Patient information: Rhinitis

Robert H Fletcher, MD

UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.2 is current through April 2007; this topic was last changed on November 27, 2006. The next version of UpToDate (15.3) will be released in October 2007.
OVERVIEW — Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and post-nasal drip (the sensation that mucus is draining from the sinuses down the back of the throat).
Almost everyone experiences rhinitis at some point during their life. Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses (eg, the common cold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs, some medical conditions, and other unidentifiable factors.
For many people, rhinitis is a lifelong condition that waxes and wanes over time. Fortunately, the symptoms of rhinitis can usually be controlled with a combination of environmental measures, medications, and immunotherapy (also called allergy shots).
ALLERGIC RHINITIS — Allergic rhinitis, also known as hay fever or grass fever, affects approximately 20 percent of people of all ages. The risk of developing allergic rhinitis is much higher in people with asthma or eczema, and in people who have a family history of asthma or rhinitis.
Allergic rhinitis can begin at any age, although most people first develop symptoms in childhood or young adulthood. The symptoms are often at their worst in children and in people in their 30s and 40s. However, the severity of symptoms tends to vary throughout life, and many people experience periods of remission.
Causes — Allergic rhinitis is caused by a nasal reaction to small airborne particles called allergens (substances that provoke an allergic reaction). In some people, these particles also cause reactions in the lungs (asthma), and eyes (allergic conjunctivitis).
The allergic reaction is characterized by activation of two types of inflammatory cells, called mast cells and basophils. These cells produce inflammatory substances, including histamine, that cause fluid to build up in the nasal tissues (congestion), itching, sneezing, and runny nose. Over several hours, these substances activate other inflammatory cells that can cause persistent symptoms.
Seasonal versus perennial allergic rhinitis — Allergic rhinitis can be seasonal (occurring during specific seasons) or perennial (occurring year round). The allergens that most commonly cause seasonal allergic rhinitis are pollens from trees, grasses, and weeds, as well as spores from fungi and molds. The allergens that most commonly cause perennial allergic rhinitis are dust mites, cockroaches, animal dander, and fungi or molds. Of these two types of allergic rhinitis, perennial allergic rhinitis tends to be more difficult to treat.
Symptoms — The symptoms of allergic rhinitis can vary from person to person. Although the term "rhinitis" refers only to the nasal symptoms, many patients also experience problems with their eyes, throat, ears, and sleep, so it is helpful to consider the entire spectrum of symptoms. Nose: watery nasal discharge, blocked nasal passages, sneezing, nasal itching, post-nasal drip, loss of taste, facial pressure or pain Eyes: itchy, red eyes, feeling of grittiness in the eyes, swelling and blueness of the skin below the eyes Throat and ears: sort throat, hoarse voice, congestion or popping of the ears, itching of the throat or ears Sleep: mouth breathing, frequent awakening, daytime fatigue, difficulty performing work
When an allergen is present year round, the predominant symptoms include post-nasal drip, persistent nasal congestion, and poor-quality sleep.
Diagnosis — The diagnosis of allergic rhinitis is based upon the presence of the nasal signs and symptoms described above. A physical examination and medical tests can confirm the diagnosis and identify the offending allergens.
Nasal examination — A nasal examination allows direct visual inspection of the lining of the nasal passages and can occasionally differentiate allergic rhinitis from other types of rhinitis. In people with allergic rhinitis, the lining of the nasal passages is very swollen and pale, sometimes to the degree that it appears bluish in color.
Identification of allergens and other triggers — It is often possible to identify the allergens and other triggers that provoke allergic rhinitis by recalling the factors that precede symptoms; noting the time at which symptoms begin; and examining a person's home, work, and school environments. Skin tests may be useful for people whose symptoms are not well controlled with medications and in whom the offending allergen is not obvious.
Treatment — The treatment of allergic rhinitis entails measures to reduce a person's exposure to known allergens or other triggers, combined with medication therapy. In most people, these measures effectively control the symptoms.
Reducing exposure to triggers — Some simple measures can reduce a person's exposure to the allergens and triggers that provoke allergic rhinitis. These measures do not apply to everyone with allergic rhinitis; persons with a known sensitivity to a particular allergen may consider these suggestions. Dust mites — Exposure to dust mites can be reduced by encasing mattresses and pillows in mite-impermeable barriers and washing sheets and blankets weekly in very hot water (at least 130ºF). Exposure can be further reduced by keeping indoor humidity lower than 50 percent, vacuuming regularly, removing carpets, and avoiding sleeping on upholstered furniture. Animal dander — Exposure to animal dander can be reduced by keeping pets out of bedrooms, sealing or placing filters over the air vents to bedrooms, and removing carpets. In some cases, it may be necessary to remove pets from the home. Cat dander, in particular, can linger in an environment long after a cat has been removed, so a person's symptoms may not improve for several months. Cockroaches — Exposure to cockroaches can be reduced by using poison bait or traps, keeping food and garbage tightly enclosed at all times, and sealing cracks to the outside. Indoor molds — Growth of indoor molds can be reduced by removing sources of standing water and persistent dampness: removing house plants, fixing leaky plumbing, correcting sinks and showers that don't drain completely, and dehumidifying damp areas to levels below 50 percent. Surfaces with visible mold growth should be cleaned with a 10 percent solution of bleach. Pollens and outdoor molds — Exposure to pollens and outdoor molds can be reduced by keeping car and house windows closed and using air conditioning during peak pollen seasons, staying inside on dry, windy days, and showering at night to remove pollens and spores from the hair and skin before bed. The American Academy of Allergy, Asthma, and Immunology has a toll free number (1-800-976-5536) and website (www.aaaai.org) for monitoring pollen and mold spore counts.
Air filters — The effectiveness of high-efficiency particulate air (HEPA) cleaners in reducing a person's exposure to allergens is uncertain. These cleaners are not very effective for reducing exposure to dust mites since little of this allergen is airborne. However, some studies have suggested that HEPA cleaners may be effective for removing cat allergens from the air.
Drug therapy — Several different classes of drugs counter the inflammation that causes symptoms of allergic rhinitis. The severity of symptoms and personal preferences usually guide the selection of specific drugs. Nasal steroids — Nasal steroids (steroids taken by a nasal spray) are usually recommended first for the treatment of allergic rhinitis. These drugs have very few side effects and dramatically relieve symptoms in most people. Studies have shown that nasal steroids are more effective than oral antihistamines for symptom relief [1].
The nasal steroids include fluticasone (Flonase®), mometasone (Nasonex®), beclomethasone (Vancenase®, Beconase®), budesonide (Rhinocort®), flunisolide (Nasarel®), and triamcinolone (Nasocort®). These drugs differ with regard to the base liquid (water-based versus alcohol-based), the frequency of doses, the spray device, and cost, but all are similarly effective for treating all the symptoms of allergic rhinitis. People with severe rhinitis may be advised to also use nasal decongestants for a few days to reduce nasal swelling and allow the steroid spray better access to the nasal passages.
Some symptom relief may occur on the first day of therapy with nasal steroids, but their maximal effectiveness may not be apparent for days to weeks. For this reason, these drugs are most effective when used regularly. Some people are able to gradually use lower doses when symptoms are less severe.
Applying the nasal spray directly onto the nasal lining is important for maximizing the effectiveness of nasal steroids. Application can be improved by directing the spray away from the nasal septum (the cartilage that divides the two sides of the nose), using an alcohol-based spray, and positioning the head down and forward after using water-based sprays.
The side effects of nasal steroids are mild and may include a slight unpleasant smell or taste or drying of the nasal lining. In some people, nasal steroids cause irritation, crusting, and bleeding of the nasal septum, especially during the winter; this side effect can be minimized by applying Vaseline to the septum before using the spray, using a saline nasal spray to restore moisture to the nasal lining, or switching to a water-based spray. Studies suggest that nasal steroids are generally safe when used for many years. However, people who use these drugs for years should have periodic nasal examinations to check for rare side effects, such as nasal infection or ulceration.
Although oral and inhaled steroids have been linked to reduced bone mineral density and hormonal side effects, the doses used in nasal steroids are low and are NOT associated with these side effects. However, clinicians usually recommend using the lowest effective dose of nasal steroids. Antihistamines — Antihistamines relieve the itching, sneezing, and runny nose of allergic rhinitis, but they do not relieve nasal congestion. Combined treatment with nasal steroids or decongestants may provide greater symptom relief than use of either alone.
The oral, over-the-counter antihistamines include brompheniramine (Dimetapp allergy®, Nasahist B®), chlorpheniramine (Chlor-Trimeton®), diphenhydramine (Benadryl®), and clemastine (Tavist®). These drugs often cause sedation and should not be used before driving or operating machinery. Simultaneous use of a decongestant may reduce the sedating effects, but patients should still use caution.
The oral, prescription antihistamines include cetirizine (Zyrtec®) and fexofenadine (Allegra®). Loratadine (Claritin®, Alavert®) is now available without a prescription. These drugs are much less sedating and are available in long-acting formulas; however, they are more expensive and are of no greater benefit than over-the-counter antihistamines for treating rhinitis symptoms.
Azelastine (Astelin®) is a prescription nasal antihistamine spray that can be used daily or only as needed to relieve symptoms of post-nasal drip, congestion, and sneezing. It starts to work within minutes after use. Patients may use up to eight total sprays per day; higher doses can cause sedation. The most commonly observed side effect is a bad taste in the mouth immediately after use. This can be minimized by keeping the head tilted forward so the medicine does not drain down the throat. Decongestants — Decongestants (like pseudoephedrine [Sudafed®, Actifed®, Drixoral®]) are often combined with antihistamines in oral, over-the-counter allergy drugs.
Several decongestant nasal sprays also are available, including oxymetazoline (Afrin®) and phenylephrine (Neo-synephrine®). Nasal decongestants must not be used for more than two to three days at a time because they may cause a different type of rhinitis, called rhinitis medicamentosa. (See "Rhinitis medicamentosa" below).
Oral decongestants elevate blood pressure and are not appropriate for people with hypertension (high blood pressure) or certain cardiovascular conditions. Men with an enlarged prostate who have difficulty urinating may notice a worsening of this symptom when they take decongestants. Cromolyn sodium — Cromolyn sodium (Nasalcrom®) prevents the symptoms of allergic rhinitis by stabilizing mast cells (the cells that can release substances which cause inflammation). This drug is available as an over-the-counter nasal spray that must be used three to four times per day, preferably before symptoms have begun, to effectively prevent the symptoms of allergic rhinitis. Cromolyn sodium has not been associated with any serious side effects. Saline nasal sprays or washes — Saline (salt water) nasal sprays and washes are effective for minimizing the nasal dryness and postnasal drip that may be associated with allergic rhinitis and its treatment. They also rinse out the allergens and irritants from the nose. Saline nasal sprays can be purchased over-the-counter and can be used by virtually everyone.
Saline washing involves rinsing the nasal passages with larger quantities of salt water. This technique can be helpful in patients who are willing and able to do it. Kits can be purchased over-the-counter or a solution can be made at home. (See "Nasal lavage" below).
Immunotherapy — Immunotherapy (desensitization therapy) refers to injections that are given to desensitize a person to known allergens (also known as allergy shots). This therapy is effective for only certain types of allergens, and is both expensive and time-consuming.
Although immunotherapy can benefit many people with allergic rhinitis, it is usually reserved for people who have a poor response to medication therapy or who are reluctant to take drugs. Immunotherapy has been shown to be effective for the treatment of allergies to cat dander and the pollen of trees, weeds, and grass.
Immunotherapy is usually started by an allergist. The therapy begins with several months of weekly injections of gradually increasing doses, followed by monthly maintenance injections. The maintenance injections can be given by a primary care provider.
Immunotherapy is usually a long-term therapy, and the benefits of this therapy may lessen when it is discontinued. However, one study in people with allergies to grass pollen found that the benefits of three to four years of immunotherapy persisted when the injections were stopped [2].
Immunotherapy injections carry a small risk of a severe allergic reaction. These reactions occur with a frequency of 6 of every 10,000 injections. The symptoms usually begin within 30 minutes of the injection. Patients are required to remain in the office after routine injections. Because drugs called beta-blockers may interfere with the ability to treat these reactions, people who take these beta-blockers are often advised not to have immunotherapy.
Other treatments — Other drugs have been studied in people with allergic rhinitis with inconclusive results. Nasal atropine — Nasal atropine is effective for the treatment of severe runny nose. This drug, available as ipratropium bromide (Atrovent®), is not generally recommended for people with glaucoma or men with an enlarged prostate. Leukotriene modifiers — Release of substances called leukotrienes may contribute to the symptoms of allergic rhinitis. Drugs that inhibit the action of leukotrienes, called leukotriene modifiers, can be very useful in patients with asthma and allergic rhinitis. However, nasal steroids are more effective than leukotriene modifiers for treating allergic rhinitis; thus, they are generally reserved for patients who cannot tolerate nasal sprays (due to nose bleeds) or azelastine (a nasal antihistamine spray).
CHRONIC NONALLERGIC RHINITIS — Nonallergic rhinitis is best defined by the chronic presence of one or more of the following four symptoms: sneezing, rhinorrhea, nasal congestion, and postnasal drainage, in the absence of any obvious cause. It usually begins in adulthood or later life. Many people with this condition notice that irritants, such as tobacco smoke, traffic fumes, or strong odors and perfumes trigger symptoms. Patients with chronic nonallergic rhinitis may not be bothered by pollen or furred animals (the common triggers in allergic rhinitis), although about one-half of people with this condition also have allergic rhinitis.
Gustatory rhinitis is a type of nonallergic rhinitis that causes a sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Treatment of nonallergic rhinitis — Treatment of nonallergic rhinitis depends upon an individual's symptoms.
Trigger avoidance — Exposure to tobacco smoke can be reduced if household members stop smoking or smoke only outside of the home. It is also important to reduce smoke exposure in day care settings or in the workplace.
Exposure to pollutants and irritants can be reduced by avoiding wood-burning stoves and fireplaces; properly venting other stoves and heaters; and avoiding cleaning agents and household sprays that trigger symptoms.
Exposure to strong perfumes and scented products is more difficult. Patients should avoid personal use of these items and may need to request that coworkers, family, or friends do the same. Some workplaces have policies regarding the use of strongly scented personal products. Azelastine (Astelin®) can be used when needed to relieve symptoms. (See "Drug therapy" above).
Medications — Nasal steroids and azelastine, used on a daily basis, have been shown to benefit patients with nonallergic rhinitis. These medications may be used alone or in combination. Patients with rhinorrhea (profuse, watery discharge from the nose) may be given ipratropium bromide (0.03 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis.
Nasal lavage — Rinsing the nose with a saline solution (nasal lavage) or nasal saline spray is helpful for many patients with nonallergic rhinitis, as well as for other rhinitis conditions. It is particularly useful for symptoms of postnasal drainage, sneezing, and congestion. Nasal lavage can be used immediately prior to nasal medication so that the mucosa is freshly cleansed when the medication is applied.
A variety of devices, including bulb syringes and bottle sprayers, may be used to perform nasal lavage (show table 2). Patients should use at least 200 mL in each nostril. Patients can make their own solutions or buy commercially-prepared kits, available without a prescription. Nasal lavage with warmed saline can be performed as needed, daily at baseline, or twice daily for increased symptoms. Nasal lavage carries few risks if performed correctly.
ATROPHIC RHINITIS — Atrophic rhinitis is an uncommon type of rhinitis that results from a gradual thinning of the nasal lining and the nasal bones. This condition most commonly occurs in older adults. The symptoms include nasal congestion, crusting of the nasal passages, and a persistent bad smell. Treatment with a saline spray or lavage often relieves the symptoms of atrophic rhinitis. Occasionally, sinus rinses containing antibiotic solutions are prescribed.
RHINITIS MEDICAMENTOSA — Rhinitis medicamentosa is a type of rhinitis that develops as a result of overuse of over-the-counter decongestant nasal sprays (not nasal steroids) or intranasal cocaine abuse.
Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition, but recovery may take as long as one year [3].
MEDICATIONS FOR OTHER PROBLEMS — Certain medications can cause or worsen nasal symptoms (especially congestion), including the following: oral contraceptives, drugs for high blood pressure, antidepressants, medications for erectile dysfunction, medications for prostatic enlargement, sedatives, and aspirin.
ASSOCIATED MEDICAL PROBLEMS — Rhinitis can be a symptom of several underlying medical conditions, including hypothyroidism, certain tumors, and conditions that cause vascular inflammation. Treatment of these underlying conditions may relieve rhinitis. Pregnancy can also cause rhinitis in some women.
NASAL POLYPS — Nasal polyps are painless overgrowths of the lining of the sinuses. These polyps may result from the persistent inflammation of allergic rhinitis, among other causes. Nasal polyps can narrow the nasal passages and cause a decreased sense of smell.
Nasal polyps can be difficult to treat. Nasal steroids can slow the growth of nasal polyps and may cause them to shrink. A brief treatment with oral steroids followed by maintenance treatment with nasal steroids can also control the growth of nasal polyps.
Surgery to remove nasal polyps (called polypectomy) may be necessary when the polyps severely narrow the nasal passages or cause recurrent sinusitis that requires antibiotic treatment. Polyps often grow back after surgery, unless nasal steroid sprays or other medications are used to slow the regrowth process.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov) Allergy, Asthma, and Immunology Online
(www.acaai.org) American Academy of Allergy, Asthma, and Immunology
(www.aaaai.org) American Academy of Otolaryngology -- Head and Neck Surgery, Inc.
(www.entnet.org) American Rhinologic Society
(www.american-rhinologic.org)