allergic rhinitis.

#1 definition of rhinitis. 

One or more of the following symptoms.
  • Nasal congestion
  • Rhinorrhea (anterior or posterior)
  • sneezing and
  • Pruritus 
  • May have associated allergic conjunctivitis
#2 differential diagnosis based in etiology
  • Allergic rhinitis (IgE mediated rhinitis)
    • perineal with seasonal exacerbation
    • Perineal without seasonal exacerbation
    • Episodic allergic rhinitis
      • All of these symptoms can be mild/intermittent versus serious/debilitating 
  • Nonallergic  rhinitis syndrome (Non IgE mediated rhinitis)
    • Infectious rhinitis
    • Vasomotor or idiopathic rhinitis
    • Non-allergies rhinitis with eosinophilic syndrome (NARES)
    • hormonal rhinitis
      • Pregnancy associated ( between 2 months of pregnancy and 2 weeks postpartum)
      • menstrual cycle associated rhinitis
    • Drug-related rhinitis ( ACE inhibitor, aspirin/NSAIDs, phosphodiesterase 5 inhibitor, alpha receptor antagonist or decongestants)
      • rhinitis medicamentosa
    • Atrophic rhinitis
  • Mixed rhinitis

#3 pathophysiology of allergic rhinitis - IgE mediated.
2 phases of present has below. Symptoms similar in both phases, however, congestion predominates in late phase
  • Early phase response
  • late phase response
IgE dependent process can also be grouped into following
  • seasonal allergies
    • seasonal allergen like pollens are the common cause
  • Perineal allergies
    • perinatal allergen like the following are the common cause
      • dust, mites, molds, animal allergen
      • occupational allergen
      • Perineal pollens
#5 testing
  • Skin testing for IgE antibody
    • preferred method
    • Based on history, environment patient lives in, living situation, occupation, activities etc. the type of allergen tested would be decided.
  • in vitro testing for a specific IgE antibody
    • 70-75% sensitive compared to the skin testing
#6 treatment options include the following

  1. Oral antihistamines
  2. Intranasal antihistamines
  3. Oral decongestants 
  4. topical decongestants
  5. oral steroid
  6. Intranasal steroid
  7. intranasal Chromylyn 
  8. Intranasal anti-cholinergic
  9. Oral leukotriene receptor antagonist

  10. nasal saline
  11. anti-IgE - omalizumab - only inpatient with asthma and allergic rhinitis
  12. Allergen immunotherapy
  13. Surgery

  • Diagnosis: Often Clinical (Characteristic symptoms, and a good response to emperic treatment with anti-histamines or nasal corticosteroids)
    • Formal diagnosis is based on evidence of sensitization, measured either by the presence of allergen-specific IgE in the serum or by positive epicutaneous skin tests (i.e., wheal and flare responses to allergen extracts) and a history of symptoms that correspond with exposure to the sensitizing allergen. It is easier to diagnose the disease when seasonal symptoms are present or when the pa- tient can clearly identify a single trigger than when symptoms are chronic or the patient reports more than one trigger, including allergens and irritants. Epicutaneous skin testing and test- ing for allergen-specific IgE have similar sensitivity, although they do not identify sensitization in an entirely overlapping group of patients.20   NEJM 2015

  • Definite Severity:
    • Moderate to Severe (presence of one or more of the following): 
      • Sleep Disturbance
      • Impairment of Usual activities or exercise 
      • Impairment of School or Work Performance
      • Troublesome Symptoms
  • Differential Diagnosis:
    • Non-allergic (noninflammatory) rhinopathy aka Vasomotor Rhinitis 
      • NAR is about 50% of all cases of Rhinitis
      • Negative Serum IgE and Skin Testing (50 % of these patient have local nasal allergic rhinitis limited to nasal mucosa)
    • Non-allergic Chronic Rhinosinusitis

    • Mixed Rhinitis (Allergic Rhinitis + nonallergic Rhinitis)
      • NAR in these cases could be a state of nasal hyper responsiveness due to AR
    • Viral Infection (AVRS)
      • Also causes seasonal symptoms
      • Rhinovirus (Peaks in September, and smaller peak in the spring) 
    • Bacterial Infection (ABRS)
    • Others
      • Rhinitis medicamentosa: Rebound congestion especially with topical decongestants
  • Treatment
    • Episodic Symptoms: Oral/Nasal H1-Antihistamine ± PRN Oral/Nasal Decongestants 
    • Mild Symptoms (Seasonal or perennial): 
      • Intranasal Steroids  OR  
      • Oral/Nasal H1-Antihistamine OR  
      • LTR Antagonist (Eg.Monteleucast)
    • Moderate to Severe Symptoms:  
      • Intranasal Steroids  OR 
      • Intranasal Steroids  PLUS  Nasal H1-Antihistamine OR 
      • Allergen Immunotherapy(SC or SL)
Allergic Rhinitis NEJM 2015


When to refer to ENT 

Rhino-Sinusitis (RS)
Acute (<4 weeks)
Subacute (4-12 weeks)
Chronic (>12 weeks)
Recurrent (2-4 or more episodes / yr with symptoms resolution in between)  BMJ 2012

Acute RS (<4 weeks duration)
  • Acute Bacterial RS: (<2 % of ARS) Abx (augmentin, or doxy) and Adjunctive Treatment
  • Acute Viral RS Adjunctive Treatment
    •  rhinovirus, influenza virus, parainfluenza virus 
  • Adjunctive Treatment
    • Analgesics: NSAIDS or Acetaminophen okay
    • Topical Glucocroticoids (momentasone 200 or 400 mcg) most beneficia in Allergic RS, and other MILD RS (debatable)
    • Topical Decongestants (oxymetazoline nasal; note also comes in opthal soln): used in AVRS not ABRS; efficacy controversial; use 3 or less days for concern of rebounds
    • Oral Decongestants (ephedrine 25 mg, psedoephedrine 60 mg, phenylephrine 10 mg, phenylpropanolamine 25 mg): No use in ABRS; Controversial efficacy in AVRS; used for 3-5 days if associated Eustachian Tube Dysfunction in AVRS; Careful in Heart Ds, HTN, BPH
    • Anti-histamines: Although frequently prescribed not recommended
    • Mucolytis: Although frequently prescribed no studies published to support its use
  • Acute Fungal RS (Mucor, Rhizopus, Aspergillus, Absidia, Basidiobolus)
  • When to do Urgent Eval
    • When suspecting complications of Sinusitis like extension to orbits or to brain
      • High Fever and Severe Headache (abscess, meningitis)
      • Abnormal Vision
      • Periorbital Edema
      • Altered Mental Status
4 main Clinical Features of CRS are BMJ 2012
  • Nasal blockage/obstruction/Nasal congestion
  • Anterior/posterior rhinorrhoea 
  • Facial pain/pressure/fullness
  • Anosmia (total/partial) 
Other minor sx.
  • Ear pain/pressure 
  • Dizziness
  • Halitosis
  • Dental pain
  • Cough
  • Drowsiness/malaise 
  • Sleep disturbance
  • Fever
3 Red flag symptoms
  • Unilateral symptoms
  • Blockage
  • Bleeding/bloodstained discharge 
  • Cacosmia
  • Proptosis
  • Diplopia
  • Epiphora
  • Neurological symptoms 
  • CRS with NP
  • CRS without NP
    • With eosinophilic inflammatory features
      • NAR
    • With other inflammatory features
      • Vasomotor Rhinitis
      • Non-allergic Rhinitis
      • GERD
      • Sarcoidosis
  • Allergic Fungal RS (AFRS)
    • Will have eosinophilic inflammation with presence of fungal hyphae (and positive skin tests)

Strep Pharyngitis NEJM 2011

Case 36-2014: An 18-Year-Old Woman with Fever, Pharyngitis, and Double Vision (Lemierre’s syndrome)
Case 32-2014: A 78-Y-O F with Chronic Sore Throat & a Tonsillar Mass (Histoplasmosis vs. SqCC)
ACUTE PHYRANGITIS with complications


Laryngitis BMJ 2014
Management of severe acute dental infections BMJ 2015

Benign Paroxysmal Positional Vertigo NEJM 2014
Sudden sensorineural hearing loss Lancet 2010

Temporomandibular disorders BMJ 2015
Hearing Loss
TMJ Disorder
  • Clinical History (Onset, duration, progression.... associated symptoms as below)
    • Hearing impairment or sudden loss of hearing
    • Vertigo
    • Headache
    • Somatosensory complaints
    • Psychiatry co-morbidity
  • Assessment of Tinnitus severity
  • Clinical Examination
  • Audiological Examination
By these above 4 steps one should define 4 MAIN QUESTIONS that warrants further work up
  • Debilitating Tinnitus or not?
  • Acute Tinnitus with Acute onset hearing loss or not?
  • Post-Traumatic Tinnitus or not?
  • Acute Pulsatile Tinnitus or not?
After these 4 questions are answered, you should be able to group the patient into one of the following 3 categories
  • No action required (if all of the Q1 - Q4 above have an answer "NO")
  • Pulsatile Tinnitus
    • Neurovascular, Cardiac or Internal Diagnostic Tests
  • Non-Pulsatile Tinnitus with
    • Sudden Hearing Loss: Work up and Treat like acute hearing loss
    • Hearing impairment: Treat for hearing impairment including cochlear implant may be needed
    • Vertigo: Vestibular Diagnostics: DDx: Meniere's Disease
    • Headache: DDx of Headache
    • Psychiatry co-morbidity: 
    • Somatosensory component
    • Post-traumatic Tinnitus
Additional References
Neck Swellings BMJ 2014
Meniere’s disease BMJ 2014
Lesion in the External Auditory Canal
Case 36-2015: A 27-Year-Old Woman with a Lesion of the Ear Canal