; e-mail: [email protected] Potential conflict of interest: None provided. Received: 25 June 2014; Revised: 30 June 2014; Accepted: 30 June 2014 DOI: 10.1002/alr.21390 View this article online at wileyonlinelibrary.com.
Key Words: allergies; allergic rhinitis; history; physical examination; allergic conjunctivitis; inhalant allergy
How to Cite this Article: Franzese CB. AAOA allergy primer: history and physical examination. Int Forum Allergy Rhinol. 2014;4: S28–S31.
of allergic disease and reassurance that medical therapy can proceed, unless further testing is warranted. Patients may state, “I have allergies,” or “I have sinus problems, but not allergies.” This self-diagnosis is frequently inaccurate and should not be passively accepted. Irritant triggers of nonallergic disorders often manifest symptoms identical to inhalant allergy, and inhalant allergy is frequently an underlying pathology complicating another disorder, such as chronic sinusitis.2 History and physical examination are important steps in the diagnosis of allergic disease.3
History The patient’s history is the single most important source of information in making the diagnosis.1 Allergy is a contributing factor in many inflammatory conditions in the head and neck region and information regarding those conditions can be helpful. If all things are considered, the number and types of potential questions to ask the patient during an allergy history become immensely impractical. Rather than an exhaustive list of questions (or extensive questionnaire), the most common and important aspects of the history should be covered, remembering that not all relevant information is likely to be obtained at the initial visit.3 The history of the allergic patient is an ongoing process continuing over the course of the patient-physician
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
S28
Allergy primer: history and physical examination
relationship, becoming very important if new or recurrent symptoms develop.1 The history of present illness contains 3 essential components: symptoms, timing, and location.3 Well-known allergy symptoms include sneezing; itchy, red, or watery eyes; clear rhinorrhea; and itchy nose. Urticaria, angioedema, complaints of increased mucus, and wheezing (particularly expiratory wheezing) are other potential allergic symptoms. Other, less well-known, less specific symptoms that may indicate allergy include complaints of chronic nasal congestion; postnasal drainage; coughing; frequent sinus infections; change in hearing, ear pressure, or pain; the feeling of ears being stopped up or congested; itchy throat; hoarseness; heartburn; gastrointestinal upset; snoring; and tiredness or fatigue.4, 5 These symptoms include other disease processes, such as asthma, chronic rhinosinusitis, Eustachian tube dysfunction, obstructive sleep apnea, and otitis media, which can be exacerbated by allergies.4, 5 Timing of symptoms includes onset of symptoms (age of onset, duration), fluctuation, or seasonality, and symptom pattern. The age of onset is important because allergic rhinitis is most common in the teen and young adult ages and is rare in the infant and geriatric populations.1 Duration of symptoms includes the timeframe of onset (ie, How many years have you had this complaint?) and time course of symptoms (ie, “My eyes itch for a week,” or “I’m congested most of the year”). Questions about time course overlap with questions about seasonality or fluctuations with exposure. The key thing is to identify if the symptom occurs year-round (perennial), occurs during a specific time of year (seasonal), or with a particular exposure or location (episodic). Establishing symptom patterns is important if multiple symptoms are elicited. Do all elicited symptoms occur together or just certain ones and with what exposures? This aids the physician in identifying potential offending allergens. Location and environment complete the critical elements of the history of present illness. The current geographic location helps establish potential allergen exposure, but prior locations in which the patient has lived may also be important. The list of possible environmental exposures is daunting when considering home, outdoor, and occupational environments, but key things to inquire about include the presence of pets (indoor or outdoor); laboratory animals or livestock; tobacco use; hobbies; stuffed animals; carpeting or draperies in the dwelling; type of heating or air conditioning; indications of mold or humidity; and nearby landscaping. If allergic symptoms do not improve or reoccur, reviewing additional environmental exposures is extremely helpful. Past medical history includes a review of any previous treatments or testing, surgeries, and medication usage. Previous treatment includes prescription medications, as well as self-administered pharmaceuticals, such as over-thecounter antihistamines, cold preparations, and intranasal corticosteroids. The effectiveness of any prior treatment
S29
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
TABLE 1. Possible physical examination findings in the
typical allergic patient Physical examination findings
Skin and general findings “Allergic salute” Supratip nasal crease or “allergic nasal crease” Urticarial lesions Eczema or atopic dermatitis Facial grimacing Ocular findings Conjunctivitis “Allergic shiner” Dennie-Morgan lines Lower eyelid edema Ear findings Serous otitis media External auditory canal dermatitis Nose and nasopharyngeal findings Clear, watery rhinorrhea Pale or bluish and boggy inferior turbinates Nasal polyps or polypoid mucosal changes Adenoid hypertrophy Oral cavity and oropharyngeal findings Tonsillar hypertrophy Lateral pharyngeal bands Posterior pharyngeal “cobblestoning” Laryngeal findings Thick, “bridging” mucus Mild vocal fold edema Pale arytenoids with mild edema
should be noted. Past surgical history, particularly sinus surgery, sleep surgery, or ear surgery, is indicative of associated disease processes. Medication review, including herbal preparations, is important because certain medications may impact the diagnosis, testing, and treatment options available to the patient. Allergic disease is hereditary and family history should include questions about other family members suffering from allergies, asthma, or eczema, or with similar complaints to the patient.
Physical examination Physical examination findings aid in making the diagnosis of inhalant allergic disease. Table 1 lists common findings
Franzese
associated with allergic disease, separated by area of examination. The following sections expand on specific findings in the corresponding area.
the skin from digital trauma or instrumentation to relieve itching may lead to repeated bouts of otitis externa.10
Skin and general findings
Although rhinorrhea can be colored or clear, allergic rhinitis is classically associated with clear, watery rhinorrhea. Venous congestion in the inferior turbinates typically results in edema (“boggy” edema) with a pale bluish or purplish discoloration.11 Nasal polyps can have infectious and inflammatory causes, and can have an association with allergic disease.12 Although extremely large nasal polyps can be visualized on anterior rhinoscopy, nasal endoscopy is necessary for the evaluation of nasal polyposis. Polypoid changes to the nasal mucosa may occur independently, particularly along the inferior turbinate. Large polypoid changes at the posterior aspect of the inferior turbinate are referred to as a “mulberry” turbinate. Adenoid hypertrophy may result from inflammatory mediators present in nasal secretions, and is more commonly seen in children, but it does occur in adults. This enlargement can contribute to nasal obstruction, sleep disordered breathing, and chronic rhinosinusitis in children.13
Nose and nasopharyngeal findings The “allergic salute” refers to a characteristic maneuver patients develop to manage rhinorrhea that involves wiping their nose with the palm of their hand or a tissue in a vertical direction that displaces the nasal tip superiorly. Over time, this creates a crease above the nasal tip (supratip), also known as the “allergic nasal crease.”2 Facial grimacing is another compensatory measure patients develop in response to nasal itchiness. Rather than a hand or finger, patients will use various facial contortions to relieve nasal itching. Patients with pharyngeal itchiness may exhibit nasal snorting or palatal “clicking” as a way to relieve their symptoms. Urticaria, or hives, is a rash of reddish, itchy wheals occurring anywhere on the body. It is associated with allergy, but may have nonallergic causes.6 Eczema or atopic dermatitis is an itchy, scaly rash of variable appearance with a tendency to involve flexural surfaces.7 It is part of the allergic triad, and 1 of the simplified criteria for its diagnosis is a history of allergic rhinitis.8
Ocular findings Allergic conjunctivitis includes findings of periorbital, lid, and conjunctival erythema/hyperemia, chemosis (clear conjunctival swelling), and watery discharge or excessive tearing.9 Venous congestion in the periorbital region resulting from nasal congestion can lead to the appearance of lower eyelid edema and dark discoloration below the lower eyelid, termed an “allergic shiner.”1 Hemosiderin leakage from congested vessels may cause permanent discoloration. Local hypoxia resulting from this congestion may cause spasms of Muller’s muscle, which manifest as DennieMorgan lines.2
Oral cavity and oropharyngeal findings Inflammatory mediators in nasal drainage flowing posteriorly affect lymphatic tissue in the oropharyngeal region. Tonsillar hypertrophy, hypertrophy of lateral pharyngeal lymphoid tissue (lateral pharyngeal bands), and hypertrophy of submucosal pharyngeal lymphoid tissue (“cobblestoning”) may all occur in the allergic patient.14
Laryngeal findings Allergic laryngitis is a less recognized cause of hoarseness, likely because its signs and symptoms are similar to laryngopharyngeal reflux. However, certain findings on mirror examination or flexible laryngoscopy suggest allergic disease, particularly thick, viscous mucoid secretions that tend to span from 1 vocal fold to the other (“bridging” mucus).15
Ear findings Nasopharyngeal edema around the Eustachian tube (ET) from inhalant allergies that results in ET dysfunction is thought to contribute to the development of serous, noninfected fluid in the middle ear space.4 The middle ear mucosa is also thought to be a target end-organ for allergic inflammation and is associated with the development of serous effusions.5 Atopic dermatitis in the external auditory canal is important to recognize. Buildup of chronic debris and breaches in
Conclusion A thorough yet focused history is important in making the diagnosis of allergic inhalant disease. Physical examination findings provide evidence of inhalant allergies, as well as other associated disease conditions. The diagnosis of allergic rhinitis can be made on history and physical examination alone, but if medical therapy fails or the diagnosis is questioned, further evaluation with diagnostic testing is warranted.
References 1.
King HC, Mabry RL, Mabry CS, Gordon BR, Marple BF, eds. Interaction with the patient. In: Allergy in ENT Practice: The Basic Guide. 2nd ed. New York: Thieme Medical Publishers; 2005:67– 104.
2. 3.
Franzese CB, Burkhalter NW. The patient with allergies. Med Clin North Am. 2010;94:891–902. Franzese CB. Diagnosis of inhalant allergies: patient history and testing. Otolaryngol Clin North Am. 2011;44:611–623.
4.
5.
Martines F, Bentivegna D. Audiological investigation of otitis media in children with atopy. Curr Allergy Asthma Rep. 2011;11:513–520. Martines F, Martines E, Sciacca V, et al. Otitis media with effusion with or without atopy: audiological
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
S30
Allergy primer: history and physical examination
6.
7.
8.
S31
findings on primary schoolchildren. Am J Otolaryngol. 2011;32:601–606. Viegas LP, Ferreira MB, Kaplan AP. The maddening itch: an approach to chronic urticaria. J Investig Allergol Clin Immunol. 2014;24:1–5. Spergel JM. Epidemiology of atopic dermatitis and atopic march in children. Immunol Allergy Clin North Am. 2010;30:269–280. Brenninkmeijer EE, Schram ME, Leeflang MM, et al. Diagnostic criteria for atopic dermatitis: a
systematic review. Br J Dermatol. 2008;158:754– 765. 9. Miraldi Utz V, Kaufman AR. Allergic eye disease. Pediatr Clin North Am. 2014;61:607–620. 10. Niebuhr M, Werfel T. Innate immunity, allergy, and atopic dermatitis. Curr Opin Allergy Clin Immunol. 2010;10:463–468. 11. Chhabra N, Houser SM. The surgical management of allergic rhinitis. Otolaryngol Clin North Am. 2011;44:779–795.
International Forum of Allergy & Rhinology, Vol. 4, No. S2, September 2014
12. DeMarcantonio MA, Han JK. Nasal polyps: pathogenesis and treatment implications. Otolaryngol Clin North Am. 2011;44:685–696. 13. Sih T, Mion O. Allergic rhinitis in the child and associated comorbidities. Pediatr Allergy Immunol. 2010;21:e107–e113. 14. Woodbury K, Ferguson BJ. Physical findings in allergy. Otolarngol Clin North Am. 2011;44:603–610. 15. Stachler RJ, Al-khudari S. Differential diagnosis in allergy. Otolaryngol Clin North Am. 2011;44:561–590.
