Rhinitis - Clinicals, Diagnosis, and Management

Pulmonology

Clinicals - History

Fact Explanation
Rhinorrhea One of the commonest symptoms of rhinitis. There may be inflammation of the nasal mucosa with involvement of IgE and degranulation of mast cells that lead to release of histamine and other cytokines including leukotrienes, and eosinophil cationic protein (ECP). Rhinorrhea
One of the commonest symptoms of rhinitis. There may be inflammation of the nasal mucosa with involvement of IgE and degranulation of mast cells that lead to release of histamine and other cytokines including leukotrienes, and eosinophil cationic protein (ECP).
Nasal itching Nasal itching present in most children, may be due to the release of histamine during type 1 hypersensitivity reaction. Nasal itching
Nasal itching present in most children, may be due to the release of histamine during type 1 hypersensitivity reaction.
Nasal congestion This is the most troublesome symptom, that can cause disturbances during both day and night. Nasal congestion
This is the most troublesome symptom, that can cause disturbances during both day and night.
Sneezing and snoring Snoring may be due to nasal congestion. Sneezing and snoring
Snoring may be due to nasal congestion.
Features of conjunctivitis Eyes may be red, itching, and lacrimation may be present. Features of conjunctivitis
Eyes may be red, itching, and lacrimation may be present.
Day time sleepiness Children can have sleeping disturbances during night time. Day time sleepiness
Children can have sleeping disturbances during night time.
Sinusitis and earache If the sinus cavities and eustachian tube is blocked by excess mucus production, it can cause sinusitis and ear pain. Sinusitis and earache
If the sinus cavities and eustachian tube is blocked by excess mucus production, it can cause sinusitis and ear pain.
Epistaxis Nasal bleeding can be seen in some patients with rhinitis. Epistaxis
Nasal bleeding can be seen in some patients with rhinitis.
Ansomia Loss or reduction of the smell. Ansomia
Loss or reduction of the smell.
History of exposure to allergens Allergens can trigger and exacerbate the rhinitis. Some of them are dust mites, mold spores, animal dander, and pollens. History of exposure to allergens
Allergens can trigger and exacerbate the rhinitis. Some of them are dust mites, mold spores, animal dander, and pollens.
History of bronchial asthma Rhinitis is associated with atopic conditions. Asthma is a common association with allergic rhinitis. History of bronchial asthma
Rhinitis is associated with atopic conditions. Asthma is a common association with allergic rhinitis.
History of using topical vasoconstrictors Overuse of topical vasoconstrictors may be associated with rhinitis, this is known as rhinitis medicamentosa. History of using topical vasoconstrictors
Overuse of topical vasoconstrictors may be associated with rhinitis, this is known as rhinitis medicamentosa.
Excess hygiene Hygiene hypothesis explains that increased hygiene itself can be a provocative factor for the development of allergic rhinitis. Excess hygiene
Hygiene hypothesis explains that increased hygiene itself can be a provocative factor for the development of allergic rhinitis.
Learning problems May be related to poor concentrate on their school work due to sneezing, rhinorrhea or nasal itching. Learning problems
May be related to poor concentrate on their school work due to sneezing, rhinorrhea or nasal itching.
Migraine Migraine is associated with allergic rhinitis as inflammatory mediators with vasoactive function are important in the pathogenesis of both 6he conditions. Migraine
Migraine is associated with allergic rhinitis as inflammatory mediators with vasoactive function are important in the pathogenesis of both 6he conditions.

Clinicals - Examination

Fact Explanation
Erythematous nasal mucosa There is inflammation of the nasal mucosa. Erythematous nasal mucosa
There is inflammation of the nasal mucosa.
Purulent nasal discharge This is usually associated with rhinosinusitis due to bacterial infections. 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. Gram negative organisms, anaerobic organisms and rarely fungi may be the cause. Purulent nasal discharge
This is usually associated with rhinosinusitis due to bacterial infections. 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. Gram negative organisms, anaerobic organisms and rarely fungi may be the cause.
Nasal polyps or septal deviation These can give rise to rhinitis. Nasal polyps or septal deviation
These can give rise to rhinitis.
Sinus tenderness Sinusitis can be associated with allergic rhinitis. Sinus tenderness
Sinusitis can be associated with allergic rhinitis.
Dental maloclusion This also sometimes associated with allergic rhinitis. Dental maloclusion
This also sometimes associated with allergic rhinitis.

Investigations - Diagnosis

Fact Explanation
Serum IgE level Usually increased in allergic rhinitis , together with mucosal IgE. Serum IgE level
Usually increased in allergic rhinitis , together with mucosal IgE.
Eosinophils in nasal secretion Mucosal inflammation is associated with tissue infiltration of T-lymphocytes (CD4+ T cells and CD25+ T cells) in the submucosa and epithelium. May be high especially in vasomotor rhinitis. Eosinophils in nasal secretion
Mucosal inflammation is associated with tissue infiltration of T-lymphocytes (CD4+ T cells and CD25+ T cells) in the submucosa and epithelium. May be high especially in vasomotor rhinitis.
Skin prick test Used for diagnosis of allergic disease. Allergen-specific IgE is determined by means of skin testing. Skin prick test
Used for diagnosis of allergic disease. Allergen-specific IgE is determined by means of skin testing.
Plain X-ray These will show opacification of the sinuses in nasal polyps. Plain X-ray
These will show opacification of the sinuses in nasal polyps.

Investigations - Management

Fact Explanation
Peak nasal inspiratory flow (PNIF) 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). Peak nasal inspiratory flow (PNIF)
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).
Full blood count 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. Viral infections can cause elevation of lymphocytes and reduction of platelets. Full blood count
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. Viral infections can cause elevation of lymphocytes and reduction of platelets.
Flexible fiberoptic rhinoscopy This is important to check any nasal polyps, as they can presents with rhinorrohea. Flexible fiberoptic rhinoscopy
This is important to check any nasal polyps, as they can presents with rhinorrohea.
Computerized tomography This is important before any treatment for associated nasal polyps, to see the extent of the condition. Computerized tomography
This is important before any treatment for associated nasal polyps, to see the extent of the condition.

Management - Supportive

Fact Explanation
Mucolytics 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. Mucolytics
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.
Decongestants 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. Repeated use can lead to damage of nasal epithelium. Decongestants
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. Repeated use can lead to damage of nasal epithelium.
Avoidance of the allergens Avoidance of the allergens may be important in allergic rhinitis. Avoidance of the allergens
Avoidance of the allergens may be important in allergic rhinitis.

Management - Specific

Fact Explanation
Antihistamine Antihistamines can improve nasal symptoms such as sneezing or nasal obstruction. 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. Newer drugs such as cetirizine, loratadine, desloratadine, and fexofenadine are also effective and causes less sedation. Antihistamine
Antihistamines can improve nasal symptoms such as sneezing or nasal obstruction. 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. Newer drugs such as cetirizine, loratadine, desloratadine, and fexofenadine are also effective and causes less sedation.
Corticosteroids Some use intranasal corticosteroids as first-line treatment for specially when the nasal congestion is troubling. 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.
Occasionally systemic steroids are also used for the treatment.
Corticosteroids
Some use intranasal corticosteroids as first-line treatment for specially when the nasal congestion is troubling. 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.
Occasionally systemic steroids are also used for the treatment.
Omalizumab 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. Omalizumab
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.
Cromolyn sodium Rhinorrhoes patients responds well to cromoglycate. Can be applied topically. Important to relieve bronchospasms. Cromolyn sodium
Rhinorrhoes patients responds well to cromoglycate. Can be applied topically. Important to relieve bronchospasms.
Ipratropium bromide nasal spray Ipratropium bromide is an anticholinergic drug used as a nasal spray in non allergic rhinitis. It is used to treat the nasal hypersecretion. Ipratropium bromide nasal spray
Ipratropium bromide is an anticholinergic drug used as a nasal spray in non allergic rhinitis. It is used to treat the nasal hypersecretion.
Surgical treatment Endoscopic sinus surgery and simple avulsion polypectomy are such surgeries performed to treat the nasal polyps. Surgical treatment
Endoscopic sinus surgery and simple avulsion polypectomy are such surgeries performed to treat the nasal polyps.

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