Rhinitis differential diagnosis: Difference between revisions

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{{Rhinitis}}
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==Overview==
Rhinitis is a very common disease that is frequently overlooked or undertreated.<ref name="pmid11449200">{{cite journal| author=Skoner DP| title=Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. | journal=J Allergy Clin Immunol | year= 2001 | volume= 108 | issue= 1 Suppl | pages= S2-8 | pmid=11449200 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11449200  }} </ref> It is associated with several comorbidities which can have significant impact on the quality of life. It can also be the initial presentation of overt systemic illnesses which can be potentially fatal.<ref name="Diseases of the Sinuses">{{cite book |last1=Romeo |first1=Jonathan |last2=Dykewicz |first2=Mark |title=Diseases of the Sinuses |publisher=Springer New York |date=2014 |pages=133-152 |chapter=Chapter 9:Differential Diagnosis of Rhinitis and Rhinosinusitis |isbn=978-1-4939-0265-1}}</ref> It is important to differentiate rhinitis from other conditions micmicking the symptoms of rhinitis such as intranasal foreign bodies, cerebrospinal fluid rhinorrhea, [[nasal polyps]] and tumors.
 
==Differential Diagnosis==
The following conditions can present with symptoms that are similar to those found in rhinitis:<ref name="pmid 20176255">{{cite journal| author=Dykewicz MS, Hamilos DL| title=Rhinitis and sinusitis. | journal=J Allergy Clin Immunol | year= 2010 | volume= 125 | issue= 2 Suppl 2 | pages= S103-15 | pmid= 20176255 | doi=10.1016/j.jaci.2009.12.989 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20176255  }} </ref><ref name="pmid24007929">{{cite journal| author=Sacre-Hazouri JA| title=[Chronic rhinosinusitis in children]. | journal=Rev Alerg Mex | year= 2012 | volume= 59 | issue= 1 | pages= 16-24 | pmid=24007929 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24007929  }} </ref><ref name="pmid18331513">{{cite journal| author=Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A et al.| title=Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). | journal=Allergy | year= 2008 | volume= 63 Suppl 86 | issue=  | pages= 8-160 | pmid=18331513 | doi=10.1111/j.1398-9995.2007.01620.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18331513  }} </ref><ref name="Allergic rhinitis-an overview of a common disease">{{cite journal |last=Rotiroti |first=Giuseppina |last2=Scadding |first2=Glenis |date=July 2016 |title=Allergic Rhinitis-an overview of a common disease |url=https://www-clinicalkey-com.ezp-prod1.hul.harvard.edu/#!/content/playContent/1-s2.0-S1751722216300063?returnurl=null&referrer=null&scrollTo=%23tbl2|journal=Paediatrics and Child Health |volume= Volume 26 |issue= Issue 7 |pages=298-303 |access-date=January 20, 2017 }} </ref>
 
* [[Nasal polyps]]
* Mechanical/structural factors such as:
# [[Deviated nasal septum]]/septal wall anomalies
# [[Adenoid hypertrophy|Adenoidal hypertrophy]]
# Nasal tumors (benign and malignant)
# Foreign bodies- Unilateral, mucopurulent [[rhinorrhea]] in children could be as a result of insertion of foreign objects into the nostril.
# Trauma
# Anatomical variants in the ostiomeatal complex
# [[Choanal atresia]]
# [[Cleft palate]]
# Pharyngeal reflux (laryngopharyngo-nasal reflux)
# Metabolic conditions such as [[acromegaly]]
* [[Cerebrospinal fluid]] [[rhinorrhea]]: In cases where [[CSF]] [[rhinorrhea]] is suspected, the [[rhinorrhea]] can be evaluated for [[beta-2 transferrin]] ([[beta-2 transferrin]] is an endogenous marker of [[CSF]] leakage).
* Ciliary dyskinesia syndrome: Chronic rhinitis with mucopurulent secretion which manifests from birth could be suggestive of [[primary ciliary dyskinesia]].
 
{| style="border: 0px; font-size: 85%; margin: 3px; width:1000px;" align="center"
 
|+
! style="background: #4479BA; color:#FFF; width: 150px;" | Disease
! style="background: #4479BA; color:#FFF;  width: 200px;" | History
! style="background: #4479BA; color:#FFF;  width: 200px;" | Physical examination
! style="background: #4479BA; color:#FFF; width: 200px;" | Laboratory or radiological findings
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |  Acute viral nasopharyngitis<ref name="pmid12517470">{{cite journal |vauthors=Heikkinen T, Järvinen A |title=The common cold |journal=Lancet |volume=361 |issue=9351 |pages=51–9 |year=2003 |pmid=12517470 |doi=10.1016/S0140-6736(03)12162-9 |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Symptoms start with [[sore throat]]
* [[Nasal congestion]] and [[runny nose]]
* [[Cough]] that may persist after the resolution of the other symptoms
* [[Fever]] is not common
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Nasal mucosa]] is [[congested]] and [[Hyperaemia|hyperemic]]
* [[Pharynx]] is typically normal
| style="padding: 5px 5px; background: #F5F5F5;" |
* Diagnosis is usually clinical and lab tests are rarely needed
* The virus can be [[Culture medium|cultured]] on human lung cells but results take time
* [[PCR]] is rapid and accurate test but done only in [[immunocompromised]] patients when the [[virus]] strain needs to be known
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Allergic rhinitis]]<ref name="pmid20232579">{{cite journal |vauthors=Pawankar R, Bunnag C, Chen Y, Fukuda T, Kim YY, Le LT, Huong le TT, O'Hehir RE, Ohta K, Vichyanond P, Wang DY, Zhong N, Khaltaev N, Bousquet J |title=Allergic rhinitis and its impact on asthma update (ARIA 2008)--western and Asian-Pacific perspective |journal=Asian Pac. J. Allergy Immunol. |volume=27 |issue=4 |pages=237–43 |year=2009 |pmid=20232579 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Characterized by repeated paroxysms of [[rhinorrhea]], [[sneezing]] and [[cough]].
* Symptoms may be related to a specific season of the year, hence the name “seasonal allergies”.
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Rhinorrhea]] fluid is usually clear and watery.
* Examination of the nose reveals a crease below the [[nasal bridge]] from repeated pulling of the nose secondary to irritation.
* [[Edema]] in the area below the eye if associated [[conjunctivitis]] is present.<ref name="pmid11449200">{{cite journal |vauthors=Skoner DP |title=Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis |journal=J. Allergy Clin. Immunol. |volume=108 |issue=1 Suppl |pages=S2–8 |year=2001 |pmid=11449200 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Skin testing using intradermal prick skin tests to determine the specific [[allergens]] causing [[allergic rhinitis]].
* Serum immune assays to determine [[IgE|IgE levels]] in the [[serum]].
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Acute sinusitis]]<ref name="pmid9347786">{{cite journal |vauthors=Low DE, Desrosiers M, McSherry J, Garber G, Williams JW, Remy H, Fenton RS, Forte V, Balter M, Rotstein C, Craft C, Dubois J, Harding G, Schloss M, Miller M, McIvor RA, Davidson RJ |title=A practical guide for the diagnosis and treatment of acute sinusitis |journal=CMAJ |volume=156 Suppl 6 |issue= |pages=S1–14 |year=1997 |pmid=9347786 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Presents with symptoms similar to [[URTI|URTIs]] ([[sneezing]], [[cough]] and [[runny nose]])
* Symptoms last for a longer time (about 10 days) with the peak of symptoms between 4th and 6th days.
* Usually, [[acute sinusitis]] is not associated with [[fever]]<ref name="pmid7242607">{{cite journal |vauthors= |title=Acute maxillary sinusitis |journal=N. Engl. J. Med. |volume=305 |issue=4 |pages=226–7 |year=1981 |pmid=7242607 |doi=10.1056/NEJM198107233050419 |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Inspection may show [[erythema]] and [[edema]] over the involved [[sinus]]
* Palpation of [[sinuses]] shows [[tenderness]] on palpation
* [[Transillumination]] of the sinuses may show opacity.
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[X ray]] and [[CT]] may show air fluid level or bubbles in the affected sinus.
* [[Culture medium|Culture]] of the nasal secretions is of limited use in [[acute sinusitis]] as nasal secretions may be contaminated by [[Flora|nasal flora]].
|-
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Infectious mononucleosis]]<ref name="pmid4864269">{{cite journal |vauthors=Niederman JC, McCollum RW, Henle G, Henle W |title=Infectious mononucleosis. Clinical manifestations in relation to EB virus antibodies |journal=JAMA |volume=203 |issue=3 |pages=205–9 |year=1968 |pmid=4864269 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Symptoms of [[pharyngitis]]: [[sore throat]] and [[Dysphagia|difficult swallowing]]
* [[Fever]]
* [[Fatigue]]
* [[Lymphadenopathy]] especially in the posterior cervical region
| style="padding: 5px 5px; background: #F5F5F5;" |
* Abdominal examination reveals [[splenomegaly]]
* [[Maculopapular rash]] may be present
| style="padding: 5px 5px; background: #F5F5F5;" |
* Positive monospot test
* Elevated [[liver enzymes]]
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WH}}
{{WS}}
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[[Category:Immunology]]

Latest revision as of 00:00, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fatimo Biobaku M.B.B.S [2]

Overview

Rhinitis is a very common disease that is frequently overlooked or undertreated.[1] It is associated with several comorbidities which can have significant impact on the quality of life. It can also be the initial presentation of overt systemic illnesses which can be potentially fatal.[2] It is important to differentiate rhinitis from other conditions micmicking the symptoms of rhinitis such as intranasal foreign bodies, cerebrospinal fluid rhinorrhea, nasal polyps and tumors.

Differential Diagnosis

The following conditions can present with symptoms that are similar to those found in rhinitis:[3][4][5][6]

  1. Deviated nasal septum/septal wall anomalies
  2. Adenoidal hypertrophy
  3. Nasal tumors (benign and malignant)
  4. Foreign bodies- Unilateral, mucopurulent rhinorrhea in children could be as a result of insertion of foreign objects into the nostril.
  5. Trauma
  6. Anatomical variants in the ostiomeatal complex
  7. Choanal atresia
  8. Cleft palate
  9. Pharyngeal reflux (laryngopharyngo-nasal reflux)
  10. Metabolic conditions such as acromegaly
Disease History Physical examination Laboratory or radiological findings
Acute viral nasopharyngitis[7]
  • Diagnosis is usually clinical and lab tests are rarely needed
  • The virus can be cultured on human lung cells but results take time
  • PCR is rapid and accurate test but done only in immunocompromised patients when the virus strain needs to be known
Allergic rhinitis[8]
  • Characterized by repeated paroxysms of rhinorrhea, sneezing and cough.
  • Symptoms may be related to a specific season of the year, hence the name “seasonal allergies”.
  • Rhinorrhea fluid is usually clear and watery.
  • Examination of the nose reveals a crease below the nasal bridge from repeated pulling of the nose secondary to irritation.
  • Edema in the area below the eye if associated conjunctivitis is present.[1]
Acute sinusitis[9]
Infectious mononucleosis[11]

References

  1. ↑ 1.0 1.1 Skoner DP (2001). "Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis". J Allergy Clin Immunol. 108 (1 Suppl): S2–8. PMID 11449200.
  2. ↑ Romeo, Jonathan; Dykewicz, Mark (2014). "Chapter 9:Differential Diagnosis of Rhinitis and Rhinosinusitis". Diseases of the Sinuses. Springer New York. pp. 133–152. ISBN 978-1-4939-0265-1.
  3. ↑ Dykewicz MS, Hamilos DL (2010). "Rhinitis and sinusitis". J Allergy Clin Immunol. 125 (2 Suppl 2): S103–15. doi:10.1016/j.jaci.2009.12.989. PMID 20176255  20176255 Check |pmid= value (help).
  4. ↑ Sacre-Hazouri JA (2012). "[Chronic rhinosinusitis in children]". Rev Alerg Mex. 59 (1): 16–24. PMID 24007929.
  5. ↑ Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A; et al. (2008). "Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)". Allergy. 63 Suppl 86: 8–160. doi:10.1111/j.1398-9995.2007.01620.x. PMID 18331513.
  6. ↑ Rotiroti, Giuseppina; Scadding, Glenis (July 2016). "Allergic Rhinitis-an overview of a common disease". Paediatrics and Child Health. Volume 26 (Issue 7): 298–303. Retrieved January 20, 2017.
  7. ↑ Heikkinen T, Järvinen A (2003). "The common cold". Lancet. 361 (9351): 51–9. doi:10.1016/S0140-6736(03)12162-9. PMID 12517470.
  8. ↑ Pawankar R, Bunnag C, Chen Y, Fukuda T, Kim YY, Le LT, Huong le TT, O'Hehir RE, Ohta K, Vichyanond P, Wang DY, Zhong N, Khaltaev N, Bousquet J (2009). "Allergic rhinitis and its impact on asthma update (ARIA 2008)--western and Asian-Pacific perspective". Asian Pac. J. Allergy Immunol. 27 (4): 237–43. PMID 20232579.
  9. ↑ Low DE, Desrosiers M, McSherry J, Garber G, Williams JW, Remy H, Fenton RS, Forte V, Balter M, Rotstein C, Craft C, Dubois J, Harding G, Schloss M, Miller M, McIvor RA, Davidson RJ (1997). "A practical guide for the diagnosis and treatment of acute sinusitis". CMAJ. 156 Suppl 6: S1–14. PMID 9347786.
  10. ↑ "Acute maxillary sinusitis". N. Engl. J. Med. 305 (4): 226–7. 1981. doi:10.1056/NEJM198107233050419. PMID 7242607.
  11. ↑ Niederman JC, McCollum RW, Henle G, Henle W (1968). "Infectious mononucleosis. Clinical manifestations in relation to EB virus antibodies". JAMA. 203 (3): 205–9. PMID 4864269.

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