Diagnosis of Vasomotor rhinitis
Vasomotor rhinitis Diagnosis: Book Excerpts
Diagnostic Tests for Vasomotor rhinitis: Online Medical Books
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Chronic Rhinitis:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Allergic rhinitis
–Rhinorrhea is typically watery and profuse
–May have associated sneezing, itchy eyes
and nose (allergic salute)
- Infectious conditions
–Chronic sinusitis: Typically has mucopurulent discharge; headache and fever may or may not be present
–Succession of URIs: Can get associated bacterial overgrowth, typically group A β
-
hemolytic Streptococcus in young children;
may have low-grade fever, lymphadenopathy,
and weight loss
–Congenital syphilis
-
Nonallergic rhinitis
–Typically due to irritants such as smoke or pungent odors
-
Vasomotor rhinitis
–A hyperactive cholinergic response
–Postnasal drip is commonly associated
-
Foreign body
–Always consider when there is unilateral nasal discharge
–Halitosis or generalized body odor
(bromhidrosis) may be present
- Nasal polyps
–10% of children with CF develop polyps
–Other causes include Kartagener syndrome (immotile cilia), recurrent sinusitis, aspirin intolerance
–Woake syndrome includes polyps, broad nasal base, frontal sinus aplasia, bronchiectasis
-
Adenoid hypertrophy
–Associated with mouth breathing, noisy respirations
–Severe cases can result in obstructive sleep apnea
-
Juvenile nasopharygeal angiofibroma
–Typically in adolescent males
–Associated with recurrent epistaxis
-
Hormonal rhinitis (rare)
–Pregnancy and hypothyroidism
Workup and Diagnosis
-
History
–Onset, duration, and severity of symptoms
–Character of nasal discharge: Purulent vs clear
–Unilateral or bilateral
–History of associated atopic conditions such as
-
environmental allergies, asthma, eczema
–Family history of atopic conditions
-
Physical exam
–Complete HEENT examination
–Degree and type of nasal discharge
–Characteristics of nasal turbinates such as enlargement,
-
color (redness indicates infection, pale or blue color indicates allergy)
–Allergic features such as allergic “shiners,” Dennie lines, high-arched palate
-
Labs
–Nasal smear
–PMNs indicate an infectious process, whereas eosinophils are consistent with an allergic response
-
Radiology
–Lateral head/neck films reveal adenoidal size and configuration, may show polyps
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Nasal Obstruction & Rhinorrhea:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Physiologic
–Nasal cycle
–Nasopulmonary reflex
–Puberty
–Menstruation and pregnancy
-
Congenital
–Choanal atresia or stenosis
–Cleft palate
–Craniofacial syndromes such as Treacher Collins, Crouzon
-
Cyst
–Dermoid, meningocele, or encephalocele
–Thornwaldt
- Infectious
–Bacterial rhinosinusitis with Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, staph
–Viral rhinosinusitis with rhinovirus, adenovirus, coxsackie
-
Viral prodrome
–Measles, mumps, mono, polio
-
Fungal (if immunocompromised)
–Aspergillosis, mucormycosis
-
Inflammatory
–Allergic rhinitis
–Nasal polyps
–Adenoid hypertrophy
–Nasopharyngeal GERD
-
Granulomatous
–Sarcoidosis
–Wegener syndrome
–SLE
–Churg-Strauss syndrome
-
Traumatic
–Foreign body
–Septal hematoma
–Septal abscess
-
Neoplastic
–Chordoma
–Craniopharyngioma
–Juvenile angiofibroma
–Olfactory neuroblastoma
-
Cystic fibrosis
-
Thyroid disease (hypo- or hyper-)
-
Ciliary dyskinesia
–Kartagener, immotile cilia syndrome, etc.
-
Chronic rhinitis
Workup and Diagnosis
-
History
–Onset, duration, severity, exacerbating and relieving
factors, work of breathing
–Family history
–Environmental history: Pets, smoke exposure
-
Physical exam
–Passage of suction catheter to rule out atresia/stenosis
–Direct rhinoscopy with otoscope, or with nasal speculum and headlight or head mirror
–Fiberoptic rhinoscopy: Flexible well tolerated, rigid (better optics) only for older children
–Examine nose before and after decongestion
-
Allergy testing
–In vitro (RAST) better tolerated in young children than
in vivo (intradermal, prick skin testing)
–Nasal cytology
- Studies
–Lateral neck X-ray: Useful for adenoid hypertrophy or nasopharyngeal cysts
–Sinus X-ray: Limited utility, essentially replaced by CT
–CT scan: Contrast only required if tumor suspected; if sinus surgery anticipated, need coronal views
–MRI: Excellent for tumors, necessary for congenital cysts (differentiate meningocele from encephalocele); much too sensitive for sinusitis
–Angiography: Useful for juvenile nasopharyngeal angiofibromas and other tumors requiring preoperative embolization
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Rhinorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin the history by asking the patient if the discharge runs from both nostrils. Is the discharge intermittent or persistent? Did it begin suddenly or gradually? Does the position of his head affect the discharge?
Next, ask the patient to characterize the discharge. Is it watery, bloody, purulent, or foul smelling? Is it copious or scanty? Does the discharge worsen or improve with the time of day? Also, find out if the patient is using medications, especially nose drops or nasal sprays. Has he been exposed to nasal irritants at home or at work? Does he experience seasonal allergies? Did he recently experience a head injury?
Examine the patient’s nose, checking airflow from each nostril. Evaluate the size, color, and condition of the turbinate mucosa (normally pale pink). Note if the mucosa is red, unusually pale, blue, or gray. Then examine the area beneath each turbinate. (See Using a nasal speculum, page 546.) Make sure to palpate over the frontal, ethmoid, and maxillary sinuses for tenderness.
To differentiate nasal mucus from cerebrospinal fluid (CSF), collect a small amount of drainage on a glucose test strip. If CSF (which contains glucose) is present, the test result will be abnormal. Finally, using a nonirritating substance, make sure to test for anosmia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Allergic rhinitis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Microscopic examination of sputum and nasal secretions reveals large numbers of eosinophils. Blood chemistry shows normal or elevated IgE. A definitive diagnosis is based on the patient’s personal and family history of allergies as well as physical findings during a symptomatic phase. Skin testing paired with tested responses to environmental stimuli can pinpoint the responsible allergens given the patient’s history. In patients who can’t tolerate skin testing, the radioallergosorbent test may be helpful in determining specific allergen sensitivity.
To distinguish between allergic rhinitis and other nasal mucosa disorders, remember these differences:
❑ In chronic vasomotor rhinitis, eye symptoms are absent, rhinorrhea is mucoid, and seasonal variation is absent.
❑ In infectious rhinitis (the common cold), the nasal mucosa is beet red; nasal secretions contain polymorphonuclear, not eosinophilic, exudate; and signs and symptoms include fever and sore throat. This condition isn’t a recurrent seasonal phenomenon.
❑ In rhinitis medicamentosa, which results from excessive use of nasal sprays or drops, nasal drainage and mucosal redness and swelling disappear when such medication is withheld.
❑ In children, differential diagnosis should rule out a nasal foreign body, such as a bean or a button.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Rhinorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin the history by asking the patient if the discharge runs from both nostrils. Is the discharge intermittent or persistent? Did it begin suddenly or gradually? Does the position of his head affect the discharge?
Next, ask the patient to characterize the discharge. Is it watery, bloody, purulent, or foul smelling? Is it copious or scanty? Does the discharge worsen or improve with the time of day? Find out if the patient is using any medications, especially nose drops or nasal sprays. Has he been exposed to nasal irritants at home or at work? Does he experience seasonal allergies? Did he recently experience a head injury?
Examine the patient’s nose, checking airflow from each nostril. Evaluate the size, color, and condition of the turbinate mucosa (normally pale pink). Note if the mucosa is red, unusually pale, blue, or gray. Then examine the area beneath each turbinate. (See Using a nasal speculum, page 690.) Be sure to palpate over the frontal, ethmoid, and maxillary sinuses for tenderness.
To differentiate nasal mucus from cerebrospinal fluid (CSF), collect a small amount of drainage on a glucose test strip. If CSF (which contains glucose) is present, the test result will be abnormal. Finally, using a nonirritating substance, be sure to test for anosmia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Rhinitis:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of rhinitis. What are the specific symptoms (i.e., stuffiness, itching, clear or purulent drainage)? Are symptoms unilateral or bilateral? When did the symptom(s) begin? Ask what the patient believes caused the symptoms.
B. Chronology. How often and when do symptoms occur? Do they predominate at certain times of the year?
C. Associated symptoms. What other symptoms are associated? What makes the symptoms better or worse? Associated complaints (e.g., frank fatigue, irritability, depression, or chest symptoms) tend to point to untreated allergic causes, systemic disease, or drug-induced illness (Table 6.2).
D. Pertinent medical history. Include questions about atopic disease, upper respiratory allergies, asthma, nasal surgery, serious infections, and current prescription medication use.
E. Lifestyle history. This discussion should address tobacco (personal use or use by those at home), alcohol or other recreational drug use, over-the-counter medication, herbal remedies, and pets in the home.
F. Family history. Is there a family history of allergies or other relevant systemic diseases?
G. Occupational history. Are there suspected environmental irritants?
Physical examination
A. General inspection of the patient frequently offers clues to the cause of the rhinitis. For example, “allergic shiners” (infraorbital, bluish discoloration of the skin) or a crease at the lower part of the nose from repeated rubbing are common physical findings of allergic rhinitis.
B. Focused physical examination (PE). Evaluate vital signs (especially temperature) and the ears, nose, and throat, including examination for lymphadenopathy and thyroid disease. A competent examination of nasal passages requires a nasal speculum (a 4–5 mm ear speculum on a handheld otoscope is acceptable for children) and a good light source. Carefully place the nasal speculum vertically into each vestibule. Insert a handheld otoscope light source through the speculum to survey for nasal patency, mucosal color (pale, red or bluish), degree and location of edema, presence and type of nasal drainage (thin, clear, thick, purulent, unilateral, or bilateral), anatomic deformities (bone spurs, septal deviation), and the presence of polyps or other masses. If swollen nasal turbinates block the view, apply a short-acting decongestant spray, then reexamine in 10 minutes. Evaluation of the posterior portion of the nose is often difficult or impossible with a nasal speculum and light source. A flexible nasopharyngoscope permits examination of the structures between the nasal vestibule and the larynx (1).
Assess the lungs and skin for signs of atopic disease (wheezing or eczema) (Chapters 8.9 and 13.4).
C. Additional physical examination. If systemic illness is suggested after the focused examination, a thorough multisystem PE is necessary (Table 6.2).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Allergic rhinitis:
Diagnosis
(Handbook of Diseases)
Microscopic examination of sputum and nasal secretions reveals large numbers of eosinophils. Blood chemistry studies show normal or elevated IgE levels, possibly linked to seasonal overproduction of interleukin-4 and -5 (involved in the allergic inflammatory process). A firm diagnosis rests on the patient’s personal and family history of allergies and on physical findings during a symptomatic phase. Skin testing, paired with tested responses to environmental stimuli, can help pinpoint the responsible allergens when interpreted in light of the patient’s history.
To distinguish between allergic rhinitis and other disorders of the nasal mucosa, remember these differences:
With chronic vasomotor rhinitis, eye symptoms are absent, rhinorrhea is mucoid, and seasonal variation is absent.
CLINICAL TIP: With infectious rhinitis (the common cold), the nasal mucosa is red; nasal secretions contain polymorphonuclear, not eosinophilic, exudate; and signs and symptoms include fever and sore throat. This condition isn’t a recurrent seasonal phenomenon.
With rhinitis medicamentosa, which results from excessive use of nasal sprays or drops, nasal drainage and mucosal redness and swelling disappear when such medication is withheld.
In children, a differential diagnosis should rule out the presence of a foreign body in the nasal passage, such as a bean or a button.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Rhinorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin the history by asking the patient if the discharge runs from both nostrils. Is the discharge intermittent or persistent? Did it begin suddenly or gradually? Does the position of his head affect the discharge? Does anything make it better? Does anything make it worse?
Next, ask the patient to characterize the discharge. Is it watery, bloody, purulent, or foul smelling? Is it copious or scanty? Does the discharge worsen or improve with the time of day? Also, find out if the patient is using medications, especially nose drops or nasal sprays. Has he been exposed to nasal irritants at home or at work? Does he experience seasonal allergies? Did he recently experience a head injury?
Examine the patient's nose, checking airflow from each nostril. Evaluate the size, color, and condition of the turbinate mucosa (normally pale pink). Note if the mucosa is red, unusually pale, blue, or gray. Then examine the area beneath each turbinate. (See Using a nasal speculum, page 542.) Be sure to palpate over the frontal, ethmoid, and maxillary sinuses for tenderness.
To differentiate nasal mucus from cerebrospinal fluid (CSF), collect a small amount of drainage on a glucose test strip. If CSF (which contains glucose) is present, the test result will be abnormal. Finally, using a nonirritating substance, be sure to test for anosmia.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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