👃 FCPS Paediatrics TOACS · Allergic Rhinitis Diagnosis
📘 Nelson Chapter 183 – Diagnosis of Allergic Disease: Dennie-Morgan folds, nasal crease, allergic shiners
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🩺 OBSERVED/INTERACTIVE STATION · CPSP FORMAT · 7 MINUTES · ALLERGIC RHINITIS · PHYSICAL SIGNS
📖 Problem-oriented Clinical Scenario + Image
👧🏻 Clinical Scenario (read aloud – 2 min):
A 4-year-old girl was referred for evaluation of chronic nasal obstruction. For 2 years, she has experienced nasal obstruction associated with episodic sneezing, itching, and purulent nasal discharge. Mother also complains of several linear wrinkles beneath the lower eyelashes, associated with dark circles (see image). Clinical examination showed hypertrophy of the inferior nasal turbinates and pale boggy mucosa.
Tasks (observed):
1️⃣ Identify the physical signs shown in the image.
2️⃣ Propose the most likely diagnosis.
3️⃣ Describe the diagnostic approach (history, physical, testing).
4️⃣ Discuss differential diagnosis of chronic nasal obstruction in a child.
A 4-year-old girl was referred for evaluation of chronic nasal obstruction. For 2 years, she has experienced nasal obstruction associated with episodic sneezing, itching, and purulent nasal discharge. Mother also complains of several linear wrinkles beneath the lower eyelashes, associated with dark circles (see image). Clinical examination showed hypertrophy of the inferior nasal turbinates and pale boggy mucosa.
Tasks (observed):
1️⃣ Identify the physical signs shown in the image.
2️⃣ Propose the most likely diagnosis.
3️⃣ Describe the diagnostic approach (history, physical, testing).
4️⃣ Discuss differential diagnosis of chronic nasal obstruction in a child.
🔍 Figure: Bilateral Dennie-Morgan folds (infraorbital skin folds) and allergic shiners (dark circles). Classic physical findings in allergic rhinitis/atopic disease. (From Nelson Textbook of Pediatrics, Chapter 183)
💡 Examiner instruction: Candidate must recognize Dennie-Morgan lines (Dennie folds) and allergic shiners as supportive signs of atopy. Must differentiate allergic rhinitis from non-allergic rhinitis, adenoid hypertrophy, sinusitis, and nasal polyps.
🔍 Examiner Q&A – Allergic Rhinitis Diagnosis (Nelson Ch.183)
❓ Q1 (Examiner): “What are the physical signs seen in the image? Name both.”
✅ Dennie-Morgan folds (Dennie lines) – prominent infraorbital skin folds extending in an arc from the inner canthus beneath and parallel to the lower lid margin.
✅ Allergic shiners – blue-gray to purple discoloration beneath the lower eyelids (due to venous stasis from chronic nasal congestion).
Both are associated with atopy/allergic rhinitis.
✅ Allergic shiners – blue-gray to purple discoloration beneath the lower eyelids (due to venous stasis from chronic nasal congestion).
Both are associated with atopy/allergic rhinitis.
❓ Q2 (Examiner): “What is the most likely diagnosis in this 4-year-old with chronic nasal obstruction, sneezing, itching, and turbinate hypertrophy?”
✅ Allergic rhinitis (likely persistent/perennial)
• Symptoms >4 days/week and >4 weeks → persistent.
• Nasal itching, sneezing, clear/purulent discharge (purulent suggests possible secondary sinusitis).
• Pale boggy turbinates on exam = classic for allergic rhinitis.
• Symptoms >4 days/week and >4 weeks → persistent.
• Nasal itching, sneezing, clear/purulent discharge (purulent suggests possible secondary sinusitis).
• Pale boggy turbinates on exam = classic for allergic rhinitis.
❓ Q3 (Examiner): “What is the ‘allergic salute’ and what physical sign can it cause?”
✅ The allergic salute is an upward rubbing of the nose with the palm or index finger to relieve itching and open the nasal airway. Chronic repetition can cause a transverse nasal crease (horizontal wrinkle over the bridge of the nose).
❓ Q4 (Examiner): “What is the diagnostic value of Dennie-Morgan folds? Are they pathognomonic for allergic disease?”
✅ Dennie-Morgan folds are a feature of atopy (seen in up to 60% of allergic patients) but can also occur in non-atopic individuals (~40%). They are suggestive but not diagnostic. Similarly, allergic shiners are common but not specific.
❓ Q5 (Examiner): “What is the first-line diagnostic test to confirm allergen sensitization in this child?”
✅ Skin prick testing (SPT) – sensitive, inexpensive, immediate results. Positive if wheal ≥3mm larger than negative control. Must stop antihistamines 5-7 days before.
Alternative: serum allergen-specific IgE (sIgE) if skin disease or medications interfere.
Alternative: serum allergen-specific IgE (sIgE) if skin disease or medications interfere.
❓ Q6 (Examiner): “What are the common aeroallergens causing perennial allergic rhinitis in children?”
✅ Indoor perennial allergens: dust mites (Dermatophagoides), animal dander (cat, dog), cockroaches, molds (Aspergillus, Penicillium, Alternaria).
Seasonal: pollens (trees – spring; grasses – late spring/summer; weeds – late summer/fall).
Seasonal: pollens (trees – spring; grasses – late spring/summer; weeds – late summer/fall).
❓ Q7 (Examiner): “What is the differential diagnosis of chronic nasal obstruction in a 4-year-old?”
✅ Differential (Nelson Ch.183):
• Allergic rhinitis
• Non-allergic rhinitis (vasomotor, NARES – non-allergic rhinitis with eosinophilia)
• Adenoidal hypertrophy (snoring, mouth breathing)
• Chronic sinusitis
• Nasal polyps (suspect cystic fibrosis)
• Foreign body (unilateral, purulent, foul odor)
• Septal deviation, choanal atresia (congenital)
• Rhinitis medicamentosa (topical decongestant overuse)
• Allergic rhinitis
• Non-allergic rhinitis (vasomotor, NARES – non-allergic rhinitis with eosinophilia)
• Adenoidal hypertrophy (snoring, mouth breathing)
• Chronic sinusitis
• Nasal polyps (suspect cystic fibrosis)
• Foreign body (unilateral, purulent, foul odor)
• Septal deviation, choanal atresia (congenital)
• Rhinitis medicamentosa (topical decongestant overuse)
❓ Q8 (Examiner): “What additional historical feature would support allergic rhinitis over adenoidal hypertrophy?”
✅ Pruritus (nasal itching, eye itching), sneezing paroxysms, clear rhinorrhea, seasonal exacerbation, family history of atopy, response to antihistamines. Adenoidal hypertrophy presents with snoring, mouth breathing, hyponasal speech, without itching.
❓ Q9 (Examiner): “Which laboratory test can support allergic rhinitis in addition to sIgE?”
✅ Nasal smear for eosinophils (Hansel stain) – presence of eosinophils supports allergic rhinitis or NARES. Peripheral eosinophilia may be present but has low sensitivity. Total serum IgE may be elevated but overlaps with non-allergic.
❓ Q10 (Examiner): “What are the complications of untreated allergic rhinitis in children?”
✅ Comorbidities/complications:
• Otitis media with effusion (Eustachian tube dysfunction)
• Chronic sinusitis
• Adenotonsillar hypertrophy → obstructive sleep apnea
• Dental malocclusion, “adenoid facies” (open mouth, elongated face)
• Exacerbation of asthma
• Impaired school performance, sleep disturbance
• Allergic conjunctivitis
• Otitis media with effusion (Eustachian tube dysfunction)
• Chronic sinusitis
• Adenotonsillar hypertrophy → obstructive sleep apnea
• Dental malocclusion, “adenoid facies” (open mouth, elongated face)
• Exacerbation of asthma
• Impaired school performance, sleep disturbance
• Allergic conjunctivitis
❓ Q11 (Examiner): “What is the initial pharmacologic treatment for persistent allergic rhinitis in a 4-year-old?”
✅ Intranasal corticosteroids (INCS) – most effective therapy for persistent allergic rhinitis (e.g., fluticasone, mometasone, budesonide). Start with once daily. Second-line: oral non-sedating antihistamines (cetirizine, loratadine) for mild intermittent symptoms.
For children ≥4 years, INCS are safe and approved.
For children ≥4 years, INCS are safe and approved.
❓ Q12 (Examiner): “When is allergen immunotherapy indicated for allergic rhinitis in children?”
✅ Indicated for children with moderate-severe persistent allergic rhinitis not controlled by pharmacotherapy, who have documented IgE sensitivity to relevant allergens. Subcutaneous (SCIT) or sublingual (SLIT) immunotherapy can modify the disease course, prevent asthma onset, and induce long-term tolerance. Usually considered after age 5 years.
🗣️ Examiner high-yield pearls (Allergic Rhinitis Diagnosis):
• Dennie-Morgan lines + allergic shiners + nasal crease = atopic stigmata.
• Purulent discharge suggests sinusitis complication.
• Skin testing is preferred over sIgE for cost and immediacy.
• First-line treatment: intranasal corticosteroids (not oral antihistamines alone) for persistent symptoms.
• Always assess for asthma and conjunctivitis.
• Dennie-Morgan lines + allergic shiners + nasal crease = atopic stigmata.
• Purulent discharge suggests sinusitis complication.
• Skin testing is preferred over sIgE for cost and immediacy.
• First-line treatment: intranasal corticosteroids (not oral antihistamines alone) for persistent symptoms.
• Always assess for asthma and conjunctivitis.
📘 Allergic Rhinitis Diagnosis – Core Concepts (Nelson Ch.183)
👃 Symptoms
Nasal congestion, rhinorrhea (clear), sneezing, nasal itching, postnasal drip, conjunctival itching. Chronic: mouth breathing, snoring.
Nasal congestion, rhinorrhea (clear), sneezing, nasal itching, postnasal drip, conjunctival itching. Chronic: mouth breathing, snoring.
🔍 Physical signs
Dennie-Morgan folds, allergic shiners, nasal crease, pale boggy turbinates, allergic salute, cobblestoning of posterior pharynx.
Dennie-Morgan folds, allergic shiners, nasal crease, pale boggy turbinates, allergic salute, cobblestoning of posterior pharynx.
🧪 Diagnostic tests
Skin prick test (gold standard), serum sIgE, nasal smear eosinophils. Total IgE less useful.
Skin prick test (gold standard), serum sIgE, nasal smear eosinophils. Total IgE less useful.
📊 Classification (ARIA)
Intermittent vs persistent (≥4 days/week, ≥4 weeks). Mild vs moderate-severe (sleep disturbance, activity impairment).
Intermittent vs persistent (≥4 days/week, ≥4 weeks). Mild vs moderate-severe (sleep disturbance, activity impairment).
⚠️ Differential
Non-allergic rhinitis, adenoid hypertrophy, sinusitis, nasal polyps, foreign body, vasomotor rhinitis, NARES.
Non-allergic rhinitis, adenoid hypertrophy, sinusitis, nasal polyps, foreign body, vasomotor rhinitis, NARES.
💊 Treatment step
1st: INCS. 2nd: oral antihistamines (non-sedating). Add-on: LTRA (montelukast), nasal antihistamines. Immunotherapy for refractory.
1st: INCS. 2nd: oral antihistamines (non-sedating). Add-on: LTRA (montelukast), nasal antihistamines. Immunotherapy for refractory.
⭐ High-yield for TOACS (Allergic Rhinitis Diagnosis):
✔ Image recognition: Dennie-Morgan folds + allergic shiners = atopic child.
✔ Nasal examination: pale, boggy, edematous turbinates (allergic) vs erythematous (infectious).
✔ Differentiate from adenoid hypertrophy (no itching, hyponasal speech).
✔ Initial treatment: intranasal corticosteroids for persistent symptoms.
✔ Complications: otitis media with effusion, sinusitis, asthma exacerbation.
✔ Image recognition: Dennie-Morgan folds + allergic shiners = atopic child.
✔ Nasal examination: pale, boggy, edematous turbinates (allergic) vs erythematous (infectious).
✔ Differentiate from adenoid hypertrophy (no itching, hyponasal speech).
✔ Initial treatment: intranasal corticosteroids for persistent symptoms.
✔ Complications: otitis media with effusion, sinusitis, asthma exacerbation.
🗣️ Candidate Role‑Play & Examiner Feedback
💬 To the candidate (role-play): You are seeing the 4-year-old and her mother. Explain the physical findings (Dennie-Morgan lines, allergic shiners), discuss the likely diagnosis of allergic rhinitis, and outline diagnostic testing and initial management. Address mother’s concern about purulent discharge and chronic nasal obstruction.
📝 Examiner Marking Grid (Allergic Rhinitis Diagnosis Station):
- ✅ Correctly identifies Dennie-Morgan folds and allergic shiners from image
- ✅ Makes diagnosis of allergic rhinitis (persistent) based on chronicity, itching, sneezing, turbinate hypertrophy
- ✅ Orders appropriate diagnostic testing: skin prick test or serum sIgE for common aeroallergens
- ✅ Discusses differential: adenoid hypertrophy, chronic sinusitis, non-allergic rhinitis
- ✅ Recommends intranasal corticosteroids as first-line treatment
- ✅ Advises avoidance measures (dust mite covers, pet removal if sensitized)
- ✅ Recognizes purulent discharge as possible sinusitis complication
- ✅ Counsels on comorbid conditions (asthma, otitis media, sleep disturbance)
🗣️ Sample candidate script (excerpt):
“The creases and dark circles under your daughter’s eyes are called Dennie-Morgan lines and allergic shiners – they are often seen in children with nasal allergies. Her chronic nasal obstruction, itching, sneezing, and boggy turbinates are classic for allergic rhinitis. The purulent discharge might mean she also has sinusitis. We will confirm with allergy skin testing to identify triggers like dust mites or pollen. The best treatment is a daily nasal steroid spray to reduce inflammation. I will also check for ear fluid and asthma symptoms.”
“The creases and dark circles under your daughter’s eyes are called Dennie-Morgan lines and allergic shiners – they are often seen in children with nasal allergies. Her chronic nasal obstruction, itching, sneezing, and boggy turbinates are classic for allergic rhinitis. The purulent discharge might mean she also has sinusitis. We will confirm with allergy skin testing to identify triggers like dust mites or pollen. The best treatment is a daily nasal steroid spray to reduce inflammation. I will also check for ear fluid and asthma symptoms.”
📚 References: Nelson Textbook of Pediatrics 22e, Chapter 183 (Diagnosis of Allergic Disease); ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines.