Rhinitis: Types and Diagnosis

SUMMARY:

Rhinitis is one of the most common diseases in the United States, affecting 1 in 6 adults, in turn contributing to significant healthcare spending and loss of productivity. Rhinitis can be allergic (AR) or non-allergic (NAR) in etiology and delineating the cause of rhinitis is a crucial step in selecting appropriate therapy. Untreated, rhinitis can lead to poor sleep, chronic fatigue, memory impairment, depression, and decreased quality of life (QOL). The American Academy of Allergy, Asthma, and Immunology (AAAAI) has published a guideline to assist providers with the diagnosis and treatment of rhinitis.

Types

Allergic Rhinitis (AR)

IgE-mediated response to a specific allergen
Allergic rhinitis should be considered when ≥ 1 of the following symptoms are present: Nasal congestion | Rhinorrhea | Sneezing | Itching
Ocular symptoms such as pruritis, discharge and scleral injection are much more common in patients with AR compared to NAR
Often seen in patients with other evidence of atopy (e.g., Asthma | Eczema)
Cough can be seen as a symptom of AR, but it is generally due to concomitant asthma and not a direct effect of rhinitis
AR can further be categorized by:
- Severity: Mild (e.g., no impact on QOL) vs Moderate/Severe (e.g., impacts QOL)
- Frequency: Intermittent (e.g., < 4 days/week or < 4 consecutive weeks/year) vs. Persistent (≥ 4 days/week and ≥ 4 consecutive weeks/year)
- Environmental exposure: Seasonal (e.g., Pollens) vs. Perennial (e.g., Dust | Pet dander)

Non-allergic Rhinitis (NAR)

Rhinitis that is independent of an IgE-mediated pathway
Vasomotor rhinitis
- Can be acute or chronic
- Common trigger is cold and dry air
- Other triggers include: Temperature or humidity changes | Strong odors | Smoke | Exercise | Airborne irritants
- Symptoms vary and include: Nasal obstruction | Increased clear secretions | Cough
- Sneezing and pruritis are less common
- Pathophysiology thought to be an abnormal neurogenic pathway
Infectious rhinitis
- Can be acute or chronic
- May be a result of viral upper respiratory infection vs an active pathogen (e.g., Fungal | Bacterial)
- Watch out for development of acute infectious bacterial rhinosinusitis
- Symptoms of acute bacterial rhinosinusitis include: Nasal congestion | Mucopurulent nasal discharge | Sinus pain and pressure | Headache | Changes in smell | Post-nasal drip | Cough
- Clinical presentation is not reliable in distinguishing between viral and bacterial causes
- Patients with nasal anatomic abnormalities are more likely to have recurrent infectious rhinitis
Hormonal rhinitis
- Changes in estrogen and progesterone can lead to rhinitis symptoms
- More common during: Pregnancy | Menstruation | Menopause | Puberty
Alcohol induced rhinitis
- Result of hyperresponsiveness to the vasodilator effects of alcohol
Gustatory rhinitis
- Clear rhinorrhea following intake of certain foods (especially hot and spicy foods)
Drug-induced rhinitis
- Many drugs can trigger rhinitis symptoms including: Nasal decongestant overuse (i.e., rhinitis medicamentosa) | Calcium channel blockers | Vasodilators (e.g., Sildenafil (Viagara)) | ACE inhibitors | Gabapentin | Psychotropics
Non-allergic occupational rhinitis
- Related to exposure to large molecule irritants at work site (i.e., triggers not typically encountered outside of the work setting)
- Can also lead to aggravation of underlying NAR or AR by non-allergic irritants (e.g., Cold air | Dust | Smoke | Chemicals)
Atrophic rhinitis
- Chronic nasal condition which can be primary or secondary
- Primary atrophic rhinitis may be related to disordered bacterial colonization and is more common in young to middle aged adults outside of the US
- Secondary atrophic rhinitis is more common in America and can develop as a response to: Excessive nasal surgery | Trauma | Irradiation | Chronic granulomatous nasal infections | Inflammatory systemic diseases
- Symptoms include: Atrophy of the nasal mucosa | Resorption of underlying bone and turbinates | Nasal dryness | Foul-smelling nasal crusts | Constant awareness of a bad smell
NAR with eosinophilia syndrome (NARES)
- Nasal eosinophilia associated with perennial intermittent symptoms of rhinitis

Diagnosis

Clinicians should complete a full history and physical on patient’s presenting with symptoms of rhinitis
- Most important step in determining cause and diagnosis of rhinitis is the patient’s clinical presentation
- Most patients can be diagnosed based on clinical history alone
History should include:
- Medication review to rule out drug induced rhinitis
- Age of onset | Frequency | Severity | Timing | Triggers | Pattern of presentation | Progression
- Previously attempted treatments
- Family history of related conditions | Co-morbid conditions
- Environmental exposures
- Impact on QOL
Physical exam should include:
- Focus on upper and lower airways (e.g., Lungs | Nasal cavities | Oropharyngeal cavity)
- Skin exam: Rule out other atopic conditions (e.g., Urticaria | Eczema)
- General: Evidence of systemic disease
- Ears | Eyes
If AR is suspected, aeroallergen skin prick testing or sIgE testing to confirm diagnosis should be performed
- Clinician should not perform food skin prick testing or sIgE for foods in suspected cases of AR as food allergies will present with alternative symptoms (e.g., Emesis | Hives | Oral swelling and pain | Anaphylaxis) and not simply allergic rhinitis

Validated scoring systems may be used to determine the severity of disease and monitor disease control (e.g., Rhinitis Control Assessment Test)

Differential diagnosis

Anatomic causes of obstruction and nasal congestion including:
- Nasal septum deviation | Nasal valve collapse | Turbinate hypertrophy | Adenoidal hypertrophy
CSF leak
- Generally unilateral clear discharge that may vary with position
Nasal foreign body
- More common in children
- Can present with unilateral obstructive symptoms and foul-smelling rhinorrhea
Ciliary dyskinesia
Pharnygonasal reflux
Nasal/sinus tumor
Vasculitis | Sarcoidosis | Systemic illness

KEY POINTS:

Allergic rhinitis (AR) and non-allergic rhinitis (NAR) are the two main forms of rhinitis, an exceedingly common disease affecting roughly 1 in 6 adults in the US
A thorough clinical history and exam should be sufficient to diagnose the etiology of a patient’s rhinitis
If allergic rhinitis is suspected, aeroallergen IgE skin prick testing or sIgE testing may be done to confirm diagnosis and establish the inciting allergen