Small and Kim Allergy, Asthma & Clinical Immunology 2011, 7(Suppl 1):S3 http://www.aacijournal.com/content/7/S1/S3 Page 2 of 8 inflammatory response over the next 4 to 8 hours (late- phase inflammatory response) which results in recurrent symptoms (usually nasal congestion) [1,4]. Classification Rhinitis is classified into one of the following categories according to etiology: IgE-mediated (allergic), auto- nomic, infectious and idiopathic (unknown). Although the focus of this article is allergic rhinitis, a brief description of the other forms of rhinitis is provided in Table 1. Traditionally, allergic rhinitis has been categorized as seasonal (occurs during a specific season) or perennial (occurs throughout the year). However, not all patients fit into this classification scheme. For example, some allergic triggers, such as pollen, may be seasonal in cooler climates, but perennial in warmer climates, and patients with multiple “seasonal” allergies may have symptoms throughout most of the year [4]. Therefore, allergic rhinitis is now classified according to symptom duration (intermittent or persistent) and severity (mild, moderate or severe) (see Figure 1) [1,5]. Rhinitis is con- sidered intermittent when the total duration of the epi- sode of inflammation is less than 6 weeks, and persistent when symptoms continue throughout the year. Symptoms are classified as mild when patients are generally able to sleep normally and perform normal activities (including work or school); mild symptoms are usually intermittent. Symptoms are categorized as mod- erate/severe if they significantly affect sleep and activ- ities of daily living and/or if they are considered bothersome. It is important to classify the severity and duration of symptoms as this will guide the manage- ment approach for individual patients [1]. Diagnosis and investigations Allergic rhinitis is usually a long-standing condition that often goes undetected in the primary-care setting. Patients suffering from the disorder often fail to recog- nize the impact of the disorder on quality of life and functioning and, therefore, do not frequently seek medi- cal attention. In addition, physicians fail to regularly question patients about the disorder during routine Table 1 Etiological classification of rhinitis [1] Description visits [1,6]. Therefore, screening for rhinitis is recom- mended, particularly in asthmatic patients since studies have shown that rhinitis is present in up to 95% of patients with asthma [7-10]. A thorough history and physical examination are the cornerstones of establishing the diagnosis of allergic rhi- nitis (see Table 2). Allergy testing is also important for confirming that underlying allergies cause the rhinitis [1]. Referral to an allergist should be considered if the diagnosis of allergic rhinitis is in question. History During the history, patients will often describe the fol- lowing classic symptoms of allergic rhinitis: nasal con- gestion, nasal itch, rhinorrhea and sneezing. Allergic conjunctivitis (inflammation of the membrane covering the white part of the eye) is also frequently associated with allergic rhinitis and symptoms generally include redness, tearing and itching of the eyes [1]. An evaluation of the patient’s home and work/school environments is recommended to determine potential triggers of allergic rhinitis. The environmental history should focus on common and potentially relevant aller- gens including pollens, furred animals, textile flooring/ upholstery, tobacco smoke, humidity levels at home, as well as other potential noxious substances that the patient may be exposed to at work or at home. The use of certain medications (e.g., beta-blockers, acetylsalicylic acid [ASA], non-steroidal anti-inflammatory drugs [NSAIDs], angiotensin-converting enzyme [ACE] inhibi- tors, and hormone therapy) as well as the recreational use of cocaine can lead to symptoms of rhinitis and, therefore, patients should be asked about current or recent medication and drug use [1]. The history should also include patient questioning regarding a family history of atopic disease, the impact of symptoms on quality of life and the presence of comorbidities such as asthma, mouth breathing, snoring, sleep apnea, sinus involvement, otitis media (inflamma- tion of the middle ear), or nasal polyps. Patients may attribute persistent nasal symptoms to a “constant cold” and, therefore, it is also important to document the fre- quency and duration of “colds” [1]. IgE-mediated (allergic) IgE-mediated inflammation of the nasal mucosa, resulting in eosinophilic and Th2-cell infiltration of the nasal lining Further classified as intermittent or persistent Autonomic Infectious Idiopathic Drug-induced (rhinitis medicamentosa) Hypothyroidism Hormonal Non-allergic rhinitis with eosinophilia syndrome (NARES) Precipitated by viral (most common), bacterial, or fungal infection Etiology cannot be determined