RHINITIS

• Rhinitis is defined as having two of the listed symptoms for ≥1 hour/day for ≥2 weeks
  • blockage
  • running (including postnasal drip)
  • sneezing (including nasal itch)
• Classification is shown in the chart below
• Nasal problems are often multifactorial, this needs to be taken into account when using the classification or considering treatment
• Allergic rhinitis:
  • is common and affects over 20% population every country
  • is diagnosed by history and examination, and should be backed up by specific allergy tests where identification of specific triggers will enable avoidance or affect choice of treatment
• Non-allergic rhinitis:
  • has a multifactorial aetiology
  • if eosinophilic, usually responds to treatment with corticosteroids
  • may be a presenting complaint for systemic disorders such as Wegener’s granulomatosis, Churg–Strauss syndrome and sarcoidoisis
• Infective rhinitis:
  • can be caused by viruses, and less commonly by bacteria, fungi and protozoa
  • is often more severe in allergic patients especially if infection occurs at the time of allergen exposure
  • treatment that addresses only the acute problem may result in incomplete resolution of the infection or a later recurrence
• Since the mucosa of the the nose and sinuses is continuous, rhinitis should be called rhinosinusitis

Diagnosis

• Take a history
• Nasal examination:
  • external and internal appearance
  • secretions (clear, discoloured, blood stained)
  • airflow
  • palpation
• Skin prick testing is safe, inexpensive and helps the clinician to identify an allergic trigger, as well as graphically demonstrating the problem to the patient. Consider:
  • RAST/specific IgE
  • blood tests, e.g. FBC, thyroid function

See chart below

Classification of rhinits

ALLERGIC	INFECTIVE	OTHER	PART OF SYSTEMIC DISORDER
Seasonal (SAR) Perennial (PAR) Occupational (OAR)	Acute Chronic	Idiopathic NARES (non-allergic rhinitis with eosinophilia) Drug induced: beta-blockers oral contraceptives aspirin NSAIDS local decongestants Autonomic (responds to anticholinergics) Atrophic Neoplastic	Primary defect in mucus cystic fibrosis Young's syndrome Primary ciliary dyskinesia Kartagener's syndrome Immunological systemic lupus erythematosus rheumatoid arthritis AIDS Antibody deficiency Granulomatous disease Wegener's sarcoidosis Hormonal hypothyroidism pregnancy old man's drip

* Check nasal inhalation technique and compliance.
INS=intranasal corticosteroids; SPT=skin prick test; RAST=radioallergosorbent test; QoL=Quality of Life; NSAID=non-steroidal anti-inflammatory drugs. Reproduced with kind permission from BSACI; http://www.bsaci.org

Treatment

Education

• The patient or carers should be informed about the potential impact of symptoms on sleep, work/school performance and the need for regular, prophylactic treatment
• Evidence-based education on effective forms of allergen avoidance and drug therapy, including safety and potential side effects, should be provided
• Treatment failure may be associated with poor compliance or with poor technique in the use of nasal sprays and drops, therefore appropriate training is imperative

Pharmacotherapy

• Despite allergen and trigger avoidance, many rhinitis sufferers continue to have persistent symptoms, the nature of which should determine the selection of medication
• Regular prophylactic medication, even in the absence of symptoms, is important
• Oral and topical antihistamines:
  • place in therapy:
    • first-line therapy for mild to moderate intermittent and mild persistent rhinitis
    • additional to intranasal steroids for moderate/severe persistent rhinitis uncontrolled on topical INS alone
• Oral H1-antihistamines:
  • effective predominantly on neurally mediated symptoms of itch, sneeze and rhinorrhoea
  • improve allergic symptoms at sites other than the nose such as the conjunctiva, palate, skin and lower airways
  • regular therapy is more effective than ‘as-needed’ use in persistent rhinitis
• Topical nasal H1-antihistamines (e.g. azelastine):
  • fast onset of action within 15 min, useful as rescue therapy
  • does not improve symptoms due to histamine at other sites, such as the eye, pharynx, lower airways and skin
• Topical intranasal corticosteroids (INS):
  • place in therapy:
    • first-line therapy for moderate to severe persistent symptoms and treatment failures with antihistamines alone
    • topical steroid drops should be used initially in nasal polyposis and severe obstruction
  • onset of action is 6–8 hours after the first dose, clinical improvement may not be apparent for a few days and maximal effect may not be apparent until after 2 weeks
  • starting treatment 2 weeks before a known allergen season improves efficacy
  • similar clinical efficacy for all INS but bioavailability varies considerably
  • systemic absorption negligible with mometasone and fluticasone, modest for the remainder and high for betamethasone and dexamethasone – these should be used short term only
  • long-term growth studies in children using fluticasone, mometasone and budesonide have reassuring safety data, unlike beclomethasone
  • concomitant treatment with CYP3A inhibitors such as itraconazole or ritonivir may increase systemic bioavailability of INS
  • raised intra-ocular pressure has been described with INS, patients with a history of glaucoma should be monitored more closely
• Systemic glucocorticosteroids:
  • rarely indicated in the management of rhinitis, except for:
    • severe nasal obstruction
    • short-term (25 mg/day for 7 days) rescue medication for uncontrolled symptoms on conventional pharmacotherapy
    • important social or work-related events, e.g. examinations, weddings
  • oral corticosteroids should be used briefly and always in combination with a topical nasal corticosteroid
• Anti-leukotrienes:
  • place in therapy:
    • montelukast is licensed in the UK for those with seasonal allergic rhinitis who also have concomitant asthma (UK license for age >6 months; zafirlukast UK license >12 years)
    • may be useful in patients with asthma and persistent rhinitis
• Topical anti-cholinergic (e.g. ipratropium bromide):
  • place in therapy:
    • in ‘old man’s drip’
    • as an ‘add on’ for allergic rhinitis when watery rhinorrhoea persists despite topical steroids and antihistamines
    • for autonomic rhinitis when the dominant symptom is profuse watery rhinorrhoea in response to irritant triggers or changes in temperature
  • decreases rhinorrhoea but has no effect on other nasal symptoms
  • needs to be used three times daily, and titrate dose according to response
  • also useful in the common cold
• Chromones (e.g. sodium cromoglicate):
  • place in therapy:
    • children and adults with mild symptoms only and sporadic problems in season or on limited exposure
    • cromoglicate and nedocromil eyedrops are useful in conjunctivitis as topical therapy
• Treatment failure should always provoke a review of compliance
• • If regular treatment has been unsuccessful, the diagnosis should be reviewed and the need for alternative treatment (e.g. surgery) should reassessed

Immunotherapy (desensitisation)

• For pollen-allergic patients who fail to respond sufficiently to conventional treatment

Treatment of rhinitis

*Check nasal inhalation technique and compliance
INS=intranasal corticosteroids; SPT=skin prick test; RAST=radioallergosorbent test; QoL=Quality of Life; NSAID=non-steroidal anti-inflammatory drugs. Reproduced with kind permission from BSACI; http://www.bsaci.org

Effect of therapies on rhinitis symptoms

Drug	Sneezing	Rhinorrhoea	Nasal obstruction	Nasal itch	Eye symptoms
H1-ANTIHISTAMINES
Oral	++	++	+	+++	++
Intranasal	++	++	+	++	0
Eye drops	0	0	0	0	+++
CORTICOSTEROIDS
Intranasal	+++	+++	+++	++	++
CHROMONES
Intranasal	+	+	+	+	0
Eye drops	0	0	0	0	++
DECONGESTANTS
Intranasal	0	0	++++	0	0
Oral	0	0	+	0	0
OT HER DRUGS
Anti-cholinergics	0	++	0	0	0
Anti-cholinergics	0	+	++	0	++

Referral

• ENT referral is needed for:
  • unilateral nasal problems
  • nasal perforations, ulceration or collapse
  • blood-stained discharge
  • crusting high in the nasal cavity
  • recurrent infection
  • periorbital cellulitis (refer urgently)
• Allergy clinic referral is needed for:
  • inadequate control of symptoms
  • allergen/trigger identification
  • to consider desensitisation
  • recurrent nasal polyps
  • multisystem allergy (e.g. rhinitis with asthma, eczema or food allergy)
  • occupational rhinitis

Asthma and rhinitis

• Asthma and rhinitis usually co-exist, with symptoms of rhinitis found in 75–80% of patients with asthma
• Rhinitis is a risk factor for the development of asthma
• Treatment of rhinitis is associated with benefits for asthma

Rhinitis in pregnancy

• Rhinitis affects at least 20% of pregnancies and can start during any gestational week
• Informing the patient that pregnancy-induced rhinitis is a self-limiting condition is often reassuring
• Regular nasal douching may be helpful
• Most medications cross the placenta, and should only be prescribed when the apparent benefit is greater than the risk to the foetus
• It is a good practice to start treatment with ‘tried and tested’ drugs
  • beclomethasone, fluticasone and budesonide appear to have good safety records as they are widely used in pregnant asthmatic women
  • cromoglicate may be helpful
  • chlorphenamine, loratidine and cetirizine may be added cautiously if additional treatment is needed but decongestants should be avoided
• Some antihistamines may increase the risk of spontaneous abortion or congenital malformation
• Topical corticosteroids have shown no evidence of harmful effects