Diagnostic Approach and Management of Complete Respiratory Disease (CRD) Allergy

Diagnostic Procedure

The American Academy of Otolaryngology-Head and Neck Surgery recommends clinical history to focus on identifying specific respiratory symptoms, their timing, and potential triggers to correlate with subsequent test results 2, 4
Objective documentation of sinonasal inflammation using anterior rhinoscopy or nasal endoscopy is recommended before proceeding with allergy testing, as suggested by the Mayo Clinic 2, 4
The American Academy of Otolaryngology-Head and Neck Surgery suggests that CT imaging is not recommended as first-line but may be useful in confirming diagnosis in patients with vague symptoms or if symptoms persist despite optimal medical treatment 2, 4
Skin Prick Testing (SPT) is the preferred first-line testing method due to higher sensitivity than serum testing, according to Rhinology guidelines 1, 6
Serum Specific IgE Testing is an alternative when skin testing is contraindicated, with less sensitivity than skin testing but not affected by medications, as stated by Rhinology 1, 6

The American Academy of Otolaryngology-Head and Neck Surgery notes that positive allergy tests indicate sensitization but don't always correlate with clinical symptoms, with up to 54% of the general population testing positive on skin prick tests 3, 7
Correlation between test results and clinical history is essential for determining clinically relevant allergens, as emphasized by the American Academy of Otolaryngology-Head and Neck Surgery 3, 7
Perennial allergens are particularly important to identify in patients with chronic respiratory symptoms, according to the Mayo Clinic Proceedings 2, 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends allergen avoidance for clinically relevant allergens identified through testing, as well as pharmacotherapy with intranasal corticosteroids as cornerstone therapy for symptom relief 5
Allergen Immunotherapy (AIT) is recommended for patients with symptoms not adequately controlled by pharmacotherapy and allergen avoidance, targeting only allergens that correlate with the patient's clinical symptoms, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 3, 7
Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are administration options for AIT, with SLIT available as FDA-approved tablets for grass, ragweed, and house dust mites, according to the American Academy of Otolaryngology-Head and Neck Surgery 8

For patients not responding to initial therapy after 3 months, the Mayo Clinic Proceedings suggests considering culture-directed antibiotic therapy, CT evaluation, immunologic testing to rule out immunodeficiency, and referral for surgical evaluation when medical management fails 2, 5, 9