PANCE Blueprint EENT (7%)

Rhinitis (ReelDx)


Allergic Rhinitis

A 6-year-old girl with increasing bilateral nosebleeds over the past week

Patient will present as → a 13-year-old boy with clear fluid discharge from his nose for 2 days duration. This has also been associated with sneezing. On nasal exam, the mucosa and turbinates appear edematous and slightly bluish. He has swollen dark circles under his eyes and a transverse nasal crease.

Rhinitis is inflammation and swelling of the mucous membrane of the nose, characterized by a runny nose and stuffiness - it can have allergic and nonallergic causes

  • Allergic rhinitis is an immunoglobulin E (IgE)– mediated reactivity to airborne antigens (e.g., pollen, molds, danders, dust). It commonly occurs in people who have other atopic diseases (e.g., asthma, eczema, atopic dermatitis) and those with a family history
    • Patients will present with boggy turbinates, allergic shiners (edematous, dark circles under eyes), and allergic salute: transverse nasal crease (from pushing up on the nose)
  • Nonallergic rhinitis has symptoms similar to those of hay fever (allergic rhinitis) but with none of the usual evidence of an allergic reaction. The exact cause of nonallergic rhinitis is unknown
    • Triggers of nonallergic rhinitis symptoms vary and can include certain odors or irritants in the air, weather changes, some medications, certain foods, and chronic health conditions.

Allergic rhinitis can almost always be diagnosed based on history alone

  • Diagnostic testing is not routinely needed unless patients do not improve when treated empirically; for such patients, skin tests or an allergen-specific serum IgE test is done

Nonallergic perennial rhinitis is usually also diagnosed based on history

  • Lack of clinical response to treatment for assumed allergic rhinitis and negative results on skin tests and/or an allergen-specific serum IgE test also suggests a nonallergic cause

Treatment of allergic rhinitis includes the avoidance of any known allergens and the use of antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy

  • Intranasal decongestants are not to be used for more than 3-5 days
  • Rhinitis medicamentosa is caused by the overzealous use of decongestant drops or sprays containing oxymetazoline or phenylephrine. This causes rebound congestion, which prompts increased use of the agent, creating a vicious cycle.
    • To treat, discontinue the irritant. It may be quite uncomfortable for the patient; sometimes, the use of topical corticosteroids is warranted through the withdrawal period
  • Even “nonsedating” antihistamines have a 15 percent sedation rate
  • Referral to an allergist/immunologist is advised for patients experiencing moderate-to-severe or prolonged symptoms of allergic rhinitis, those with coexisting conditions such as asthma or nasal polyposis, individuals with significant allergic complications, or for those interested in or needing immunotherapy options

Treatment of nonallergic rhinitis is similar and includes

  • Avoidance of known triggers
  • Topical intranasal glucocorticoids, topical antihistamines, and ipratropium have been shown to be beneficial
    • Topical anticholinergic, ipratropium nasal spray (0.03%), two sprays in each nostril 3 times daily, is effective for cold-air-induced rhinitis
  • Treatments effective for allergic rhinitis (oral antihistamines and cromolyn) may be added in mixed rhinitis

osmosis Osmosis
Rhinitis treatments

Treatment includes avoidance of any known allergens and use of antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy.

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Cromolyn (mast cell stabilizers)
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Montelukast (Singulair)
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First generation H1 blockers
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Second generation antihistamines
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Question 1
A 22-year-old woman presents with sneezing, runny nose, postnasal drip, and nasal congestion for the last week. She says this happens every spring. She is not allergic to any medications. Which of the following is the most appropriate pharmacologic treatment for this patient?
Azithromycin (Zithromax)
Azithromycin is used to treat bacterial infections not allergic disorders.
Oral corticosteroids
Oral corticosteroids are not typically first-line for seasonal allergic rhinitis unless the symptoms are severe and unresponsive to other treatments.
Intranasal corticosteroids
Pseudoephedrine is a decongestant that may relieve the nasal congestion, but has no effect on the allergic response.
Question 1 Explanation: 
Along with a minimally sedating oral antihistamine intranasal corticosteroids are considered first-line treatment for moderate to severe allergic rhinitis. They reduce inflammation and symptoms such as sneezing, itching, and nasal congestion. The can be administered regularly or as needed. For predictable exposures it's best to initiate therapy two days before, continuing through, and for two days after the end of exposure.
Question 2
A 9 year-old patient presents for follow up of his allergic rhinitis symptoms. He continues to complain of nasal congestion, sneezing, rhinorrhea, and eczema despite avoidance therapy and treatment with oral cetirizine (Zyrtec) and nasal flunisolide (Nasarel). Examination reveals pale, boggy nasal mucosa and eczema of the face and lower extremities. Which of the following is the most appropriate treatment at this time?
Ipratropium bromide
Ipratropium bromide does not alleviate the sneezing and pruritus symptoms this patient is experiencing.
Montelukast is less effective than intranasal steroids in the management of allergic rhinitis.
Cromolyn sodium
Cromolyn sodium is much less potent than intranasal steroids and will likely not improve the patient's symptoms.
Question 2 Explanation: 
Immunotherapy is recommended in patients with severe allergic rhinitis who fail to respond to drug therapy and allergen avoidance. This patient has failed avoidance therapy, as well as antihistamines and intranasal corticosteroids.
Question 3
Which physical examination finding distinguishes allergic rhinitis from other rhinitis etiologies?
Clear rhinorrhea
See D for explanation.
Erythematous pharynx
See D for explanation.
Nasal flaring
See D for explanation.
Pale nasal turbinates
Question 3 Explanation: 
On physical examination, the mucosa of the turbinates is usually pale or violaceous with allergic rhinitis because of venous engorgement in contrast to the erythema of viral rhinitis.
There are 3 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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