Rhinitis physical examination

Rhinitis is one of the most common conditions presenting for medical care in several countries.^[1] It is a heterogenous disorder which is sometimes mistakenly treated with triviality.^[2] Rhinitis significantly affects the quality of life of affected individuals, and also constitute a huge financial burden to the society.^[3] A careful history and physical examination is essential for accurate diagnosis, treatment, and prevention of the potential complications associated with chronic rhinitis.^[4][5] It is essential to examine all the organ systems that are potentially affected by allergies.^[2] A detailed examination of the upper respiratory tract should be done in all patients presenting with rhinitis.^[2]

The examination of patients with rhinitis should include an examination of the nose, and assessment for possible comorbidities and complications. The physical examination of a patient with rhinitis may reveal the following:^[6][7]

• Rhinorrhea may be seen
• Mouth breathing from nasal congestion
• Sniffing
• Allergic shiners: Dark eye shadows beneath the lower eye lid due to blood/fluid accumulation in the infraorbital groove as a result of congestion of the nose/sinuses. It is commonly seen in childhood allergic rhinitis, and the degree of darkness is associated with the chronicity and severity of disease. It can also be seen in nonallergic rhinitis.
• Dennie–Morgan lines: These are wrinkles/ extra skin fold underneath the lower eyelids. It is seen in children with allergic diseases such as allergic rhinitis.
• Allergic salute- A habitual gesture of rubbing the nose upward because of nasal discomfort and pruritus. It sometimes produces a persistent horizontal crease across the nose.

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Increased temperature may be seen especially when there is an infectious etiology (infectious rhinitis/rhinosinusitis)

Ocular findings: Commonly seen in patients with allergic rhinitis. Some of the ocular findings include:^[8]

• Bilateral conjunctival injection, papillae and cobblestones.
• Corneal involvement in severe cases (atopic and vernal keratoconjunctivitis).
• Frequent rubbing of the eyes, irritability, lacrimation, mucus discharge.
• Blepharospasm
• Periorbital edema

Nasal findings: Examination of the nasal cavity with a speculum or otoscope may reveal the following:

• Swollen/edematous turbinates
• Pale, bluish or erythematous mucosa. The mucosa is often pale/bluish in allergic rhinitis. Beefy red mucosa can be seen in rhinitis medicamentosa.^[9]

Ear findings: Otoscopic examination of the ears may reveal signs suggestive of associated co-morbidities such as:

• Otitis media with effusion– common in patients with allergic rhinitis.
• Acute otitis media

Face

• Facial tenderness/discomfort on palpation of the sinuses. This often occurs when the inflammation extends into the sinuses (rhinosinusitis), and it can be as a result of infection or allergy
• Abnormal facial development such as elongated facies may be seen, especially in chronic mouth breathers.^[4]

Mouth and Throat

• Coexisting conditions like hypertrophied adenoids may be seen.
• Dental malocclusion frequently occurs in children who are chronic mouth breathers.^[4]
• High arch in the palate
• Cobblestoning of the oropharynx
• Posterior drainage of nasal secretions

Neck

• Swollen lymph nodes may be seen in infectious rhinitis secondary to upper respiratory tract infections.

• Eczema may be seen in patients with allergic rhinitis if there is coexisting atopic dermatitis.

• A thorough chest examination is essential, as it may reveal abnormalities suggestive of other pathological conditions or co-morbidities such as respiratory tract infections, asthma.

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