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Rhinitis
Executive Editor, InnovAiT
E-mail: chantal.simon{at}oxfordjournals.org
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Abstract
The GP curriculum and...Rhinitis describes inflammation of the nasal mucosa. Clinically, it presents with symptoms of nasal discharge, itching, sneezing and nasal blockage or congestion. Rhinitis is a very common condition, affecting more than one in five of the UK population on an ongoing basis, and can be classified into allergic, non-allergic and infective types. Infective causes of rhinitis include bacteria and viruses, such as the common cold. They are not considered further here.
Ear, nose and throat (ENT) conditions are common reasons for patients to visit the GP. It is important that GPs in training know how to manage such conditions. Curriculum statement 15.4: Ear, nose and throat (ENT) and facial problems require GPs in training to be able to:
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Allergic rhinitis |
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The prevalence of allergic rhinitis is increasing in the UK. It is the predominant form of rhinitis in children and accounts for about one in three cases in adulthood. Individuals with atopy or a family history of rhinitis are at most risk. Allergic rhinitis is a risk factor for the development of asthma and most asthmatics have a degree of rhinitis. Rhinitis is a serious condition as it affects quality of life and school and work attendance and performance.
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Diagnosis of allergic rhinitis |
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Patients with allergic rhinitis usually present with bilateral intermittent nasal blockage, itching of the nose, eyes, palate and throat, sneezing and/or watery nasal discharge. Examination may reveal swollen inferior turbinates, blockage of the nasal airway, pale or dusky mauve mucosa and/or nasal discharge. There may also be an ‘allergic crease’ on the bridge of the nose from persistent rubbing, especially in young sufferers. In all cases, ask about potential allergens (Box 1). Allergic rhinitis can be classified by frequency and severity of symptoms (Fig. 1) and whether symptoms are perennial or seasonal.
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Box 1. Common allergens causing allergic rhinitis
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Hayfever is rhinitis and/or conjunctivitis and/or wheeze due to an allergic reaction to pollen. It occurs at different times in the year depending on which pollen is involved (Table 1). The type of pollen that causes hay fever is also connected to where the sufferer lives. In the UK, most hay fever is caused by grass pollen (60%) and silver birch pollen (25%).
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Investigation of allergic rhinitis |
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If symptoms are intrusive and difficult to control, refer to an allergy clinic for skin prick testing or radio-allergosorbent testing. Blood tests for IgE may help identify allergens.
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Management of allergic rhinitis |
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The management of rhinitis is summarized in Fig. 2. Provide information on the symptoms and causes of rhinitis and possible treatments (Box 2).
Box 2. Using steroid nose sprays
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Allergen avoidance
Allergen avoidance may help in some cases. For example, dietary modification (such as avoidance of dairy products) or removing pets from a home improves symptoms in some cases. If the patient is unable to give up the pet, advise to keep the pet out of the rooms that the patient spends most time in, and especially the bedroom, and regular vacuuming and/or replacing carpets with hard flooring that can be washed regularly. Pollen avoidance measures include:
- Use of nasal airguards (available from www.nasalairguard.co.uk)
- Keeping windows/door closed during the pollen season
- Fitting a pollen filter on the car air circulation system
- Staying indoors when the pollen count or humidity is high and/or minimizing early morning activity when the pollen count is at its highest
- Avoiding mowing the lawn
- Wearing wrap around sunglasses
- Showering, washing hair, bathing eyes and/or nasal douching to wash off pollen after going outside
Evidence that house dust mite avoidance measures result in clinical improvement is poor. In committed families, advise: complete barrier bed coverings, removal of carpets, removal of soft toys from beds, high temperature washing of bed linen, regular vacuuming and wet dusting, ventilation of the bedroom (opening the window and door most days), applying acaricides to soft furnishings and dehumidification.
Nasal douching and steam inhalation
Nasal douching with saline and/or saline eye drops are safe and may be helpful especially for hay fever sufferers. Steam inhalation may also give some temporary relief from the discomfort of nasal blockage.
Oral antihistamines
Despite allergen and trigger avoidance, many rhinitis sufferers continue to have persistent symptoms, the nature of which should determine the selection of medication. Take a careful history of previous treatments tried. Include both over-the-counter and prescribed medication. Often, treatments have not been used regularly or for long enough to constitute a fair trial of efficacy.
Oral antihistamines are safe and effective. They can significantly improve quality of life. They have the advantage of improving associated symptoms, such as conjunctivitis, as well as the symptoms of rhinitis. Regular treatment is more effective than the needed treatment for patients with persistent symptoms. Avoid first-generation antihistamines (such as chlorphenamine) as these adversely affect work and school performance. Suitable second-generation antihistamines include loratadine and fexofenadine. An alternative is a topical antihistamine such as azelastine nasal drops. These are faster acting, with an onset of action within 15 minutes, but do not improve symptoms at other sites apart from the nose. Topical antihistamines are particularly useful as a rescue therapy.
Nasal steroids
Topical nasal steroids act through the anti-inflammatory effect of steroids. They are roughly twice as effective as oral antihistamines in the treatment of allergic rhinitis. They start to act within 6–8 hours of the first dose, but symptoms may not improve for several days and maximum effect may not be apparent for up to 2 weeks. For this reason, starting treatment 2 weeks before a known allergen season improves efficacy. Poor technique may also be a factor in failure to respond to sprays and drops—check technique (Box 2).
All intranasal steroids are equally effective; however, bioavailability varies enormously between preparations. Systemic absorption is minimal with fluticasone and mometasone. Systemic absorption is high for betamethasone and dexamethasone, so these should not be used long term. Bioavailability may be increased in patients taking itraconazole and certain antiviral medications. In general, steroid nasal drops are reserved for those patients with more severe symptoms. Box 2 contains advice for patients on the application of intranasal steroid sprays and drops.
Common side effects from intranasal steroids include local irritation, sore throat and nose bleeds. These can affect up to 10% of those using intranasal steroids. Local irritation may be reduced by switching to a preparation that does not contain benzalkonium chloride as a preservative, such as Rhinocort or Flixonase nasules. Monitor the growth of children on long-term intranasal steroids or if the child is having topical steroid treatment at multiple sites, for example a steroid inhaler for asthma, steroid cream for eczema and intranasal steroids. Patients with glaucoma should be monitored carefully as intranasal steroids may increase intraocular pressure.
Oral steroids
Oral corticosteroids are rarely indicated in the management of rhinitis. Possible reasons to prescribe include:
- severe nasal obstruction
- short-term rescue medication for uncontrolled symptoms on conventional treatment
- important social or work-related events, for example examinations and weddings
Oral steroids should only be used in short courses of 5–10 days and always in combination with a topical nasal corticosteroid. A suitable dose is 20–30 mg daily for an adult. Injected preparations are not recommended.
Leukotriene receptor antagonists
Leukotriene receptor antagonists, such as montelukast, are roughly as effective as antihistamines in the treatment of allergic rhinitis, but response is less predictable. Combination with antihistamines does not increase efficacy. They may improve symptoms in those patients with concurrent asthma.
Desensitization
Desensitization to allergens has a 50–70% success rate. Risk of anaphylaxis is high so, in the UK, provision is limited to specialist centres with full resuscitation facilities. Refer via an allergy clinic.
Other treatment options
Other treatment options include:
- Topical decongestants (e.g. ephedrine nasal drops)—these are effective in reducing symptoms of nasal congestion short term. They must be used frequently (three or four times daily). Long-term use (10 days or more) should be discouraged as vasoconstriction results in mucosal damage which in turn can lead to worsening of nasal congestion (rhinitis medicamentosa). Oral decongestants are less effective than topical decongestants but do not have a rebound effect.
- Topical anticholinergics (e.g. ipratropium bromide nasal spray tds)—decreases rhinorrhoea but has no effect on other nasal symptoms
- Topical chromones (e.g. sodium cromoglicate or nedocromil sodium)—less effective than topical steroids but can be useful, particularly in children or pregnant women, to give some relief
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Non-allergic rhinitis |
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There are many causes of non-allergic rhinitis. These include:
- Non-allergic rhinitis with eosinophilia syndrome—perennial symptoms with acute exacerbations. More than half have bronchial hyper-reactivity. Many go on to develop asthma and/or nasal polyps.
- Vasomotor (autonomic) rhinitis—triggered by physical or chemical agents. May be difficult to distinguish from allergic rhinitis as symptoms and signs are similar. Both are common and may coexist in the same patient. Vasomotor rhinitis tends to have less itch and symptoms may be exacerbated by tobacco, change in air temperature and perfumes.
- Drugs—ACE inhibitors, alpha blockers, cocaine, chlorpromazine, prolonged use of nasal decongestants, aspirin or other non-steroidal anti-inflammatories
- Hormonal—pregnancy, hormone replacement therapy (HRT) and the combined oral contraceptive pill may all cause nasal stuffiness
- Food—alcohol and spicy foods are particularly implicated
- Atrophic—due to surgery, trauma or radiation
- Inherited—cystic fibrosis, Kartagener's syndrome and Young's syndrome
- Immune—systemic lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome, Churg–Strauss syndrome, immune deficiency, sarcoidosis and Wegener's granulomatosis
- Malignancy—lymphoma, melanoma and squamous cell carcinoma
Try the treatment measures used for allergic rhinitis as appropriate. Treatment is often less successful.
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Referral for specialist care |
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Refer all patients with unilateral symptoms, new nasal polyps, nasal crusting or bleeding or nasal deformity for ENT review. Refer patients not responding to treatment in primary care for ENT review or to an allergy clinic. Surgical options for treatment include nasal cautery or partial excision of the inferior nasal turbinates for severe nasal blockage when medical treatment has failed. Children on prolonged courses of intranasal steroids who have slow growth should be referred for paediatric review.
Key points
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References |
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Bousquet J, Van CP, Khaltaev N. Allergic rhinitis and its impact on asthma. The Journal of Allergy and Clinical Immunology (2001) 108:S147–334.[CrossRef][Web of Science][Medline]
British Society for Allergy and Clinical Immunology (BSACI). Guidelines for the management of allergic and non-allergic rhinitis (2008) Accessed via www.blackwell-synergy.com/doi/pdf/10.1111/j.1365-2222.2007.02888.x [date last accessed 29.05.2008].
Lynch J, Simon C. Oxford GP Library: Respiratory problems (2007) Oxford: Oxford University Press. ISBN: 9780198571377.
RCGP. Curriculum statement 15.4-ENT and facial problems. Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15_4_ENT_&_facial_problems.pdf [date last accessed 29.05.2008].
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