Chronic Rhinitis: Evaluation and Treatment
Initial Diagnostic Approach
Begin by classifying rhinitis as allergic versus nonallergic, as this fundamentally determines treatment strategy. 1
Key History Elements to Obtain
- Pattern and timing: Determine if symptoms are seasonal, perennial, perennial with seasonal exacerbations, or episodic 1
- Specific symptoms: Nasal congestion, rhinorrhea (anterior/posterior), sneezing, nasal itching, eye symptoms 1
- Triggers: Identify precipitating factors including allergens, irritants, foods, alcohol, medications, occupational exposures 1
- Response to prior medications: Document what has been tried and effectiveness 1
- Comorbid conditions: Screen for asthma, sinusitis, otitis media, sleep disturbance 1, 2
- Quality of life impact: Assess work/school absences, sleep quality, fatigue, smell/taste changes 1
Physical Examination Findings
- Examine nasal cavity for appearance of turbinates (pale/edematous suggests allergic; erythematous suggests perennial allergic or nonallergic), nasal secretions, septum deviation, and presence of nasal polyps 1, 3
- In selected cases, fiber optic nasal endoscopy may be useful 1
Diagnostic Testing
Perform specific IgE testing (preferably skin testing) to differentiate allergic from nonallergic rhinitis. 1, 2
- Skin prick tests are the preferred diagnostic method with approximately 70-75% sensitivity compared to in vitro assays 1
- Select allergens based on patient's age, history, geographic location, and environmental exposures 1
- Negative testing for aeroallergens confirms nonallergic rhinitis 4, 5
- Nasal cytology may aid in differentiating allergic rhinitis and NARES (nonallergic rhinitis with eosinophilia syndrome) from other forms 1
Treatment Algorithm for Allergic Rhinitis
Mild Intermittent Allergic Rhinitis (symptoms <4 days/week or <4 weeks/year)
Start with second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) OR intranasal antihistamines (azelastine, olopatadine). 2, 3
- Intranasal antihistamines are equal or superior to oral antihistamines and have the unique advantage of improving nasal congestion 2
- Avoid first-generation antihistamines due to sedation, performance impairment, and anticholinergic effects 2
Moderate to Severe or Persistent Allergic Rhinitis (symptoms >4 days/week and >4 weeks/year)
Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) are first-line therapy as they are the most effective single medication class for controlling all nasal symptoms. 1, 2, 3
- Dosing: 200 mcg once daily (2 sprays per nostril) 2
- Critical counseling point: Direct sprays away from nasal septum toward lateral nasal wall to prevent irritation and bleeding 2
- Maximum efficacy requires several days of consistent daily use 2
- For seasonal allergic rhinitis, start before pollen season begins for optimal prophylaxis 2
Add-On Therapies When Monotherapy Insufficient
- Add oral antihistamine (cetirizine 10 mg daily) if nasal itching, sneezing, or eye symptoms persist despite intranasal corticosteroids 2
- Add intranasal ipratropium 0.03% for persistent rhinorrhea; effective for rhinorrhea but no effect on other symptoms 2, 4
- Consider oral decongestants (pseudoephedrine) for severe congestion, but screen for contraindications: hypertension, anxiety, cardiac conditions 1, 2
- Limit topical decongestants (oxymetazoline) to maximum 3-5 days to prevent rhinitis medicamentosa 1, 2
Adjunctive Non-Pharmacologic Measures
- Nasal saline irrigation helps clear secretions and reduce congestion 1, 2
- Allergen avoidance: Identify specific triggers through testing and implement targeted strategies 2
- Complete avoidance of animals is most effective for animal allergies 2
- Minimize exposure to tobacco smoke, strong odors, temperature/humidity extremes 2
Immunotherapy Consideration
Offer allergen immunotherapy to patients with documented specific IgE antibodies who fail pharmacotherapy with or without environmental controls. 1, 2
- Immunotherapy is the only disease-modifying treatment available 2, 5
- Can prevent new allergen sensitizations and reduce future asthma risk 2
Treatment Algorithm for Nonallergic Rhinitis
Nonallergic rhinitis represents approximately 25% of chronic rhinitis cases and includes 8 major subtypes. 4, 6
First-Line Therapy
Intranasal corticosteroids are the mainstay of treatment for nonallergic rhinitis. 1, 4, 6
- Same agents and dosing as allergic rhinitis (fluticasone, mometasone, budesonide) 6
- Intranasal antihistamines (azelastine, olopatadine) are also effective as monotherapy or combined with intranasal corticosteroids 4, 3, 6
Symptom-Specific Therapies
- For prominent rhinorrhea: Intranasal ipratropium bromide 0.03% is highly effective 1, 4, 6
- For gustatory rhinitis (rhinorrhea with eating): Intranasal anticholinergics are treatment of choice 7
- For vasomotor rhinitis: Combination of intranasal corticosteroids and intranasal antihistamines relieves both congestion and rhinorrhea 1
Important Caveat
Antihistamines have limited efficacy in nonallergic rhinitis syndromes, making proper diagnosis essential. 7
Specific Nonallergic Rhinitis Subtypes
Rhinitis Medicamentosa
Institute intranasal corticosteroids AND discontinue nasal decongestant sprays. 1
Drug-Induced Rhinitis
- May be caused by ACE inhibitors, phosphodiesterase-5 inhibitors, alpha-receptor antagonists, aspirin, NSAIDs 1
- Consider medication adjustment if clinically appropriate 1
Atrophic Rhinitis
Treatment involves continuous nasal hygiene (nasal lavage, crust debridement) and topical/systemic antibiotics when purulent secretions or acute infection present. 1
Evaluation for Chronic/Recurrent Rhinosinusitis
When to Suspect Rhinosinusitis vs. Rhinitis Alone
- Rhinosinusitis presents with nasal congestion, mucopurulent drainage, facial pain/pressure, and reduced sense of smell 1, 2
- Chronic rhinosinusitis defined as ≥12 weeks of symptoms with documented inflammation 1
Additional Workup for Chronic/Recurrent Cases
Obtain CT of paranasal sinuses to confirm diagnosis and detect structural abnormalities. 1
- Nasal endoscopy may be obtained to confirm diagnosis, detect masses/lesions, perform biopsy or culture 1
- Test for allergy and immune function in chronic/recurrent cases to identify modifying factors 1, 8
Treatment for Chronic Rhinosinusitis
High-volume saline nasal irrigation combined with intranasal corticosteroids form the cornerstone of medical management. 8
- Consider minimum 3-week course of antibiotics for chronic infectious sinusitis (targeting H. influenzae, anaerobes, S. pneumoniae) 8
- Short courses of oral corticosteroids for nasal polyps 8
- Functional endoscopic sinus surgery (FESS) reserved for patients failing medical therapy, with anatomic obstruction, or refractory nasal polyps 1, 8
Follow-Up and Monitoring
Periodic Assessment Should Include
- Symptom control and quality of life measures 1
- Time lost from work/activities, sleep quality, smell/taste, fatigue 1
- Medication side effects and compliance 1
- Presence of comorbid conditions (sinusitis, asthma, otitis media) 1
- Consider tapering medications to minimize adverse reaction risk 1
Referral Indications
- Symptoms not adequately controlled with pharmacotherapy 2
- Suspected complications or uncertain diagnosis 2
- Consideration for immunotherapy 1
- Surgical evaluation for severe septal deviation, turbinate hypertrophy, refractory sinusitis, nasal polyps 1
Critical Pitfalls to Avoid
- Never use antibiotics for allergic rhinitis—they are ineffective and contribute to antimicrobial resistance 2
- Avoid first-generation antihistamines in most patients due to sedation and impaired performance 2
- In children <3 years, avoid decongestants and antihistamines due to risk outweighing benefits 2
- In older adults, exercise extreme caution with first-generation antihistamines due to increased anticholinergic sensitivity 2
- Do not overlook mixed rhinitis (combination allergic and nonallergic), present in 44-87% of allergic rhinitis patients 1
- Monitor for asthma, as allergic rhinitis increases asthma risk and treating rhinitis may improve asthma control 2