Rhinitis

• Rhinitis


  Inflammation of the nasal lining, characterised by rhinorrhoea, nasal congestion, sneezing and itching. Usually viral or allergic in origin.
• Rhinitis


  • Can be perennial (persistent), being either non-allergic or allergic
  • If allergic, it could be seasonal allergic, i.e. hay fever
• Allergic Rhinitis


  Mucosal reaction in response to allergen exposure. The patient would come into contact with an allergen, which, for SAR, is usually either pollen or fungal spores.
• Allergic Rhinitis


  1. Allergen lodges within the mucus blanket lining the nasal membranes and activates immunoglobulin E IgE antibodies — formed from previous allergen exposure — on surface of mast cells

  2. Potent chemical mediators are released, primarily histamine, but also leukotrienes, kinins and prostaglandins, which exert their action via neural and vascular mechanisms

  3. Early-phase allergic reaction is the immediate response to an allergen and causes nasal itch, rhinorrhoea, sneezing and nasal congestion

  4. A late-phase reaction then occurs 4-12 hours after allergen exposure, with nasal congestion as the main symptom
• Symptoms vary from person to person and come and go throughout the season
• Moderate to severe symptoms


  If one or more of the following are present: Sleep disturbance, Impairment of daily activities, leisure and/or sport, Impairment of school or work, Troublesome symptoms
• Mild symptoms


  If none of the above are present
• Seasonal Allergic Rhinitis Triggers

  • Grass/hay pollen (May to July)
  • Tree pollen (March to May)
  • Weed pollen (March to September)
• Perennial Allergic Rhinitis Triggers

  • Moulds/fungi (August to September)
  • House dust mite faeces
  • Feathers
  • Animal dander — flakes of dead skin, fur, urine, saliva
  • Work environment — latex, flour, wood dust, chemicals etc
• Persistent Non-allergic Rhinitis Triggers

  • Smoke, strong smells, chemicals, fumes, changes in temperature or humidity
  • Puberty, pregnancy
  • Emotion/stress
  • Hot, spicy, alcohol, colourings, preservatives
  • Beta-blockers, ACE-inhibitors, aspirin and other NSAIDS, OCs and topical decongestants
• Seasonal variation


  Symptoms in the summer months suggest intermittent allergic rhinitis, whereas year round symptoms suggest perennial rhinitis
• History of asthma, eczema or intermittent allergic rhinitis in the family


  If a first-degree relative suffers from atopy, intermittent allergic rhinitis is much more likely
• Triggers


  • When pollen counts are high, symptoms of intermittent allergic rhinitis worsen
  • Infective rhinitis and vasomotor rhinitis will be unaffected by pollen count
  • Patients with persistent rhinitis might suffer from worsening symptoms when pollen counts are high, but symptoms should still persist when indoors compared with intermittent rhinitis sufferers who usually see relief of symptoms when away from pollen
• Allergic Rhinitis Management/Treatment


  1. Identify causative allergen if possible before medication is started

  2. Measures to limit exposure to the allergen will be beneficial in reducing the symptoms experienced by the patient
• Antihistamines


  • Both sedating and nonsedating antihistamines are effective in reducing the symptoms
  • Second generation ones include acrivastine, cetirizine or loratadine, which are all equally effective and considered to be nonsedative, but they aren't truly nonsedating and cause different levels of sedation
  • They compete with histamine for histamine receptors, reducing release. Therefore, reduces symptoms such as rhinorrhoea, sneezing and itch. It's also effective on eye symptoms, but has less effect on nasal congestion
• Mast cell stabilisers


  • Sodium cromoglicate can be used as a nasal spray or eye drops and it reduces the breakdown of mast cell and thus reduces release of mediators. It also lessens inflammation.
  • It has to given prior to allergen exposure (prophylaxis) and must be used regularly
• Topical Anti-inflammatories


  • E.g. corticosteroid nasal sprays such as beclometasone, fluticasone
  • 1st line for severe symptoms
  • Good for nasal congestion
  • Also ease eye symptoms
  • Inhibit release of allergic mediators from mast cells, suppress mediator response, reduce oedema and reduce migration of eosinophils and neutrophils to nasal mucosa
  • Slow acting - 2-3 weeks for max effect, need to start prior to season
  • Use once or twice daily
• Other Medications


  • Saline nasal sprays help to wash out the pollen
  • Steroid nasal sprays such as mometasone furoate, fluticasone furoate or fluticasone propionate but only to be used in moderate to severe symptoms
  • Fluticasone propionate reduces inflammation and swelling, reducing irritation. It contains a steroid to help relieve the itchiness and sneezing
• Practical Measures - Allergic Rhinitis

  • Keep windows and doors shut as much as possible
  • Monitor pollen forecast daily and stay indoors whenever possible, esp. when pollen counts are high
  • Shower and change clothes after being outside to wash pollen off
  • Put a barrier balm such as Vaseline around nostrils to trap pollen (hay fever)
  • Avoid cutting grass, large grassy areas, camping
  • Wear wrap-around sunglasses
  • Keep car windows closed, consider a pollen filter
  • Avoid areas with potentially high pollen levels as well as city centres as many intermittent allergy sufferers will have increased sensitivity to other irritants, e.g. car exhaust fumes and cigarette smoke
• Non-allergic Rhinitis Management/Treatment


  • Refer
  • Dependent on cause
  • Avoid triggers if possible
  • Topical corticosteroid may help
• Allergic Rhinitis Referral


  • Wheezing or shortness of breath
  • Tightness in chest
  • Associated ear pain
  • Painful sinuses
  • Purulent eye discharge — secondary infection
  • Severe symptoms unresponsive to therapy — may need short course of oral steroid