Chronic Rhinitis
Jesse P. McRae, MD, FACAAI
Editor’s Note: Due to color constraints and other production
considerations, Figures 1 & 2 of this article are not printed in
the journal. They are available online at dcmsonline.org.
Abstract: Rhinitis simply refers to inflammation of the nasal passages.
The symptoms that result include congestion, sneezing, rhinorrhea,
post-nasal drainage, cough and itching of the nose and throat. Forty
million people are believed to have rhinitis and the resulting cost is
$2.7 billion annually, making it one of the most common causes of lost
work and school absence.1 Sleep disturbance can be quite troublesome.2
Rhinitis can have several causes. Basically, rhinitis can be divided into
two categories: Non-allergic and allergic.3 This article will cover both
areas but will focus primarily on allergic causes.
Non-Allergic Rhinitis
Persistent nasal symptoms may be caused by any of several
non IgE-mediated mechanisms, including drug side effects,
infectious, hormonal, occupational, or structural/anatomical
factors. These causes of rhinitis are associated with negative
allergy testing.
Infectious Rhinitis
The cause can be bacterial, viral, or fungal. Signs and
symptoms include mucopurulent nasal discharge, facial pain,
cough and pressure sensation and may involve the paranasal
sinuses. Fever may not be present.
Hormonal Rhinitis
Pregnancy, menstrual cycles, and occasionally hypothyroid-
ism can lead to rhinitis, usually characterized by nasal conges-
tion. A cyclical pattern may be discernible to the patient.
Occupational Rhinitis
Many airborne substances may cause nasal irritation in-
cluding chemicals, wood dust, animal exposures, and even
molds producing mycotoxins (e.g. Aspergillus). Identification
of triggering factors and avoidance measures constitute the
mainstay of treatment for this problem.
Structural/Anatomical Factors
Rhinitis symptoms, particularly rhinorrhea and congestion
can be caused by structural issues such as a deviated nasal
septum, nasal polyposis, adenoidal hypertrophy, cysts, or
rarely, tumors. Persistent or intermittent congestion without
itching should alert the clinician to the presence of a polyp
or other physical obstructions. Nasal polyps in children raise
the suspicion of cystic fibrosis. In adults, nasal polyps when
accompanied by aspirin allergy and asthma, are referred to
as “aspirin or Samter’s triad.” Aspirin desensitization should
be considered in those cases. Nasal polyps may or may not
be associated with allergy factors.
Address Correspondence to: Jesse P. McRae, MD, allergist/immu-
nologist in private practice, Jacksonville, FL. Email: jessemcraemd@
fdn.com.
26 Vol. 59, No. 2 2008 Northeast Florida Medicine
Trauma
A recent onset of profuse rhinorrhea without other signs of
rhinitis can be caused by cerebrospinal fluid leakage from a
basal skull fracture. Rhinorrhea in a patient with a history of
recent head trauma should always arouse this suspicion which
is a neurosurgical emergency. A glucose test of the secretions
can be done and should be quantified. The transudate from
allergic rhinitis should not contain glucose. While the posi-
tive glucose is a recognized screening test, the presence of
beta-2-transferrin in the secretions is now recognized as the
preferred confirmatory test.
Drug Induced Rhinitis
Over the counter nasal vasoconstrictors (oxymetazoline,
phenylephrine) may cause rebound nasal congestion and
can lead to dependence on the medication. This is called
“rhinitis medicamentosa”. Although not a true addiction,
the dependency to vasoconstrictor sprays can be profound
and long term. Other pharmacologic classes of nasal sprays
(steroid, antihistamine, anti-cholinergic) do not cause this
“rebound” effect.
Anti-hypertensive medications may cause or exacerbate
rhinitis, particularly nasal congestion. Angiotensin convert-
ing enzyme (ACE) inhibitors and beta adrenergic blockers,
reserpine, methyldopa, guanethidine, phentolamine, and
aspirin all have been reported to cause this side effect. Cocaine
abuse also can result in chronic rhinitis.
Gustatory Rhinitis
Ingestion of certain foods, especially hot or spicy foods or
alcohol, can trigger rhinitis in some individuals. This is believed
to be mediated via the vagus nerve and usually is manifested
as profuse rhinorrhea. Anti-cholinergic nasal sprays seem to
be effective to treat this infrequent disorder. Antihistamines
have little, if any, benefit. This is totally different from IgE-
mediated food allergies which are covered in another article
in this issue. Food allergies, in fact, usually cause a different
pattern of symptoms and not isolated rhinitis.
Vasomotor Rhinitis
This common entity includes symptoms similar to other
forms but appears triggered by non-specific exposures such
as cleaning odors, changes in temperature or position, espe-
cially cold, dry air. The syndrome is believed to be caused
by an excess in sympathetic vasomotor activity. Allergy
evaluation is expected to be negative and treatment is often
unsatisfactory.
Allergic Rhinitis
Also called “hay fever”, allergic rhinitis is an inflammatory
disorder in which histamine and other chemical mediators
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(cytokines, leukotrienes) producing the symptoms are released
from mast cells in response to specific IgE antibodies. This
process requires prior sensitization of low doses, sometimes
for several years. The disorder may be arbitrarily labeled
seasonal or perennial depending on whether the exposure
to allergens is seasonal or year round. Seasonal allergens are
typically pollens and molds. Perennial allergens include animal
dander, dust mites, outside molds (e.g. Alternaria) or some
occupational exposures.
Allergic Rhinitis Symptoms
Typical symptoms include nasal congestion, rhinorrhea,
sneezing, itching of the eyes, nose and throat, cough and
post-nasal drainage. Additional symptoms now recognized
include daytime somnolence, depression, fatigue, irritability
and even memory loss. Mucosal congestion has the largest
impact on sleep loss.
Evaluation of Allergic Rhinitis
After a detailed history and physical examination, physi-
cal factors can sometimes be identified. These might include
cysts, polyps, deviated nasal septum or an infection in the
upper respiratory tract. A foreign body must be considered
in children. Typically, with allergic rhinitis, the turbinates are
edematous, pale and shiny with a more serous exudate (Fig-
ure 1, dcmsonline.org). The edema may at times be sufficient
to occlude the nasal passage. Nasal polyps may be present.
The pharynx may be hyperemic with increased lymphoid
follicular hypertrophy (cobblestoning) reflecting chronic
post-nasal drainage. Visible signs may include dark circles
around the eyes (allergic shiners), edema of the conjunctivae
and sometimes a transverse nasal skin crease, produced by
constant rubbing of the nose. In children, this is referred to
as the “allergic salute”. Some serous otitis media may also be
present. Allergic rhinitis and asthma frequently co-exist.
Evaluation of specific IgE to allergens present in the area
is the standard means to identify triggers. Skin testing is the
standard in vivo method used by allergists. This consists of
prick testing followed by intra-dermal testing at differing
dilutions. Several in vitro tests are present, CAP (immuno-
assay capture) and RAST (radioallergosorbent test) and are
fairly accurate, but they do not always offer testing for the
allergens needed for a certain area. These tests are sensitive
and over-interpretation of results may occur. Therefore, cau-
tion must be used in ordering these tests and using them as
a basis of therapy.
Triggers of Allergic Rhinitis
Several triggers of IgE production are common to North
Florida. The common ones in this area are dust mites, animal
dander, mold spores and pollen.
Dust Mites- Mites are microscopic arachnids that feed
on organic matter that has settled from the air (Figure 2,
dcmsonline.org). Dust mites are more prevalent in areas with
higher humidity, especially the southeastern United States.
Mites are found in areas of settled dust such as carpet, bed-
ding, upholstering etc. There can be several thousand in every
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gram of dust from carpeting. Reduction measures include
dehumidification, carpet treatment or removal and bedding
encasements. Rarely, relocation to a drier climate is necessary
to control this allergy, especially if asthma is also a component.
Immunotherapy is often needed for meaningful reduction of
symptoms of this allergy.
Mold Spores- Molds are microscopic fungi that reproduce
by releasing spores into the air. The spores of many species
trigger histamine release and produce allergy symptoms.
Measures to control mold in the home include reduction of
humidity and cleaning with a dilute bleach solution (1 cup
per gallon of water) or use of a commercial mold cleaner.
Sources of water incursion (plumbing leaks, roof or window
leaks) should be repaired.
Animal Dander - General surveys suggest that 40% of house-
holds have a dog and 25% have a cat. Allergies to animals
result from reaction to a protein that originates in the skin. It
is, therefore, found in the saliva as well. Removal of the animal
from the patient’s environment is the preferred “treatment”
but desensitization with allergy shots works well if reduced
exposure is not feasible. Allergies to small animals (hamsters,
gerbils,etc.) are possible but not usually significant. Horse
dander allergies are more common and can be quite severe.
(I treated one veterinarian with allergies to several exotic zoo
animals that ultimately necessitated changing jobs.)
Pollen - Pollen is the most well known of allergic triggers and
was the first one described by Dr. Noon in 1909.4 The com-
mon plant categories producing pollen of allergic significance
in Florida are trees (spring), grass (summer) and weeds (fall).
The most potent pollen allergens in Florida appear to be oak
trees, Bahia grass and ragweed. Florida pollen counts can be
found at www.aaaai.org/nab.5
Treatment of Allergic Rhinitis
The therapy of allergic rhinitis can be divided into three
levels, depending on the degree of the patients’ symptoms.
Those levels include environmental avoidance/reduction
measures, medications and immunotherapy (allergy shots).
Reduction measures are appropriate for several allergens,
including animal dander, feathers, dust mites, molds and a
few occupational exposures.
Several medications exist for allergic rhinitis treatment:
Antihistamines - This has been one of the mainstays of treat-
ment for many years. Older H1 blockers (diphenhydramine,
cyproheptadine) are sedating but are effective otherwise. Newer
H1 blockers are non-sedating (loratidine, fexofenadine).
Decongestants- These act as alpha-adrenergic agonists and
include pseudoephedrine and phenylephrine. They may have
adverse effects including insomnia, tachycardia, and decreased
urinary flow in males or increased blood pressure.
Nasal Steroids-This pharmacologic class probably has had the
largest impact on allergic rhinitis. Steroids reduce swelling
and inflammation of the nasal passages very effectively but
may take several days to reach optimal effect. Possible side
effects include nasal irritation, epistaxis, or rarely, nasal septal
Northeast Florida Medicine Vol. 59, No. 2 2008 27
atrophy/perforation. Patients on this medication should be
evaluated for this effect periodically. Some ophthalmologists
believe that increased intra-ocular pressure may occur with this
class of medication, but the preponderance of evidence suggests
that there is not a significant increase in ocular pressure.
Leukotriene receptor antagonists-Blocking the effects of cys-
teinyl leukotrienes often leads to reduced allergy symptoms.
Montelukast is indicated for treatment of asthma and allergic
rhinitis and can be used in children as young as 2 years old.
Immunotherapy
Also called desensitization or allergy shots, this is an anti-
gen specific method of gradually increasing the exposure to
allergens, usually at weekly intervals, to a maximal tolerated
dose. Precise information must be known about the patient’s
allergies as well as knowledge about which antigens are com-
patible in solution with one another. (e.g., grass pollen and
dust mite cannot be mixed together). Also, it incurs the risk
of anaphylaxis and must be given in a physician’s office where
treatment for anaphylaxis is available. A convenient package
of the treatment of anaphylaxis as well as current Position
Statements regarding immunotherapy indications and con-
traindications can be obtained from the American Academy
of Allergy, Asthma and Immunology at www.aaaai.org.5
Immunotherapy is generally the best option for meaningful
long term reduction of patients’ symptoms. Allergy shots are
effective about 85% of the time. Current research suggests that
patients may soon have the option of receiving immunotherapy
doses sublingually rather than subcutaneously.6
Conclusion
Evaluation of the patient with chronic rhinitis involves
first identifying whether or not allergies are the basis of
the symptoms. Reduction measures and judicious use of
medications are also employed initially. Patients that fail to
respond adequately to these measures are then candidates for
immunotherapy which may need to last 3-5 years.
References
1. Naclerio RM. Understanding the inflammatory processes
in upper allergic airway disease and asthma. J Allergy Clin
Immunol 1998;101:S345.
2. Craig TJ, McCann, et al. The correlation between allergic
rhinitis and sleep disturbance. J Allergy Clin Immunol 2004;114:
S139-45.
3. Dykewecz Mark. Executive Summary of joint task force practice
parameters on diagnosis and management of rhinitis. Annals
of Allergy Asthma Immunology 1998;81:463-468
4. Dworetzki, M., et al. Noonan and Freeman on prophylactic
inoculation against hay fever. J Allergy Clin Immunol
2003;111:1142-1144.
5. American Academy of Allergy and Immunology. www.aaaai.
org/nab and www.aaaai.org. Accessed March 2008.
6. Wilson, DR, Torres-Lima M, et al. Sublingual immunotherapy
for allergic rhinitis: Systematic review and meta analysis. Allergy.
2005;60:4-12.

Other Recommended Resources

1. The Food Allergy & Anaphylaxis Network. www.foodallergy.org.
2. Florida Allergy, Asthma & Immunology Society. www.faais.org.

28 Vol. 59, No. 2 2008 Northeast Florida Medicine www . DCMS online . org