xRead - September 2022

Wise et al.

Page 56

has been shown to have poor predictive value. 781 The reliability and predictive value of the patient history alone for AR exceeds that of the physical exam alone. 781 In clinical practice, the diagnosis of AR is often made by history alone. 780 Physical examination— Physical examination is part of the evaluation of patients with suspected AR. 7,26,218,761,777 This includes an assessment of the multiple organ systems of the head and neck, such as the integumentary system; external auditory canal, tympanic membrane, and middle ear; nasal cavities; orbits and periorbital tissues; oral cavity and pharynx; larynx via indirect laryngoscopy; and cervical tissues. 26,218,761,777 It may include auscultation of the lungs, given comorbid conditions of asthma, or complaints of wheezing or coughing with exposure. 7 It is not uncommon for physical examination of patients with AR complaints to be completely normal, particularly in patients with intermittent exposure. 779 However, physical signs suggestive of AR may include mouth-breathing, nasal itching, or a transverse supratip nasal crease, throat clearing, periorbital edema, or “allergic shiners” (dark discoloration of the lower lids and periorbital area). 26,777 Examination of the ear may reveal retraction of the tympanic membrane or transudative fluid. 26,218,777 Examination of the nose may reveal inferior turbinate hypertrophy, congested/edematous nasal mucosa, purplish or bluish nasal mucosa, and clear rhinorrhea. 26,218,761,777 Examination of the eyes may reveal conjunctival erythema and/or chemosis. 26,777 Physical examination alone is poorly predictive and more variable when compared to history taking in the diagnosis of AR, with the average sensitivity, specificity, positive predictive value, and negative predictive values of the patient history higher than those of the physical examination. 781 Most guidelines recommend a physical examination as part of the diagnosis of AR, despite a lack of high-level evidence. Without a physical examination, other potential causes of symptoms such as CRS, could not be fully evaluated or eliminated. A patient history combined with a physical examination improves diagnostic accuracy. 781 • Aggregate Grade of Evidence: D (Level 3b: 1 study; Level 4: 3 studies; Level 5: 4 guidelines; Table VIII.A). • Benefit: Improve accuracy of diagnosis, avoid unnecessary referrals, testing, or treatment. Possible improved diagnosis of AR with physical examination findings, evaluation/exclusion of alternative diagnoses. • Harm: Possible patient discomfort from routine examination, not inclusive of endoscopy. Potential misdiagnosis, inappropriate treatment. • Cost: Minimal. • Benefits-Harm Assessment: Preponderance of benefit over harm, potential misdiagnosis and inappropriate treatment if physical exam used in isolation. • Value Judgments: Making a presumptive diagnosis of AR on history (ideally combined with physical examination) is reasonable and would not delay treatment initiation. Confirmation with diagnostic testing is required for progression to AIT, or desirable with inadequate response to initial treatment.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

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