Rhinitis

Rhinitis is inflammation of the lining of the nose.

Allergy is a common cause but it is not the only one.

Symptoms vary from the itching, sneezing and watery nasal discharge classically associated with allergy to the dry, crusting, and over-patent airway seen in atrophic rhinitis.

Allergic rhinitis is generally managed with one or more of:

• nasal decongestants
• oral antihistamines
• steroids
  • topical steroids
  • short courses of oral steroids may occasionally be used
• topical anticholinergics

Additionally, in allergic rhinitis, an additional and very important principle, is identification and avoidance of the allergen if possible.

Bacterial rhinosinusitis

When the nasal discharge is profuse, blockage of the sinus ostia may occur resulting in acute bacterial sinusitis.

• a systematic review concluded (1):
  • there is insufficient evidence of benefit to warrant the use of antibiotics for upper respiratory tract infections in children or adults. Antibiotics cause significant adverse effects in adults. The evidence on acute purulent rhinitis and acute clear rhinitis suggests a benefit for antibiotics for these conditions but their routine use is not recommended
• a meta-analysis concluded that (2):
  • common clinical signs and symptoms cannot identify patients with rhinosinusitis for whom treatment is clearly justified.
  • this meta-analysis states that antibiotics are not justified even if a patient reports symptoms for longer than 7-10 days

Management of acute rhinosinusitis (3):

• avoid antibiotics as 80% resolve in 14 days without; they only offer marginal benefit after 7days number needed to treat (NNT)15
• use adequate analgesia
• consider 7-day delayed or immediate antibiotic when purulent nasal discharge NNT8
• in persistent infection use an agent with anti-anaerobic activity eg. co-amoxiclav
• antibiotic choice - seven day course (adult)
• amoxicillin 500mg TDS 1g if severe or
• doxycycline 200mg stat then100mg OD or
• phenoxymethylpenicillin 500mg QDS
• for persistent symptoms: co-amoxiclav 625mg TDS
• note amoxicillin, phenoxymethylpenicillin or co-amoxiclav cannot be used if penicillin allergic

Note that prolonged use of nasal nasal decongestants may predispose to rhinitis medicamentosa.

Notes:

• as the lining of the nose and paranasal sinuses are continuous, it is rare for inflammation to affect one without the other. As such, the description rhinosinusitis is often more appropriate
  • postnasal drip (PND) is the drainage of secretions from the nose or paranasal sinuses into the pharynx (4)
    • often the condition is described as a chronic condition associated with repeated episodes of cold and flu
    • there is accumulation of mucus in the postnasal space due to an abnormality in the mucociliary clearance (patient refers to this as ’catarrh’) (5)
  • in UK both chest physician and otolaryngologists recommend the term ‘rhinosinusitis’ for post nasal drip syndrome (PNDS) (5)
  • see linked item for more information re: PNDS

Reference:

• ((1) Arroll B, Kenealy T. Antibiotics for the common cold and acute purulent rhinitis. Coochrane Database Syst Rev 2005; (3): CD000247
• (2) Young J et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008 Mar 15;371(9616):908-14
• (3) Public Health England (October 2014). Management of infection guidance for primary care for consultation and local adaptation
• (4) Sanu A, Eccles R. Postnasal drip syndrome. Two hundred years of controversy between UK and USA. Rhinology. 2008;46(2):86-91
• (5) O'Hara J, Jones NS. "Post-nasal drip syndrome": most patients with purulent nasal secretions do not complain of chronic cough. Rhinology. 2006;44(4):270-3.