Rhinitis affects a significant portion of the world population and increases the cost of health care by billions of dollars in treatment costs and missed days of work. Allergic rhinitis is the most common cause. Rhinitis is primarily a clinical diagnosis which can be confirmed with specific testing as indicated to ascertain causative agents. Initial treatment includes using topical agents like intranasal corticosteroids and inhaled antihistamines as the first-line therapies for both allergic rhinitis and chronic rhinitis. Therapy can evolve in a stepwise manner depending on the primary symptom complaint prior to referral for advanced therapies such as allergen immunotherapy.
Key points
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Rhinitis is a prevalent ailment affecting millions of people across the world with allergic rhinitis being the most common etiology.
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The diagnosis is mostly clinical, though testing may be needed to identify the causative agent.
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Topical agents like intranasal corticosteroids or inhaled antihistamines are the first-line therapies for both allergic and nonallergic rhinitis.
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Persistent symptoms of rhinitis can be targeted with specific therapy to provide relief.
Introduction
Rhinitis is defined as the presence of one of the following symptoms: rhinorrhea, nasal stuffiness, nasal itching, sneezing, or cough. It is extremely common and affects everyone some time in their life. Rhinitis may be present on its own or be a part of other disease syndromes.
Epidemiology
Rhinitis is very prevalent, and the rates of allergic rhinitis (AR) are 10% to 30% of adults and 40% of children in the United States with some estimates suggesting up to 400 million people worldwide are affected. , The rates are much higher in patients who suffer from asthma. AR is present in 75% of patients with asthma and is present in almost all patients with the diagnosis of allergic asthma. It affects the quality of life in most patients, and symptoms caused by rhinitis include disturbed sleep, daytime sleepiness, impaired attention, irritability as well as learning and memory deficits. This causes significant loss of work and school days as well a loss of productivity, especially on days when allergies are at their worst levels.
According to the Global Asthma Network Phase I, the overall prevalence of rhinoconjunctivitis is 13.3% in adolescents and 7.7% in children studied across 25 countries. , Of note, there was high variability noted among the different countries. Environmental factors such as pollution, mold, window condensation, incense use, and other factors were associated with the higher prevalence, in a study conducted in China with a P<.05.
Cost of Health Care
It is difficult to ascertain the actual cost to treat a patient with AR. There are estimates that up to 70% of individuals may purchase over-the-counter medications to treat their symptoms with or without an official diagnosis. , Productivity losses were calculated by Crystal-Peters and colleagues, using data from the National Health Interviews Study (NHIS) including the use of sedating over-the-counter allergy medications and worker’s self-assessment regarding productivity. The cost was estimated to be up to $5.2 billion per year, and this was partly due to survey participants reporting the sedative effects of the medications as a contributing factor.
Types of Rhinitis
There are multiple types of rhinitis but the common ones are as follows.
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Allergic rhinitis
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Nonallergic rhinitis (NAR)
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Rhinitis of pregnancy
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Occupational rhinitis
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Atrophic rhinitis
Allergic Rhinitis
This is the commonest type of rhinitis and can be intermittent AR, seasonal AR (SAR), or perennial AR (PAR) depending on the offending agent. Most patients complain of nasal congestion, watery nasal discharge, itching, and sneezing. Nasal itching differentiates AR from other types. Patients may complain of fatigue and poor sleep. Many also complain of snoring and frequent headaches. ,
Examination of the nasal mucosa may be pale and edematous but may also be normal. Children may have purplish discoloration under the eyes called allergic shiners and a nasal crease on top of the nose from constant rubbing due to nasal itching.
Nonallergic Rhinitis
NAR is often a diagnosis of exclusion and presents with nasal stuffiness, rhinorrhea, and postnasal drip. Itching of the eyes and nose are notably absent. Typical triggers for NAR are strong odors like cigarette smoke, perfumes, exhaust fumes from cars, and cleaning products. Children with NAR tend to have milder nasal symptoms with a less severe clinical course. Special types of NAR are: vasomotor rhinitis (VMR) which is rhinorrhea in response to cold dry air or temperature changes and gustatory rhinitis which is rhinorrhea in response to eating spicy foods caused by vagal responses.
Rhinitis medicamentosa
This condition is caused by overuse of over-the-counter nasal decongestant sprays, such as oxymetazoline and xylometazoline, that cause rebound congestion after stopping. However, its presentation and development are inconsistent where it may occur within 3 days of use or may not develop after 6 weeks of use. This leads to a vicious cycle of overuse and dependency on these nasal sprays. On a physical examination, the nasal mucosa is swollen red and inflamed.
Medication-induced rhinitis
Many commonly used medications can cause rhinitis, making it important to take a good medication history when patients complain of chronic rhinorrhea. These include antihypertensive medications like the alpha-blocker clonidine, angiotensin-converting enzyme inhibitors, calcium channel blockers, and thiazide diuretics. Medications used for erectile dysfunction, antidepressants, benzodiazepines, psychotropic medications, and certain antiseizure medications like gabapentin can also cause rhinorrhea.
Rhinitis of Pregnancy
This is a diagnosis of exclusion. Rhinitis occurs in the last 2 months of pregnancy when all other causes are excluded and the condition resolves after 2 weeks of delivery, which is classified as rhinitis of pregnancy. , The exact mechanism in pregnancy is unknown but may be due to an increase in estrogen and progesterone. Estrogen can lead to nasal vascular engorgement causing congestion, and both estrogen and progesterone can increase eosinophil migration.
Occupational Rhinitis
Occupational rhinitis is caused by exposure to irritants or allergens that are specific to a patient’s place of work. Patients complain of resolution of symptoms when they are away from work, like on weekends.
Alcohol-induced rhinitis
Some people complain of rhinorrhea after alcohol ingestion. This is seen in some healthy individuals but is much more common in asthmatics and patients with aspirin allergies. It is an exaggerated response of alcohol-induced vasodilation and is more common with individuals who drink wine.
Atrophic Rhinitis
This typically occurs in the elderly who have had repeated nasal or sinus procedures. The nasal mucosa is atrophic and gets colonized with bacteria which causes a bad odor and crusting besides nasal congestion with a dry feeling.
Recreational drug use
The use of intranasal recreational drugs like heroin and cocaine can also cause chronic rhinorrhea and should be included in the broad differential diagnosis. No clear studies indicate the quantity and duration of recreational drug use that may lead to the development of rhinitis.
Systemic diseases
Many systemic diseases may have presentations that include rhinorrhea. Most of these diseases involve the sinuses as well and are not limited to the nose. Some of these diseases include hypothyroidism, cystic fibrosis, granulomatous polyangiitis, and sarcoidosis.
Diagnosis
Rhinitis is considered a clinical diagnosis. For AR, there is no gold standard and little definitive diagnostic criteria. Consensus states that initial diagnosis can be made if there is a known allergen exposure with greater than or equal to 2 of the following symptoms: nasal congestion, nasal pruritus, rhinorrhea, or sneezing. Experts recommend an immunoglobulin E (IgE)-mediated hypersensitivity skin testing (aeroallergen skin prick test) to confirm the diagnosis and offending agent, if there is a strong history consistent with AR. If greater than or equal to 2 symptoms persist for greater than or equal to 1 hour per day for greater than or equal to 12 weeks, then it is categorized as chronic rhinosinusitis (CRS).
In all patients, clinical history should be obtained, which includes questions regarding symptom severity, duration, and frequency. Patient-specific questions are important such as age of onset, pattern of presentation, triggers (or suspected triggers), timing during the year, and progression of each individual symptom. Family history and personal medical history should include asthma and other rhinitis-associated conditions, or conditions that mimic rhinitis such as nasal septal wall abnormalities, turbinate hypertrophy, adenoidal hypertrophy, nasal tumors, nasal polyps (with or without chronic rhinitis), nasal collapse, primary ciliary dyskinesia, and pharyngeal reflux.
Physical examination with appropriate equipment (nasal speculum, otoscopy with nasal adaptor) can be used to narrow down the differentials. In patients with chronic rhinitis without atopy or positive allergy testing, it may indicate NAR. Further differentiation of subtypes can be done via nasal provocation test with allergen, microbiologic and cytologic evaluation, and assessing IgE levels in the nasal cavity. , , If there are suspected structural or functional abnormalities, the lack of improvement with treatment, or other complications, patients should be referred to ENT or allergist for further testing.
Some experts’ statements suggest using validated questionnaires to assess the severity of patients’ symptomatology to help guide treatment; however, the certainty of evidence is low. There are several validated questionnaires including the Sinonasal Outcome Test (SNOT-22) which focuses on quality of life and symptom control for patients with AR. The Visual Analog Scale can be utilized to assess the severity of rhinitis which are in line with the “Allergic Rhinitis and its Impact on Asthma” (ARIA) guidelines.
Treatment
Allergic Rhinitis
When possible, avoiding allergen exposure and triggering factors is the first step. Per the ARIA initiative guidelines and expert opinion, first-line therapy is oral or intranasal antihistamine (INAH), such as azelastine, for mild AR and SAR. , Second-generation oral antihistamines are generally preferred over first-generation antihistamines to avoid potential side effects of sedation, poor sleep quality, and more specifically anticholinergic side effects. Patients can utilize intranasal cromolyn prior to being exposed to triggering allergies to mitigate the subsequent rhinitis symptoms. , ,
In the case of persistent AR, moderate AR, or severe AR, intranasal corticosteroid is the first-line and preferred monotherapy. Some experts recommend using a combination of intranasal corticosteroid (INCS) and INAH for moderate and severe SAR symptoms. , ,
There is low evidence on the efficacy of oral leukotriene receptor antagonists (LTRA), such as montelukast or zafilukast, and expert opinion does not recommend its use for the initial treatment of AR unless the patient cannot tolerate alternative therapies. Studies have shown, however, that LTRAs are effective in treating chronic SAR and PAR. Expert opinion recommends its use for patients who suffer from both AR and asthma. Oral corticosteroid therapy can be used in very severe AR or in cases that are not improving, but the evidence is poor.
Depending on specific symptoms, additional therapies can be utilized. Intranasal ipratropium has been noted to help with rhinorrhea in conjunction with INCS. Intranasal decongestants can be used for short-term treatment for severe mucosal edema which may be preventing other medications from being effective. Of note, it is not routinely used due to side effects such as rhinitis medicamentosa. Comparatively, oral decongestant may help to relieve nasal congestion without causing dependence. For asthmatic patients suffering from AR, the combination of oral decongestant and second-generation oral antihistamines may significantly help relieve symptoms.
Nasal irrigation with saline can be utilized to moisten dry nasal passages, reduce inflammation, increase mucociliary clearance, and clear mucosal passages of blood and mucus. However, contamination in the devices used can lead to worsening CRS via backwash or lead to exposure of bacteria or parasites if contaminated tap water is being used. It is, therefore, important that patients carefully follow the instructions written on the saline irrigation bottles to avoid contamination. , ,
First-line therapy for CRS is topical nasal saline and topical nasal corticosteroid spray. Hypertonic saline (nasal saline irrigation) was found to be more effective over isotonic solution in CRS. , Of note, if individuals have nasal polyps then intranasal corticosteroids are considered the first-line treatment.
Patients with moderate or severe AR can be referred for allergen immunotherapy (AIT) if symptoms are not well controlled with initial measures of avoiding allergens or other pharmacotherapy. Additionally, immunotherapy may reduce the severity of other comorbid conditions such as asthma.
Nonallergic Rhinitis
First-line therapy is INCS or INAH. First- and second-generation antihistamines can be used in VMR and NAR to treat nasal congestion, postnasal drainage, and rhinorrhea. Inhaled ipratropium has been found to be effective in decreasing symptoms of rhinorrhea, but LTRA are not effective. In moderate and severe NAR that is resistant to monotherapy, the combination of INCS and INAH can be very effective. , ,
Special populations
For pediatric patients, treatment is focused on avoiding triggers/allergens, immunotherapy, and pharmacotherapy. Therapy regimen is like the adults as written earlier. Patients as young as 2 years old can be treated with fluticasone INCS, loratadine oral antihistamine, and intranasal cromolyn. There is a low likelihood that patients under the age of 2 years old exhibit signs of AR. Intranasal histamines and some sublingual immunotherapies are available for children greater than 5 years old.
In pregnant patients, nasal saline is considered first-line therapy. As of 2015, the FDA replaced the previously used pregnancy category classification (A, B, C, X) allowing for more discussion regarding safety and use. Many medications used to treat rhinitis fall under the B and C categories. “Category B” designate animal studies have shown no risk to the fetus, but there are no adequate studies in humans, and “Category C” show an adverse effect to the fetus, but no adequate studies in humans are available—but the benefits may out weight the risks. Most INCS are well tolerated, except for triamcinolone (INCS) which is contraindicated (category C). Oral second-generation antihistamines (such as diphenhydramine, cetirizine, and loratadine—category B), INAHs (limited data), intranasal cromolyn (category B), LTRA (such as montelukast—category B), and intranasal ipratropium (category B) are considered low risk in pregnancy in limited studies. Oral decongestants should be avoided during the first trimester of pregnancy and cautiously used in the second and third trimesters. , ,
Complementary and alternative treatment
There is a growing population of patients interested in nonpharmacologic options for the treatment. Evidence remains inconsistent with limited accurate and reliable data. However, clinicians may offer acupuncture for some patients, taking into account that many cultures incorporate a level of these practices as noted in the Clinical Practice Guidelines Otolaryngology, and Head and Neck Surgery. , The World Health Organization estimated that up to 80% of the global population may utilize some aspects of complementary and alternative treatment. Targeted acupuncture of the sphenopalatine ganglion acupoint may be helpful. Another modality of treatment recommended is the use of osteopathic manipulative treatment. Techniques recommended include lymphatic pump techniques, rib raising, thoracic inlet and outlet release, with the goal of correcting cervical dysfunction that may be preventing lymphatic drainage and increased muscle tone causing associated congestion and headaches. , Future studies and more evidence is needed to address the effectiveness of these specific treatment modalities, but some of them may be beneficial. ,
See Table 1 for a summary of recommendations.
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