Manifestations

In seasonal allergic rhinitis, exposure is followed by complaints of paroxysmal sneezing, a watery nasal discharge with congestion, and nasal pruritus. Conjunctival and pharyngeal itching often occurs. Less specific symptoms are postnasal drainage or fullness or aching in the frontal areas.

The patient might exhibit an allergic salute, an upward thrust of the palm against the nares to relieve itching and open the nasal airways and a gaping expression from mouth breathing. Allergic shiners or Dennie's lines are wrinkles beneath the lower eyelid. Speech can have a nasal quality. In children, nasal irritation can result in nose picking and recurrent epistaxis. Sleep disruption is often associated with nasal obstruction and mouth breathing. Patients might have sleep apnea-like symptoms, including restless sleep, snoring, or nighttime coughing, associated with postnasal mucus drainage and mild hoarseness. The nasal mucosa is typically moist, with enlarged, pale turbinates and serous discharge. Because the sense of smell is impaired, appetite may be decreased. Maxillomandibular alignment problems (overbite or underbite) result from chronic symptoms.

In perennial allergic rhinitis, nasal congestion, itching, obstruction, and frequent sniffing may be associated with a loss of sense of taste or smell, with decreased hearing and a popping sensation in the ears. A lower sneezing threshold often occurs with altered autonomic reflexes in perennial allergic rhinitis. Paroxysms of sneezing and rhinorrhea can result from changes in ambient temperature, head movement, odors from perfume, tobacco smoke, irritants, alcohol, and exposure to small quantities of antigen. Exercise reverses nasal congestion temporarily, from minutes to hours.

The turbinates are usually swollen and edematous and may be mistaken for nasal polyps, which are pearl-gray gelatinous masses and unusual in uncomplicated allergic rhinitis. Below the turbinates, the floor of the nostril is often prominent as a result of mucosal edema. One third to one half of children with allergic rhinitis have eustachian tube obstruction and resultant serous otitis. Otoscopy reveals a retracted or bulging tympanic membrane, impaired mobility, or a fluid level. In patients with intact tympanic membranes, tympanometry to measure middle ear pressures provides an indirect measure of eustachian tube function (Lazo-Saenz et al., 2005). The edematous nasal mucosa can obstruct the ostia, resulting in congestion or sinusitis with pressure symptoms or headache that is particularly notable with bending forward. Up to one third of patients have a lower respiratory tract component, including exercise-induced and mild persistent asthma.

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