168  III  ALLERGY AND RHINOLOGY

4. How does one distinguish clear rhinorrhea of rhinitis from CSF leak?
CSF leak presents with clear rhinorrhea and oftentimes has a unilateral presentation. There is
generally a history of preceding trauma though CSF leak can be spontaneous or idiopathic.
Approximately 70% to 80% of CSF rhinorrhea is attributed to accidental trauma. If there is any
doubt about a diagnosis CSF leak, qualitative β2-transferrin of nasal discharge is checked. β2
transferrin is found only in the CSF and its presence in nasal discharge therefore indicates
CSF leak.

5. What is non-allergic rhinitis with eosinophilia (NARES) and how is it

differentiated from allergic rhinitis?
NARES is a perennial cause of rhinitis and common symptoms include congestion and clear
nasal discharge. Nasal cytology demonstrates increased levels of eosinophils similar to allergic
rhinitis, though these patients do not have sensitization on skin prick testing or specific IgE
blood tests.
6. What is rhinitis medicamentosa and how is it treated?
Rhinitis medicamentosa is rebound congestion that occurs with long-term use of intranasal
decongestants that contain α-adrenergic compounds such as phenylephrine, oxymetolazine, or
xylometolazine. Rebound effect is due to downregulation of α-adrenergic receptors as well as
desensitization. Nasal sprays containing these medications should be limited to 3 to 5 days of use to
avoid the rebound effect. Treatment of rhinitis medicamentosa involves weaning the intranasal
decongestant spray, the addition of intranasal corticosteroids, and in some cases systemic
corticosteroids. In refractory cases, inferior turbinate reduction may be needed.

7. What is hormonal rhinitis?

Hormonal rhinitis is most often seen in pregnant women and about 20% to 30% of pregnant women
will develop rhinitis of pregnancy. It is felt that rhinitis of pregnancy is due to changes in estrogen
and progesterone though the mechanism remains undetermined. Symptoms generally resolve within
2 weeks after delivery. Hypothyroidism has also been implicated as a potential cause of chronic
rhinitis.

8. What is atrophic rhinitis?

Atrophic rhinitis is characterized by nasal dryness and congestion. Symptoms of atrophic rhinitis
include crusting, purulent nasal discharge, nasal obstruction, and halitosis. This form of rhinitis
typically presents in middle-aged populations. The cause of primary atrophic rhinitis is unknown and
it is uncommon in North America, but has increased prevalence in areas with warm temperatures.
Secondary atrophic rhinitis is seen in individuals who have undergone multiple aggressive sinonasal
surgeries, but is also associated with trauma and granulomatous diseases. Secondary atrophic
rhinitis is typically seen in an older population.
9. What is work-related rhinitis?
Work-related rhinitis is rhinitis that is associated with environmental exposures. Occupational rhinitis
has a prevalence of approximately 5% to 15% worldwide. The rhinitis may be allergic or nonallergic
and is further divided based on the substance causing the symptoms. Provoking substances may be
irritants, corrosives or immunogens. Irritants include perfumes, paints, dust, and smoke. Corrosive
rhinitis is associated with high levels of exposure to chemicals such as chlorine, sulfur dioxide, and
ammonia. Immunologic exposure results in an IgE mediated response and include animal danders
and grains. To diagnose work-related rhinitis it is helpful to have patients keep a diary of the timing
of their symptoms.
10. What is gustatory rhinitis?
Gustatory rhinitis is a noninflammatory rhinitis that presents with symptoms of rhinorrhea and/or
postnasal drip following eating. It is more common with spicy or hot foods and is also more
common in the elderly. Current prevalence is unknown and the mechanism is thought to be due to
parasympathetic activation.
11. What are the common drugs associated with rhinitis?
Angiotensin-converting enzyme inhibitors, β-adrenergic blockers, amiloride, hydralazine, many
psychotropic medications, and phosphdiesterase-5 inhibitors.

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