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Wise et al.

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hours, children with AR exhibit decreased productivity. Comorbidities associated with AR, such as like rhinosinusitis, Eustachian tube dysfunction, and associated conductive hearing loss may further contribute to learning dysfunction. 775,776 AR poses a substantial burden to individuals and society. It can reduce productivity and QOL in affected patients, and contribute to comorbid conditions. This results in a significant impact to the overall health system. 773

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VIII. Evaluation and diagnosis

In an individual patient, the clinical suspicion for a diagnosis of AR is highlighted by the clinical history and often supported by the physical examination. The diagnosis is confirmed by objective testing, which may be performed by various means. This section reviews the existing evidence behind various aspects of evaluation and diagnosis of the AR patient.

VIII.A. Clinical examination History

Clinical history is an essential part of the evaluation of patients with a suspected diagnosis of AR. 7,26,218,761,777 History taking includes the type of symptoms experienced, timing and duration of symptoms, frequency of symptoms, any environmental exposures eliciting symptoms at home/work/school, and medications or other measures that relieve or exacerbate symptoms. 7,26,218,761,777,778 In addition, past medical history including comorbid conditions such as asthma or obstructive sleep apnea, family history of atopic disorders, social history (ie, pets, work exposures, home environment), and current medications should be obtained. 7,26,218,761,777,778 Information regarding patient response to self-treatment with over-the-counter medications for AR is also helpful. Nasal congestion or obstruction, nasal pruritis, clear rhinorrhea, and sneezing are classic symptoms of AR. 7,26,218,761,777,778 Patients may complain of associated symptoms of ocular pruritis, erythema, and/or tearing, oral cavity or pharyngeal pruritis, and wheezing or cough (reactive airway disease and/or asthma). 7,26,778 Additional associated symptoms may include hyposmia or anosmia, snoring or sleep-disordered breathing, aural congestion or pruritis, and sore throat. 778,779 Commonly, patients with suspected AR will present with multiple complaints, with 96% presenting with 2 or more symptoms. 778 Patients with PAR tend to report more congestive symptoms (sinus pressure, nasal block-age/congestion, and snoring) than patients with SAR. Patients with persistent AR are more likely to report the presence of sore throat, cough, sneezing, rhinorrhea, and postnasal drip. 778 Rhinorrhea, sneezing, sniffing, hyposmia/anosmia, nasal obstruction, and itchy nose rank highest for diagnostic utility among symptoms of AR. 779 Several guidelines suggest the diagnosis of AR be made when patients present with a history consistent with an allergic cause and 1 or more of the symptoms listed in the previous paragraph, despite the lack of high-level evidence to support such a recommendation 7,26,218,761,777,780 (Table VIII.A). However, the lack of higher level evidence is not surprising as a clinical history and physical examination is essential to any medical diagnosis and randomized studies would require participants to receive an intervention without a clinical history. Using a physical examination alone to diagnose AR

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.