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 use of antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy
- Intranasal decongestants not to be used 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 to 15 percent sedation rate
Treatment of nonallergic rhinitis is similar and includes
- Avoidance of known triggers
- Topical intranasal glucocorticoids, topical antihistamines, and ipratropium have 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 |
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Picmonic
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.
Question 1 |
A 35 year-old patient has recurrent seasonal rhinitis and a history of mild asthma. Which of the following should be included for first-line management?
Immunotherapy Hint: Immunotherapy (desensitization) is indicated as a last resort in patients who fail to either respond to pharmaceutical management or face prolonged exposure to known allergens. | |
Decongestants Hint: Decongestants have a limited role in helping to decrease edema, and are generally ineffective in relieving allergic symptoms. | |
Corticosteroid inhalers | |
Cromolyn sodium (Intal) Hint: Cromolyn sodium has been found to be moderately effective for some patients with allergic symptoms, but it is not usually first-line management. |
Question 1 Explanation:
Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies.
Question 2 |
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) Hint: Azithromycin is used to treat bacterial infections not allergic disorders. | |
Phenylephrine (Neo-synephrine) Hint: Neo-synephrine is not indicated in the treatment of allergic rhinitis. | |
Nedocromil | |
Pseudoephedrine Hint: Pseudoephedrine is a decongestant that may relieve the nasal congestion, but has no effect on the allergic response. |
Question 2 Explanation:
Nedocromil inhibits mast cell degranulation and is an effective treatment for allergic rhinitis. It may take 2-6 weeks for full therapeutic effect.
Question 3 |
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 Hint: Ipratropium bromide does not alleviate the sneezing and pruritus symptoms this patient is experiencing. | |
Montelukast Hint: Montelukast is less effective than intranasal steroids in the management of allergic rhinitis. | |
Immunotherapy | |
Cromolyn sodium Hint: Cromolyn sodium is much less potent than intranasal steroids and will likely not improve the patient's symptoms. |
Question 3 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 4 |
Which physical examination finding distinguishes allergic rhinitis from other rhinitis etiologies?
Clear rhinorrhea Hint: See D for explanation. | |
Erythematous pharynx Hint: See D for explanation. | |
Nasal flaring Hint: See D for explanation. | |
Pale nasal turbinates |
Question 4 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 4 questions to complete.
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References: Merck Manual · UpToDate
