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Rhinitis

h-puppyWhat is rhinitis?

Rhinitis is the medical term for any condition causing the symptoms of a stuffy nose (blockage or congestion), increased nasal secretions (runny nose), sneezing and itching. These symptoms are a natural response to any source of irritation or inflammation. Any stimulus can cause these symptoms since the nose only knows these four “languages” to indicate that there is a problem. The origin of these symptoms, that is allergic or non-allergic, cannot be determined from the symptoms alone.

What causes rhinitis?

Common causes of rhinitis include:

  • Allergic reactions (contact of the respiratory mucosa with an airborne allergen)
  • Chemical irritant exposure (like cigarette smoke and some cleaning agents, pungent odors, and the like)
  • Changes in the weather, temperature and humidity
  • Viral infections (the common cold)
  • Anatomical abnormalities (like nasal septal deviation and nasal polyps)
  • Certain medications themselves (especially nasal sprays like Afrin, Neosynephrine, etc.)

These causes are explained in greater detail below. Rhinitis which last less than six weeks is usually caused by viral infections (a common cold); the other causes usually produce a more chronic set of symptoms that last longer than six weeks.

What are the symptoms of rhinitis?

  • Congestion – A normal function of the nose is warming and humidifying the air that we breathe in. the nose accomplishes this by increasing the blood supply to the tissues of the nose which will produce mild swelling of the nasal tissues. This swelling usually occurs in the only one nasal passage at a time. Most individuals are not even aware of these natural ‘nasal cycles’ which may last from 30 minutes to four hours. However, when there is additional congestion or the passages are small, these nasal cycles may become more apparent. Increased nasal congestion can be expected as a natural response to any source of inflammation and irritation. Also changes in head position, such as lying down, and strenuous exercise may adversely affect the amount of nasal congestion. Severe nasal congestion can also result in facial pressure and pain as well as dark circles under the eyes.

  • Excess secretions – Normally the nose clears particles which land on the surface lining of the nose (nasal mucosa) by producing a sticky secretion call mucus; hence the nose is always producing some amount of mucus. Mucus is normally a clear or white, thin, sticky liquid. The natural route of nasal mucus is toward the back of the nasal passages, and under normal conditions, a small amount of mucus is constantly being swallowed. When the amount of these secretions become increase, then a postnasal drip is perceived. The natural mechanism for removing these secretions from the back of the throat is coughing or frequent clearing of the throat. A sore throat can occur from chronically breathing through the mouth, a postnasal drip, or a frequent cough/throat clearing. When mucous production is excessive, these extra secretions may travel toward the front of the nose (runny nose).

  • Itching and sneezing – this can also be a natural response to inflammation and irritation. Sneezing is an attempt by the nose to expel the irritant. Itching is most commonly associated with allergic reactions.

What is sinusitis?

Sinusitis is when the four sets of air sinus cavities become infected or inflamed. If an infection is present, the secretions from the nasal passages normally become yellow or green. Although they occur together frequently, sinusitis is not the same as rhinitis. Sinus congestion or sinus problems are often mistaken to refer to nasal congestion, when that is not entirely accurate. Acute sinusitis is usually caused by either a viral or bacterial infection. Treatment consists of clearing the congestion and combating the infection with antibiotics if the infection is bacterial in origin.

Unfortunately, there are no antibiotics which can effectively clear viral infections; the body’s own defense mechanisms must do that. When medicines are not able to cure a chronic sinusitis, then drainage by surgical methods may be necessary. Sinus X-rays help diagnose the presence of sinusitis and follow-up X-rays are helpful in determining whether the infection and congestion has resolved.

How is rhinitis diagnosed?

Rhinitis is not a disease, but simply a term describing the symptoms produced by any source of nasal irritation or inflammation. In order to treat these symptoms more effectively, it is important to try and determine the underlying cause. The conditions responsible for rhinitis are primarily diagnosed by a medical interview, a physical exam and certain diagnostic tests. The medical interview consists of a careful discussion of the exact symptoms, environmental factors and exposures, results of previous therapy, nose, ears and throat. The presence of allergic rhinitis can be best diagnosed by allergen skin tests. Negative skin tests to the panel of allergens do not mean that you are not having symptoms, but rather this indicates that the source of your symptoms is something other than contact with allergens. Other useful procedures may include sinus X-rays, examination of nasal secretions, or a blood test to check the serum level of a protein (IgE) associated with allergic conditions.

Common Specific Causes of Rhinitis

Vasomotor Rhinitis

The most common source of chronic nasal and sinus symptoms. Only 25% of people with chronic, recurrent nasal and sinus problems have allergic rhinitis. The symptoms of vasomotor rhinitis are almost identical to those of allergic rhinitis and include recurrent or chronic nasal congestion, excessive mucus production, sneezing, etc. However, rather than being caused by an underlying sensitivity of the mucosa of the nose to the irritant effects of certain factors. In these individuals, the allergen skin tests are negative.

Irritant factors usually trigger the symptoms, and some of these factors may not be thought of as irritants by the patient. These irritants are nonspecific and do not involve any recognition by the allergic immune system. Common causes of this irritant rhinitis include exposure to cigarette smoke, strong odors or fumes, such as: perfumes, chemical smells, fabric stores, flowers; certain chemicals such as hairspray, cleaning solvents and solutions, chlorine from swimming pools, gasoline, car exhaust, and air pollution; and fine particles in the air like laundry powder, dust and cut grass. Changes in the temperature, weather and humidity can be perceived as an irritant by the nose. Some patients are very sensitive to temperature changes. For example, some patients start sneezing when leaving an air-conditioned building if the outside temperature and humidity is different from that inside. Spices used in cooking and temperature of the food may cause nasal irritation; symptoms may occur during or right after meals. Other things which aggravate vasomotor rhinitis are alcoholic beverages (particularly wine and beer), aspirin, and certain blood pressure medications.

The actual mechanism by which these irritants produce symptoms is not well understood, but it appears to be related to the increased sensitivity of some persons to a lower dose of the irritant. For example, if the concentration of cigarette smoke is high enough it will produce some amount of symptoms in nearly everyone exposed to this dose. Thus, vasomotor rhinitis is probably an exaggeration of the normal nasal response to irritant. This response will occur at a dose which does not produce symptoms in the majority of those exposed to the irritants. Vasomotor rhinitis occurs more often in people who smoke and in older individuals. Persons with allergic rhinitis will also have a component of their symptoms which are vasomotor (or irritant) in origin. Vasomotor rhinitis can’t be cured, but fortunately these symptoms can be significantly reduced by a combination of avoidance, when possible, and medications.

Patients with vasomotor (irritant) rhinitis should avoid substances causing nasal irritation to the extent possible. Saline nasal sprays and lavages are cleansing and reduce irritation; they may be safely used several times a day. Unless primary symptoms are runny nose, these patients should avoid drugs, such as antihistamines, which dry the nose. Topical steroid nasal sprays may be beneficial. An anticholinergic nose spray may also help some patients. Surgery is not useful unless other mechanical problems are associated.

Allergic Rhinitis

The symptoms of allergic rhinitis are caused by exposure to a substance to which the patient has become allergic. Allergies require a genetic predisposition to become allergic; thus, allergies tend to run in families and take time to develop. Persons who have allergies make a specific allergic antibody which can recognize the allergen in a very precise manner. This antibody is found in highest concentrations in the tissues of the respiratory tract (nose, sinus, lungs) and the skin. Sometimes it is also present the gastrointestinal tract. The skin test can demonstrate the presence of the antibody in the skin of allergic people. A positive skin test reflects to a great extent to the reaction which occurs in the nose when contact with an allergen occurs. Positive prick tests correlate well with the symptoms produced following a deliberate allergen challenge. The most helpful approach to treating allergic rhinitis depends on which particular allergen is responsible for the symptoms.

Mechanical Blockage

Mechanical blockage of the nose really isn’t rhinitis, though it produces congestion or blockage which is a symptom of rhinitis. When rhinitis of any origin and mechanical blockage coexist, the symptoms are likely to be more severe. Mechanical blockage should be suspected when one side is more affected than the other or only one side is affected. Common causes of mechanical obstruction include nasal septal deviation, enlarged adenoids, nasal polyps, and enlargement of the burbinates (structures in the nose which help warm and humidify the air). Most patients with mechanical blockage learn to put up their symptoms. Surgery will improve severe symptoms caused by deviated septum, large turbinates, large adenoids, and chronic sinusitis. Surgery is generally necessary for nasal tumors.

Medicine-induced (Rhinitis medicamentosa)

There are several medications that can cause chronic nasal congestion, including:

  • Birth control pills
  • Female hormone preparation medicines
  • Beta blockers
  • Vasodilators
  • Over-the-counter decongestant nasal sprays

While the over-the-counter nasal decongestant sprays work quickly and effective, if they are used often, the medicine begins to have a lesser effect on the condition because it can cause damage to the nasal tissues. If there is no underlying disorder for nasal congestion, avoiding over-the-counter nasal decongestants will cure rhinitis medicamentosa. Talk with your doctor about ways to stop using these sprays.

The Common Cold

The most common source of acute rhinitis is the common cold. It can be caused by more than 200 viruses. Children, in particular young children in school or day care, usually have eight to 12 colds each year, usually clustered in the winter. Fortunately, the frequency of colds lessens after immunity has been produced following exposure to many viruses. Colds usually begin with a sensation of congestion, rapidly following by runny nose and sneezing. Over the next few days, congestion becomes more prominent, nasal mucus usually becomes colored light tan or light green, and there may be a light fever and cough. Cold symptoms spontaneously resolve over the next few days to one to two weeks. The cough may persist for up to six weeks in some patients.

How is rhinitis treated?

Unfortunately, there is no medicine available to help prevent rhinitis all together; however, there are treatment options available to help reduce and control your symptoms.

  • Antihistamines – Antihistamines dry excess secretions and reduce itching and sneezing. There are dozens of different antihistamines. Some are available over-the-counter in any pharmacy, and others require a prescription. The response to antihistamines varies from person to person; an antihistamine which causes sleepiness and no relief of symptoms in one individual may be just right for someone else. When an antihistamine causes drowsiness, try taking it just at bedtime; the beneficial effects may last for 24 hours without causing daytime drowsiness. However, there are now several new antihistamines which do not cause drowsiness. Some people notice that after using the same antihistamine regularly for about four to six weeks, it doesn’t control the symptoms as well as it did initially. If this happens it may be useful to switch to another antihistamine.

  • Decongestants – Decongestant nose sprays work within minutes and the effect lasts for hours. However, these medications should not be used regularly for more than three to five days, otherwise, they can cause rhinitis medicamentosa. Patients with chronic rhinitis should avoid this type of medication unless your physician has prescribed them as part of your treatment. Oral decongestants are found in most over-the-counter and prescription allergy medications. Oral decongestants do not cause rhinitis medicamentosa but need to be avoided by some patients with high blood pressure. One advantage of decongestants is that they do not cause drowsiness.

  • Topical Steroid Sprays – These are prescription medications which are very safe to use. They can be very effective at controlling most nasal and sinus symptoms; however, it will take 7 to 14 days to experience the benefit that these medications can produce. Furthermore, these sprays produce the most benefit if they are used regularly each day for several weeks. The usual directions are one spray in each nostril twice a day for four to six weeks

  • Antibiotics – Antibiotics are for the treatment of bacterial infections. They do not affect the course of the usual viral upper respiratory tract infections and are of no benefit for non-infections rhinitis. In treating chronic sinusitis, usually three full weeks of antibiotic therapy is necessary to eradicate the infection.

  • Surgery – Nasal surgery will usually cure or improve symptoms caused by mechanical blockage or chronic sinusitis. However, not all causes of obstructions respond well to surgery; surgery and surgical alternatives need to be carefully considered. Sometimes chronic sinusitis and nasal polyps may coexist.

  • Topical Atropine – Atropine and the related drug ipratropium bromide will block the symptom of runny nose. Atropine can be taken orally, and is a component in some antihistamine/decongestant preparations. At the present time, these medications are not commercially available as a nasal spray; however some physician adapt the asthma metered dose inhaler for nasal application.

  • Immunotherapy – This form of treatment is also called desensitization, hyposensitization or “allergy shots”. Immunotherapy is used in the treatment of allergic patients with respiratory symptoms, mainly of hay fever or asthma. In this form of therapy, injections of allergen extract are given in gradually increasing amounts over a period of months. The goal is to induce a degree of tolerance to the allergens and to bring about a decline in the symptoms and the medication requirements. It will usually take six to eight months of immunotherapy before the benefits of these injections become apparent; usually these injections are continued for at least two years after symptoms have significantly decreased before being discontinued.

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