Borders Ref Help Toolkit
When to refer
Symptoms still significantly effecting quality of life despite medical treatment
How to Refer
SCI Gateway
Rhinitus
Warning
Rhinitis can be broadly classified as
- Allergic rhinitis
- Non – allergic rhinitis
Presenting symptoms
- Nasal blockage – normally bilateral, can be unilateral if coexisting septal deviation
- Nasal discharge – normally clear and bilateral. If unilateral consider CSF leak – send sample for B2 transferrin.
- Sneezing and Itching – thought to make allergic rhinitis more likely
Other points to cover in the history
- Severity of symptoms throughout the year
- Animal contact from home or work
- Symptoms while on holiday - if better suggests reacting to something in local environment
- Coexisting eye symptoms – suggests allergy
- Whether patient is taking over the counter medication
- Asthma - strong association with allergic rhinitis with evidence that controlling allergic rhinitis can help control asthma
Examination
- Nasal inflammation
- Septal deviation – if the symptoms are bilateral or intermittent where sometimes the nose is clear/not troublesome this is unlikely to be significant factor in the symptoms
- Polyps – if seen manage as for nasal polyposis
Patient information sheets
Nasal irrigation/douching
Taking a nasal spray
Management
Ensure not taking regular nasal decongestant – this causes rhinitis medicamentosa
Avoid precipitants where possible eg animals, dusty environment
Intermittent symptoms
- Nasal irrigation
- If no improvement trial oral antihistamine
- If no improvement trial topical steroid spray
Persistent symptoms
- Nasal irrigation
- If no improvement trial topical nasal steroid (minimum 1 month) using correct technique (Patient information sheet)
- If ongoing symptoms:
- add oral antihistamine
- consider topical ipratropium bromide if clear nasal discharge is the predominant symptom
Taking a nasal steroid spray
A common cause of treatment failure is using a nasal steroid spray using the wrong technique. Most patients will use their dominant hand to spray both sides of the nose. The inflammation in the nasal cavity comes from the lateral wall rather than the septum so to achieve the correct delivery of the spray the patient should use the right hand to spray the left nose and the left hand to spray the right nose so that the spray will be pointing at the lateral nasal wall rather than the septum. This will also reduce the risk of bleeding.