Assessing Nasal Symptom Severity
By asking the patient to evaluate individual symptom severity using a 7-point visual analog scale, interval data are generated with lower measurement error and a correspondingly higher precision compared with a 5-point equal interval scale. Figure 1 in the original guideline document is an example of the type of visual analog scale that is recommended to evaluate severity of rhinitis.
Since the duration of allergic rhinitis symptoms is different in every patient, each analysis of symptom severity should specify the period during which the evaluation is being made (e.g., more than 24 hours, more than 2 weeks, or a point-in-time evaluation). It may also be helpful in some patients to distinguish patterns of symptoms (e.g., daytime or nighttime, indoor or outdoor). Recognizing these possible confounding variables, the further characterization of symptoms is left to the discretion of the physician.
Objective measurement of symptoms should be incorporated into evaluation of rhinitis severity if considered helpful by the health care professional and could include the following: (1) presence or absence of episodes of sneezing; (2) number of sneezes per episode; (3) amount of nasal tissue used during a given period; (4) amount of swelling seen on physical examination and/or anterior rhinoscopy; and (5) various rhinometric techniques.
Assessing Non-Nasal Symptom Severity
Since non-nasal symptoms are not found universally in patients with rhinitis, they are not included in the rhinitis severity scale outlined in Figure 1 in the original guideline document, which has been specifically designed to permit an evaluation of nasal symptoms. Since they are so frequently associated with rhinitis, however, they may also be evaluated, using a scale similar to that used for nasal symptoms (Figure 2 in the original guideline document). Adjustment in a treatment regimen based on severity of non-nasal symptoms can be made by the health care professional on an individual basis, similar to the adjustments recommended for nasal symptoms.
Global Assessment of Nasal and Non-nasal Symptom Severity
A global scale provides additional information about the status of the patient beyond what is found with individual symptoms. It asks the patient to globally rate the combination of the nasal and non-nasal symptoms on a 7-point scale. Unlike the scales for nasal and non-nasal symptoms, a score of 7 on the global evaluation scale indicates that the patient is having no symptoms. Overall symptoms can be rated using the scale shown in Figure 3 in the original guideline document.
Quality of Life in the Assessment of Rhinitis Severity
Quality of life is an important consideration in the evaluation and treatment of patients with allergic rhinitis. Disease-specific quality-of-life surveys for allergic rhinitis have been developed and standardized for children and adults. Such surveys facilitate the recognition of individual effects of the disease on the patient's quality of life, which may not otherwise be mentioned by patients and may be ignored or trivialized by patients and health care professionals. Use of surveys by physicians at each clinic visit can help to evaluate the effects of treatment interventions on symptom control and the patient's quality of life. In addition, patients and families learn to recognize the effects of allergic rhinitis symptoms on the quality of their life.
The visual analog scale shown in Figure 4 in the original guideline document, which assesses the patient's quality of life, can be used by the physician as adjunctive data to support the initial evaluation of rhinitis severity based on nasal symptoms. It can also be used by the physician as a means of patient follow-up after determining the initial management of the patient. It incorporates activities and functioning during the day and sleeping at night.
The Impact of Current and Past Medications on Assessment of Rhinitis Severity
Determining past responsiveness and adverse effects from medications (including over-the-counter or herbal medications) can help guide the health care practitioner in selection of future therapeutic approaches and directly affects the evaluation of rhinitis severity. It is important therefore to determine the current and past medications that each patient has received, including whether a particular medication was either ineffective or had produced a significant adverse effect. Failure of a drug used consistently has a different significance for severity evaluation than failure of the drug due to poor compliance. Nonprescription antihistamines, topical alpha1-decongestants and cromolyn, and herbal remedies may not necessarily be reported by patients spontaneously. Long-term daily use of topical decongestants is of special concern, since they frequently produce rhinitis medicamentosa. Current use of medications for rhinitis or other conditions and their effect on rhinitis severity should be considered. A beneficial therapeutic effect on rhinitis may be seen with the use of medications for non-nasal conditions (e.g., leukotriene modifiers or orally inhaled corticosteroids). If these agents are withdrawn or the dose is decreased, an increase in symptoms of rhinitis may occur. These are variables that cannot easily be controlled for unless a sophisticated model is used to explain a large number of comorbidities and their treatment.
Rhinitis Medication Assessment
The visual analog scale shown in Figure 5 in the original guideline document can be used to evaluate medications. This scale includes those medications (including alternative medications) that the patient has used in the past for nasal and non-nasal symptoms and how effective they were (i.e., to what extent they relieved or aggravated nasal symptoms or produced adverse effects). Visual analog scales should be constructed for the effectiveness and side effect profile of each past and current nasal and non-nasal medication used by the patient.
