Rhinitis and rhinosinusitis represent a significant health problem in modern society cause their increasing frequency as well as their substantial financial burden on society (1,2).
An accurate investigation of upper airways disorders is extremely important for several reasons (3,4). The first one is related to the quality of life of patients; the second is that a late diagnosis can lead to severe disorders. The third is associated with the fact that an upper respiratory tract may extend to the lower tract if not correctly treated.
An accurate and precise diagnosis of nasal disease should be fundamental for ENT surgeon as well as for allergist, chest physicians, and pediatricians. A lot of diagnostic tools have been described, and their applicability, specificity, and sensitivity were classified in 2011 with a Position Paper by the EAACI (5).
The ideal diagnostic tool should be straightforward to use, have high specificity and sensitivity and a low cost.
In this paper, we will describe the diagnostic techniques available in rhinology considering their utility and applicability.
Not all the diagnostic techniques must be used in every patient, but the diagnostic route should be planned on the basis of the symptoms and the efficacy of the therapeutic strategies using the concept of stratification to avoid unnecessary and expensive exams (1).
For these reasons, we divided the exams into different levels of complexity.
A) LEVEL ONE
This is considered the basic level in rhinology and should be the armamentarium of all allergist, chest physician and pediatrics as well as ENT surgeons.
This first step is vital to understanding, and diagnosing the disease and gives preliminary therapeutic strategies and orient for further diagnostic investigations.
A.1) HISTORY OF THE PATIENT
An accurate medical history of the patient is fundamental in every field of medicine.
A one to one interview evaluates the presence, severity and duration of symptoms and can orient the diagnostic route. To assess the severity of symptoms is useful to use a visual analogue scale (VAS).
A.2) QUALITY OF LIFE INSTRUMENTS
Sino-nasal diseases can have a significant impact on quality of life and the effects of disease on daily activities as perceived by the patient are considered as an essential characteristic of rhinitis severity (4).
Health-related quality of life has been defined as “the functional effects of an illness and its consequent therapy upon a patient, as perceived by the patient”. Data are collected on questionnaires that can be generic or specific.
Quality of life instruments are used most for clinical trials but can be useful, associated with standard medical measures, to quantify clinical outcome (6).
A.3) NASAL EXAMINATION
The evaluation of a patient with sino-nasal symptoms should start with inspection and palpation of the nose and face.
An evaluation of the shape of the external nose and nasal valve can give information about anatomical anomalies and post-traumatic diseases as well as a widened dorsum of the nose can indicate the presence of polyps that cause deformation of nasal bones (Woakes Syndrome).
After an inspection of the shape of the nose, we can obtain some functional information visualizing nasal valve both during inspiration and expiration.
Anterior rhinoscopy allows an evaluation of the anterior compartment of the nasal cavity and gives the first data that can orient the diagnosis such as septal deviation or congestion of the turbinates.
Anterior rhinoscopy is limited in its evaluation of the entire nose bust represent the first step in the rhinological diagnostic route.
Nasal endoscopy allows visualization and a global evaluation of the nasal cavities.
Endoscopy is performed by flexible or rigid endoscope attached to a strong light source by glass fibre and generally connected to a camera.
The exam is generally preceded by local administration of anesthetic and decongestion drugs to improve the visualization end decrease patient discomfort.
Rigid endoscopy has proven to be more patient-friendly, supplies a better image than flexible endoscopy and significantly more structures were visualized with the rigid scope than the flexible scope (7).
It is advisable to be meticulous and systematic performing a rigid endoscopy.
The exam, using a 0 or 30 degree angled telescope, begins with the inspection of the whole inferior meatus, until the nasopharynx is reached and a good evaluation of tubaric ostium is obtained .
Presence of secretions or polyps from the sphenoethmoid recess can be seen, a sign of posterior ethmoid or sphenoid pathology.
Then, with a backward movement, the inspection of the middle meatus begin again from the nasal valve, avoiding changing the angle of the scope inside the nose to prevent damage and discomfort.
This second step aims to search for signs of pathology of the anterior ethmoidal complex by the presence of pathology of the osteo-meatal-complex (OMC) or the posterior one, given by secretions or polyps above the middle turbinate.
The third and last step is performing an accurate inspection of the head and the upper portion of the middle turbinate with the exploration of olfactory cleft.
B) LEVEL TWO
Once assessed the medical history of the patients including his symptoms, their severity and a full endoscopic examination of the nasal cavities, some tools are available to achieve a differential diagnosis between and within three main roads: rhinitis, rhinosinusitis with/without polyps and sino-nasal neoplasms.
B.1) ALLERGY TEST
As the allergen-specific IgE is the triggering factor of symptoms of allergic rhinitis, the goal of diagnostic tests is to demonstrate the presence and activity of such IgE. In vivo skin prick test (SPT) is the gold standard for the detection of allergic sensitizations for its efficiency, safety, and low costs.
Second level tests as serum allergen-specific IgE detection, basophil degranulation test and specific nasal provocation test are available to confirm a diagnosis or useful if symptoms and SPT disagree.
To remember the need for discontinuation of antihistamines at least five days before the SPT to avoid false negative results.
To better detail the phenotypic characteristics of rhinitis, nasal cytology is a useful, cheap and easy-to-apply diagnostic tool that allows identifying the normal cells (ciliated and mucinous), the inflammatory cells (lymphocytes, neutrophils, eosinophils, mast cells), bacteria, or fungal hyphae/spores.
This test aims to discriminate the different pathological conditions and to evaluate the effect of various stimuli (allergens, infectious, irritants, physical-chemical) and it is a crucial tool for the differential diagnosis among rhinitis (Table 1).
Evaluation of mucociliary clearance by ciliary beat frequency analyzed with phase-contrast microscopy can also be assessed (8,9).