RHINITIS
Anastasia Rowland-Seymour, MD
Rhinitis is described as inflammation of the nasal mucosa seasonal allergens are trees, grasses, and weeds. Com-
and is characterized by the constellation of symptoms, in- mon perennial allergens include dust mites, cock-
cluding nasal congestion, rhinorrhea, sneezing, and itching roaches, animal proteins, dander, and molds. Diagnos-
of the eyes and/or nose. The sinuses, ears, and throat may ing occupational rhinitis can be challenging because
also be involved. Allergic rhinitis is by far the most common symptoms may occur several hours after exposure.
type of rhinitis. Types of rhinitis include allergic rhinitis, Additionally, with chronic exposure, symptoms may not
infectious rhinitis (viral and bacterial), and nonallergic rhi- improve on weekends, requiring longer periods of
nitis. Nonallergic rhinitis includes nonallergic rhinitis with avoidance. With occupational rhinitis, patients typically
eosinophilia syndrome (NARES), vasomotor rhinitis, gus- present with concomitant occupational asthma. Physi-
tatory rhinitis (vagally mediated), hormonal rhinitis (e.g., cal examination may reveal allergic shiners; injected
related to pregnancy and hypothyroidism), rhinitis medi- conjunctivae; clear nasal discharge; pale, bluish boggy
camentosa (e.g., topical decongestants; antihypertensives turbinates; and cobblestoning in the posterior pharynx.
and oral contraceptives), anatomic rhinitis (e.g., deviated Allergen avoidance is of utmost importance. Maintain-
septum, choanal atresia, adenoid hypertrophy, foreign body, ing indoor humidity to "50% to limit house dust mite
nasal tumor), immotile cilia syndrome (ciliary dyskinesis), and mold growth may be helpful. First-line treatment
granulomatous rhinitis (e.g., Wegener’s granulomatosis, sar- of allergic rhinitis is topical intranasal steroids. Addi-
coidosis), and atrophic rhinitis (colonization with Klebsiella tional treatment choices include oral or intranasal anti-
ozaenae). histamines as a good second choice. Intranasal cromo-
One must also consider cerebrospinal fluid leak or nasal lyn started several weeks prior to allergy season may be
polyps. Nasal polyps often occur in common with allergic effective, leukotriene inhibitors alone or in conjunction
rhinitis, but not necessarily a causal relationship, and may with antihistamines are useful, and oral decongestants
not respond to medications. can be effective. Topical decongestants must be used
A careful history and physical examination usually can sparingly because of the development of tachyphylaxis
determine the cause of the rhinitis. Historical clues to diag- after 3–7 days of use. With prolonged use a resulting
nosis include environmental exposures, occupational expo- rebound nasal congestion and rhinitis medicamentosa
sure, personal and family history of allergies, additional past develop. Hypertonic saline rinsing of the nares can be
medical history (hypothyroidism, pregnancy, sarcoidosis), used for additional benefit in both acute and chronic
recent sick contacts, and medication usage (!5 days of tak- rhinosinusitis. If medical maneuvers fail, skin testing
ing nasal sympathomimetics). Physical clues may include and immunotherapy remain an option. Perennial aller-
“allergic shiners” (dark circles under eyes); pale, bluish gic rhinitis appears to be a predisposing factor
boggy turbinates; and cobblestoning in posterior pharynx for acute bacterial rhinosinusitis by causing ostial
(allergic rhinitis) versus erythematous turbinates (rhinitis obstruction.
medicamentosa, infectious, or vasomotor rhinitis). B. NARES accounts for 15%–20% of patients with rhini-
tis. It is characterized by perennial symptoms of nasal
A. Allergic rhinitis is by far the most common type of rhi- congestion, nasal itching, rhinorrhea, hyposmia, and
nitis. Estimates suggest 9%–40% of the U.S. population sneezing. These symptoms are milder than in patients
have some degree of allergic rhinitis. In 80% of cases, with perennial allergic rhinitis, but they are still bother-
allergic rhinitis develops by age 20 years. Incidence some. Nasal secretions contain 25% eosinophils on
wanes as we age, and it is much less common in the smear. IgE antibodies to inhalant allergens are usually
geriatric population. History of eczema and family his- absent. Some researchers believe this is a precursor to
tory of atopy may help in the diagnosis. Symptoms the triad of asthma, nasal polyposis, and aspirin allergy.
occur in individuals who produce an immunoglobulin E The most useful medications have proved to be topical
(IgE)–mediated response to particular allergens. Aller- nasal steroids, and if polyps are present, leukotriene
gens may be one or many, seasonal or perennial. Common inhibitors have also been shown to be helpful.
32
33
Patient with RHINITIS
Chronic, intermittent, Acute (7–10 days)
or seasonal
A Allergic symptoms No allergic symptoms Cont’d on p 35
Assess for environmental Cont’d on p 35
triggers, including occupational
Remove triggers No triggers
if possible found
Persistent Nasal smear
symptoms for eosinophils
Antihistamines
Nasal steroids
Cromolyn
#25% eosinophils Few eosinophils
B NARES C Vasomotor rhinitis
Inhaled steroids Inhaled steroid
Ipratropium ipratropium
C. Vasomotor rhinitis (idiopathic rhinitis) is an umbrella result from autonomic dysfunction in the nose where
term for many types of nonallergic rhinitis, including the parasympathetic system dominates, resulting in
gustatory and hormonal rhinitis. Patients with vaso- vasodilation and edema of the nasal vasculature. Id-
motor rhinitis complain of chronic nasal congestion iopathic rhinitis is a diagnosis of exclusion. Allergy
with or without persistent rhinorrhea, exacerbated skin testing is negative. Nasal steroids are useful, and
by cold air, strong odors, stress, or inhaled irritants. if rhinorrhea is a major factor, ipratropium can be
For the most part, vasomotor rhinitis is believed to effective.
(Continued on p 34)
34
D. Imaging (CT scan of sinuses) should be limited to those and anaerobic bacteria each account for a small pro-
patients who have persistent symptoms or if symptoms portion of cases. Of symptomatic patients, 30% have
recur. Recurrent rhinosinusitis may also indicate an un- negative bacterial cultures, suggesting either viral or
derlying process such as nasal polyps, other anatomic allergic disease. Because it is not possible to predict
abnormalities, ciliary dysfunction, cystic fibrosis, im- which cases of ABRS will resolve spontaneously, the
mune deficiency, sarcoidosis, Wegener’s granulomatosis, use of an antimicrobial is recommended.
or relapsing polychondritis. Last, atrophic rhinitis is a Prior antibiotic use is a major risk factor for infection
syndrome of progressive atrophy of the nasal mucosa in with antimicrobial-resistant strains. For patients with
the elderly debilitated population. Patients report a per- mild disease who have not received antibiotics in the
sistent foul odor that is a result of nasal mucosal coloniza- prior 4–6 weeks, initial therapy should include amoxicil-
tion with Klebsiella ozaenae. These patients respond best lin-clavulanate, amoxicillin, cefpodoxime, cefuroxime,
to nasal irrigation. or cefdinir. Fluoroquinolones or high-dose amoxicillin-
E. Prolonged use of intranasal decongestants can result in clavulanate is recommended as first-line therapy for
rebound congestion (rhinitis medicamentosa). The res- patients with mild disease who have had recent antibiot-
toration of normal nasal function may take up to 21 days ics or for patients with moderate disease. Treatment
after withdrawal of the sympathomimetics. Additionally, with a macrolide after treatment failure with amoxicillin
numerous medications can cause rhinitis, including anti- or a cephalosporin will result in a second treatment
hypertensives such as angiotensin-converting enzyme failure in about 60% of cases as a result of high
inhibitors, reserpine, phentolamine, methyldopa, and rates of resistance to macrolides in penicillin-resistant
beta blockers; chlorpromazine; gabapentin; penicilla- S. pneumoniae and H. influenzae.
mine; aspirin; NSAIDs; exogenous estrogens; and oral
contraceptives. The use of intranasal cocaine can cause
References
these symptoms as well.
F. Infectious rhinitis can be caused by both viruses and Becker B, Borum S, Nielsen K, et al. A time-dose study of the effect of
bacteria (bacterial rhinitis), with the common cold topical ipratropium bromide on methacholine-induced rhinorrhoea in
patients with perennial non-allergic rhinitis. Clin Otolaryngol
being the most common cause of infectious rhinitis. 1997;22(2):132–134.
Acute infectious rhinitis is often considered in con- deShazo RD, Kemp SF. Rhinosinusitis. South Med J 2003;96(11):
junction with acute sinusitis. Symptoms statistically 1055–1060.
Dykewicz MS, Fineman S. Executive Summary of Joint Task Force Prac-
associated with culture-proven acute bacterial sinus- tice Parameters on Diagnosis and Management of Rhinitis. Ann
itis include nasal congestion, purulent rhinorrhea, Allergy Asthma Immunol 1998;81(5 Pt 2):463–468.
postnasal drip, facial or dental pain, and cough. The Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management
of rhinitis: complete guidelines of the Joint Task Force on Practice
guidelines recommend that a diagnosis of acute bac- Parameters in Allergy, Asthma and Immunology. American Academy
terial rhinosinusitis (ABRS) is appropriate in patients of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol
who have had symptoms of a viral upper respiratory 1998;81(5 Pt 2):478–518.
Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing
infection who have not improved after 10 days or definitions for clinical research and patient care. Otolarygol Head
worsen after 5–7 days. Streptococcus pneumoniae Neck Surg 2004;131(6):S1–62.
and Haemophilus influenzae account for 50% of rhi- Poole MD, Portugal LG. Treatment of rhinosinusitis in the outpatient
setting. Am J Med 2005;118(7A):455–505.
nosinusitis bacterial isolates. Moraxella catarrhalis, Tomooka LT, Murphy C, Davidson TM. Clinical study and literature
other streptococcal species, Staphylococcus aureus, review of nasal irrigation. Laryngoscope 2000;110(7):1189–1193.
35
Patient with RHINITIS
(Cont’d from p 33)
Chronic, intermittent, Acute (7–10 days)
or seasonal
No allergic symptoms
Clear discharge
Erythematous turbinates
Review medication list
Other upper Offending medications Other
respiratory infection
Offending symptoms
medications
E Rhinitis Symptoms
medicamentosa persist !10 days
Viral rhinitis
No offending E Rhinitis Remove See Chronic
medications medicamentosa Supportive medication Rhinitis
therapy
Remove
medications Purulent discharge
Hypersensibility to No triggers
nonspecific triggers F ABRS (can occur with
such as cold air, chronic allergic sinusitis)
strong odors, irritants
D Systemic disease Antibiotics
and other
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