History

Fact Explanation
Rhinorrhea [1,10] One of the commonest symptoms of rhinitis. [1] There may be inflammation of the nasal mucosa [8] with involvement of IgE and degranulation of mast cells that lead to release of histamine [4] and other cytokines including leukotrienes, and eosinophil cationic protein (ECP).
Nasal itching [1,11] Nasal itching [1,2] present in most children, may be due to the release of histamine during type 1 hypersensitivity reaction.
Nasal congestion [1] This is the most troublesome symptom, that can cause disturbances during both day and night. [1]
Sneezing and snoring [2,11] Snoring may be due to nasal congestion. [1,2]
Features of conjunctivitis [11] Eyes may be red, itching, and lacrimation may be present. [3]
Day time sleepiness [1] Children can have sleeping disturbances during night time. [1,7]
Sinusitis and earache [9] If the sinus cavities and eustachian tube is blocked by excess mucus production, it can cause sinusitis and ear pain. [4]
Epistaxis [2] Nasal bleeding can be seen in some patients with rhinitis. [2]
Ansomia [10] Loss or reduction of the smell. [2]
History of exposure to allergens [6] Allergens can trigger and exacerbate the rhinitis. [1,2] Some of them are dust mites, mold spores, animal dander, and pollens.
History of bronchial asthma [6] Rhinitis is associated with atopic conditions. [3,6] Asthma is a common association with allergic rhinitis.
History of using topical vasoconstrictors [3] Overuse of topical vasoconstrictors may be associated with rhinitis, this is known as rhinitis medicamentosa. [3]
Excess hygiene [5] Hygiene hypothesis explains that increased hygiene itself can be a provocative factor for the development of allergic rhinitis. [5]
Learning problems [12] May be related to poor concentrate on their school work due to sneezing, rhinorrhea or nasal itching. [12]
Migraine [13] Migraine is associated with allergic rhinitis as inflammatory mediators with vasoactive function are important in the pathogenesis of both 6he conditions. [13]
References
  1. ADHAM TAMER M. H.. Treatment of Allergic Rhinitis With Desloratadine: Results of a Multinational Observational Study in the Middle East Gulf Region. World Allergy Organization Journal [online] 2011 August, 4(8):130-134 [viewed 01 July 2014] Available from: doi:10.1097/WOX.0b013e31822a6e9a
  2. LUND VJ, PREZIOSI P, HERCBERG S, HAMOIR M, DUBREUIL C, PESSEY JJ, STOLL D, ZANARET M, GEHANNO P. Yearly incidence of rhinitis, nasal bleeding, and other nasal symptoms in mature women. Rhinology [online] 2006 Mar, 44(1):26-31 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16550946
  3. JONES MP, WALKER MM, FORD AC, TALLEY NJ. The overlap of atopy and functional gastrointestinal disorders among 23 471 patients in primary care. Aliment Pharmacol Ther [online] 2014 Jun 25 [viewed 01 July 2014] Available from: doi:10.1111/apt.12846
  4. VAZOURAS KONSTANTINOS GI, PARTHENIOU JOTA, DIMOLIATIS IOANNIS DK. Alleviation and prevention of severe allergic rhinitis and conjunctivitis following long-term lemon juice use: a case report. Array [online] 2009 December [viewed 02 July 2014] Available from: doi:10.4076/1757-1626-2-8971
  5. STRACHAN DP. Hay fever, hygiene, and household size. BMJ [online] 1989 Nov 18, 299(6710):1259-1260 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1838109
  6. WANG DY. Risk factors of allergic rhinitis: genetic or environmental? Ther Clin Risk Manag [online] 2005 Jun, 1(2):115-123 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661616
  7. CRAIG TIMOTHY J., TEETS STEPHANIE, LEHMAN ERIK B., CHINCHILLI VERNON M., ZWILLICH CLIFFORD. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids☆☆☆★★★. Journal of Allergy and Clinical Immunology [online] 1998 May, 101(5):633-637 [viewed 02 July 2014] Available from: doi:10.1016/S0091-6749(98)70171-X
  8. GWATKIN R, PLUMMER PJ, BYRNE JL, WALKER RV. Rhinitis of Swine V. Further Studies on the Aetiology of Infectious Atrophic Rhinitis Can J Comp Med Vet Sci [online] 1951 Feb, 15(2):32-38 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1791252
  9. ALKAN A, ÇELEBI N, BAş B. Acute Maxillary Sinusitis Associated with Internal Sinus Lifting: Report of a Case Eur J Dent [online] 2008 Jan:69-72 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633157
  10. NEWTON JR, AH-SEE KW. A review of nasal polyposis Ther Clin Risk Manag [online] 2008 Apr, 4(2):507-512 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067
  11. KIM JH, KIM JE, CHOI GS, HWANG EK, AN S, YE YM, PARK HS. A Case of Occupational Rhinitis Caused by Rice Powder in the Grain Industry Allergy Asthma Immunol Res [online] 2010 Apr, 2(2):141-143 [viewed 09 September 2014] Available from: doi:10.4168/aair.2010.2.2.141
  12. MIN YG. The Pathophysiology, Diagnosis and Treatment of Allergic Rhinitis Allergy Asthma Immunol Res [online] 2010 Apr, 2(2):65-76 [viewed 09 September 2014] Available from: doi:10.4168/aair.2010.2.2.65
  13. SABERI A, NEMATI S, SHAKIB RJ, KAZEMNEJAD E, MALEKI M. Association between allergic rhinitis and migraine J Res Med Sci [online] 2012 Jun, 17(6):508-512 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634285

Examination

Fact Explanation
Erythematous nasal mucosa [1] There is inflammation of the nasal mucosa. [1]
Purulent nasal discharge [6] This is usually associated with rhinosinusitis due to bacterial infections. [3] This condition is taken into consideration if the symptoms of rhinitis does not settle after 10-14 days of onset. Streptococcus pneumoniae and Haemophilus influenzae are the most common organisms causing acute rhinosinusitis. [6] Gram negative organisms, anaerobic organisms and rarely fungi may be the cause.
Nasal polyps [5] or septal deviation These can give rise to rhinitis. [1]
Sinus tenderness [4] Sinusitis can be associated with allergic rhinitis. [1]
Dental maloclusion [2] This also sometimes associated with allergic rhinitis. [2]
References
  1. VAZOURAS KONSTANTINOS GI, PARTHENIOU JOTA, DIMOLIATIS IOANNIS DK. Alleviation and prevention of severe allergic rhinitis and conjunctivitis following long-term lemon juice use: a case report. Array [online] 2009 December [viewed 02 July 2014] Available from: doi:10.4076/1757-1626-2-8971
  2. WANG DY. Risk factors of allergic rhinitis: genetic or environmental? Ther Clin Risk Manag [online] 2005 Jun, 1(2):115-123 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661616
  3. O'HARA J, JONES NS. "Post-nasal drip syndrome": most patients with purulent nasal secretions do not complain of chronic cough. Rhinology [online] 2006 Dec, 44(4):270-3 [viewed 04 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17216744
  4. ALKAN A, ÇELEBI N, BAş B. Acute Maxillary Sinusitis Associated with Internal Sinus Lifting: Report of a Case Eur J Dent [online] 2008 Jan:69-72 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633157
  5. NEWTON JR, AH-SEE KW. A review of nasal polyposis Ther Clin Risk Manag [online] 2008 Apr, 4(2):507-512 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067
  6. ARROLL B, KENEALY T. Antibiotics for acute purulent rhinitis : Probably effective but not routinely recommended BMJ [online] 2002 Dec 7, 325(7376):1311-1312 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124786

Differential Diagnoses

Fact Explanation
Allergic rhinitis Various allergens can trigger allergic rhinitis with classic symptoms such as rhinorrhoea, itching, and sneezing. Skin test is used for see the offending agent. [1]
Vasomotor rhinitis The symptoms are same as in allergic rhinitis, but when compared to allergic rhinitis the symptoms like itching and sneezing are less common. [2] The cause of the vasomotor rhinitis may be related to problems in autonomic nervous system.
Sinusitis Patient may be having high fever, facial pain, rhinorrhea with tenderness over the sinuses. [3]
Nasal polyps Nasal polyps arise from the nasal mucosa and preset with rhinorrhoea, nasal obstruction, and anosmia. On examination there will be polyps, which may need medical and surgical treatment. [4]
References
  1. MIN YG. The Pathophysiology, Diagnosis and Treatment of Allergic Rhinitis Allergy Asthma Immunol Res [online] 2010 Apr, 2(2):65-76 [viewed 30 June 2014] Available from: doi:10.4168/aair.2010.2.2.65
  2. JONES AS, LANCER JM. Vasomotor rhinitis. Br Med J (Clin Res Ed) [online] 1987 Jun 13, 294(6586):1505-1506 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1246666
  3. WORRALL G. Acute sinusitis Can Fam Physician [online] 2011 May, 57(5):565-567 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093592
  4. NEWTON JR, AH-SEE KW. A review of nasal polyposis Ther Clin Risk Manag [online] 2008 Apr, 4(2):507-512 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067

Investigations - for Diagnosis

Fact Explanation
Serum IgE level [2] Usually increased in allergic rhinitis , together with mucosal IgE. [1,4]
Eosinophils in nasal secretion [2,4] Mucosal inflammation is associated with tissue infiltration of T-lymphocytes (CD4+ T cells and CD25+ T cells) in the submucosa and epithelium. [2] May be high especially in vasomotor rhinitis. [1]
Skin prick test [2] Used for diagnosis of allergic disease. [2] Allergen-specific IgE is determined by means of skin testing. [4]
Plain X-ray [4] These will show opacification of the sinuses in nasal polyps. [3]
References
  1. JONES AS, LANCER JM. Vasomotor rhinitis. Br Med J (Clin Res Ed) [online] 1987 Jun 13, 294(6586):1505-1506 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1246666
  2. WANG DY. Risk factors of allergic rhinitis: genetic or environmental? Ther Clin Risk Manag [online] 2005 Jun, 1(2):115-123 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661616
  3. NEWTON JR, AH-SEE KW. A review of nasal polyposis Ther Clin Risk Manag [online] 2008 Apr, 4(2):507-512 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067
  4. STONE KD, PRUSSIN C, METCALFE DD. IgE, Mast Cells, Basophils, and Eosinophils J Allergy Clin Immunol [online] 2010 Feb, 125(2 Suppl 2):S73-S80 [viewed 09 September 2014] Available from: doi:10.1016/j.jaci.2009.11.017
  5. BIST SS, BISHT M, PUROHIT JP. Primary Atrophic Rhinitis: A Clinical Profile, Microbiological and Radiological Study ISRN Otolaryngol [online] :404075 [viewed 09 September 2014] Available from: doi:10.5402/2012/404075

Investigations - Fitness for Management

Fact Explanation
Full blood count [1,2] Occasionally patient can present with fever, therefore to rule out the other conditions that can presents with fever, one should look at the platelets ,white cell count and lymphocyte count. Patient may be having increased white cell count (leucocytosis) in bacterial infections. [1] Viral infections can cause elevation of lymphocytes and reduction of platelets.
References
  1. KRAMER MS, TANGE SM, MILLS EL, CIAMPI A, BERNSTEIN ML, DRUMMOND KN. Role of the complete blood count in detecting occult focal bacterial infection in the young febrile child. J Clin Epidemiol [online] 1993 Apr, 46(4):349-57 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8482999
  2. JOUSIMIES-SOMER HR, SAVOLAINEN S, YLIKOSKI JS. Macroscopic purulence, leukocyte counts, and bacterial morphotypes in relation to culture findings for sinus secretions in acute maxillary sinusitis. J Clin Microbiol [online] 1988 Oct, 26(10):1926-1933 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC266793

Investigations - Followup

Fact Explanation
Peak nasal inspiratory flow (PNIF) [1] Usually nasal congestion due to mucus production reduces the nasal flow and patency of the nasal passages in patients with rhinitis. Nasal congestion is improved with the treatment and thus the peak nasal inspiratory flow (PNIF). [2]
References
  1. ADHAM TM. Treatment of Allergic Rhinitis With Desloratadine: Results of a Multinational Observational Study in the Middle East Gulf Region World Allergy Organ J [online] , 4(8):130-134 [viewed 27 June 2014] Available from: doi:10.1097/WOX.0b013e31822a6e9a
  2. CRAIG TIMOTHY J., TEETS STEPHANIE, LEHMAN ERIK B., CHINCHILLI VERNON M., ZWILLICH CLIFFORD. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids☆☆☆★★★. Journal of Allergy and Clinical Immunology [online] 1998 May, 101(5):633-637 [viewed 01 July 2014] Available from: doi:10.1016/S0091-6749(98)70171-X

Investigations - Screening/Staging

Fact Explanation
Flexible fiberoptic rhinoscopy [1] This is important to check any nasal polyps, [2] as they can presents with rhinorrohea. [1]
Computerized tomography [2] This is important before any treatment for associated nasal polyps, to see the extent of the condition. [2]
References
  1. SULLIVAN WB, LINEHAN AT 4TH, HILMAN BC, WALCOTT DW, NANDY I. Flexible fiberoptic rhinoscopy in the diagnosis of nasal polyps in cystic fibrosis. Allergy Asthma Proc [online] 1996 Sep-Oct, 17(5):287-92 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8922149
  2. NEWTON JR, AH-SEE KW. A review of nasal polyposis Ther Clin Risk Manag [online] 2008 Apr, 4(2):507-512 [viewed 30 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067

Management - General Measures

Fact Explanation
Mucolytics [6] These include expectorants, mucolytics, and mucokinetic drugs. Due to the inflammation, there can be mucus collection in the airway which can further blocks and damage the airway. [3]
Decongestants [4,6] Decongestants activate the alpha-adrenergic receptors on nasal mucosa. These can be applied topically or orally. Relieving the congestion helps in improving the symptoms, specially day time somnolence. eg:- pseudoephedrin hydrochlorur 60 mg once a day. [4] Repeated use can lead to damage of nasal epithelium. [1]
Avoidance of the allergens [5] Avoidance of the allergens may be important in allergic rhinitis. [2,6]
References
  1. GREENBAUM J. Topical Treatment of Allergic Rhinitis Can Fam Physician [online] 1982 Oct:1813-1815 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2306725
  2. LUND VJ, PREZIOSI P, HERCBERG S, HAMOIR M, DUBREUIL C, PESSEY JJ, STOLL D, ZANARET M, GEHANNO P. Yearly incidence of rhinitis, nasal bleeding, and other nasal symptoms in mature women. Rhinology [online] 2006 Mar, 44(1):26-31 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16550946
  3. MASOOD A, MOUMOULIDIS I, PANESAR J. Acute rhinosinusitis in adults: an update on current management Postgrad Med J [online] 2007 Jun, 83(980):402-408 [viewed 04 July 2014] Available from: doi:10.1136/pgmj.2006.054767
  4. ALKAN A, ÇELEBI N, BAş B. Acute Maxillary Sinusitis Associated with Internal Sinus Lifting: Report of a Case Eur J Dent [online] 2008 Jan:69-72 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633157
  5. WANG DY. Risk factors of allergic rhinitis: genetic or environmental? Ther Clin Risk Manag [online] 2005 Jun, 1(2):115-123 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661616
  6. MIN YG. The Pathophysiology, Diagnosis and Treatment of Allergic Rhinitis Allergy Asthma Immunol Res [online] 2010 Apr, 2(2):65-76 [viewed 09 September 2014] Available from: doi:10.4168/aair.2010.2.2.65

Management - Specific Treatments

Fact Explanation
Antihistamine [6] Antihistamines can improve nasal symptoms such as sneezing or nasal obstruction. [6] There are two generations of antihistamines. Though the first-generation antihistamines are effective for the treatment of rhinitis, they are associated with sedation. Now it is considered that second generation antihistamines are the first choice in allergic rhinitis. [2] Newer drugs such as cetirizine, loratadine, desloratadine, and fexofenadine are also effective and causes less sedation.
Corticosteroids [6] Some use intranasal corticosteroids as first-line treatment for specially when the nasal congestion is troubling. [1] Relieving the nasal congestion will be helpful in improving the snoring and sleeping disturbances. Eg:- intranasal budesonide per nostril Antiinflammatory effect of steroids will last for several hours and therefore they need repeated regular topical application. [1] Occasionally systemic steroids are also used for the treatment.
Omalizumab [6] This is a recombinant IgG1 monoclonal antibody, that only binds to IgE in the serum, and inhibits the contact of IgE with the mast cells, thus the degranulation. [4]
Cromolyn sodium [1] Rhinorrhoes patients responds well to cromoglycate. [1] Can be applied topically. Important to relieve bronchospasms.
Ipratropium bromide nasal spray [6] Ipratropium bromide is an anticholinergic drug used as a nasal spray in non allergic rhinitis. It is used to treat the nasal hypersecretion. [5]
Surgical treatment [3] Endoscopic sinus surgery and simple avulsion polypectomy are such surgeries performed to treat the nasal polyps. [3]
References
  1. GREENBAUM J. Topical Treatment of Allergic Rhinitis Can Fam Physician [online] 1982 Oct:1813-1815 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2306725
  2. JONES MP, WALKER MM, FORD AC, TALLEY NJ. The overlap of atopy and functional gastrointestinal disorders among 23 471 patients in primary care. Aliment Pharmacol Ther [online] 2014 Jun 25 [viewed 01 July 2014] Available from: doi:10.1111/apt.12846
  3. NEWTON JR, AH-SEE KW. A review of nasal polyposis Ther Clin Risk Manag [online] 2008 Apr, 4(2):507-512 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504067
  4. OKUBO KIMIHIRO, NAGAKURA TOSHIKAZU. Anti-IgE Antibody Therapy for Japanese Cedar Pollinosis: Omalizumab Update. Allergol. Int. [online] 2008 December, 57(3):205-209 [viewed 04 July 2014] Available from: doi:10.2332/allergolint.R-08-164
  5. NACLERIO R. Anticholinergic Drugs in Nonallergic Rhinitis World Allergy Organ J [online] , 2(8):162-165 [viewed 04 July 2014] Available from: doi:10.1097/WOX.0b013e3181b35336
  6. MIN YG. The Pathophysiology, Diagnosis and Treatment of Allergic Rhinitis Allergy Asthma Immunol Res [online] 2010 Apr, 2(2):65-76 [viewed 09 September 2014] Available from: doi:10.4168/aair.2010.2.2.65