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Questions and Answers
Which symptom is most characteristic of allergic rhinitis when differentiating it from non-allergic rhinitis?
What is a common irritant associated with seasonal allergic rhinitis?
Which class of drugs is known to potentially induce rhinitis?
What condition can lead to atrophic rhinitis due to morphological changes in the nasal mucosa?
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Which of the following specifically characterizes the symptoms of allergic rhinitis?
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What is the duration for empiric antibiotic therapy in the treatment of acute bacterial rhinosinusitis (ABRS)?
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Which antibiotic is recommended for patients with a penicillin allergy when treating uncomplicated ABRS?
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Which of the following should be avoided due to potential negative effects for patients with hypertension when treating nasal congestion?
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What is the recommended length of treatment for chronic rhinosinusitis?
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When should a follow-up visit be scheduled after initiating treatment for acute rhinosinusitis?
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What condition is likely indicated by the presence of nasal cytology showing increased eosinophils yet negative allergy testing?
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Which symptom is associated with atrophic rhinitis?
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What is the primary cause of acute rhinosinusitis in most cases?
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In patients with acute bacterial rhinosinusitis, which symptom is a key indicator of worsening condition?
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Which treatment option is appropriate for relieving nasal congestion in patients with non-allergic rhinitis?
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Which physical exam finding is most consistent with allergic rhinitis?
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When treating rhinitis medicamentosa, what is the primary management approach?
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In which rhinitis condition does eating hot or spicy foods trigger an acute onset of clear rhinorrhea?
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Which of the following is NOT a typical symptom of Viral Rhinitis?
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What is a common complication associated with untreated non-allergic rhinitis?
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Which laboratory test is recommended for diagnosing NARES?
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For chronic rhinosinusitis, which of the following treatments is commonly indicated?
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What is a classic symptom indicating a movement towards acute bacterial rhinosinusitis?
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What typical finding in the nasal exam can differentiate allergic rhinitis from infectious rhinitis?
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Study Notes
Rhinitis Overview
- Inflammation of nasal mucosa marked by nasal congestion, rhinorrhea, sneezing, itching, and/or postnasal drainage.
- Can manifest as acute or chronic conditions.
- Allergic Rhinitis (AR) vs Non Allergic Rhinitis (NAR) are common forms.
- AR and Viral rhinitis are the most prevalent, distinguished by itching in AR.
- Allergic rhinitis triggers include pollen and mold for seasonal, and dust mites, insect debris, and animal dander for perennial.
Rhinitis Causes
- Medications/Drug induced: Common culprits include:
- Antihypertensives, NSAIDs, guanethidine, chlordiazepoxide, amitriptyline, aspirin, oral contraceptives, hormone therapy, prolonged nasal decongestant use, illicit drugs.
- Atrophic rhinitis: Thinning of nasal mucosa due to decreased mucociliary clearance leading to bacterial overgrowth, surgery, radiation, or inflammatory conditions.
- Hormonal rhinitis: Triggered by pregnancy, contraceptives, HRT, and puberty.
Rhinitis Presentation
- AR: Nasal congestion, headache, clear rhinorrhea, sneezing, nasal passage itching, conjunctivae, palate, pharynx, postnasal drainage, throat clearing, sore throat, coughing, epiphora (excess tearing).
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NAR:
- Viral Rhinitis: Sneezing, coughing, sore or burning throat, malaise, headache, occasional fever.
- Occupational/environmental: Weather changes, tobacco smoke, diesel or automotive fumes, strong odors, perfumes.
- Vasomotor: Temperature changes, exercise, strong odors (rapid onset of nasal congestion).
- Gustatory: Eating hot or spicy foods (acute onset of clear rhinorrhea).
- NARES: Nasal cytology shows increased eosinophils despite negative allergy testing.
- Senile: Triggered by foods, odors, and environmental irritants.
- Medications/Drugs: Nasal congestion, rebound nasal congestion, thick post-nasal drip, nasal crusting, frequent throat clearing, anosmia, foul odor of nose, epistaxis, perforation.
- Atrophic: Nasal crusting, nasal dryness, congestion, anterior/posterior nasal drainage.
- Hormonal: Nasal congestion and rhinorrhea, resolves after initial hormone increase.
Rhinitis Physical Exam
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Mucosa: Pale, boggy, edematous, pale pink or bluish hue.
- NAR or Vasomotor rhinitis: Bright red to bluish and hypertrophied turbinates.
- Rhinitis medicamentosa: Injected, edematous, dry/rubbery, pale turbinates.
- Atrophic rhinitis: Crusted, dried mucus or blood.
- Turbinates: Hypertrophied.
- Discharge: Clear watery → yellowish → greenish or thick yellowish-white.
- Conjunctivae: Inflamed, edematous.
- Allergic features: Allergic shiners, Dennie Lines, Allergic salute.
- Adenoids: Enlarged in children.
- Pharynx: Erythema, cobblestoning.
- Wheezing: May be present if concurrent asthma exists.
Rhinitis Diagnostics
- Diagnosis typically based on history and exclusion.
- Uncomplicated cases do not require lab workup.
- For cases with exudate (colored or translucent discharge), tests may include:
- CBC: To assess for leukocytosis.
- Bacterial culture: To identify specific microorganisms.
- Giemsa or Wright's-stained smear: To evaluate for leukocytosis (infection) or eosinophilia (AR).
- Allergy testing (skin and blood) may be performed.
- Nasal cytology for NARES or CSF leak investigation.
- Nasal mucosal biopsy for atrophic rhinitis.
- CT imaging for chronic sinusitis, neoplasm, polyps concerns.
Rhinitis Differentials
- Allergic, Non-Allergic, Atrophic, Rhinosinusitis, Medication/drug induced, Hormonal.
- Other potential differential diagnoses:
- Nasal polyposis
- Structural abnormalities
- Systemic and inflammatory causes
- Cerebrospinal fluid leak
Rhinitis Treatment
- Relieve symptoms, practice self-care, and avoid triggers.
- Fever and headache: Acetaminophen 325-650mg PO q4h prn.
- Rhinorrhea:
- Pseudoephedrine 30-60mg PO q4h prn.
- Phenylephrine 0.25% - 0.5% nasal spray 1-2 sprays in each nostril q4h prn (no more than 3 days).
- Intranasal ipratropium bromide 0.03% 2 sprays in each nostril 2-4x/day prn.
- Cough:
- Dextromethorphan 15- 30mg PO q4h prn.
- Codeine 10-15mg PO q4h prn
- Nasal saline irrigation is recommended.
- Expectorants: Guafinesin 200-400mg PO q4h prn or extended release 600-1200mg PO q12h prn.
- Intranasal corticosteroids for AR: Fluticasone, mometasone, triamcinolone 2 sprays each nostril daily x 2-3 weeks.
- Treatment for Vasomotor rhinitis: Symptomatic treatment, humidifier, environmental trigger avoidance, saline irrigation, phenylephrine 10mg q4h prn, intranasal ipratropium bromide 0.03% 2 sprays 2-4x/day prn.
- Rhinitis Medicamentosa: Stop medications, intranasal corticosteroids in the interim (resolves 2-3 weeks), systemic steroids (prednisone 30mg PO daily x5 days).
- Atrophic: Mupirocin antibiotic ointment intranasally 2-3x daily.
- Desensitizing immunotherapy may be considered.
- Surgical interventions for anatomical conditions (nasal polyps, septal deviation).
Rhinitis Patient Education / Follow Up
- Limit exposure to irritants and others with acute URI.
- Follow up in 2-3 months.
- Be aware of potential complications like OM, repeat respiratory infections, restless sleep, chronic fatigue, asthma exacerbation.
- Referral to an allergist or otolaryngologist as needed.
Rhinosinusitis Overview
- Inflammation of the nasal mucosa and mucous membranes of one or more of the paranasal sinuses (frontal, sphenoid, posterior ethmoid, anterior ethmoid, maxillary).
- Commonly develops after a viral URI.
- Classified as acute, recurrent (RARS), or chronic.
- Viruses are responsible for >95% of acute cases, with only 0.5% -2% progressing to acute bacterial sinusitis.
Rhinosinusitis Presentation
- Acute viral (AVRS): Purulent nasal drainage with focal facial pain/pressure and nasal congestion/obstruction lasting 10 days – 12 weeks.
- Acute bacterial (ABRS): Suspected if symptoms worsen after 10 days, fever > 101, focal facial pain, headache, malaise, sore throat, cough, elevated WBC.
- Chronic: Persistent cough with postnasal drip or cold-like symptoms lasting > 12 weeks, thick mucus, popping ears, anosmia, halitosis, foul nasal odor.
Rhinosinusitis Physical Exam
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Nasal exam: Purulent nasal secretions, erythema of mucosa and turbinates.
- Red swollen nasal mucosa (infection)-vs- pale swollen watery secretions (allergic).
-
Sinus exam: Tenderness of affected sinuses on palpation.
- Ethmoid sinus involvement: Chemosis, proptosis, conjunctival injection, extraocular muscle palsy, orbital fixation.
- Oral cavity: Inspection to rule out dental abscess if maxillary involvement is suspected.
- Otoscopic exam: Assess for ear popping, otalgia, hearing loss, aural fullness to rule out OM or OM effusion.
Rhinosinusitis Diagnostics
- Diagnosis is based on history, signs/symptoms, and duration.
- Uncomplicated cases do not require labs or imaging.
- Cultures of nasal/throat secretions are not typically recommended.
- Sinus aspirate cultures may assist with antibiotic selection (performed by an otolaryngologist).
- Sinus mucosal biopsy, sinus culture, and fiber optic rhinoscopy for suspected invasive fungal infections.
- CT scan with contrast for chronic conditions with complications.
- MRI for suspected neoplasm or intracranial tissue involvement.
Rhinosinusitis Differentials
- AVRS vs ABRS
- Recurrent acute RS
- Acute fungal RS
- Invasive fungal RS
- Chronic RS
- Mucormycosis
- Allergic vs Non-allergic rhinitis
- Nasal polyps
- Structural abnormalities
- Migraines
- Dental problems
Rhinosinusitis Treatment
- Nasal saline spray, irrigation, cool mist humidifier, increased fluid intake, heated mist to face.
- Oral analgesics for pain: Ibuprofen 400-600g every 6-8 hours prn, acetaminophen 650mg every 4-6 hours prn.
- Nasal decongestants: Phenylephrine 1-2 sprays each nostril 3-4x day prn (limit 3 days), Afrin 1-2 sprays each nostril 2-3x day prn (limit 3 days).
- Oral decongestants: Pseudoephedrine 30-60mg PO q4h prn.
- Expectorants: Guafinesin 200-400mg PO q4h prn or extended release 600-1200mg PO q12h prn.
- Intranasal corticosteroids: Fluticasone, mometasone, triamcinolone 2 sprays each nostril daily x 2-3 weeks.
- Antibiotic therapy: Empiric antibiotic therapy for 5-10 days to cover common organisms (S. pneumoniae, H. influenza, M. catarrhalis).
- Uncomplicated ABRS treatment options include:
- Amoxicillin 500mg PO 3x/day or Amoxicillin 1G PO 2x/day.
- Augmentin 500mg PO 3x/day or Augmentin 875mg PO 2x/day.
- Penicillin Allergy: Doxycycline 100mg PO 2x/day.
- Macrolides are no longer recommended due to resistance to S. pneumoniae.
- Fluoroquinolones are reserved as a last resort for high-risk complications.
- Uncomplicated ABRS treatment options include:
- Acute infections failing one course of therapy are treated with a second course from a different drug class for 14 days.
- Chronic rhinosinusitis treatment: 3-6 weeks.
- Augmentin XR 875-1000mg/125mg PO q12h.
- Cefuroxime 250-500mg PO 2x/daily.
- Penicillin Allergy: Doxycycline 100mg PO 2x/day AND clindamycin 300mg PO q6h.
Rhinosinusitis Patient Education/Follow Up
- Check for improvement 48-72 hours.
- Return visit in 10-14 days.
- Awareness of serious complications.
- Avoid cigarette smoke, allergens.
- Recognize that antihistamines dry nasal secretions.
- Be mindful that decongestants may worsen hypertension and tachycardia.
- Drink fluids and irrigate with saline.
- Complete a full course of antibiotics.
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Description
Explore the different types of rhinitis, including allergic and non-allergic forms. This quiz covers the causes, common triggers, and the physiological processes behind nasal inflammation. Test your knowledge of symptoms and treatment options associated with this condition.
