Rhinitis

Rhinitis refers to inflammation of the nasal mucosa. The condition is classified into allergic, nonallergic, and infectious rhinitis. Allergic rhinitis is due to a type I hypersensitivity reaction. Non-allergic rhinitis is due to increased blood flow to the nasal mucosa. Infectious rhinitis is caused by an upper respiratory tract infection. All 3 types present with nasal congestion, rhinorrhea, and sneezing. Diagnosis is mainly clinical. Management includes antihistamines, decongestants, and immunotherapy.

Last update:

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Epidemiology and Etiology

Epidemiology

  • Infectious rhinitis (“common cold” or upper respiratory infection [URI]):
    • Most common form
    • Common in children. Estimated incidence: 6 episodes per patient per year
    • Approximately 8% of URIs are complicated by rhinosinusitis in children aged 6–35 months
    • Genetic disorders, such as Kartagener syndrome (with immobile cilia) impair mucosal ciliary movement and predispose individuals to recurrent rhinosinusitis episodes
  • Allergic rhinitis:
    • Most common type of rhinitis
    • Occurs in approximately 10%–30% of adults and up to 40% of children annually in the United States
    • Increased risk in individuals with atopy, including eczema or asthma
  • Non-allergic rhinitis:
    • Affects up to approximately 7% of the population in the United States
    • Occurs later in life than allergic rhinitis
    • 70% of patients present > 20 years of age; more common in females

Etiology

InfectiousAllergicNon-allergic
Usually caused by a viral or bacterial infectionType I hypersensitivity reactionAn increase in blood flow to the nasal mucosa due to irritants, but not allergens
Acute:
  • Viral: rhinovirus (most common), coronavirus, influenza virus, adenovirus, parainfluenza virus
  • Bacterial: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Escherichia coli, Klebsiella
Chronic:
  • Fungal: Aspergillus, Rhizopus oryzae
  • Associated with immunodeficiency disorders
  • Seasonal (e.g., pollens, molds)
  • Perennial (e.g., house dust, mites)
  • Occupational (e.g., animal antigens; can be included in non-allergic if caused by irritants rather than allergens)
  • Rhinitis medicamentosa (e.g., overuse of decongestant nasal sprays)
  • Drug-induced rhinitis (e.g., antihypertensives, nonsteroidal anti-inflammatory drugs [NSAIDs])
  • Pregnancy rhinitis
  • Honeymoon rhinitis
  • Gustatory rhinitis (e.g., response to hot or spicy foods)
  • Non-airflow rhinitis (e.g., structural abnormalities)
  • Atrophic rhinitis

Pathophysiology

Infectious rhinitis

  • Viruses typically use intercellular adhesion molecule-1 host receptor to enter into nasal epithelial cells. 
  • Signaling within cells occurs via NF-kB leading to the elaboration of pro-inflammatory cytokines, which leads to:
    • Plasma exudation from submucosal capillaries
    • Recruitment of polymorphonuclear cells to nasal epithelium via interleukin-8
  • Local production of cytokines and kinins results in the classic symptoms of infectious rhinitis/the common cold.

Allergic rhinitis

Type I hypersensitivity reaction triggers inflammation in the nose, which is immunoglobulin E (IgE)-mediated.

  • After initial exposure to an allergen in atopic individuals, IgE antibodies bind to IgE receptors on mast cells throughout the respiratory mucosa and to basophils in the peripheral blood.
  • B cells then differentiate into plasma cells and produce IgE antibodies specific to the antigen.
  • When the same allergen is inhaled, IgE antibodies are bridged by the allergen’s antigen.
  • Mast cells and basophils are activated → release of histamine, leukotrienes, and kinins + inflammatory infiltrates with eosinophils → sneezing, rhinorrhea, and congestion (symptoms of allergic rhinitis)

Non-allergic rhinitis

  • No single unifying pathogenesis theory
  • Hormonal or autonomic stimuli produce a decrease in sympathetic activity and/or an increase in parasympathetic activity.
    • Sympathetic stimulation causes vasoconstriction of the nasal blood vessels (so decreased activity causes reduced vasoconstriction when needed).
    • Parasympathetic stimulation causes vasodilatation of the nasal blood vessels and increased mucous secretions (so increased activity causes an over-response).
  • Other abnormal responses to neurogenic stimuli include increased concentrations of vasoactive intestinal peptide (potent vasodilator) and substance P (pain reception).
  • Subtypes:
    • Rhinitis medicamentosa: rebound phenomenon after excessive use of decongestant nasal drops, usually seen after 3 consecutive days of use
    • Drug-induced rhinitis: caused by antihypertensives and NSAIDs
    • Pregnancy rhinitis: persistent edema of the nasal mucosa and even airway obstruction may be caused by hormonal changes during pregnancy.
    • Honeymoon rhinitis: occurs following intense sexual excitement
    • Gustatory rhinitis: associated with spicy food and/or alcohol, which stimulates the palatine sensory receptors and produces a cholinergic response
    • Non-air flow rhinitis: associated with choanal atresia and tracheostomy
Pathological changes in non-allergic rhinitis

Pathological changes in non-allergic rhinitis. When the nasal mucosa is exposed to irritants, goblet cells overcrowd normal epithelia, causing mucin hypersecretion and decreased mucociliary activity, leading to congestion and other symptoms of rhinitis.

Image by Lecturio.

Clinical Presentation

General symptoms of rhinitis include:

  • Nasal congestion: Can increase sinus pressure, which leads to headaches
  • Rhinorrhoea: The color of the nasal secretion may vary (clear, yellow, or green) in infectious rhinitis.
  • Sneezing
  • Post-nasal drip
  • Itching (usually of the nose, eyes, and/or throat)
  • Conjunctival symptoms:
    • Bilateral watery eyes
    • Conjunctival injection
    • Itching or burning
    • Sensation of a foreign object
  • Snorting, sniffing, coughing, clearing throat, palatal click
  • Other constitutional symptoms may be seen, such as fever, malaise, chills, irritability, etc.
  • Physical findings (see descriptions in Diagnosis):
    • Allergic shiners
    • Allergic facies
    • Allergic salute
    • Dennie-Morgan lines

Specific symptoms for the individual categories of rhinitis include the following:

  • Infectious rhinitis is more likely to lead to complications:
    • Sinusitis
    • Otitis media
    • Croup
    • Pharyngitis
    • Secondary bacterial pneumonia
  • Allergic rhinitis presents in recurrent episodes easily linked to a specific allergen. Associated conditions include:
    • Allergic conjunctivitis
    • Atopic dermatitis
    • Bronchial asthma
  • Non-allergic rhinitis is characterized by the chronic presence of nasal congestion, rhinorrhea, and postnasal drainage. It is distinguished via:
    • Its late onset
    • Absence of sneezing and facial itching
    • Congestion and drainage (prominent symptoms)
    • Perennial symptomatology

Diagnosis

Diagnosis is clinical, based on characteristic symptoms, suggestive clinical history, and supportive physical exam findings.

  • Characteristic symptoms: sneezing, rhinorrhea, nasal itching and congestion, postnasal drip, cough, fatigue, etc.
  • Suggestive clinical history (depending on the form of rhinitis):
    • Pattern of episodes
    • Chronicity
    • Seasonal variation of symptoms
    • History of medication 
    • Presence of co-existing conditions
    • Occupational exposures
    • Environmental history
    • Identification of precipitating factors
  • Physical exam findings
    • Allergic shiners: infraorbital edema and darkening
    • Dennie-Morgan lines: lines or folds below the lower lids
    • Allergic salute: transverse nasal crease caused by rubbing of the nose
    • Allergic facies: open mouth due to mouth breathing with highly arched palate and dental malocclusion
    • Pale nasal mucosa that is sensitive to touch
    • Edematous nasal turbinates
    • Clear rhinorrhea
    • Retracted tympanic membranes with serous fluid build-up
    • Potential surgically correctable conditions:
      • Deviated nasal septum
      • Polyps
      • Enlarged turbinates
  • Allergen skin test, in-vitro testing, or radioallergosorbent test (RAST) is useful in detecting allergic rhinitis but not necessary for making a diagnosis. RAST measures serum concentrations of IgE antibodies against a specific allergen.
  • Routine laboratory findings are typically normal and not indicated in diagnosis.

Management

Infectious rhinitis

  • The mainstay of treatment is symptomatic and supportive, as most cases of infectious rhinitis are of viral etiology, which is self-limiting and resolves spontaneously and steadily within a few days.
  • Some patients may require antibiotics for laboratory-documented bacterial pharyngitis.
    • Treat rhinitis due to group A beta-hemolytic streptococci with PO penicillin or amoxicillin for 10 days (cephalexin if penicillin is known to cause rash; clindamycin or macrolide if penicillin is known to cause anaphylaxis).
    • Timely treatment is crucial for the prevention of acute rheumatic fever.
  • Other underlying causes of rhinitis need to be identified and treated (e.g., retroviral therapy for HIV, penicillin for group A streptococcus, nystatin for candida).

Allergic rhinitis

  • Avoidance of causative allergens (e.g., pollen, dust, animal fur)
  • First-line options that may be used orally or as intranasal sprays:
    • Antihistamines (e.g., fexofenadine, diphenhydramine, desloratadine, cetirizine, loratadine, azelastine)
    • Decongestants or sympathomimetics (e.g., pseudoephedrine, phenylephrine)
    • Corticosteroids (e.g., budesonide, fluticasone) 
    • Anticholinergics (e.g., ipratropium bromide)
    • Mast cell stabilizers (e.g., cromolyn sodium nasal spray)
  • Second-line options:
    • Leukotriene receptor antagonists (e.g., montelukast) 
    • Immunotherapy (e.g., controlled exposure to gradually increasing doses of the allergen to downregulate the IgE response) 
    • Resection of hypertrophic nasal turbinates or polyps
    • Nasal saline irrigation

Non-allergic rhinitis

  • Correct the underlying cause (e.g., discontinue medication, correct choanal atresia, avoid consumption of spicy food and other triggers).
  • First-line medical options:
    • Topical antihistamines (e.g., azelastine)
    • Topical intranasal glucocorticoids (e.g., fluticasone)
  • Second-line medical options:
    • Combination of topical antihistamines and topical intranasal glucocorticoids
    • Decongestants or sympathomimetics (e.g., pseudoephedrine) 
    • Nasal lavage with hypertonic NaCl solution 
    • Resection of hypertrophic nasal turbinates or polyps

Differential Diagnosis

  • Nasal polyps: benign lesions of the nasal mucosa or paranasal sinuses due to chronic mucosal inflammation that present with postnasal drip, bilateral nasal obstruction, and impaired olfactory function
  • Foreign nasal body: common in children < 5 years old. Often involves food items or small toys. Presents with unilateral rhinorrhea that can become foul-smelling or purulent, signs of nasal obstruction, or epistaxis.
  • Deviated nasal septum: a deviation of the nasal septum from the midline that can lead to unilateral dyspnea, nasal congestion, and snoring
  • Adenoid hypertrophy: enlargement of the pharyngeal tonsils. Common among children. Presents with mouth breathing, mucopurulent nasal discharge, snoring, and/or impaired hearing.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details