Differential Diagnosis of Allergic Rhinitis

Red Flag Symptoms

Nasal tumors

Unilateral symptoms, +/- visual changes, lack of nasal itch, lack of sneezing, recurrent epistaxis.

Wegner’s Granulomatosis

Epistaxis, recurrent sinusitis, pulmonary involvement, hematuria, systemic symptoms

Sarcoidosis

Associated hilar adenopathy, occasionally pyoderma gangrenosum.

Viral rhinitis

Nasal obstruction and congestion, infections are self-limiting and will resolve with or without treatment of symptoms (acute)

Vasomotor rhinitis

Perennial symptoms of congestion, hypersecretion, pruritus and/or sneezing associated with temperature changes, humidity, ingestion of spicy food or alcohol, and odors.

Hormonal or drug-induced rhinitis

May be associated with pregnancy, oral contraceptive use, or hypothyroidism. Medications associated with triggering symptoms of rhinitis include ACE inhibitors, reserpine, guanethidine, phentolamine, methyldopa, prazosin, beta blockers, chlorpromazine, topical nasal decongestants, aspirin, and nonsteroidal anti-inflammatory drugs. Difficult to diagnose, but may resolve after delivery, or hyperthyroidism treatment.

Nonallergic rhinitis with eosinophilia syndrome

Congestion and nasal eosinophilia with no obvious allergic source. Negative skin testing and/or RAST. May be associated with non- IgE-mediated asthma, aspirin intolerance, and nasal polyps. A subtype of this condition is blood eosinophilia nonallergic rhinitis syndrome. It is unclear whether these two conditions differ from other non- allergic rhinitis syndromes or if they are simply variants of allergic rhinitis without identifiable allergens.

Bacterial rhinosinusitis

Nasal obstruction, fever, facial pain, worsening of symptoms without treatment (chronic).

Occupational rhinitis

Triggered by a chemical or irritant in the occupational environment.

Structural or mechanical conditions

Choanal atresia, deviated septum, enlarged adenoids, foreign bodies, hypertrophic turbinates