Podcast
Questions and Answers
What are common irritants associated with seasonal allergic rhinitis?
What are common irritants associated with seasonal allergic rhinitis?
Which type of rhinitis is characterized by thinning of the nasal mucosa?
Which type of rhinitis is characterized by thinning of the nasal mucosa?
Which medication is associated with medication-induced rhinitis?
Which medication is associated with medication-induced rhinitis?
What symptom differentiates allergic rhinitis from non-allergic rhinitis?
What symptom differentiates allergic rhinitis from non-allergic rhinitis?
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During which life stage can hormonal rhinitis commonly occur?
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?
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?
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?
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?
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?
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?
Which symptom is primarily associated with viral rhinitis?
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What indicates the presence of atrophic rhinitis during a physical exam?
What indicates the presence of atrophic rhinitis during a physical exam?
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What is a common trigger for vasomotor rhinitis?
What is a common trigger for vasomotor rhinitis?
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Which diagnostic test is most relevant for confirming atrophic rhinitis?
Which diagnostic test is most relevant for confirming atrophic rhinitis?
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Which medication is contraindicated for treating rhinitis medicamentosa?
Which medication is contraindicated for treating rhinitis medicamentosa?
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What is typical for chronic rhinosinusitis in terms of symptoms?
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?
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?
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?
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?
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?
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?
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?
What might nasal crusting and dryness during examination indicate?
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Which symptom is characteristic of hormonal rhinitis?
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.
