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Questions and Answers
What are common irritants associated with seasonal allergic rhinitis?
Which type of rhinitis is characterized by thinning of the nasal mucosa?
Which medication is associated with medication-induced rhinitis?
What symptom differentiates allergic rhinitis from non-allergic rhinitis?
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During which life stage can hormonal rhinitis commonly occur?
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What is the recommended duration for empiric antibiotic therapy for most common organisms in acute bacterial rhinosinusitis?
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Which antibiotic is NOT recommended for treating acute bacterial rhinosinusitis due to resistance issues?
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When treating chronic rhinosinusitis, for how long should Augmentin XR be prescribed?
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What should be checked within 48-72 hours after starting treatment for acute bacterial rhinosinusitis?
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What is a potential side effect of using decongestants for patients with hypertension?
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Which symptom is primarily associated with viral rhinitis?
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What indicates the presence of atrophic rhinitis during a physical exam?
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What is a common trigger for vasomotor rhinitis?
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Which diagnostic test is most relevant for confirming atrophic rhinitis?
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Which medication is contraindicated for treating rhinitis medicamentosa?
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What is typical for chronic rhinosinusitis in terms of symptoms?
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Which treatment method is commonly used for symptomatic relief in acute rhinosinusitis?
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What differentiates acute bacterial rhinosinusitis from acute viral rhinosinusitis?
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What is NOT a characteristic finding of allergic rhinitis on physical examination?
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Which medication option is recommended for temporally relieving rhinorrhea in non-allergic rhinitis?
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Which differential diagnosis is appropriate for nasal polyps?
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What condition is indicated by a positive eosinophil count in nasal cytology with negative allergy testing?
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What might nasal crusting and dryness during examination indicate?
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Which symptom is characteristic of hormonal rhinitis?
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Study Notes
Overview and Presentation
- Inflammation of the nasal mucosa is characterized by nasal congestion, rhinorrhea, sneezing, pruritis, and/or postnasal drainage.
- Rhinitis can be acute or chronic.
- Allergic (AR) and Non-Allergic rhinitis (NAR) are common forms.
- Common irritants for seasonal AR include pollen and mold, while dust mites, insect debris, and animal dander are common irritants for perennial AR.
Allergic Rhinitis
- Symptoms include nasal congestion, headache, clear rhinorrhea, sneezing, pruritis of nasal passages, conjunctivae, palate, pharynx, postnasal drainage, frequent throat clearing, sore throat, coughing, and epiphora.
Non Allergic Rhinitis
- Viral Rhinitis: Symptoms include sneezing, coughing, sore or burning throat, malaise, headache, occasional fever.
- Occupational/environmental: Symptoms can be triggered by weather changes, tobacco smoke, diesel or automotive fumes, strong odors, and perfumes.
- Vasomotor: Symptoms onset is rapid and can be triggered by temperature changes, exercise, and strong odors.
- Gustatory: Symptoms include acute onset of clear rhinorrhea triggered by eating hot or spicy foods.
- NARES: Nasal cytology shows increased eosinophils, but allergy testing is negative.
- Senile: Symptoms are triggered by foods, odors, and environmental irritants.
Medications/Drugs Related to Rhinitis
- Symptoms include nasal congestion, rebound nasal congestion, thick post-nasal drip, nasal crusting, frequent throat clearing, anosmia, foul odor of nose, epistaxis, perforation.
Atrophic Rhinitis
- Symptoms include nasal crusting, nasal dryness, congestion, anterior/posterior nasal drainage.
Hormonal Rhinitis
- Symptoms include nasal congestion and rhinorrhea.
Physical Exam Findings
- Mucosa appears 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 are hypertrophied.
- Clear watery discharge can progress to yellowish, greenish, or thick yellowish-white.
- Conjunctivae are inflamed and edematous.
- Allergic shiners (dark circles under eyes), Dennie Lines (wrinkle under lower lids), Allergic salute (horizontal crease across external nose) may be observed.
- Enlarged adenoids may be present in children.
- Erythema and cobblestoning may be present in the posterior pharynx.
- Wheezing may occur if concurrent asthma is present.
Diagnostics
- Diagnosis relies on history and exclusion.
- Lab workup is not indicated for uncomplicated cases.
- Exudate (colored or translucent nasal discharge) may require a CBC, bacterial culture, and a Giemsa or Wright’s-stained smear.
- Leukocytosis and polymorphonuclear neutrophils suggest infection other than a typical viral URI, while eosinophilia suggests AR.
- Allergy testing, nasal cytology, nasal mucosal biopsy, and CT Imaging may be used depending on the suspected condition.
Differentials
- Allergic
- Non-Allergic
- Atrophic
- Rhinosinusitis
- Medication/drug induced
- Hormonal
- Nasal polyposis
- Structural
- Systemic and inflammatory causes
- Cerebrospinal fluid leak
Treatment
- Focus on symptom relief and self-care.
- 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 nostril q4h prn (no more than 3 days), intranasal ipratropium 0.03% 2 sprays in each nostril 2-4x/day prn.
- Cough: Dextromethorphan 15 – 30mg PO q4h prn or Codeine 10 -15mg PO q4h prn.
- Nasal saline irrigation, 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) are also used in treatment.
Intermittent Allergic Rhinitis Treatment
- Intranasal corticosteroids, intranasal antihistamines, oral antihistamines, oral decongestants (in low doses for short periods).
Persistent Allergic Rhinitis Treatment
- Intranasal corticosteroids, nasal cromolyn, oral antihistamines, oral decongestants, immunotherapy.
Vasomotor Rhinitis Treatment
- Treat symptomatically, use humidifier, avoid environmental triggers, saline irrigation, phenylephrine 10mg q4h prn, intranasal ipratropium bromide 0.03% 2 sprays 2-4x/day prn.
Rhinitis Medicamentosa Treatment
- Stop medication, use intranasal corticosteroids for 2-3 weeks, systemic steroids prednisone 30mg PO daily x5 days may be necessary.
Atrophic Rhinitis Treatment
- Intranasal mupirocin antibiotic ointment 2-3x daily.
Desensitizing Immunotherapy
- May be used in cases of Allergic Rhinitis.
Surgery
- May be used in cases of Nasal Polyps, septal deviation and other anatomic conditions.
Patient Education and Follow Up
- Limit exposure to irritants and others with acute URI.
- Follow up in 2-3 months.
- Be aware of complications, including om, repeat respiratory infections, restless sleep, chronic fatigue, and asthma.
- Referral to allergist or otolaryngologist may be needed.
Rhinosinusitis
- Inflammation of the nasal mucosa and mucous membranes, or one or more of the paranasal sinuses (frontal, sphenoid, posterior ethmoid, anterior ethmoid, maxillary).
- Typically develops after a viral URI.
- Classified as acute, recurrent (RARS), or chronic.
- Over 95% of acute rhinosinusitis cases are caused by self-limiting viruses, only 0.5% - 2% progress to acute bacterial sinusitis.
Acute Viral (AVRS) vs Acute Bacterial (ABRS) Rhinosinusitis
- AVRS: Purulent nasal drainage presenting with focal facial pain/pressure, nasal congestion/obstruction lasting 10 days - 12 weeks.
- ABRS: Symptoms worsen after 10 days, fever > 101, focal facial pain, headache, malaise, sore throat, cough, elevated WBC count.
Chronic Rhinosinusitis
- Persistent cough with postnasal drip or cold-like symptoms lasting >12 weeks, thick mucus, popping ears, anosmia, halitosis, foul nasal odor.
Physical Exam Findings
- Nasal Exam: Purulent nasal secretions, erythema of mucosa and turbinates. Red swollen nasal mucosa (infection) vs pale swollen watery secretions (allergic).
- Sinus Exam: Palpation for tenderness of affected sinuses, ethmoid sinus involvement may lead to chemosis, proptosis, conjunctival injection, extraocular muscle palsy, and orbital fixation.
- Oral Cavity Inspection: Rule out dental abscess if maxillary cavity involvement is suspected.
- Otoscopic Exam: Check for ear popping, otalgia, hearing loss, aural fullness, to rule out Otitis Media or Otitis Media effusion.
Diagnostics
- History, Signs/Symptoms, Duration
- Lab workup and imaging are not recommended for uncomplicated cases.
- Cultures of nasal/throat secretions are not recommended.
- Sinus mucosal biopsy, sinus culture, and fiber optic rhinoscopy may be performed by an otolaryngologist in case of suspected invasive fungal infection.
- CT scan with contrast may be needed in chronic cases with complications.
- MRI may be needed if neoplasm or extension to intracranial tissues is suspected.
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
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 hrs 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: Guaifenesin 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 abx therapy for 5-10 days to cover most common organisms (S.pneumoniae, H.influenza, M.catarrhalis)
Antibiotic Therapy
- Empiric abx therapy for 5-10 days to cover most common organisms (S.pneumoniae, H.influenza, M.catarrhalis) while awaiting lab confirmation.
- Uncomplicated ABRS: Amoxicillin 500mg PO 3x/day or Amoxicillin 1G PO 2x/day, Augmentin 500mg PO 3x/day or Augmentin 875mg PO 2x/day, Doxycycline 100mg PO 2x/day (penicillin allergy).
- Macrolides are no longer recommended due to resistance to S.pneumoniae.
- Reserve fluoroquinolones as a last resort (high risk complications).
Treatment for Acute Infections
- If one course of therapy fails, treat with a second course from a different drug class x14 days.
Treatment for Chronic Rhinosinusitis
- Treat for 3-6 weeks: Augmentin XR 875 – 1000mg /125mg PO q12h, Cefuroxime 250 – 500mg PO 2x/daily, Doxycycline 100mg PO 2x/day AND clindamycin 300mg PO q6h (penicillin allergy).
Patient Education and Follow Up
- Check for improvement 48-72 hours.
- Return visit 10-14 days.
- Be aware of complications.
- Avoid cigarette smoke and allergens.
- Antihistamines can dry nasal secretions.
- Decongestants may exacerbate HTN and tachycardia.
- Drink fluids and irrigate with saline.
- Complete the full course of antibiotics.
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Description
This quiz covers the key aspects of rhinitis, including the distinctions between allergic and non-allergic types. It delves into the symptoms associated with each form and the common irritants that trigger them. Test your knowledge on the causes, symptoms, and classifications of rhinitis.
