Rhinitis Associated With Systemic Diseases or Anatomical Defects

The presence of systemic findings or the persistence of nasal symptoms despite treatment should prompt consideration of systemic diseases or anatomical problems resulting in nasal symptoms. Structural problems typically will present with a predominance of unilateral symptoms or initially unilateral symptoms. Nasopharyngoscopy, paranasal computed tomography, and/or otolaryngological consultation are major considerations with lateralizing nasal complaints or bleeding noted from one nasal airway or unremitting congestion (Fig. 5). Nasal septal deviations are the most common anatomical nasal variants noted, but often septal deviation is not primarily responsible for the symptoms unless very severe or coupled with mucosal disease such as allergic rhinitis or PNAR. Profuse rhinorrhea should prompt testing of the secretions for glucose or for p2-transferrin (p-trace protein) to exclude cerebrospinal fluid rhinorrhea.

Table 7

Laboratory Tests for Systemic Diseases Associtated with Nasal Symptoms

Test

Diagnoisis

Erythrocyte sedimentation rate

Wegener's granulomatosis

Relapsing polychondritis

Sarcoidoisis

Tuberculosis

Syphilis

Cystic fibrosis

Delayed-type hypersensitivity testing VDRL test Sweat chloride

Cystic fibrosis transmembrane regulator genotyping Cystic fibrosis

Antineutrophil cytoplasmic antibody

Wegener's granulomatosis Churg Strauss vasculitis Sarcoidosis

Common variable immunodeficiency

IgA deficiency

Hypothyroidism

Sjogren's syndrome

Sjogren's syndrome

Immotile cilia syndrome

Angiotension-converting enzyme level Quantitative immunoglobulins

Thyroid-stimulating hormone ANA, anti-Ro (SSA), anti-La (SSB) Schirmer tear test" Saccharine Taste Test6

"A 5 x 35 m m piece of sterile filter paper is folded 5 mm from the end and inserted over the inferior eyelid at the junciton of the middle and lateral third. The eye is gently closed for 5 min and the length of wetting is meanured after removal. Less than 5 mm indicates sidnificant dryness, normal is more than 15 mm. (Available from Alcon Laboratories, Fort Worth, TX.)

^Saccharine is placed with a cotton swab on the inferior turbinate, at the junction of the anterior and middle thirds of the turbinate. The time required for tasting is recorded, with normal usually less than 20 min. Greater than 30 min before tasting is considered indicative of dysfunction of ciliary motility. The patient must be instructed to not sniff, blow the nose or use any toopical nasal therapies during the test. (Stanley P, MacWilliam L, Greenstone M, et al. Efficacy of a saccharine test for screening to detect abnormal mucociliary clearance. Br J Dis Chest 1984;78:62. Corbo GM, FGoresi A, Bonfitto P, et al. Measurement of nasal mucociliary clearance. Arch Dis Child 1989;64:546.)

Wegener's granulomoatosis may present initially with upper airway complaints, particularly hearing loss, intractable sinusitis, and persistent nasal congestion associated with purulent or bloody nasal discharge. Sarcoidosis of the nasal airway may appear similarly, although not usually as necrotizing. Persistent sinusitis or recurring infectious complications should prompt consideration of cystic fibrosis, partially cleft or submucosal cleft palate, humoral immunodeficiency, or ciliary dysfunction. Table 7 lists potentially useful tests to discriminate among the systemic possibilities.

The treatment of allergic rhinitis is three-pronged—allergen exposure modification or avoidance, allergen immunotherapy (allergy shots), and/or pharmacotherapy (Fig, 6, Table 8). Clinical studies confirming efficacy of various therapies utilize symptoms as primary outcome variables. More objective means of assessing allergic rhinitis have been somewhat useful but have not supplanted symptom scores in clinical trials. These other methods include acoustic rhinometry, rhinomamometry, nasal peak flow, nitric oxide

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