A 27-year-old male presented with a 2-year history of paroxysmal sneezing and nasal congestion, which mostly occurred during April to June. Flexible fiberoptic rhinoscopy revealed slight hypertrophy of both inferior turbinates, with a normal pinkish hue and a marked cobblestone appearance of the nasopharyngeal mucosa, particularly at the torus tubarius and superior segment of the fossa of Rosenmuller (Figure 1). With a positive skin prick test result, a diagnosis of allergic rhinitis was made. The patient was underwent sublingual allergen-specific immunotherapy that was combined with the administration of antihistamines and an intranasal steroid at the start of treatment. At follow-up, 6 months after the start of treatment, the patient reported marked relief from his allergic rhinitis symptoms, and on performing flexible fiberoptic rhinoscopy, he did not show signs of cobblestone mucosa.
Figure 1.
Flexible fiberoptic rhinoscopy demonstrated the cobblestone appearance of the nasopharyngeal mucosa
A cobblestone appearance is an uncommon finding, where polygonal cells bulge out from the mucosal surface to a varying degree, and it is usually seen in the posterior pharyngeal wall or laterally behind the tonsillar pillars; it supposedly reflects lymphoid nodular hyperplasia of the immune system responding to stimulating factors such as acid reflux, postnasal drainage, breathing in dry air, or more likely allergies, as in our case [1]. The cobblestone appearance is included together with the Dennie–Morgan sign, allergic shiners, allergic salute, and its consequence, the horizontal nasal crease among physical features highly suggestive of allergic rhinitis, and it is useful as an adjunct to sensitivity testing for establishing the allergic diagnosis [2].
Although not pathognomonic, the presence of a cobblestone appearance of the nasopharyngeal mucosa in a patient consulting for nasal congestion is highly suggestive of allergic rhinitis and should prompt physicians to perform an allergologic assessment.
Footnotes
Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Santa Marta e Santa Venera Hospital-ASP 3 CT (Decision Date: 25.07.2017).
Informed Consent: Written informed consent was obtained from the patient who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - I.L.M.; Design - C.A., I.L.M.; Supervision - I.L.M.; Literature Search - C.A.; Writing Manuscript - C.A., I.L.M.; Critical Review - I.L.M.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
References
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