Health Questions and Answers

Rhinitis

Define rhinitis.
Rhinitis is tissue inflammation and nasal hyperfunction that leads to nasal congestion/obstruction, rhinorrhea, nasal itching, and/or sneezing. Although rhinitis is generally not life-threatening, it is associated with significant loss of productivity and decreased quality of life.

What pathophysiology underlies rhinitis?
Nasal congestion arises from engorgement of blood vessels due to the effects of vasoactive mediators and neural stimuli. Rhinorrhea is due to hypersecretion of the nasal glands, leading to tissue transudate. The autonomic nervous system mediates both vascular tone and secretions. Sympathetic innervation constricts the vessels, decreasing congestion, whereas the parasympathetic innervation vasodilates the vessels, enhancing congestion. Itching occurs in association with histamine release from mast cells and basophils secondary to antigenic stimulation.

Is there a link between rhinitis and asthma?
Yes. It is becoming more and more clear that the upper airway and lower airway are linked, and the term “the united airways” has been coined by some. The similarities are that they are both lined by columnar epithelium and the airway epithelium is at the center of pathogenesis in both rhinitis and asthma. Rhinitis is a strong independent risk factor for asthma (perennial greater than allergic) and up to 40% of allergic rhinitis patients have asthma. Also, the severity of a patient’s allergic rhinitis has been shown to correlate with the asthma severity. However, the comparison of upper and lower airway is not absolute. Pathophysiologically, the lower airway exhibits more epithelium shedding than the upper airway, and eosinophilia is more predominant in the lower airway of persons with asthma.

How is rhinitis categorized?
Rhinitis can be divided into allergic and nonallergic types.

Allergic Rhinitis

Describe the allergic response in allergic rhinitis.
The primary phase involves a type 1 Gell and Coombs type of hypersensitivity with the antigen binding to immunoglobulin (Ig) E receptors, causing mast cells and basophils to release mediators such as histamine, serotonin, leukotrienes, and prostaglandins. This phase occurs within 5 minutes of antigen exposure. The late phase (secondary phase) occurs 4-6 hours after antigen exposure and involves the migration of inflammatory cells (neutrophils and eosinophils) and the release of mediators by basophils.

What are the “allergic salute,” “allergic shiners,” and “allergic gape”?
Patients (particularly children) with persistent rhinorrhea often wipe the nose in a upward direction with the palm of the hand, which has been referred to as the allergic salute. Consequently, these patients may have a horizontal crease in the skin of the lower nose by the tip. Also, patients with allergic rhinitis can have darkened areas under their eyes, which are referred to as allergic shiners. The allergic gape is a characteristic open mouth from nasal obstruction causing mouth breathing.

What complications are associated with allergic rhinitis?
Poorly controlled symptoms of allergic rhinitis can lead to a surprising amount of disability, with reported 3.5 million work days lost and 2 million school days missed. Consequences include sleep loss with daytime somnolence, significant cognitive disability, and reduced quality of life. Children in particular can suffer psychosocial detriment and learning difficulties. Quality of life is affected more by rhinitis than by asthma. Subsequent pathologies can evolve, including sinusitis, otitis media with hearing loss, abnormal craniofacial abnormalities, and/or aggravation of asthma. Some treatments for allergic rhinitis may also indirectly contribute to lack of productivity, such as first-generation H1 antihistamines that, unfortunately, are sedating.

How do antihistamines aid in the treatment of allergic rhinitis?
Antihistamines act by blocking H1-receptor sites, thereby interfering with mast cell and basophil histamine release. Although the first-generation antihistamines are associated with drowsiness, the newer ones are nonsedating and, where applicable, should be preferred over the first-generation drugs. Interestingly, the newer antihistames have also been found to exhibit a degree of anti-inflammatory effect. They can be used orally or intranasaly and reduce rhinorrhea, itching, and sneezing, as well as some blockage. Nasal antihistamines have a significantly faster onset of action than oral antihistamines.

How do steroids aid in treating allergic rhinitis?

Topical steroids decrease local inflammation caused by vasoactive mediators, decrease rhinorrhea by reducing the reactivity of acetylcholine receptors, decrease basophil and eosinophil counts, and decrease sneezing by desensitizing irritant receptors. Because of a slow onset of action, it can take days or a week to obtain maximum benefits.

What role does ipratropium bromide play in the treatment of allergic rhinitis?
Ipratropium bromide is a topical anticholinergic agent that antagonizes the effect of acetylcholine at parasympathetically innervated submucosal glands. It is effective in reducing the mucosal gland hypersecretion that causes rhinorrhea, but it is ineffective against the other symptoms of congestion, itching, and sneezing. Combining ipratropium with nasal steroids produces a greater effect on rhinorrhea than either alone. Its use may be beneficial in a select group of patients in whom rhinorrhea predominates over other symptoms.

How may immunotherapy benefit patients with allergic rhinitis?
Immunotherapy can be effective in patients who are sensitive to allergens for which a potent extract is available and who have severe symptoms that fail medical management. Age and comorbidity limit patient suitability and there can be serious adverse effects, including anaphylaxis. The treatment involves injecting the offending antigen into the patient. Improvement can require many months and, if it occurs, therapy should continue for 3-5 years. Although there are many proposed mechanisms, the overall mechanism behind the relief of immunotherapy is unknown.

Non Allergic Rhinitis

List the causes of nonallergic rhinitis.

  • Pharmacology (rhinitis medicamentosa)
  • Infection
  • Structural abnormalities
  • Irritatation
  • Hormonal factors
  • Atrophy
  • Substance abuse (e.g., cocaine, alcohol, nicotine)
  • Foreign bodies
  • Trauma
  • Temperature
  • Exercise
  • Recumbency
  • Emotions
  • Decreased nasal airflow states (e.g., after laryngectomy or tracheostomy)
  • Systemic diseases (e.g., Wegener’s granulomatosis, sarcoid, superior vena cava syndrome, and Horner’s syndrome)
  • Idiopathic disease (e.g., vasomotor rhinitis, eosinophilic or basophilic nonallergic rhinitis)

What is rhinitis medicamentosa?
Rhinitis medicamentosa is drug-induced rhinitis that is caused by rebound nasal congestion. It is often associated with prolonged use of topical decongestants. It is thought that a semi-ischemic state is induced by the strong vasoconstrictive effect of topical decongestants. With time, this effect leads to the metabolic accumulation of vasodilators that are responsible for the rebound vasodilation. The condition can become irreversible with the development of vascular atony. Also, benzalkonium chloride, a preservative in some vasoconstrictor preparations, can cause mucosal irritation and decreased mucoilliary clearance via ciliostasis and can exasperate rhinitis medicamentosa.

How is rhinitis medicamentosa treated?
The administration of topical decongestants should be discontinued. Systemic decongestants (if appropriate) and nasal saline spray can provide symptomatic relief. Also, the administration of topical steroids can be started to decrease congestion and the withdrawal effect. It is paramount that the patient is educated on “abuse” of topical decongestants and that he or she understands that the topical steroids will not give the normal fast response of the decongestant and that days may be required for a maximal effect to occur. Without this information, the patient could revert to his old habits, dissapointed with the steroid effect. Furthermore, the initial cause of obstruction that led to the use of topical decongestants should be specifically treated (e.g., allergy, structural problem, infection).

Name some structural abnormalities that can cause rhinitis.

  • Deviated nasal septum
  • Turbinate hypertrophy
  • Nasal valve collapse
  • Polyps
  • Neoplasms (e.g., papilloma, angiofibroma, malignancy)
  • Intranasal and extranasal deformities

What is occupational rhinitis? How does the effect of irritants in nonallergic rhinitis differ from an allergic response?
Occupational rhinitis is divided into two types: (1) irritants that cause rhinitis and (2) allergic rhinitis. Dust, gases (e.g., formaldehyde), chemicals, and air pollution (e.g., smoke, sulfur dioxide) can cause nasal congestion and rhinorrhea via direct irritative effects on the mucosa. In contrast, an allergic response is due to interaction with IgE antibodies and histamine-releasing cells. Accordingly, the history for irritant rhinitis involves transient symptoms when exposed to the irritant, and as toxic damage to the mucosa occurs, the symptoms may not abate with short rest periods or on cessation of work. With allergic rhinitis, the symptoms generally improve with short rest periods and disappear after exposure to the allergen.

Describe the endocrine or hormonal causes of nonallergic rhinitis.
Pregnancy, menstruation, and oral contraceptive use can all cause nasal congestion. The increased estrogen levels associated with these states inhibit acetylcholinesterase, leading to increased parasympathetic tone and tissue edema. Hypothyroidism is also associated with rhinitis. In this state, parasympathetic activity predominates over the hypoactive sympathetic state, causing vasodilation of the nasal mucosa.

What is atrophic rhinitis?
Atrophic rhinitis, or ozena, is associated with atrophy of the nasal mucosa and turbinates in association with excessive crusting and mucopurulent discharge. This socially debilitating condition is marked by an extremely foul odor that can be easily detected by others. Patients often complain of epistaxis, nasal obstruction, headaches, and the foul smell. Although the cause is unknown, hereditary, infectious, developmental, nutritional, and endocrine factors have been implicated. Atrophic rhinitis may also be iatrogenic because it may be associated with excessive turbinate resection. Although no cure exists, treatment revolves around frequent saline irrigation and topical antibiotics. Surgical options have been aimed at narrowing the nasal cavity and nostril.

Date Last Updated: 03/08/2010
Reference:

  1. Bernstein L: Is the use of benzalkonium chloride as a preservative for nasal formulations a safety concern? A cautionary note based on compromised mucociliary transport. J Allerg Clin Immunol 105(1 pt 1):39-44, 2000.
  2. Blaiss MS: Cognitive, social, and economic costs of allergic rhinitis. Allergy Asthma Proc 21:7-13, 2000.
  3. Cummings CW, Frederickson JM, Harker LA (eds.): Otolaryngology-Head & Neck Surgery, 3rd ed. St. Louis, Mosby-Year Book, 1998.
  4. Mehle M: Are nasal steroids safe? Curr Opin Otolaryngol Head Neck Surg 11:201-205, 2003.
  5. Murray J, Rusznak C: Asthma and rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 11:49-53, 2003.
  6. Pasha R: Otolaryngology Head and Neck Surgery: Clinical Reference Guide. San Diego, Singular, 2000.
  7. Rosenwasser LJ: Treatment of allergic rhinitis. JAMA 113:17S-24S, 2002.
  8. Salib RJ, Drake-Lee A, Howarth PH: Allergic rhinitis: Past, present, and the future. Clin Otolaryngol 28:291-303, 2003.
  9. Schoenwetter WF: Allergic rhinitis: Epidemiology and natural history. Allergy Asthma Proc 21:1-6, 2000.
  10. Settipane RA: Complications of allergic rhinitis. Allergy Asthma Proc 20:209-213. 1999.
  11. Vinuya R: Upper airway disorder and asthma: A syndrome of airway inflammation. Ann Allergy Asthma Immunol 88(4 Suppl): 8-15, 2002.

One Response to “Rhinitis”

  1. Allergic Shiners Says:

    Allergic shiners is just a manifestation of nasal allergies such as allergic rhinitis. Although there is nothing to fear, you must take precautions to avoid it

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