RHINITIS

 inflammation and irritation of the nasal mucous membrane 

 often coexist with upper respiratory disorders such as asthma
 it affects 10%-30% of the total population worldwide
 Rhinitis can be acute or chronic, allergic or non-allergic (Common Colds)

Etiology
 Rhinitis may cause by a variety of factors including changes in temperature, odors. 
 Allergic may occur with exposure to allergen such as foods (peanuts, walnuts, Brazil nuts, wheat,
shellfish, soy, cow’s milk and eggs), and particles in the indoor and outdoor environment
 Drug induced rhinitis using anti-hypertensive agents, ACE inhibitors, betablockers and statins, anti-
depressant, anti-psychotics (Risperdal), nasal decongestant, penicillin, aspirin, anti-anxiety drugs 
 The most common non-allergic rhinitis is the common colds

Description ALLERGIC RHINITIS VIRAL RHINITIS (COMMON

 Inflammation of the nasal mucosa
and the lining the eyelids
(conjunctivitis) caused by inhaled
airborne allergen that triggers an
immune response
 The most common allergic reaction
 It can affect anyone at any age
 Most common in young children
and adolescents
 The onset of allergic rhinitis occurs
during childhood   Causative virus is influenza
 Allergic rhinitis does not
predispose to the development of
asthma
Types of Allergic rhinitis  Symptoms typically peak on the
Seasonal Allergic rhinitis/ Hay fever
 Occurs occasionally (spring, fall,
summer)  People are most infectious (likely to
 Caused by airborne pollens from
trees, grass, weeds or mold.
 Symptoms are episodic
Perennial Allergic rhinitis
 Occurs year round 
 Dust mites, mold, cockroaches,
house dust, feathers, fungi,
tobacco smoke, material or
industrial chemicals
COLDS)
 Most frequent viral infection 
 Common colds are used
when referring to URI that
is self-limited and caused
by a virus.
 Cold refers to an infectious,
acute inflammation of
mucous membrane of the
nasal cavity
 Highly contagious because
virus is shed for 2 days
before the symptoms
appear and during the first
part of symptomatic phase
 The virus survives better
when humidity is low in the
colder months of the year 
 Each virus has multiple
strains so people are
susceptible to colds
throughout the year
second, third or fourth days
of infection and last about 1 week.
pass the cold onto others) during
the first 24 hours of the illness, and
they usually remain infectious for as
long as the symptoms last.
Causes Common Indoor Allergen  Rhinovirus most common
 Dust mite feces virus that causes common
 Dog and cat dander flu
 Molds and cockroach droppings  Other are coronavirus,
adenovirus, influenza virus,
Common Outdoor Allergen and parainfluenza virus
 Trees- oak, maple, walnut, ash 
 Weeds- ragweed, tumbleweed,
pigweed, cockle weed
 Grasses- Bermuda, blue grass,
redtop, orchard
 Molds- aspergillus, Cladosporium

Family history
Pathophysiology Allergens (pollens, molds, dust mites,
animal dander) are deposited on the nasal
IgE- The antibody mucosa causing local inflammation and
involved in immediate increased capillary permeability. Local
hypersensitivity immunoglobulin E (IgE-) is produced.
reactions, or allergic Mast cells produce histamines and release
reactions that develops causing vasodilation, mucosal edema,
in minutes of exposure mucus secretions, stimulation of itch
to an antigen receptors and a reduce threshold of
Stimulates the release of sneezing. 
mast cell granules which
contain histamine and
heparin
Clinical Classic symptoms are   Low grade fever, Nasal
manifestations  Paroxysmal sneezing attacks due congestion, rhinorrhea,
to sensory nerve stimulation nasal discharge, halitosis,
 Rhinorrhea- profuse watery nasal sneezing, teary watery eyes,
discharge or runny nose due to sore throat, general malaise
mucus gland stimulation and muscle aches
 Nasal obstruction -affecting the  Symptoms may last form 1-
Eustachian tube and due to mucus 2 weeks
secretions and vasodilation 
 Itchiness in the eyes, ears and
nose and throat
 Headache/ sinus pain
 Allergic salute- upward rubbing of
the nose with the palm of the hand
which can leave a crease below
the bridge
 Allergic shiners- dry circles under
the eyes from congestion and
edema
Diagnostic test Skin testing
 Confirms hypersensitivity to
allergens
CBC
 Might reveal high eosinophils (type
of disease-fighting white blood
cell) associated with allergic
 reaction
 high levels of eosinophils in your
blood or in tissues at the site of an
infection or inflammation
Nasal smear
 Increase number of eusinophils
suggest allergic reaction
Rhinoscopy
 Visualization of nasopharynx,
useful to rule out nasal obstruction
 examination of the nasal cavities
enabling to note nasal secretions,
swelling of the turbinates,
properties of the mucosal surface,
position of the nasal septum,
ulcerations or presence of foreign
bodies using the nasal speculum
and light source
Diagnosis  Ineffective breathing pattern rt nasal obstruction
 Ineffective Airway Clearance
MEDICAL The management of Rhinitis depends on  Adequate fluid intake, rest,
MANAGEMENT the cause which may identified through prevention of chilling,
the history and physical examination. expectorants
 Eliminate the allergen from the  Warm salts gargles soothe
environment the throat
 Anti-histamines- for sneezing,  NSAIDS- aspirin or ibuprofen
pruritus and rhinorrhea  relieves pain and aches q
 Older Sedating antihistamines  Antihistamines- used to
 Inexpensive, OTC, short acting and relieve sneezing, rhinorrhea
effective and nasal congestion 
 Diphenhydramine (Benadryl)  Petrolleum jelly can soothe
 Chlorphenamine irritated skin around the
 SE: sedation, drowsiness, dry nares
mouth, nausea, dizziness, blurred  Guaifenesin an expectorant
vision and nervousness to remove secretions
 Instruct the pt to avoid driving cars  Topical nasal decongestant
 Should be taken at night (Phenylephrine (Neo-
 New-Non-Sedating/Less Synephrine)- should be used
Sedating antihistamine with caution, its over used
 Obtained by prescription, more can produce rebound rhinitis
expensive, long acting and (rhinitis medicamentosa)
effective  Zinc lozenges and zinc nasal
 Loratadine (Claritin) spray for common cold it
 Fexofenadine (Allegra) shortened the symptomatic
 Cetirezine phase
 Steam inhalation or heated
Decongestant humidified air remedies to
 Shrink the nasal mucous
treat common cold at
membrane by vasoconstriction, for home  
nasal decongestion
 Do not use OTC nasal  
 decongestant because their effect
is short live and has rebound
effect- nasal mucosal edema
 Pseudoephedrine,
phenylephrine
Anticholinergic agents
 Produce bronchodilation by
reducing intrinsic vagal tone to the
airways
 Act as drying agents, inhibits
mucous secretions. 
 Atropine sulfate 

Corticosteroids (oral/ intranasal)

 Reduce inflammation of nasal
mucosa/ for severe congestion
 Prevent mediator release

Side effects of steroid nasal sprays

 a stinging or burning sensation in
the nose.
 dryness and crustiness in the
nose.
 a dry, irritated throat.
 an unpleasant taste in the mouth.
 itchiness, redness and swelling in
the nose.
 nosebleed
Intranasal cromolyn sodium
(Nasalcrom)
 Mast cell stabilizer
 Hinders the release of chemical
mediators and histamines from the
mast cells

Immunotherapy/allergy shots
 May be considered if medications
and environment modification is
not responsive 
 Involves injecting the child with
larger doses of allergen to reduce
the magnitude of body’s allergic
response
 Keep epinephrine at the bedside
and monitor the RR (vital sign
changes such as DOB is a sign of
anaphylactic reaction). Possible
anaphylactic reaction to the allergy
serum may occur
NURSING  Minimize contact with offending  Hand hygiene
INTERVENTIONS allergen such as dust, molds,  Wear surgical mask
animals, fumes, powders, sprays,  Use tissues to avoid the
 and smoking spread of the virus when
 Dust mite exposure can be coughing or sneezing
reduced by encasing bed pillows  Cough or sneeze into the
and mattress using dust proof upper arm if tissues are
covers not available
 Washing bed linens and stuffed  Adequate fluid intake, rest,
animals in hot water weekly prevention of chilling,
 Replace carpet with wood or vinyl expectorants
 Install air cleaners  Warm salts gargles soothe
 Keep the household humidity at the throat
40%-50%  Administer NSAIDS,
 Limit the number of indoor plants Antihistamines, Zinc
 Ventilate the house lozenges and zinc nasal
 Keep pets outside the house if spray, Steam inhalation or
possible heated humidified air for 15-
 Dry shoes thoroughly- medium for 20 minutes
mold production
 Instruct the patient to use saline
nasal sprays and aerosol that may
help to sooth mucous membranes,
softening crusted secretions
 Instruct the patient to blow into
the nose before applying the any
medication into the nasal cavity
 Keep the patient head upright and
spray quicky and firmly into each
nasal away from the nasal septum

RHINOSINUSITIS (Acute or Chronic)

 Inflammation of one or more paranasal sinuses and nasal cavity
 It is usually precipitated by congestion from viral upper respiratory infection and nasal allergy. 
 Rhinosinusitis sis classified by duration of symptoms as Acute (less than 4 weeks), sub-acute (4-12
weeks) and chronic (more than 12 weeks)
 Can be cause by bacterial or viral infection 

Types Acute Rhinosinusitis Chronic Sinusitis

Description  Is classified as acute bacterial  Is a suppurative inflammation
rhinosinusitis or acute viral of the sinuses with chronic
rhinosinusitis.  irreversible change in the
 Rapid onset and duration of less than mucosa and sinus bony area.
4 weeks)   Symptom persist more than
 Temporary inflammation 12 weeks
 Seasonal, allergy bacteria, viruses  Prolong inflammation and
 Symptoms go away impairment
 Usually virus  Often brought by allergy,
asthma, cystic fibrosis,
immunodeficiency, Nasal
polyps, deviated septum
 Difficult to treat
 Often continuous with acute
Pathophysiology  ARS follows a viral or colds such as  Chronic sinusitis is usually a
unresolve viral or bacterial infection or complication of acute
 an exacerbation of allergic rhinitis.   sinusitis. Prolong and
 Acute sinusitis occurs when the sinus
cavity is invaded by bacteria causing
mucosal inflammation and edema that
blocks the sinuses. The volume of
secretions increases and the affected
sinuses fills with purulent material.
Inflammation and infection interfere
with protection cleansing action of the
cilia covering the sinus mucous
membrane. Impaired mucociliary
transport leads to stagnant of
secretions in the sinuses. Nasal
congestion caused by inflammation
and edema of the nasal lining and
production of thick mucus that
obstructs the
paranasal sinuses provides an
excellent medium for bacterial
overgrowth.
 If the drainage is obstructed by a
deviated septum, nasal polys, tumors
or by hypertrophied turbinates, sinus
infection may persist as smoldering
(persistent) secondary infection or
progress to an acute suppurative
process causing purulent discharge)
Causes  Main caused by infection due
BACTERIAL or VIRAL
INFECTION.  60% of the cases of
acute rhinosinusitis cause typically by
Streptococcus Pneumoniae, H.
Influenzae, less common S. aureus,
Moraxella Catarhalis.
 Viral infection (cold or flu) does not
directly caused symptoms but it
inflamed sinuses.   as deviated septum (crooked
 Allergy- sinusitis is associated with
allergic rhinitis (hay fever or nasal
allergy) as immune response to
allergens by sending mucus to the
lining of the nose causing both nose
and sinuses to swell. Ostia can close
and infection can occur
 Irritants-many irritants can swell the
sinuses and sometimes paralyzed the
cilia. These includes air pollution,
tobacco smoke, car exhaust, gasoline
and paint fumes, perfumes,
household chemicals and pesticides.   hypertrophied adenoids
 Foreign bodies such as nasal
endotracheal tubes, naso gastric
tubes can predispose to sinusitis.
repeated infections result in
irreversible changes in the
mucosal lining of the sinus.
Nasal polyps, deviated
septum, inhibit sinus
drainage which can lead to
infection. The frontal and
sphenoid sinuses are most
often involved.
 Obstruction in the ostia of
the frontal, maxillary and
anterior ethmoid sinuses
(known as osteomeatal
complex) is the usual cause
of CRS and recurrent acute
sinusitis. 
 Both aerobic and anaerobic
has been implicated in CRS
Common aerobic bacteria
alpha hemolytic streptococci
and S. Aureus. Common
anaerobic include gram
negative bacilli, and
fusobacterium
 Anatomical obstruction such
wall between the nostril)
 nasal polyps (fluid filled sac),
 tumour (benign or malignant)
can predisposed to
rhinosinusitis. It can block
the ostia
 Diseases-cystic fibrosis
(excessive, thick mucus that
impairs breathing), asthma
(narrowed air passages in the
lungs,  chronic tonsilitis
(infected tonsils)
(swelling of adenoids above
the tonsils)
 Tubes in the mouth and nose can
irritate mucous lining causing swelling
and obstructing the ostia, damage the
ostia directly or introduce bacteria
when inserted 
 Dryness- impairs cilia and mucus flow
 Certain medications-antihistamines
Clinical Major Minor
manifestations  Facial pian, pressure fullness  Headaches
 Chronic nasal congestion discharge  Halitosis
 Anosmia  Fatigue, cough
 Fever  Tooth pain, ear pain pressure
fullness
Clinical  Purulent nasal discharge  Impaired mucociliary
Manifestations accompanied by nasal obstruction due clearance and ventilation
to nasal congestion   Cough -thick discharge
 Facial pain-pressure fullness in the constantly drip backward the
anterior face or periorbital region pharynx 
referred to the head (Maxillary-  Chronic hoarseness,
cheek, Frontal- above the eyebrows, headache in the periorbital
Ethmoid- in and out of the eyes, edema
Sphenoid- behind the eyes, occiput,  Chronic nasal congestion 
top of the head)
 High Fever (30degrees)  Chronic nasal discharge
 Red and edematous nasal mucosa (clear or purulent)
 Anosmia (lack of smell)  Post nasal drip
 Inspection: Head, neck, nose, ears,  Persistent nasal obstruction
sinuses pharynx are examined
 Palpation: Tenderness over the
infected sinus area
 Percussion: tapped lightly if pain 
 Transillumination of the affected area
may reveal decrease in the
transmission of light with
rhinosinusitis 
Diagnostics  Sinus aspiration- to confirm maxillary and frontal rhinosinusitis to identify
Findings the pathogen
 Sinus X rays and CT scan- to show air fluid in acute sinusitis, obstruction in
Chronic
 Nasal and sinus endoscopy-to visualize the nasal cavity and sinus drainage
pathways and can identify if deviated septum 
Nursing Diagnosis  Acute pain/ Altered Body Comfort related to inflamed sinuses
 Hyperthermia related to bacterial infection and inflammation
 Ineffective airway clearance related to acute or chronic obstruction of sinuses

Medical Antibiotics 
management  for Acute rhinosinusitis- 10-14 days. To shrink the nasal mucosa, relieves
(Treatment of pain and treat infection
sinusitis depends  for CRS and recurrent sinusitis- 2-4 weeks up to 12 months in some cases
on the cause) just to eradicate the offending organism
 Amoxicillin-cluvanic acid (Augmentin)- antibiotic of choice
 Penicillin
 Doxycycline, levofloxacin, moxifloxacin 
 Cephalosphorins- cephalexin, cefuroxime, cefalor, cefixime, trimethoprim
sulfamethoxazole
Analgesics
 NSAIDS and acetaminophen

Intranasal Saline lavage 

 can reduce inflammation and clear the passages of stagnant mucus

Topical Decongestant and nasal spray

 can increase the patency and improve drainage of the sinuses.
 pseudoepedrine 

Intranasal corticosteroids 
 to produce complete or marked improvement in acute symptoms either viral
or bacteria
 Beclomethasone
 Side effects: nasal irritation, head ache, nausea, light headedness,
rhinorrhea, watery eyes, sneezing, dry nose and throat
 Budesonide
 Side Effects: epistaxis, pharyngitis, nasal irritation, cough 
 Mometasone
 SE: headache, epistaxis, pharyngitis, nusculo-skeletal pain, arthralgia

Surgical 1. Functional Endoscopic Sinus Surgery/(FESS)

management  one of the most common surgical methods to treat chronic sinus infections. 
 In a FESS procedure, the surgeon uses a magnifying endoscope to see and
remove affected tissue and bone.
 the goal of sinus surgery is to flush out infected material, open up blocked
passages, and keep enough healthy tissue so that your nose and sinuses can
function normally.
 To correct structural deformities that obstruct the ostia (openings) of the
sinuses
 It moderately or completely relieves the symptoms in more than 81%-91%
 At the end of your sinus surgery, they will use the innovative Hydrodebrider
System. This special device delivers a powered spray to “wash out” your
sinuses, helping to remove the bacteria associated with chronic sinus
infections.
2. Cauterizing polyps, correcting of deviated septum, incising and draining the
sinuses and removal of tumors
2. Computerized Guided Surgery- is used to increase the precision of the
surgical procedure and to minimized complications 
Nursing  Apply warm compresses in the nose, face, and eye part to reduce
Interventions and pain.
Patient Education  Drink plenty of water to liquify thick secretions 
 Avoid coffee and liquor because it can cause dryness of the sinuses
 Steam the sinuses. Sniff the steam that can reduce pain lightened
the sinuses and to remove secretions. 
 Advise the patient to seek medical attention for acute sinus infection to
 prevent chronic sinus disease
 Rest. This will help to recover ahead of time and it aids to fight infection
 Elevate the head part when sleeping. This will help to lightened the sinuses 
 Instruct the patient about methods to promote drainage of the sinuses
(humidification of air and use warm compresses to relieve pressure
 Advise to avoid swimming or diving while in acute infection which may cause
contaminated water to be force into the sinus (frontal sinus)
 Stop smoking or any type of tobacco
 Instruct the client about the correct use of nasal spray through
demonstration and return demonstration to evaluate the understanding
 Stresses the importance of antibiotic therapy for complete duration 
 Tell patient with recurrent sinusitis to begin decongested (Pseudoephedrine)
at first sign of sinusitis. This promotes drainage and decreases the risk for
bacterial infection
 Teach the patient how to irrigate nasal passages with saline to remove
mucus near the sinus and enhance drainage.
 Explain to the patient about high fever, severe headache and nuchal rigidity
are signs of potential complication
 Referral to primary care provider if periorbital edema and severe pain on
palpation occur
Complications of Rhinosinusitis
 Infection from sinusitis can spread to  Frontal sinusitis can lead
the middle ear causing otitis media.  osteomyelitis of the frontal
 Serious complications may occur bones
when infection spread directly to the  Ethmoid sinusitis may lead to
bone or along venous channels of the orbital cellulitis usually begins
skull into adjacent structures such as with edema of the eyelids
the orbit or CNS  and rapidly progresses to
 Orbital cellulites- edema of ptosis (drooping of eyelid),
conjunctiva, dropping eyelid, bulging eyes, edema of
limitation of extra ocular motion and bulbar conjunctiva, and
visual loss indicate orbital cellulites diminished ocular movements
 Osteomyelitis- requires prolonged  Febrile and acutely ill require
antibiotic therapy  immediate attention, because
 Mucocele- cyst of paranasal sinuses pressure of the optic nerve
 Cavernous sinus, meningitis, brain can lead to loss of vision and
abscess spread the infection to
intracranial infection
(meningitis)