Small and Kim Allergy, Asthma & Clinical Immunology 2011, 7(Suppl 1):S3 http://www.aacijournal.com/content/7/S1/S3 Page 4 of 8 Before seeking medical attention, patients often attempt using over-the-counter or other medications to manage their symptoms. Assessing patient response to such treatments may provide information that can aid in the diagnosis and subsequent management of allergic rhinitis. For example, symptom improvement with newer, second-generation antihistamines (e.g., deslorata- dine [Aerius], fexofenadine [Allegra], loratadine [Clari- tin]) is strongly suggestive of an allergic etiology. However, it is important to note that response to first- generation antihistamines (e.g., brompheniramine mal- eate [Dimetane], chlorpheniramine maleate [Chlor-Tri- polon], clemastine [Tavist-1]) does not imply an allergic etiology since the anticholinergic and sedative properties of these agents reduce rhinorrhea and may improve sleep quality regardless of whether the inflammation is allergic. Previous response to intranasal corticosteroids may also be suggestive of an allergic etiology, and likely indicates that such treatment will continue to be benefi- cial in the future [1]. Important elements of the history for patients with suspected allergic rhinitis are summarized in Table 2. Physical examination The physical examination of patients with suspected allergic rhinitis should include an assessment of out- ward signs, the nose, ears, sinuses, posterior orophar- ynx (area of the throat that is at the back of the mouth), chest and skin (see Table 2). Outward signs that may be suggestive of allergic rhinitis include: per- sistent mouth breathing, rubbing at the nose or an obvious transverse nasal crease, frequent sniffling or throat clearing, and allergic shiners (dark circles under the eyes that are due to nasal congestion). Examination of the nose typically reveals swelling of the nasal mucosa and pale, thin secretions. An internal endo- scopic examination of the nose should also be consid- ered to assess for structural abnormalities and nasal polyps [1]. The ears generally appear normal in patients with allergic rhinitis; however, assessment for Eustachian tube dysfunction using a pneumatic otoscope should be considered. Valsalva’s maneuver (increasing the pressure in the nasal cavity by attempting to blow out the nose while holding it shut) can also be used to assess for fluid behind the ear drum [1]. The sinus examination should include palpation of the sinuses for evidence of tenderness or tapping of the maxillary teeth with a tongue depressor for evidence of sensitivity. The posterior oropharynx should also be examined for signs of post nasal drip (mucous accumu- lation in the back of the nose and throat), and the chest and skin should be examined carefully for signs of con- current asthma (e.g., wheezing) or dermatitis [1]. Diagnostic tests Although a thorough history and physical examination are required to establish the clinical diagnosis of rhinitis, further diagnostic testing is usually necessary to confirm that underlying allergies cause the rhinitis. Skin-prick testing is considered the primary method for identifying specific allergic triggers of rhinitis. Skin prick testing involves placing a drop of a commercial extract of a spe- cific allergen on the skin of the forearms or back, then pricking the skin through the drop to introduce the extract into the epidermis. Within 15-20 minutes, a wheal-and-flare response (an irregular blanched wheal surrounded by an area of redness) will occur if the test is positive. Testing is typically performed using the aller- gens relevant to the patient’s environment (e.g., pollen, animal dander, moulds and house dust mites). A reason- able alternative to skin prick testing is the use of aller- gen-specific IgE tests (e.g., radioallergosorbent tests [RASTs]) that provide an in vitro measure of a patient’s specific IgE levels against particular allergens. However, skin prick tests are generally considered to be more sen- sitive and cost effective than allergen-specific IgE tests, and have the further advantage of providing physicians and patients with immediate results [1,6]. Treatment The treatment goal for allergic rhinitis is relief of symp- toms. Therapeutic options available to achieve this goal include avoidance measures, oral antihistamines, intra- nasal corticosteroids, leukotriene receptor antagonists, and allergen immunotherapy (see Figure 2). Other therapies that may be useful in select patients include decongestants and oral corticosteroids. If the patient’s symptoms persist despite appropriate treatment, referral to an allergist should be considered. As mentioned ear- lier, allergic rhinitis and asthma appear to represent a combined airway inflammatory disease and, therefore, treatment of asthma is also an important consideration in patients with allergic rhinitis. Allergen avoidance The first-line treatment of allergic rhinitis involves the avoidance of relevant allergens (e.g., house dust mites, moulds, pets, pollens) and irritants (e.g., tobacco smoke). Patients allergic to house dust mites should be instructed to use allergen-impermeable covers for bed- ding and to keep the relative humidity in the home below 50% (to inhibit mite growth). Pollen exposure can be reduced by keeping windows closed, using an air conditioner, and limiting the amount of time spent out- doors during peak pollen seasons. For patients allergic to animal dander, removal of the animal from the home is recommended and usually results in a significant reduction in symptoms within 4-6 months. However,