4. Diagnosis
Diagnosis starts with taking a thorough history about symptoms, sport environment and a possible link between these two. Questions about triggering factors or symptom improvement after a resting break or treatment are useful. Clinical examination should include both evaluation of the external and internal nose. The general aspect of the nasal mucosa, the nasal septum and the nasal valve can be appreciated with anterior rhinoscopy. Nasal endoscopy offers the advantage of a global evaluation of the nasal cavity and sinus outflow tracts53. Examination of the external nasal pyramid and tip with valve tests will give information about important structural abnormalities, nasal valve dysfunction and alar collapse.54.
Technical exams such as anterior rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow (PNIF) measurements and can be used to objectify reported nasal blockage and measure nasal resistance55. However, these objective measurements do not always correspond well with symptoms of nasal obstruction and results should always be correlated with subjective parameters.
Every athlete with airway symptoms should be screened for allergies as a causal factor of rhinitis. The validated AQUA questionnaire is often used as a screening tool to identify athletes with allergic disease (specificity 97.1%, sensitivity 58.3% when score > 5)56, 57. However, the final diagnosis of AR is based upon a correlation between the typical history and the systemic detection of allergen-specific IgE, either by skin prick test (SPT) or in the serum 58. When a mismatch exists between symptoms and systemic IgE detection, a specific nasal allergen challenge can be considered 59. Nasal cold dry air challenge can objectify the presence of NHR 47. Unlike exercise-induced bronchoconstriction (EIB), no specific test is currently available to diagnose exercise-induced rhinitis which is consequently solely based on self-reporting.
Treatment options
Different types of nasal pathology in athletes should be treated according to the respective guidelines 20, 21, 60. However, due to the World Anti-Doping Agency (WADA) regulations61, athletes ought to adhere to strict regulations in terms of pharmacological treatment. Treatment differs between mucosal and structural pathology and options are summarized in table 1.