Management of Chronic Rhinitis with Hypersensitivity
The most effective treatment for chronic rhinitis with hypersensitivity is a combination of intranasal corticosteroids and intranasal antihistamines, tailored to the specific subtype of rhinitis. 1
Diagnostic Confirmation
- Confirm diagnosis with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography (CT) 1
- Evaluate for underlying allergies through skin prick testing or blood tests for specific IgE, particularly for perennial allergens such as dust mites, pet dander, and fungi 1, 2
- Assess for comorbid conditions including asthma, immunodeficiency, and ciliary dyskinesia that may modify management approach 1
First-Line Treatment Options
For Allergic Component:
- Intranasal corticosteroids are the cornerstone therapy and most effective treatment for allergic rhinitis symptoms 3, 2
- Second-generation antihistamines (fexofenadine, loratadine, desloratadina, cetirizina) for predominant symptoms of sneezing and itching 3, 4
- Saline nasal irrigation to remove irritants, reduce congestion, and improve medication delivery 1, 2
For Non-allergic Component:
- Intranasal anticholinergics (ipratropium bromide) are effective specifically for rhinorrhea 2
- Concomitant use of ipratropium bromide nasal spray with intranasal corticosteroids is more effective than either drug alone for rhinorrhea 2, 3
Treatment Algorithm Based on Severity
Mild Symptoms:
- Start with intranasal corticosteroids and saline lavage 1
- Monitor response for 3 months 1
- Add second-generation antihistamine if itching and sneezing are prominent 3, 5
Moderate to Severe Symptoms:
- Higher potency intranasal corticosteroids 1
- Saline nasal lavage 1
- Consider combination therapy with intranasal antihistamine and intranasal corticosteroid 3, 6
- Short course of oral corticosteroids (5-7 days) if nasal polyps are present or symptoms are intractable 2, 3
Management of Refractory Cases
For patients not responding to initial therapy after 3 months: 1
Surgical options should be considered when: 2
Special Considerations
- Avoid predetermined "one-size-fits-all" medical protocols as prerequisites for surgery, as they are not patient-centered and may delay effective treatment 2
- Certain subtypes of chronic rhinosinusitis (like fungal ball) should not rely primarily on medical management and require surgical intervention 2
- Avoid antifungal therapy as it is not recommended for chronic rhinosinusitis management 1
- For vasomotor rhinitis (a form of non-allergic rhinitis), intranasal azelastine has shown efficacy 7
Common Pitfalls to Avoid
- Prescribing antibacterial therapy without evidence of purulent nasal discharge 2
- Failing to confirm diagnosis with objective evidence of inflammation 1
- Overlooking allergic components that could be effectively managed 1, 5
- Implementing rigid treatment regimens rather than tailoring therapy to the specific subtype and severity of disease 2
- Delaying surgical referral in cases where specific subtypes (fungal ball, severe polyposis with obstruction) would benefit from early surgical intervention 2
Long-term Management
- Regular follow-up to assess response to therapy and adjust treatment as needed 2
- Consider allergen immunotherapy for patients with allergic rhinitis who have demonstrable evidence of specific IgE antibodies to clinically relevant allergens and inadequate response to pharmacotherapy 2, 3
- Environmental control measures for identified allergens 3
- Patient education regarding chronic nature of condition and importance of adherence to treatment regimen 2