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An overview of rhinitis

An overview of rhinitis
Author:
David Peden, MD
Section Editor:
Jonathan Corren, MD
Deputy Editor:
Anna M Feldweg, MD
Literature review current through: Jan 2024.
This topic last updated: Jul 20, 2023.

INTRODUCTION AND DEFINITION — Rhinitis is common, affecting nearly everyone at one time or another. This topic provides an overview of the various types of acute and chronic rhinitis that are most common among adults and children. Rhinitis caused by viral respiratory infection is usually self-evident and is presented separately. (See "Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections" and "The common cold in adults: Diagnosis and clinical features".)

OVERVIEW — There are multiple causes of rhinitis (table 1). Different syndromes are recognized mainly by clinical history, patterns of symptoms, and, to a lesser extent, physical signs.

Definition — Rhinitis is the presence of one or more of the following nasal symptoms [1]:

Sneezing

Rhinorrhea (anterior and/or posterior)

Nasal congestion (stuffiness)

Nasal itching

Cough

"Rhinosinusitis" (also known as sinusitis) is a term that encompasses disorders affecting both the nasal passages and paranasal sinuses and has overlapping but distinct symptoms from pure rhinitis. Symptoms of sinus involvement may include nasal congestion, posterior nasal drainage (which is often purulent), facial pressure and/or pain, headache, and, in some cases, reduced sense of smell. Rhinosinusitis is reviewed elsewhere:

Acute rhinosinusitis in adults – (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment".)

Acute bacterial rhinosinusitis in children – (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis" and "Acute bacterial rhinosinusitis in children: Microbiology and management".)

Chronic rhinosinusitis – (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Chronic rhinosinusitis without nasal polyposis: Management and prognosis" and "Chronic rhinosinusitis with nasal polyposis: Management and prognosis".)

Most common forms — The most common forms of rhinitis are [1]:

Allergic rhinitis

Various forms of nonallergic rhinitis

Atrophic rhinitis

Rhinitis of pregnancy

Occupational rhinitis

Less common causes of rhinitis include systemic diseases that can present with prominent rhinitis and rhinitis caused by nasal or systemic medications/drugs.

Uncommon conditions that can mimic rhinitis include nasal tumors and leakage of cerebral spinal fluid into the nasal cavity. (See 'Differential diagnosis' below.)

SPECIFIC DISORDERS

Allergic rhinitis — Ten to 30 percent of adults and up to 40 percent of children suffer from allergic rhinitis [1]. The risk is increased in individuals with eczema or asthma [2,3].

Allergic rhinitis can begin at any age, although most affected individuals develop symptoms as children or young adults. Some combination of nasal itching, watery rhinorrhea, nasal congestion (stuffiness), and sneezing is typical. Nasal itching helps distinguish allergic rhinitis from most other forms of rhinitis. Children often manifest nasal itch with various types of nose rubbing rather than actually complaining of itch. Approximately 40 percent of adults and children note poor sleep, and over 75 percent report fatigue. Snoring due to nasal congestion is often noted by the patient's family members. Common comorbidities include increased frequencies of headaches, rhinosinusitis (approximately 40 percent), and asthma (approximately 35 percent) [2].

Gross physical findings of chronic allergic rhinitis, found mainly in children, may include "allergic shiners," which are blue/gray to purple discoloration under the eyes, and a transverse nasal crease, which forms from repeatedly rubbing the nose and pushing the tip of the nose up with the hand in response to nasal itching (the "allergic salute") (figure 1).

Examination of the anterior nasal mucosa with an otoscope may be normal but can yield useful information. The nasal mucosa in patients with allergic rhinitis classically appears edematous and pale. In contrast, the nasal mucosa in patients with nonallergic rhinitis is usually normal in color, and it is beefy red in patients with an acute viral rhinosinusitis or rhinitis medicamentosa. (See 'Nasal decongestant sprays' below.)

Allergic rhinitis is classified as intermittent if symptoms occur in response to specific exposures (eg, cats), seasonal if symptoms occur at certain times of year, or persistent (perennial) if symptoms occur year-round [3,4]. Patients with seasonal allergic rhinitis have associated allergic conjunctivitis in approximately 70 percent of cases, characterized by itchy, red, watery eyes. (See "Allergic conjunctivitis: Clinical manifestations and diagnosis".)

Common allergens causing seasonal allergic rhinitis are tree, grass, and weed pollens, as well as outdoor molds (table 2).

Indoor allergens, including house dust mites, cockroaches, allergens from household furbearing pets, rodents, and fungi, are most commonly associated with perennial rhinitis.

The diagnosis and treatment of allergic rhinitis are presented separately. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Pathogenesis of allergic rhinitis (rhinosinusitis)" and "Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis" and "Pharmacotherapy of allergic rhinitis".)

Nonallergic rhinitis — Nonallergic rhinitis is a common condition characterized by the chronic presence of one or more of the following: nasal congestion (stuffiness), rhinorrhea, and postnasal drainage. It is a diagnosis of exclusion, and, thus, specific etiologies must be excluded (such as allergic, infectious, pharmacologic, structural, hormonal, vasculitic, metabolic, and atrophic causes) [5].

Clinically, it is distinguished from allergic rhinitis by the following:

Onset at a later age.

Absence of nasal and ocular itching and prominent sneezing.

Nasal congestion and postnasal drainage are prominent symptoms.

Symptoms are perennial.

Typical triggers in nonallergic rhinitis include irritant odors and strong fragrances, such as tobacco smoke, perfumes, diesel and car exhaust (ie, patients become congested when sitting in traffic), cleaning products, newsprint, changes in temperature, and alcoholic beverages [6]. Subtypes of nonallergic rhinitis include:

Vasomotor rhinitis, which is characterized by intermittent symptoms of congestion (stuffiness) and/or watery nasal discharge and an exaggerated reaction to nonspecific irritants, such as air pollution or temperature changes, especially exposure to cold, dry air [7,8].

Gustatory rhinitis, which is an episodic condition with prominent, watery rhinorrhea triggered most often by hot or spicy foods and caused by a vagally mediated reflex [9,10].

Diagnosis and management of the different forms of nonallergic rhinitis are reviewed elsewhere. (See "Chronic nonallergic rhinitis".)

Mixed rhinitis — Mixed rhinitis is the combination of allergic and nonallergic rhinitis. It is the most common form of rhinitis in adults. (See "Chronic nonallergic rhinitis".)

Occupational rhinitis — Occupational rhinitis is caused by airborne allergens or irritants in the patient's workplace [11-13]. Patients with occupational rhinitis often report that symptoms are more prominent at work and improve on days off. The underlying mechanism may be allergic or irritant (table 3). Common examples of substances that can cause occupational rhinitis include proteins from the urine and fur of laboratory animals, food proteins in food processing, enzymatic proteins in detergent manufacturing, and organic dusts in woodworking. (See "Occupational rhinitis".)

Other causes of rhinitis — There are a number of other causes of rhinitis (table 1).

Nasal decongestant sprays — Nasal decongestant sprays can cause a disorder called rhinitis medicamentosa (table 1). The physical examination in patients with rhinitis medicamentosa often reveals swollen, red nasal mucous membranes. Diagnosis most heavily relies upon the history of use of a causative medication.

Many days of regular use of over-the-counter decongestant nasal sprays leads to rebound nasal congestion as the medication wears off, prompting patients to administer the medicine more frequently to obtain relief. This begins a vicious cycle of nasal congestion, both caused and temporarily relieved by the medication, with escalating use and eventual dependency [14]. The risk of developing rhinitis medicamentosa from over-the-counter nasal decongestants can be minimized by limiting use to a maximum of approximately five days, not exceeding recommended frequencies, and using as few doses as possible during those days. There is also evidence that this is less likely to occur if the patient is administering an intranasal corticosteroid along with the nasal decongestant.

Treatment begins with withdrawal of the medication. Other measures are discussed separately. (See "Chronic nonallergic rhinitis", section on 'Management of rhinitis medicamentosa'.)

CPAP-rhinitis — Some patients who use nasal positive pressure devices, such as continuous positive airway pressure (CPAP), to treat obstructive sleep apnea develop new nasal symptoms, commonly termed "CPAP-rhinitis." Symptoms include nasal dryness, crusting, and nasal obstruction. Physical examination shows a dry, erythematous, nasal mucosa. This probably results from damage to the nasal mucosa by cold, dry air under pressure. A randomized trial of 63 patients found that use of a topical nasal corticosteroid spray beginning 10 days before and for the first month of CPAP use did not alter the prevalence of nasal symptoms or improve compliance with CPAP [15]. CPAP-rhinitis usually responds to nasal irrigation with saline, combined with warming and humidification of the pressurized air using distilled water in a reservoir-hot plate device available for most machines. Small amounts of petroleum jelly applied to the anterior nose may be helpful. A discussion of nasal irrigation and patient education with instructions for performing irrigation are found separately. (See "Patient education: How to rinse out your nose with salt water (The Basics)" and "Pharmacotherapy of allergic rhinitis", section on 'Nasal saline'.)

Intranasal cocaine use — Intranasal cocaine also causes nasal congestion. (See "Cocaine use disorder: Epidemiology, clinical features, and diagnosis", section on 'Pulmonary system'.)

Systemic medications — Certain systemic medications have been implicated in causing rhinitis symptoms through local inflammation, neurogenic effects, or unknown mechanisms. The presenting symptom is usually nasal congestion without other nasal symptoms. These drugs include the following (table 1) [16]:

Alpha blockers, such as clonidine, methyldopa, guanfacine, prazosin, doxazosin, and phentolamine.

Other antihypertensives, such as angiotensin-converting enzyme inhibitors, beta blockers (both oral and ophthalmic preparations), calcium channel blockers, mecamylamine, amiloride, hydralazine, chlorothiazide, and hydrochlorothiazide.

Erectile dysfunction drugs, such as sildenafil, tadalafil, and vardenafil.

Some antidepressants, benzodiazepines, psychotropics, and antiseizure medications, such as chlordiazepoxide-amitriptyline, chlorpromazine, risperidone, thioridazine, and gabapentin.

Intermittent use of nonsteroidal antiinflammatory drugs (in patients with aspirin-exacerbated respiratory disease [AERD]). (See "Aspirin-exacerbated respiratory disease".)

Estrogens and progesterone may contribute to rhinitis symptoms, although data from clinical trials have been mixed [17-22].

Rhinitis of pregnancy — Rhinitis associated with pregnancy has been defined as nasal congestion in the last one to two months of pregnancy without other signs of respiratory tract infection and with no known allergic cause, disappearing completely within two weeks after delivery [23,24]. Other causes of rhinitis must be excluded. This condition is reviewed separately. (See "Recognition and management of allergic disease during pregnancy", section on 'Pregnancy rhinitis'.)

Alcohol-induced rhinitis — Nasal symptoms following alcohol ingestion, most commonly nasal congestion and/or rhinorrhea, are reported in up to 14 percent of healthy individuals, 33 percent of people with asthma, and 75 percent of people with AERD [25]. (See "Aspirin-exacerbated respiratory disease", section on 'Reactions to alcoholic beverages'.)

Alcohol-induced upper airway symptoms are not due to "alcohol allergy" but rather an exaggerated response to the known properties of alcohol, particularly vasodilation. Some patients require several drinks to notice these effects, while others react to minimal amounts, and many note that wine is especially problematic [26]. Symptoms may be intermittent and, in patients with allergic rhinitis, may only occur during peak pollen seasons and can be of rapid onset or take several hours to develop.

Atrophic rhinitis — Atrophic rhinitis (sometimes called "empty nose syndrome") in Westernized countries typically occurs in older adults who have undergone repeated sinus and nasal surgeries. Although mild thinning of the nasal mucosa is seen with normal aging, atrophic rhinitis refers to exaggerated and progressive atrophy of the nasal lining, leading to colonization with bacteria. Symptoms include nasal congestion, crusting, and a persistent bad smell. Treatment consists of daily nasal lavage and lubrication combined with topical antibiotics. This topic is reviewed in detail elsewhere. (See "Atrophic rhinosinusitis".)

Systemic diseases — Systemic diseases that are associated with rhinitis symptoms include granulomatous diseases (eg, granulomatosis with polyangiitis, sarcoidosis, midline granuloma), cystic fibrosis, hypothyroidism, immotile cilia syndromes, and immunodeficiencies. However, most of these conditions more typically involve the nose and sinuses, rather than just the nose, as well as symptoms in other organ systems.

DIFFERENTIAL DIAGNOSIS

Disorders causing prominent nasal obstruction — Nasal obstruction is a common symptom of rhinitis, although not all patients with nasal obstruction have rhinitis. A general approach to the patient presenting with nasal obstruction is reviewed separately. (See "Nasal obstruction: Diagnosis and management".)

A patient with persistent unilateral nasal obstruction needs further evaluation by an otolaryngologist for structural problems, such as a deviated septum or intranasal mass, since the obstruction caused by rhinitis is nearly always bilateral.

Structural abnormalities — Structural causes of nasal symptoms include congenital abnormalities, acquired abnormalities (enlarged adenoids, foreign bodies, septal deviation and perforation, nasal polyps), and tumors. These are reviewed in detail separately. (See "Etiologies of nasal obstruction: An overview" and 'Nasal tumors' below.)

Disorders of acid reflux — Gastroesophageal reflux disease has been linked to both chronic cough and postnasal drip. In patients with symptomatic reflux, a trial of antireflux therapy may improve concomitant nasal symptoms.

(See "Laryngopharyngeal reflux in adults: Evaluation, diagnosis, and management".)

(See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)

(See "Medical management of gastroesophageal reflux disease in adults".)

Nasal tumors — Patients with tumors of the nasal cavity usually present with a chronic history of sinus congestion and recurrent nasal obstruction. Many patients complain of nasal discharge and intermittent epistaxis. These symptoms can mimic those of chronic rhinosinusitis or nasal polyps and may delay the diagnosis of cancer. However, unilateral symptoms should prompt further evaluation, such as nasal endoscopy and/or imaging.

An overview of nasal tumors is presented separately. (See "Etiologies of nasal obstruction: An overview" and "Cancer of the nasal vestibule" and "Tumors of the nasal cavity" and "Clinical manifestations, pathologic features, and diagnosis of extranodal NK/T cell lymphoma, nasal type".)

Cerebral spinal fluid rhinorrhea — Leakage of cerebral spinal fluid (CSF) may cause one or more nasal symptoms and usually results in unilateral or bilateral clear nasal discharge, without signs and symptoms of mucosal inflammation. CSF rhinorrhea can result from skull or nasal fractures, intracranial surgery, and inferior extension of sellar masses. (See "Nasal trauma and fractures in children and adolescents" and "Causes, presentation, and evaluation of sellar masses" and "Skull fractures in adults" and "Skull fractures in children: Clinical manifestations, diagnosis, and management".)

NORMAL NASAL REFLEXES — The nasal tissues are extensively innervated. There are multiple nasal reflexes that cause periodic nasal congestion, rhinorrhea, or sneezing. These are overlooked by most people. However, patients may occasionally notice them. A basic knowledge of nasal reflexes is useful in distinguishing normal from pathologic triggers. Normal nasal reflexes include the following [22,27]:

Postural reflexes – Increased congestion with supine position and increased congestion in the lower nasal passage when lying on one side. The normal nasal cycle in the vertical position produces alternating congestion of the nostrils.

Crutch reflex – Increased congestion with pressure in the ipsilateral axilla.

Hot and cold cutaneous temperature reflexes – Sneezing upon sudden exposure of the skin to extreme heat or cold.

Visible and infrared light reflexes – Sneezing upon sudden exposure to bright light.

Bronchonasal reflex – Bronchoconstriction in response to nasal stimulation (such as with cold air).

Ovulatory rhinitis – Increased nasal congestion in the periovulatory period of the menstrual cycle.

There are certain stimuli that can trigger sneezing in some individuals. The prevalence of these reflexes is not well defined, and, thus, it is difficult to categorize them as "normal" reflexes, although they are described in otherwise healthy people:

Sneezing after meals has been reported as a familial trait, possibly provoked by gastric fullness [28,29].

Sneezing immediately upon sexual ideation or shortly after orgasm has also been described [30].

REFERRAL — Both allergists and otolaryngologists manage patients with various types of rhinitis.

Referral to an allergy/immunology specialist is appropriate if the suspected diagnosis is allergic rhinitis and basic medical management has already been tried without adequate relief. Such patients may benefit from allergy testing (eg, skin testing or in vitro testing) to identify specific allergens relevant to that patient, which can then guide environmental control measures or allergen immunotherapy as appropriate. Similarly, the diagnosis of nonallergic rhinitis is one of exclusion, and skin testing is often performed to exclude allergic causes. (See "Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis".)

Referral to an otolaryngology expert is appropriate if structural issues are suspected or the patient has a history of past facial trauma or unilateral symptoms. If the diagnosis of rhinitis is uncertain or if reflux of gastric acid is suspected, an otolaryngologist can visualize the anatomy of the larynx (to determine if laryngeal edema is present), as well as examine the nasal cavity and pharynx for abnormalities. (See "Laryngopharyngeal reflux in adults: Evaluation, diagnosis, and management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)

Basics topics (see "Patient education: Environmental allergies in adults (The Basics)" and "Patient education: Environmental allergies in children (The Basics)")

Beyond the Basics topics (see "Patient education: Allergic rhinitis (Beyond the Basics)" and "Patient education: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)" and "Patient education: Trigger avoidance in allergic rhinitis (Beyond the Basics)")

SUMMARY

Definition – Rhinitis is a common condition characterized by one or more of the following symptoms: sneezing, rhinorrhea (anterior or posterior), nasal congestion (stuffiness), and nasal itching. (See 'Introduction and definition' above.)

Most prevalent types – The most common forms of rhinitis are allergic, nonallergic, and mixed allergic, although there are several additional disorders that are seen with regularity (table 1). (See 'Overview' above.)

Patterns of allergic rhinitis – Allergic rhinitis may be seasonal or perennial and intermittent or persistent. Patients with seasonal allergic rhinitis are typically sensitized to pollens and may have associated allergic conjunctivitis (table 2). Indoor allergens, such as dust mites and pet danders, are common triggers for perennial rhinitis. (See 'Allergic rhinitis' above.)

Nonallergic rhinitis – Nonallergic rhinitis is a diagnosis of exclusion, distinguished clinically from allergic rhinitis by the absence of nasal and ocular itching, a later age of onset, prominent nasal congestion, no relevant specific immunoglobulin E (IgE) sensitivity, and different triggers. Vasomotor rhinitis and gustatory rhinitis are variably classified as subtypes of nonallergic rhinitis. (See 'Nonallergic rhinitis' above.)

Occupational rhinitis – Occupational rhinitis can be caused by many different exposures in the workplace. The pathophysiology can be allergic, nonallergic, or irritant in nature (table 3). (See 'Occupational rhinitis' above.)

Other causes of rhinitis – Other causes of rhinitis include decongestant nasal sprays and systemic medications, structural abnormalities, pregnancy, atrophic rhinitis, alcohol, and certain systemic diseases (table 1). (See 'Other causes of rhinitis' above.)

Normal nasal reflexes – Occasionally, patients notice normal nasal reflexes and ask about them. Familiarity with these is helpful in discerning pathologic triggers from normal variations in nasal function. (See 'Normal nasal reflexes' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Robert Fletcher, MD, MSc, who contributed to earlier versions of this topic review.

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