Introduction
Definition
Multi-morbidities of allergic rhinitis
Asthma
Extent of co-occurrence
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Lack of nasal function, i.e. purifying, warming and humidifying inspired air;
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Nasobronchial reflex (nasal irritants, allergens or cold stimuli);
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Rhinovirus adhesion theory (increased susceptibility to allergic inflammation and intracellular adhesion molecule (ICAM)-1 expression) [12]; and
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“Migration” of T cell responses to other tissues after initial sensitization. Braunstahl [13] has shown that allergen challenge in one part of the airway is followed by a response in all other parts;
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The idea of postnasal drip (carriage of inflammatory cytokines/mediators from nasopharynx to lower airways) has been largely abandoned, since the ‘drip’ travels to the gut, by virtue of the larynx, not to the lower airway, unless the subject is deeply unconscious.
Effects of co-occurrence
References | Study type | No. patients | Age/Profile | Aim of the study | Results |
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Ciprandi et al. [16] | Prospective | 89 (AR), 940 (controls) | Adults | Follow up of patients with AR every 2 years for 8 years to investigate spirometric abnormalities/BHR | 34 of 89 AR patients developed BHR after 8 years Sensitization to mite, birch and parietaria, as well as rhinitis duration are risk factors |
Navarro et al. [17] | Epidemiologic prospective; multi centre | 942 (with asthma) | Mean age: 35.5; 63% female | Investigate the link between the upper and lower airways | 89.5% had AR Correlation between severity of rhinitis and asthma (p < 0001) and inverse correlation with age (p < 0.0001) and severity of asthma (p < 0.05) |
Ko et al. [18] | Cross sectional; questionnaire | 600 (with asthma) | 267 male; 333 female | Evaluation of prevalence of AR in asthma | 77% of asthmatics had rhinitis in the past 12 months (of whom 96% were previously diagnosed with AR) |
In patients with asthma and rhinitis, 49% use nasal steroids, resulting in fewer ED visits (13 vs 25%) and fewer hospitalizations for asthma (5 vs 13%) | |||||
Valero et al. [19] | Cross-sectional international population study; based on questionnaire | 3225; 1 positive skin test | Age range: 10–50; 53% male | Evaluation of the link between AR, asthma and skin test sensitization | Asthma presents in 49% of AR patients |
Asthma severity was associated with length of time from onset and with allergic rhinitis severity | |||||
Patients with asthma have a higher number of allergen sensitizations and higher sensitization intensity than those without asthma (p < 0.01) |
Atopic dermatitis (AD)
Extent of co-occurrence
Effects of co-occurrence
Food allergy
Extent of co-occurrence
Treatment
Eosinophilic oesophagitis (EoE)
Description
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Symptoms related to esophageal dysfunction;
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Eosinophil-predominant inflammation on esophageal biopsy, which is required for diagnosis, characteristically consisting of a peak value of ≥15 eos per high power field (eos/hpf) [38];
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Response to treatment (dietary elimination; topical corticosteroids) supports, but it is not required, for diagnosis (Strong recommendation, low evidence) [37].
Extent of co-occurrence
Treatment
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Dietary therapy is an effective treatment for eosinophilic esophagitis in children and adults. Dietary therapy is based upon the observation that patients with eosinophilic esophagitis have high rates of food allergies, and that those allergies may contribute to the development of eosinophilic esophagitis [44].
Allergic conjunctivitis
Extent of co-occurrence
Effects of co-occurrence
Treatment
Rhinosinusitis
Extent of co-occurrence
Effects of co-occurrence
Chronic rhinosinusitis with nasal polyps (CRSwNP)
Otitis media with effusion (OME)
Extent of co-occurrence
Effects of co-occurrence
Treatment
Adenoid hypertrophy (AH)
Extent of co-occurrence
Treatment
Olfactory dysfunction
Extent of co-occurrence
Effects of co-occurrence
Treatment
Laryngitis, cough and vocal problems
Effects of co-occurrence
Treatment
Gastro esophageal reflux (GER)
Obstructive sleep apnea (OSA) and sleep impairment
Treatment
Fatigue and learning impairment
Extent of co-occurrence
Effects of co-occurrence
Treatment
Turbinate hypertrophy
Extent of co-occurrence
Effects of co-occurence
Treatment
Diagnosis
Multi-morbidities of AR | Definitive medical history, symptoms and signs |
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Asthma | Ask about any history of cough, wheeze, shortness of breath, exercise-induced bronchospasm |
Examine the chest for wheeze, hyperexpansion | |
Assess peak expiratory flows and spirometry in older children preferably with reversibility testing with beta-2 agonists | |
If in doubt, undertake an exercise, mannitol or methacholine challenge test or measure exhaled nitric oxide (FENO) | |
Conjunctivitis | Ask about a history of red, itchy, watery eyes, eye rubbing |
Examine eyes | |
Rhinosinusitis | Ask about a history of nasal obstruction or discharge (purulent) with or without hyposmia, headache, facial pain or cough |
Undertake nasendoscopy in older children | |
CT scan/sinus X-rays not recommended unless there are complications or failed therapy, unilateral symptoms or severe disease unresponsive to medical therapy | |
Otitis media with effusion (OME)/impaired hearing | Ask questions related to immune deficiency and/or recurrent infections |
Ask about any speech and language delay, increasing volume of TV, shouting, poor concentration, failing performance at school, frustration, irritability | |
Examine the ears using a pneumatic otoscope if possible, and Weber and Rinne tests | |
Use tympanoscopy for evaluation of tympanic membrane and middle ear | |
Undertake tympanometry | |
Use a whisper test to screen otitis media with effusion and hearing loss | |
Use audiometry in older children—pure tones, speech | |
Obstructive sleep apnea and sleep problems | Enquire about any history of disturbed sleep, snoring, apnoea, tiredness, irritability |
Assess nasal airway using spatula misting, nasal inspiratory peak flow, visual examination of nostrils and nasendoscopy in older children to view nasal airway and adenoids | |
Consider sleep study | |
Atopic dermatitis | Ask about skin symptoms of itching, redness, rash |
Food allergy | Ask about symptoms related to food intake |
Ask for oral allergy syndrome (OAS): Allergic reaction that occurs upon contact of the mouth and throat with raw fruits or vegetables which may be tolerated when cooked | |
Eosinophilic oesophagitis | Ask for symptoms related to esophageal dysfunction as solid food dysphagia, chest pain, heartburn and upper abdominal pain |
Assess esophageal biopsies | |
Adenoid hypertrophy | Ask about nasal obstruction, open mouth breathing and snoring |
Examine the face | |
Perform posterior rhinoscopy; nasal and nasopharyngeal rigid/flexible endoscopy | |
Olfactory dysfunction | Ask for olfactory dysfunction, hyposmia, anosmia |
Evaluate nasal airway and smell function tests | |
Laryngitis, cough and vocal problems | Ask for symptoms including irritation in the throat, the sensation of difficult to shift mucus and cough |
Examine throat and larynx, see vocal cords and arytenoids | |
Gastro esophageal reflux | Ask for symptoms of indigestion, regurgitation, cough |
Examine throat and larynx | |
Fatigue and learning impairment | Ask about fatigue and learning impairment, school success |
Ask about sleep quality, nasal obstruction and nasal discharge | |
Turbinate hypertrophy | Ask about nasal obstruction |
Perform anterior rhinoscopy and nasal endoscopy, acoustic rhinometry pre and post decongestant shows whether mucosal lining or bony structure is responsible |