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Allergy/Immunology - Rhinitis, Conjunctivitis, and Sinusitis - Fast Facts | NEJM Resident 360

Rhinitis

Rhinitis is defined as inflammation of the nasal mucous membranes and encompasses a broad group of disorders with etiologies including the following:

• Allergic rhinitis (AR)

  • local AR

• Nonallergic rhinitis (NAR)

  • vasomotor

  • food-induced (gustatory)

  • infectious rhinitis

  • NAR with eosinophilia

  • occupational

  • atrophic

  • hormonal

  • rebound/chemical rhinitis (rhinitis medicamentosa)

  • geriatric rhinitis

Allergic rhinitis (hay fever) can be seasonal (occurring at a particular time of year) or perennial (present year-round). The diagnosis is usually made clinically based on history and physical exam and supported by skin prick and intradermal testing with environmental allergen extracts.

• Seasonal allergic rhinitis is caused by pollen from trees, grasses, and weeds; the timing of peak pollen counts varies by geographical area.

• Perennial allergic rhinitis is caused by indoor allergens, including dust mites, cockroaches, molds, and animal danders.

Common Findings in Allergic Rhinitis
Symptoms

• sneezing

• rhinorrhea

• nasal obstruction and congestion

• nasal itching

• postnasal drip

• cough

• facial pressure

• fatigue

|

• pallor of the nasal mucosa

• swollen turbinates

• clear rhinorrhea

• cobblestoning of the posterior pharynx

• allergic shiners (infraorbital edema and
  darkening due to subcutaneous
  venodilation)

• Dennie–Morgan lines (lines/folds below the lower eyelids)

• allergic salute (transverse nasal crease
  due to repeated rubbing of the nose)

| | Common Findings in Allergic Conjunctivitis | | Symptoms | Physical Exam Signs | |

• ocular itching

• watering of the eyes

• burning

|

• tearing

• conjunctival edema

• hyperemia

• watery discharge

• eyelid edema

• photophobia

|

Allergic Shiners

(Source: Photo courtesy of David Amrol, MD.)

Cobblestone Throat

Diagnosis and Management of Rhinitis

The following algorithm from the Joint Task Force on Practice Parameters for Allergy and Immunology demonstrates the evaluation and treatment of patients with suspected rhinitis:

Algorithm for Approach to Patients with Rhinitis

Testing

The diagnosis of rhinitis can be presumed based on clinical symptoms and exam and treated empirically. However, the identification of culprit allergens can help with allergen avoidance and has been associated with improved patient outcomes. Allergen-specific testing can be performed via skin-prick and intradermal testing (preferred) or by blood tests (allergen-specific immunoglobulin E [IgE]) to identify allergen triggers. 

Differential diagnosis can include:

• chronic nonallergic rhinitis (see list above)

• chronic rhinosinusitis (with or without polyps)

• septal wall abnormalities (e.g., deviated septum)

• nasal valve collapse

• turbinate hypertrophy (with or without concha bullosa)

• adenoidal hypertrophy

• foreign body

• nasal tumors

• cerebral spinal fluid leak

• primary ciliary dyskinesia syndrome

• illicit drug use (e.g., intranasal cocaine)

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Management

Allergic rhinitis: The approach to managing a patient with allergic rhinitis depends on the frequency and severity of symptoms. The following figures summarize pharmacotherapy for episodic and persistent, mild, and moderate-to-severe symptoms. To help guide treatment, the 2020 Joint Task Force Practice Parameter Update recommends scoring symptoms using a visual analog scale (VAS) of 0-10 where 0 is no symptoms and 10 is worst possible symptoms.

Abbreviations: IN, intranasal; INAC, intranasal anticholinergic; IN(AH & CS), intranasal antihistamine and corticosteroid administered by a single device; INAH+INCS, these 2 preparations administered by separate devices; IND, intranasal decongestant; OAH 2G, oral antihistamine, second generation; OCS, oral corticosteroid; PRN, as needed; PSE, pseudoephedrine; Tx, treatment
(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Abbreviations: IM, intramuscular; OCS, oral corticosteroid; SQ, subcutaneous
(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Nonallergic rhinitis: Treatment of infectious and chemical nonallergic rhinitis should target the underlying etiology. For all other nonallergic rhinitis, the following figures summarize pharmacotherapy for episodic and persistent, mild, and moderate-to-severe symptoms based on the VAS (0-10; 0 is no symptoms and 10 is worst possible symptoms).

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Allergen immunotherapy should be considered in patients with refractory symptoms despite medical management or if adverse effects from pharmacotherapy limit use.

• Allergen immunotherapy can be given as subcutaneous injections (allergy shots) or as sublingual tablets, which are only available for a limited number of allergens, such as grass and ragweed (ages ≥5 years) and dust mites (ages ≥18 years). 

• Children with moderate-to-severe allergic rhinitis should be referred to an allergist because allergen immunotherapy has been shown to alter the progression of allergic disease and reduce the subsequent development of asthma.

Rhinosinusitis

Rhinosinusitis is inflammation of one or more of the paranasal sinuses and is often classified by duration as follows:

• acute rhinosinusitis: up to 4 weeks of symptoms

• subacute rhinosinusitis: 4–8 weeks of symptom duration

• chronic rhinosinusitis (CRS): symptoms lasting at least 8–12 weeks

  • CRS can be classified as: 

    • CRS with nasal polyps (CRSwNP)

    • CRS without nasal polyps (CRSsNP)

    • allergic fungal rhinosinusitis (AFRS)

Management

Most acute sinus infections are caused by viruses and improve within 2 weeks without antibiotic treatment. A bacterial infection should be considered if symptoms worsen or fail to improve within 7–10 days. First-line antibiotics include amoxicillin and amoxicillin/clavulanate, but watchful waiting is often appropriate. CT of the sinuses is not recommended for diagnosis of acute rhinosinusitis but is indicated in chronic, refractory, or recurrent rhinosinusitis. 

Chronic sinusitis: Treatment typically includes nasal steroids and nasal saline lavage. See Medical Therapies for Adult Chronic Sinusitis (JAMA 2015, Figure 2) for an evidence-based approach to medical therapy for chronic sinusitis. In June 2019, dupilumab was the first biologic approved by the FDA for treatment in adults with a history of chronic rhinosinusitis with nasal polyps.

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