Rhinitis Flashcards
A patient with irritation and inflammation of the
nasal mucous membranes complains of rhinorrhea,
nasal congestion, and postnasal drip. What is the
most likely general diagnosis based on this
information?
Rhinitis
What are the main forms of rhinitis?
● Allergic rhinitis
● Nonallergic rhinitis
Allergic rhinitis reflects what type of Gell and
Coombs hypersensitivity?
Type I (anaphylactic/immediate) hypersensitivity with both
early and late-phase reactions occurring after re-exposure
to the antigen (see section on Allergy)
What are the primary subtypes of allergic rhinitis?
● Seasonal allergic rhinitis
● Perennial allergic rhinitis
● Mixed allergic rhinitis
What are the classic symptoms of allergic rhinitis?
● Sneezing ● Rhinorrhea ● Nasal congestion ● Pruritus (nasal, palatal, ocular) ● Watery eyes ● Postnasal drainage ● Anosmia/hyposmia
Diagnosis of allergic rhinitis hinges most heavily
on what factor?
Clinical history
What comorbidities are commonly associated
with allergic rhinitis?
Asthma, acute rhinosinusitis, otitis media with effusion,
sleep disordered breathing, and obstructive sleep apnea
What treatments exist for allergic rhinitis?
Intranasal/oral corticosteroids, intranasal/oral antihist-
amines, leukotriene inhibitors, cromolyn sodium, immune
therapy (sublingual and injection)
A patient presents with nasal congestion, rhinorrhea,
and postnasal drip but has a history of negative
allergy testing. What type of rhinitis does this most
likely represent? What are the major subtypes
associated with this condition?
● Nonallergic rhinitis: ○ Infectious rhinitis ○ Vasomotor rhinitis (60%) ○ Nonallergic rhinitis of eosinophilia syndrome (NARES) ○ Gustatory rhinitis ○ Occupational ○ Hormonally induced ○ Medication induced ○ Atrophic ○ Inflammatory/immune-related disorders
What are the key symptoms associated with non-allergic rhinitis?
● Sneezing
● Rhinorrhea
● Nasal congestion
● Postnasal drainage
True or False. Negative allergy testing is required
for the diagnosis of nonallergic rhinitis.
False
Viral infections (rhinovirus, respiratory syncytial
virus, parainfluenza virus, adenovirus, influenza
virus, and enterovirus) can result in URI
symptoms, including congestion, rhinorrhea, and postnasal drip, but often they do not cause pruritic symptoms. The infection typically resolves within 7 to 10 days. What diagnosis does this describe?
Infectious rhinitis
In what type of nonallergic rhinitis is there excess
parasympathetic tone resulting in vasodilation,
which can be triggered by cold temperatures and
strong smells?
Vasomotor rhinitis
What are the characteristics of vasomotor
rhinitis?
It is a diagnosis of exclusion. Patients usually manifest this
condition in older age, with copious clear rhinorrhea that is
triggered by alcohol, temperature, or humidity changes or
exposure to odors.
What are the common triggers for vasomotor
rhinitis?
Changes in temperature, change in relative humidity, odors
(e.g., perfumes, cleaning agents), second-hand tobacco
smoke, alcohol, sexual arousal, and emotional changes can
be triggers.
What is the underlying pathophysiology
associated with vasomotor rhinitis?
This condition is poorly understood. It may be related to the
increased neural efferent input to mucosal vasculature.
Though controversial, what surgical interventions
can be considered in patients with vasomotor
rhinitis?
Vidian neurectomy
What type of nonallergic rhinitis manifests with
perennial symptoms including sneezing, watery
rhinorrhea, nasal pruritus, and intermittent
hyposmia/anosmia; demonstrates ~10 to 20%
eosinophils on nasal smear, and is associated with
negative in vivo and in vitro allergy testing?
NARES
A 33-year-old man has profuse watery rhinorrhea
whenever he eats his favorite hot and spicy meals.
What is the likely diagnosis?
Gustatory rhinitis
What is the underlying pathophysiology of
gustatory rhinitis?
Vagally (cholinergically) mediated vasodilation after eating
especially with hot or spicy foods
What type of rhinitis is can be associated with (1) inhaled protein or chemical antigens that result in an IgE-mediated response (allergic rhinitis), (2) inhaled chemical respiratory sensitizers that cause an unknown immune response, or (3) exacerbation of rhinitis and is often associated with concurrent asthma?
Occupational rhinitis
Pregnancy, puberty, menstruation, and
hypothyroidism can all be associated with what
type of rhinitis?
Hormonally induced rhinitis
During pregnancy, hormone-induced vasodilation,
vascular pooling, and increased blood volume can contribute to congestion and rhinitis. Is it more common for this to occur as a new diagnosis of rhinitis or as an exacerbation of preexisting rhinitis?
1/3 of women = exacerbation
2/3 of women = de novo = typically resolves ~2 weeks after
delivery
What are some common medications that can
cause rhinitis?
Angiotensin-converting enzyme (ACE) inhibitors, β-blockers and other antihypertensives, erectile dysfunction or pulmonary hypertension medications (i.e., sildenafil), oral contraceptives and aspirin in sensitive individuals. Ethanol in wine, beer, and other alcoholic beverages can result in vasodilation and rhinitis.
What condition is associated with rebound nasal congestion secondary to using topical nasal decongestants (α-adrenergic) for more than 5 to 7 days?
Rhinitis medicamentosa
What condition is associated with degeneration
of sinonasal sensory and autonomic nerve fibers
leading to mucosal gland involution, squamous metaplasia of the sinonasal epithelium, and significant alteration of mucociliary transport and can be either primary or secondary (after surgery or trauma)?
Atrophic rhinitis (also called rhinitis sicca or ozena)
What organism commonly colonizes the nasal
mucosa in patients suffering from atrophic
rhinitis?
Klebsiella ozaenae
What are the clinical examination findings
associated with atrophic rhinitis?
● Foul odor
● Yellow/green crusting
● Atrophic/fibrotic mucosa
In addition to the categories of rhinitis included
above, what important inflammatory-immune
diseases are also associated with nonallergic
rhinitis?
● Granulomatous infections (rhinoscleroma,
rhinosporidiosis)
● Wegener granulomatosis
● Sarcoidosis
● Midline granuloma
● Churg-Strauss syndrome
● Relapsing polychondritis
● Amyloidosis
(Covered in the section on inflammatory/infectious nasal
masses and Systemic Disease sections of this chapter)
What management options have demonstrated
utility in the management of nonallergic rhinitis?
● Intranasal glucocorticoids*
● Intranasal antihistamine (azelastine [Astelin, Astepro],
olapatadine [Patanase])*
● Intranasal ipratropium bromide (Atrovent)
● Nasal irrigation
● Adjunctive oral medications (antihistamines, decongest-
ants)
*Primary management: Use full dose daily, often in
combination (results are better with intranasal steroid and
antihistamine than with either alone).
What specific feature of nonallergic rhinitis is the
target of ipratropium bromide intranasal spray?
Watery rhinorrhea
What is the proposed reason an intranasal
antihistamine nasal spray would offer a benefit to
patients with nonallergic rhinitis?
Anti-inflammatory: Decreased eosinophil activation, ex-
pression of adhesion molecules, and cytokine production.
Potentially decreases neurogenic excitation from olfactory
stimuli.
