Rhinitis

Background: Rhinitis is inflammation of the lining of the nasal cavity. It can be intermittent or persistent. Severe rhinitis is indicated by any of the following: Sleep disturbance, impairment of activities e.g. school, work, leisure or “Troublesome symptoms”. It is commonly associated with asthma.

Symptoms include: nasal obstruction/congestion, rhinorrhoea, hyposmia, sneezing and itching of the nose/palate/eyes.

There are multiple causes including:

• Allergic rhinitis +/- allergic conjunctivitis (Allergic rhinitis - NHS (www.nhs.uk))
• Non-allergic rhinitis which includes (Non-allergic rhinitis - NHS (www.nhs.uk)

• Viral rhinitis – “the cold”
• Hormonal rhinitis – can be associated with pregnancy
• Vasomotor rhinitis – Watery nasal discharge often without sneezing, hyposmia or nasal obstruction (as opposed to allergic rhinitis). Usually bilateral. If unilateral, consider CSF leak
• Atrophic rhinitis – characterised by nasal crusting, common in elderly or those with granulomatosis with polyangitis
• Rhinitis medicamentosa – causes by chronic nasal decongestant use e.g. otrivine, sudafed

Symptoms can also be classified as intermittent or persistent

How to manage:

Allergic rhinitis

Advice should be given on allergen reduction / avoidance.  Allergens include:

• Spring – Tree pollen
• Summer – Grass pollen
• Autum / winter – Fungi
• All year – Cat / Dog / House dust mite (often characterised by symptoms which are worse in the morning and ease during the day when out and about)

Medical management includes saline nasal rinses (e.g. sterimar), topical nasal steroid sprays

Oral antihistamines can also be added to help control allergic symptoms

For more resistant cases, consider fluticasone + azelastine (Dymista) topical nasal spray

Viral rhinitis

Symptomatic management with 5 days topical nasal decongestant + sterimar nasal spray if needed

Vasomotor rhinitis

Treated with topical nasal steroid sprays initially. If does not control symptoms, consider adding topical ipratropium bromide nasal spray.

Rhinitis medicamentosa

Discontinue the use of the offending agent (usually over the counter nasal decongestants e.g. otrivine, Sudafed). Patients will often have a psychological reliance on these medications and may require an alternative method of controlling their nasal obstruction when coming off the decongestant as stopping it results in rebound nasal congestion. Consider a 2 month course of topical nasal steroids while stopping the topical decongestant after 1 month.  Saline nasal rinses can also provide some symptomatic relief. Consider reviewing the patient to determine if a further underlying cause of nasal obstruction exists.

Referral guidance:

Specific IgE RAST test can be performed in primary care, however, many patients will be able to clearly identify an allergic trigger and so this is often not neccessary

Most of these patients have significant improvement with medical management. Surgical interventions are rarely utilised.

Consider referral to ENT on a routine basis for patients where there is diagnostic doubt after failed initial therapy