Rhinitis
Gail S. Marion
No universal system of definition or classification exists for rhinitis—a common presenting symptom. Rhinitis connotes inflammation of the nasal mucosa, but also commonly refers to a constellation of rhinopathy symptoms, including mucus drainage, stuffiness, sneezing, and itching. Rhinitis currently affects about 40 million Americans with annual costs to society of more than $15 billion dollars (1). Considered a minor complaint, it is frequently untreated. Proper evaluation and treatment of rhinitis is not only economically important, but also improves health outcomes and quality of life for patients (2–4). An important example is increasing evidence that aggressive allergic rhinitis management improves the management of asthma because the nose serves as a filter for inhaled air (2,5).
Approach
Evaluation of rhinitis requires determining whether the symptoms are caused by (a) allergy; (b) infection; (c) anatomic defect; (d) serious systemic illness; or (e) some combination of these (Table 6.2).
A. Etiology. Allergic rhinitis (seasonal and perennial), which causes most recurrent or chronic rhinitis, is increasing in children and adults (2). Infections (viral and bacterial) are the second most common cause. Allergy and infection produce bilateral nasal complaints, whereas most rhinitis relating to structural problems of the nose is unilateral.
B. Special concerns. Approximately 1% of rhinitis is caused by foreign bodies, anatomic defects, trauma, drug side effects, idiopathic syndromes, systemic diseases, and neoplasm (Table 6.2). In such patients, recent onset of persistent symptoms is present with other associated symptoms.
History
A. Characteristics of rhinitis. What are the specific symptoms (i.e., stuffiness, itching, clear or purulent drainage)? Are symptoms unilateral or bilateral? When did the symptom(s) begin? Ask what the patient believes caused the symptoms.
B. Chronology. How often and when do symptoms occur? Do they predominate at certain times of the year?
C. Associated symptoms. What other symptoms are associated? What makes the symptoms better or worse? Associated complaints (e.g., frank fatigue, irritability, depression, or chest symptoms) tend to point to untreated allergic causes, systemic disease, or drug-induced illness (Table 6.2).
D. Pertinent medical history. Include questions about atopic disease, upper respiratory allergies, asthma, nasal surgery, serious infections, and current prescription medication use.
E. Lifestyle history. This discussion should address tobacco (personal use or use by those at home), alcohol or other recreational drug use, over-the-counter medication, herbal remedies, and pets in the home.
F. Family history. Is there a family history of allergies or other relevant systemic diseases?
G. Occupational history. Are there suspected environmental irritants?
Physical examination
A. General inspection of the patient frequently offers clues to the cause of the rhinitis. For example, “allergic shiners” (infraorbital, bluish discoloration of the skin) or a crease at the lower part of the nose from repeated rubbing are common physical findings of allergic rhinitis.
B. Focused physical examination (PE). Evaluate vital signs (especially temperature) and the ears, nose, and throat, including examination for lymphadenopathy and thyroid disease. A competent examination of nasal passages requires a nasal speculum (a 4–5 mm ear speculum on a handheld otoscope is acceptable for children) and a good light source. Carefully place the nasal speculum vertically into each vestibule. Insert a handheld otoscope light source through the speculum to survey for nasal patency, mucosal color (pale, red or bluish), degree and location of edema, presence and type of nasal drainage (thin, clear, thick, purulent, unilateral, or bilateral), anatomic deformities (bone spurs, septal deviation), and the presence of polyps or other masses. If swollen nasal turbinates block the view, apply a short-acting decongestant spray, then reexamine in 10 minutes. Evaluation of the posterior portion of the nose is often difficult or impossible with a nasal speculum and light source. A flexible nasopharyngoscope permits examination of the structures between the nasal vestibule and the larynx (1).
Assess the lungs and skin for signs of atopic disease (wheezing or eczema) (Chapters 8.9 and 13.4).
C. Additional physical examination. If systemic illness is suggested after the focused examination, a thorough multisystem PE is necessary (Table 6.2).
Testing
A. Clinical laboratory tests. After a thorough history and focused physical examination, most common causes of rhinitis will not require additional testing to initiate effective treatment. Microscopic examination of nasal secretions can be done to help define uncertain allergic or bacterial causes of rhinitis, although most primary care clinicians often leave these tests to an otolaryngologist because these are usually done to clarify less common causes of rhinitis (3). Prompt referral is indicated if doubt exists, serious pathology is suspected or found, PE is difficult secondary to nasal obstruction, or symptoms do not improve with treatment.
B. Diagnostic imaging. If an anatomic abnormality or sinus pathology is suspected, limited computerized tomography (CT) of the sinuses is recommended (1,3,5).
Diagnostic assessment
The patient’s story is critical to determining an accurate diagnosis. Additionally, purulent nasal drainage implies an infectious cause, whereas clear discharge suggests a noninfectious cause. Viral infection will create whitish to pale yellow drainage with associated symptoms of generalized head or body aches, nasal congestion, and sneezing. Bacterial infection will cause yellow or green drainage with focal sinus pain, upper teeth complaints, and possibly fever. Look for edematous, erythematous turbinates. Other less common infectious sources (fungal or parasitic) should be suspected if treatment fails or the patient has a suggestive medical or travel history (5).
To distinguish between allergic and nonallergic rhinitis, focus on symptoms of sneezing, clear drainage, postnasal drip, itching, nasal congestion, generalized sinus pressure, specific irritants or allergens, and family and personal history of atopy and allergy. Next, consider seasonal, perennial, or geographic relationships. The presence of blue or pale boggy turbinates with clear drainage suggests an allergic process.
After a thorough history is taken, the physical examination should confirm the patient’s story and help identify any anatomic defects or systemic disease. Several follow-up visits may be necessary to assess, treat, and educate those with allergic rhinitis and to confirm any need for further evaluation or treatment by an otolaryngologist or allergist (4).
References
1. Fornadley JA. The stuffy nose and rhinitis. Med Clin North Am 1999;83:211–224.
2. Hadley JA. Evaluation and management of allergic rhinitis. Med Clin North Am 1999;83:13–25.
3. Galen BA. Rhinitis. Lippincott’s Primary Care Practice 1997;1:129–141.
4. Leopold D, Ferguson BJ, Piccirillo JF. Outcomes assessment. Otolaryngol Head Neck Surg 1997;117:S58–S68.
5. Benninger MA, Anon JB, Mabry RL. The medical management of rhinosinusitis. Otolaryngol Head Neck Surg 1997;117:S41–S49.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
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