How should I evaluate and manage a patient presenting with rhinitis characterized by nasal congestion, rhinorrhea, sneezing, and itching?

Evaluation and Management of Rhinitis

Initial Evaluation

Begin with a focused history to differentiate allergic from nonallergic rhinitis, as this distinction fundamentally determines treatment approach. 1

Key Historical Features to Elicit

• Symptom pattern and timing: Seasonal occurrence suggests allergic rhinitis from pollens; perennial symptoms suggest dust mites, molds, or animal dander; episodic symptoms after specific exposures suggest allergic triggers 1
• Specific symptom characteristics: Nasal itching, sneezing paroxysms, and ocular symptoms (redness, tearing, itching) strongly suggest allergic rhinitis 1, 2
• Trigger identification: Ask specifically about exposure to pollens, animals, dust, strong odors, perfumes, temperature/humidity changes, and tobacco smoke 1, 3
• Quality of life impact: Assess sleep quality, work/school absenteeism, fatigue level, and general well-being 1
• Family history: Atopy in first-degree relatives increases likelihood of allergic rhinitis 1
• Comorbid conditions: Screen for asthma, sinusitis, otitis media, and atopic dermatitis 1
• Current medications: Document all prescription, over-the-counter, and herbal preparations, as some medications can cause rhinitis 1

Physical Examination Findings

• Nasal mucosa appearance: Pale, edematous mucosa suggests allergic rhinitis; erythematous mucosa suggests infectious or irritant causes 2
• Nasal discharge character: Clear rhinorrhea is typical of allergic rhinitis; purulent discharge suggests bacterial infection 2, 4
• Structural abnormalities: Assess for septal deviation, turbinate hypertrophy, and nasal polyps 1
• Associated findings: Examine eyes for conjunctival injection, ears for effusion, throat for postnasal drainage, and lungs for wheezing 1

Diagnostic Testing

Skin prick testing or serum-specific IgE testing for aeroallergens is essential to definitively differentiate allergic from nonallergic rhinitis. 2, 3, 5

• When to test: Perform allergy testing when history suggests allergic triggers or when empiric treatment fails 1
• Critical pitfall: Never diagnose allergic rhinitis based on positive testing alone—testing must correlate with clinical history and symptom timing 2
• Negative testing significance: Negative skin prick testing or serum-specific IgE essentially rules out IgE-mediated allergic rhinitis and confirms nonallergic rhinitis 2

Classification Framework

Classify rhinitis as allergic or nonallergic based on history, examination, and IgE testing results. 1

Allergic Rhinitis Subtypes

• Seasonal: Symptoms during specific pollen seasons 1
• Perennial: Year-round symptoms from dust mites, molds, animal dander 1
• Episodic: Sporadic symptoms after specific aeroallergen exposures 1

Nonallergic Rhinitis Subtypes

• Idiopathic (vasomotor): Triggered by irritants, temperature changes, strong odors without IgE mechanism 1, 5, 6
• Infectious: Viral (≤10 days) or bacterial rhinosinusitis 4
• Medication-induced: Rhinitis medicamentosa from topical decongestant overuse 1, 6
• Hormonal: Pregnancy-related 5, 6

Note: Mixed rhinitis (combined allergic and nonallergic) occurs in 44-87% of allergic rhinitis patients and is more common than either pure form. 1

Treatment Algorithm

For Allergic Rhinitis

Intranasal corticosteroids are the most effective single-agent therapy for allergic rhinitis and should be considered first-line for moderate-to-severe symptoms. 1, 7, 8

Stepwise Pharmacotherapy Approach

Mild intermittent symptoms:

• Start with oral second-generation antihistamines (cetirizine, loratadine, fexofenadine, desloratadine) 1, 7, 8
• These effectively control sneezing, itching, rhinorrhea, and associated ocular symptoms 1
• Avoid first-generation antihistamines due to sedation 8

Moderate-to-severe or persistent symptoms:

• Initiate intranasal corticosteroids as first-line therapy without requiring prior antihistamine trial 1
• Intranasal corticosteroids control all four major symptoms (sneezing, itching, rhinorrhea, congestion) more effectively than antihistamines 1, 7
• Direct spray away from nasal septum to minimize local side effects 1
• Use lowest effective dose in children 1

Nasal congestion predominant:

• Add oral decongestants (pseudoephedrine or phenylephrine) for short-term relief 1
• Monitor blood pressure in hypertensive patients 1, 6
• Critical warning: Limit topical decongestants to ≤3 days to prevent rhinitis medicamentosa 1

Rhinorrhea predominant:

• Add intranasal anticholinergics (ipratropium) for refractory rhinorrhea 1
• Minimal effect on other symptoms but effective for watery discharge 1

Combination therapy:

• Intranasal antihistamine plus intranasal corticosteroid provides greater relief than monotherapy 3
• Leukotriene receptor antagonists can be added but are less effective than intranasal corticosteroids 1

Refractory cases:

• Short course (5-7 days) of oral corticosteroids for very severe symptoms 1
• Never use parenteral corticosteroids due to long-term side effect risk 1
• Consider allergen immunotherapy when medications fail and symptoms significantly impair function 1, 3

Allergen Avoidance Measures

• Implement empiric avoidance of identified triggers even before testing results 1, 7
• Specific measures based on positive IgE testing results 7
• Address environmental irritants including tobacco smoke and pollutants 7

For Nonallergic Rhinitis

Treatment is empiric and symptom-directed since pathophysiology varies. 5, 6

• Intranasal corticosteroids: Effective for idiopathic nonallergic rhinitis 1, 6
• Intranasal antihistamines: Useful alternative, though may cause sedation or bitter taste 1, 6
• Intranasal anticholinergics: First-line for rhinorrhea-predominant symptoms 6
• Oral decongestants: For congestion, with same precautions as allergic rhinitis 6
• Avoid allergen immunotherapy: Not indicated for nonallergic rhinitis 3

For Infectious Rhinitis

Viral URI (≤10 days):

• Symptomatic relief with oral antihistamines and intranasal saline irrigation 7
• Antibiotics not indicated 4

Acute bacterial rhinosinusitis (purulent drainage ≥10 days):

• Consider watchful waiting versus amoxicillin-clavulanate for 5-10 days 4
• Add intranasal corticosteroids and saline irrigation for symptom relief 4

Follow-Up and Monitoring

• Assess quality of life at each visit: work/school performance, sleep quality, smell/taste, fatigue 1
• Screen for comorbidities: Sinusitis, asthma, otitis media 1
• Taper medications when possible to minimize adverse effects 1
• Periodically examine nasal septum in patients using intranasal corticosteroids to detect mucosal erosions 1
• Patient education: Review environmental controls, proper medication technique, and trigger avoidance at each visit 1

When to Refer to Allergist/Immunologist

Consider referral when: 1

• Prolonged symptoms despite treatment
• Complications (sinusitis, otitis media, nasal polyps)
• Comorbid asthma
• Need for systemic corticosteroids
• Symptoms significantly impair function or quality of life
• Medication failure or intolerable side effects
• Rhinitis medicamentosa
• Need for allergen identification or immunotherapy consideration