Chronic Rhinitis

Jesse P. McRae, MD, FACAAI

Editors Note: Due to color constraints and other production considerations, Figures 1 & 2 of this article are not printed in the journal. They are available online at dcmsonline.org.

Trauma

Abstract: Rhinitis simply refers to inflammation of the nasal passages.

The symptoms that result include congestion, sneezing, rhinorrhea, post-nasal drainage, cough and itching of the nose and throat. Forty million people are believed to have rhinitis and the resulting cost is $2.7 billion annually, making it one of the most common causes of lost work and school absence.1 Sleep disturbance can be quite troublesome.2 Rhinitis can have several causes. Basically, rhinitis can be divided into two categories: Non-allergic and allergic.3 This article will cover both areas but will focus primarily on allergic causes.

A recent onset of profuse rhinorrhea without other signs of rhinitis can be caused by cerebrospinal fluid leakage from a basal skull fracture. Rhinorrhea in a patient with a history of recent head trauma should always arouse this suspicion which is a neurosurgical emergency. A glucose test of the secretions can be done and should be quantified. The transudate from allergic rhinitis should not contain glucose. While the positive glucose is a recognized screening test, the presence of beta-2-transferrin in the secretions is now recognized as the preferred confirmatory test.

Non-Allergic Rhinitis

Persistent nasal symptoms may be caused by any of several non IgE-mediated mechanisms, including drug side effects, infectious, hormonal, occupational, or structural/anatomical factors. These causes of rhinitis are associated with negative allergy testing.

Drug Induced Rhinitis

Infectious Rhinitis

The cause can be bacterial, viral, or fungal. Signs and symptoms include mucopurulent nasal discharge, facial pain, cough and pressure sensation and may involve the paranasal sinuses. Fever may not be present.

Over the counter nasal vasoconstrictors (oxymetazoline, phenylephrine) may cause rebound nasal congestion and can lead to dependence on the medication. This is called rhinitis medicamentosa. Although not a true addiction, the dependency to vasoconstrictor sprays can be profound and long term. Other pharmacologic classes of nasal sprays (steroid, antihistamine, anti-cholinergic) do not cause this rebound effect. Anti-hypertensive medications may cause or exacerbate rhinitis, particularly nasal congestion. Angiotensin converting enzyme (ACE) inhibitors and beta adrenergic blockers, reserpine, methyldopa, guanethidine, phentolamine, and aspirin all have been reported to cause this side effect. Cocaine abuse also can result in chronic rhinitis.

Hormonal Rhinitis

Pregnancy, menstrual cycles, and occasionally hypothyroidism can lead to rhinitis, usually characterized by nasal congestion. A cyclical pattern may be discernible to the patient.

Occupational Rhinitis

Gustatory Rhinitis

Many airborne substances may cause nasal irritation including chemicals, wood dust, animal exposures, and even molds producing mycotoxins (e.g. Aspergillus). Identification of triggering factors and avoidance measures constitute the mainstay of treatment for this problem.

Structural/Anatomical Factors

Rhinitis symptoms, particularly rhinorrhea and congestion can be caused by structural issues such as a deviated nasal septum, nasal polyposis, adenoidal hypertrophy, cysts, or rarely, tumors. Persistent or intermittent congestion without itching should alert the clinician to the presence of a polyp or other physical obstructions. Nasal polyps in children raise the suspicion of cystic fibrosis. In adults, nasal polyps when accompanied by aspirin allergy and asthma, are referred to as aspirin or Samters triad. Aspirin desensitization should be considered in those cases. Nasal polyps may or may not be associated with allergy factors.
Address Correspondence to: Jesse P. McRae, MD, allergist/immunologist in private practice, Jacksonville, FL. Email: jessemcraemd@ fdn.com.

Ingestion of certain foods, especially hot or spicy foods or alcohol, can trigger rhinitis in some individuals. This is believed to be mediated via the vagus nerve and usually is manifested as profuse rhinorrhea. Anti-cholinergic nasal sprays seem to be effective to treat this infrequent disorder. Antihistamines have little, if any, benefit. This is totally different from IgEmediated food allergies which are covered in another article in this issue. Food allergies, in fact, usually cause a different pattern of symptoms and not isolated rhinitis.

Vasomotor Rhinitis

This common entity includes symptoms similar to other forms but appears triggered by non-specific exposures such as cleaning odors, changes in temperature or position, especially cold, dry air. The syndrome is believed to be caused by an excess in sympathetic vasomotor activity. Allergy evaluation is expected to be negative and treatment is often unsatisfactory.

Allergic Rhinitis

Also called hay fever, allergic rhinitis is an inflammatory disorder in which histamine and other chemical mediators

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(cytokines, leukotrienes) producing the symptoms are released from mast cells in response to specific IgE antibodies. This process requires prior sensitization of low doses, sometimes for several years. The disorder may be arbitrarily labeled seasonal or perennial depending on whether the exposure to allergens is seasonal or year round. Seasonal allergens are typically pollens and molds. Perennial allergens include animal dander, dust mites, outside molds (e.g. Alternaria) or some occupational exposures.

gram of dust from carpeting. Reduction measures include dehumidification, carpet treatment or removal and bedding encasements. Rarely, relocation to a drier climate is necessary to control this allergy, especially if asthma is also a component. Immunotherapy is often needed for meaningful reduction of symptoms of this allergy. Mold Spores- Molds are microscopic fungi that reproduce by releasing spores into the air. The spores of many species trigger histamine release and produce allergy symptoms. Measures to control mold in the home include reduction of humidity and cleaning with a dilute bleach solution (1 cup per gallon of water) or use of a commercial mold cleaner. Sources of water incursion (plumbing leaks, roof or window leaks) should be repaired. Animal Dander - General surveys suggest that 40% of households have a dog and 25% have a cat. Allergies to animals result from reaction to a protein that originates in the skin. It is, therefore, found in the saliva as well. Removal of the animal from the patients environment is the preferred treatment but desensitization with allergy shots works well if reduced exposure is not feasible. Allergies to small animals (hamsters, gerbils,etc.) are possible but not usually significant. Horse dander allergies are more common and can be quite severe. (I treated one veterinarian with allergies to several exotic zoo animals that ultimately necessitated changing jobs.) Pollen - Pollen is the most well known of allergic triggers and was the first one described by Dr. Noon in 1909.4 The common plant categories producing pollen of allergic significance in Florida are trees (spring), grass (summer) and weeds (fall). The most potent pollen allergens in Florida appear to be oak trees, Bahia grass and ragweed. Florida pollen counts can be found at www.aaaai.org/nab.5

Allergic Rhinitis Symptoms

Typical symptoms include nasal congestion, rhinorrhea, sneezing, itching of the eyes, nose and throat, cough and post-nasal drainage. Additional symptoms now recognized include daytime somnolence, depression, fatigue, irritability and even memory loss. Mucosal congestion has the largest impact on sleep loss.

Evaluation of Allergic Rhinitis

After a detailed history and physical examination, physical factors can sometimes be identified. These might include cysts, polyps, deviated nasal septum or an infection in the upper respiratory tract. A foreign body must be considered in children. Typically, with allergic rhinitis, the turbinates are edematous, pale and shiny with a more serous exudate (Figure 1, dcmsonline.org). The edema may at times be sufficient to occlude the nasal passage. Nasal polyps may be present. The pharynx may be hyperemic with increased lymphoid follicular hypertrophy (cobblestoning) reflecting chronic post-nasal drainage. Visible signs may include dark circles around the eyes (allergic shiners), edema of the conjunctivae and sometimes a transverse nasal skin crease, produced by constant rubbing of the nose. In children, this is referred to as the allergic salute. Some serous otitis media may also be present. Allergic rhinitis and asthma frequently co-exist. Evaluation of specific IgE to allergens present in the area is the standard means to identify triggers. Skin testing is the standard in vivo method used by allergists. This consists of prick testing followed by intra-dermal testing at differing dilutions. Several in vitro tests are present, CAP (immunoassay capture) and RAST (radioallergosorbent test) and are fairly accurate, but they do not always offer testing for the allergens needed for a certain area. These tests are sensitive and over-interpretation of results may occur. Therefore, caution must be used in ordering these tests and using them as a basis of therapy.

Treatment of Allergic Rhinitis

The therapy of allergic rhinitis can be divided into three levels, depending on the degree of the patients symptoms. Those levels include environmental avoidance/reduction measures, medications and immunotherapy (allergy shots). Reduction measures are appropriate for several allergens, including animal dander, feathers, dust mites, molds and a few occupational exposures. Several medications exist for allergic rhinitis treatment: Antihistamines - This has been one of the mainstays of treatment for many years. Older H1 blockers (diphenhydramine, cyproheptadine) are sedating but are effective otherwise. Newer H1 blockers are non-sedating (loratidine, fexofenadine). Decongestants- These act as alpha-adrenergic agonists and include pseudoephedrine and phenylephrine. They may have adverse effects including insomnia, tachycardia, and decreased urinary flow in males or increased blood pressure. Nasal Steroids-This pharmacologic class probably has had the largest impact on allergic rhinitis. Steroids reduce swelling and inflammation of the nasal passages very effectively but may take several days to reach optimal effect. Possible side effects include nasal irritation, epistaxis, or rarely, nasal septal
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Triggers of Allergic Rhinitis

Several triggers of IgE production are common to North Florida. The common ones in this area are dust mites, animal dander, mold spores and pollen. Dust Mites- Mites are microscopic arachnids that feed on organic matter that has settled from the air (Figure 2, dcmsonline.org). Dust mites are more prevalent in areas with higher humidity, especially the southeastern United States. Mites are found in areas of settled dust such as carpet, bedding, upholstering etc. There can be several thousand in every
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atrophy/perforation. Patients on this medication should be evaluated for this effect periodically. Some ophthalmologists believe that increased intra-ocular pressure may occur with this class of medication, but the preponderance of evidence suggests that there is not a significant increase in ocular pressure. Leukotriene receptor antagonists-Blocking the effects of cysteinyl leukotrienes often leads to reduced allergy symptoms. Montelukast is indicated for treatment of asthma and allergic rhinitis and can be used in children as young as 2 years old.

Immunotherapy

Also called desensitization or allergy shots, this is an antigen specific method of gradually increasing the exposure to allergens, usually at weekly intervals, to a maximal tolerated dose. Precise information must be known about the patients allergies as well as knowledge about which antigens are compatible in solution with one another. (e.g., grass pollen and dust mite cannot be mixed together). Also, it incurs the risk of anaphylaxis and must be given in a physicians office where treatment for anaphylaxis is available. A convenient package of the treatment of anaphylaxis as well as current Position Statements regarding immunotherapy indications and contraindications can be obtained from the American Academy of Allergy, Asthma and Immunology at www.aaaai.org.5 Immunotherapy is generally the best option for meaningful long term reduction of patients symptoms. Allergy shots are effective about 85% of the time. Current research suggests that patients may soon have the option of receiving immunotherapy doses sublingually rather than subcutaneously.6 Conclusion Evaluation of the patient with chronic rhinitis involves first identifying whether or not allergies are the basis of the symptoms. Reduction measures and judicious use of medications are also employed initially. Patients that fail to respond adequately to these measures are then candidates for immunotherapy which may need to last 3-5 years.
1. 2. 3. 4. 5. 6. Naclerio RM. Understanding the inflammatory processes in upper allergic airway disease and asthma. J Allergy Clin Immunol 1998;101:S345. Craig TJ, McCann, et al. The correlation between allergic rhinitis and sleep disturbance. J Allergy Clin Immunol 2004;114: S139-45. Dykewecz Mark. Executive Summary of joint task force practice parameters on diagnosis and management of rhinitis. Annals of Allergy Asthma Immunology 1998;81:463-468 Dworetzki, M., et al. Noonan and Freeman on prophylactic inoculation against hay fever. J Allergy Clin Immunol 2003;111:1142-1144. American Academy of Allergy and Immunology. www.aaaai. org/nab and www.aaaai.org. Accessed March 2008. Wilson, DR, Torres-Lima M, et al. Sublingual immunotherapy for allergic rhinitis: Systematic review and meta analysis. Allergy. 2005;60:4-12. The Food Allergy & Anaphylaxis Network. www.foodallergy.org. Florida Allergy, Asthma & Immunology Society. www.faais.org.

References

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Other Recommended Resources

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