• Clinical science

Rhinitis

Abstract

Rhinitis usually refers to inflammation of the nasal mucosa as a result of a type 1 hypersensitivity reaction (allergic rhinitis) and/or upper respiratory tract infection (infectious rhinitis). Clinical manifestations of rhinitis include nasal congestion, sneezing, rhinorrhea, and post-nasal drip. Furthermore, patients with allergic rhinitis complain about itching eyes and exacerbation of symptoms in certain seasons or with exposure to various allergens (e.g., dust). Management of allergic rhinitis involves identifying and avoiding the causative allergen. Nasal decongestants such as oral antihistamines (e.g., cetirizine) and intranasal sympathomimetics (e.g., xylometazoline) are used for symptomatic relief. Intranasal glucocorticoids are also very effective in the management of allergic rhinitis but should be used judiciously. Certain rarer forms of rhinitis – such as vasomotor rhinitis and atrophic rhinitis – are not associated with an inflammatory process. Vasomotor rhinitis is caused by a number of autonomic and/or hormonal stimuli that increase blood flow to the nasal mucosa, resulting in nasal congestion and rhinorrhea. Treatment of vasomotor rhinitis primarily involves avoiding the causative stimulus. Atrophic rhinitis results in a foul-smelling, crust-filled nasal cavity, which lacks turbinates. Most cases of atrophic rhinitis are idiopathic and primarily affect middle-aged women of low socioeconomic status. No specific recommendations exist for the treatment of atrophic rhinitis, but nasal lavage and surgical procedures to reduce the volume of the nasal cavity are effective in some cases. Because infectious rhinitis almost always simultaneously involves the sinuses (rhinosinusitis), it is discussed in the sinusitis learning card.

Classification

References:[1]

Allergic rhinitis

Classification criteria Definition
Temporal pattern of allergen exposure Episodic Exposure to allergens that are normally not a part of the patient's environment (e.g., visit to a farm)
Seasonal rhinitis Exposure to allergens that occur during certain seasons (e.g., hay fever, which is caused by exposure to pollen)
Non-seasonal Exposure to allergens that are normally a part of the patient's environment (e.g., allergic rhinitis caused by house-dust)
Frequency of symptoms Intermittent < 4 days/week or < 4 weeks/year
Persistent > 4 days/week or > 4 weeks/year
Severity of symptoms Mild Symptoms do not interfere with the quality of life.
More severe Symptoms interfere with the quality of life

Intranasal sympathomimetics should not be used for more than three days because of the risk of rebound nasal congestion (rhinitis medicamentosa)!

References:[2][3][4][5]

Atrophic rhinitis

  • Definition: chronic rhinitis associated with atrophy and sclerosis of nasal mucosa
  • Etiological classification
    • Primary atrophic rhinitis (ozaena): idiopathic condition which primarily affects middle-aged women of low socio-economic status
    • Secondary atrophic rhinitis occurs following:
      • Granulomatous diseases of the nasal cavity
        • Infectious causes: syphilis, leprosy, rhinoscleroma
        • Non-infectious causes: SLE, Wegner's granulomatosis
      • Radiotherapy and/or operations involving the nasal cavity
  • Clinical features
    • Extremely foul smelling nasal cavity; but the patient is unaware of the foul smell (merciful anosmia)
    • Nasal cavity is spacious, lacks turbinates, and covered in yellowish-green crusts.
    • Epistaxis
  • Diagnostics: No specific diagnostic test is indicated.
  • Treatment: No form of treatment can completely eliminate symptoms.
    • Removal of nasal crusts:
      1. Irrigation of the nasal cavity with warm saline
      2. Application of 25% glucose in glycerine, antibiotic solutions, and/or estradiol to the wall of the nasal mucosa
      3. Systemic antibiotics (e.g., fluoroquinolones, rifampicin, streptomycin)
    • Surgical procedures that decrease the volume of the nasal cavity
      • Modified Young's procedure
      • Insertion of teflon paste, fat, or bone underneath the mucosa of the nasal cavity

Topical sympathomimetic drugs (e.g., xylometazoline) are contraindicated in the case of atrophic rhinitis since they may decrease vascular perfusion of the nasal cavity and worsen symptoms!

Vasomotor rhinitis

  • Definition: Vasomotor rhinitis is a general term for rhinitis that is caused by an increase in blood flow to the nasal mucosa as a result of:
  • Etiology
    • Most often idiopathic
    • Drug-induced rhinitis is caused by one of the following drugs:
    • Rhinitis medicamentosa: rebound nasal congestion that is seen upon discontinuing intranasal sympathomimetics (e.g., xylometazoline)
    • Gustatory rhinitis: rhinitis that is associated with spicy food and/or alcohol
    • Emotional stimuli (e.g., anxiety, excitement)
    • Irritant odors (e.g., cigarette smoke, perfumes, car exhaust)
    • Weather patterns (e.g. cold and dry air, changes in temperature and humidity)
    • Honeymoon rhinitis: rhinitis associated with sexual activity
    • Hormonal rhinitis
  • Clinical features
  • Treatment:
    • Address the underlying cause of rhinitis (e.g., discontinue the offending drug)
    • Medical therapy
    • Surgical therapy
      • Resection of hypertrophic nasal turbinates in order to relieve nasal obstruction
      • Endoscopic vidian neurectomy

References:[1][6][7][8]

Differential diagnoses

Other conditions that may present with nasal congestion include:

  • Nasal polyps
  • Deviated nasal septum
  • Adenoid hypertrophy (in case of children)
  • Foreign nasal body
    • Epidemiology: : mostly young children (2–5 years)
    • Etiology: : organic (e.g., food; items) or inorganic objects (e.g., pearls; , stones, small toys, button cell batteries) are inserted into the nose
    • Clinical features
      • Unilateral, foul smelling, purulent rhinorrhea
      • Nasal obstruction
      • Epistaxis
    • Diagnostics
      • Headlight or otoscope
      • Flexible fiberoptic endoscopy
    • Treatment: removal through positive pressure techniques; ; if this fails, extraction via endoscopy and anesthesia
    • Complications: Paired disc magnets and button cell batteries can lead to tissue necrosis and septal perforation (quick removal is essential!).

References:[9][10]

The differential diagnoses listed here are not exhaustive.

last updated 08/15/2018
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