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Rhinitis

by Marvin P. Fried, MD

Rhinitis is inflammation of the nasal mucous membrane, with resultant nasal congestion, rhinorrhea, and variable associated symptoms depending on etiology (eg, itching, sneezing, watery or purulent rhinorrhea, anosmia). The cause is usually viral, although irritants can cause it. Diagnosis is usually clinical. Treatment includes humidification of room air, sympathomimetic amines, and antihistamines. Bacterial superinfection requires appropriate antibiotic treatment.

There are several forms of rhinitis. For allergic rhinitis, see Allergic Rhinitis.

Acute rhinitis

This form of rhinitis, manifesting with edema and vasodilation of the nasal mucous membrane, rhinorrhea, and obstruction, is usually the result of a common cold (see Common Cold); other causes include streptococcal, pneumococcal, and staphylococcal infections.

Chronic rhinitis

This form of rhinitis is generally a prolongation of subacute inflammatory or infectious viral rhinitis but may also rarely occur in syphilis, TB, rhinoscleroma, rhinosporidiosis, leishmaniasis, blastomycosis, histoplasmosis, and leprosy—all of which are characterized by granuloma formation and destruction of soft tissue, cartilage, and bone. Nasal obstruction, purulent rhinorrhea, and frequent bleeding result. Rhinoscleroma causes progressive nasal obstruction from indurated inflammatory tissue in the lamina propria. Rhinosporidiosis is characterized by bleeding polyps. Both low humidity and airborne irritants can result in chronic rhinitis.

Atrophic rhinitis

This form of rhinitis results in atrophy and sclerosis of mucous membrane; the mucous membrane changes from ciliated pseudostratified columnar epithelium to stratified squamous epithelium, and the lamina propria is reduced in amount and vascularity. Atrophic rhinitis is associated with advanced age, granulomatosis with polyangiitis (GPA, formerly known as Wegener granulomatosis), and iatrogenically induced excessive nasal tissue extirpation. Although the exact etiology is unknown, bacterial infection frequently plays a role. Nasal mucosal atrophy often occurs in the elderly.

Vasomotor rhinitis

This form of rhinitis is a chronic condition in which intermittent vascular engorgement of the nasal mucous membrane leads to watery rhinorrhea and sneezing. Etiology is uncertain, and no allergy can be identified. A dry atmosphere seems to aggravate the condition.

Symptoms and Signs

Acute rhinitis results in cough, low-grade fever, nasal congestion, rhinorrhea, and sneezing.

Chronic rhinitis manifestations are similar to those of acute rhinitis, but in prolonged or severe cases, patients may also have thick, foul-smelling, mucopurulent drainage; mucosal crusting; and/or bleeding.

Atrophic rhinitis results in abnormal patency of the nasal cavities, crust formation, anosmia, and epistaxis that may be recurrent and severe.

Vasomotor rhinitis results in sneezing and watery rhinorrhea. The turgescent mucous membrane varies from bright red to purple. The condition is marked by periods of remission and exacerbation. Vasomotor rhinitis is differentiated from specific viral and bacterial infections of the nose by the lack of purulent exudate and crusting. It is differentiated from allergic rhinitis by the absence of an identifiable allergen.

Diagnosis

The different forms of rhinitis are diagnosed clinically. Testing is unnecessary.

Treatment

  • For viral rhinitis, decongestants, antihistamines, or both

  • For atrophic rhinitis, topical treatment

  • For vasomotor rhinitis, humidification and sometimes topical corticosteroids and oral pseudoephedrine

Viral rhinitis may be treated symptomatically with decongestants (either topical vasoconstriction with a sympathomimetic amine, such as oxymetazoline q 8 to 12 h or phenylephrine 0.25% q 3 to 4 h for not more than 7 days, or systemic sympathomimetic amines, such as pseudoephedrine 30 mg po q 4 to 6 h). Antihistamines (see Table: Oral H 1 Blockers) may be helpful, but those with anticholinergic properties dry mucous membranes and therefore may increase irritation. Decongestants also may relieve symptoms of acute bacterial rhinitis and chronic rhinitis, whereas an underlying bacterial infection requires culture or biopsy, pathogen identification, antibiotic sensitivities, and appropriate antimicrobial treatment.

Treatment of atrophic rhinitis is directed at reducing the crusting and eliminating the odor with topical antibiotics (eg, bacitracin, mupirocin), topical or systemic estrogens, and vitamins A and D. Occluding or reducing the patency of the nasal cavities surgically decreases the crusting caused by the drying effect of air flowing over the atrophic mucous membrane.

Treatment of vasomotor rhinitis is by trial and error and is not always satisfactory. Patients benefit from humidified air, which may be provided by a humidified central heating system or a vaporizer in the workroom or bedroom. Systemic sympathomimetic amines (eg, for adults, pseudoephedrine 30 mg po q 4 to 6 h prn) relieve symptoms but are not recommended for long-term use because they thicken the mucus and may cause tachycardia and nervousness. Topical vasoconstrictors are avoided because they cause the vasculature of the nasal mucous membrane to lose its sensitivity to other vasoconstrictive stimuli—eg, the humidity and temperature of inspired air. Topical corticosteroids (eg, mometasone 2 sprays bid) can be of some benefit.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • BACTROBAN
  • AFRINOL, SUDAFED
  • BACIIM
  • ELOCON, NASONEX
  • No US brand name

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