Rhinitis

Question 1

A patient with irritation and inflammation of the
nasal mucous membranes complains of rhinorrhea,
nasal congestion, and postnasal drip. What is the
most likely general diagnosis based on this
information?

Answer 1

Rhinitis

Question 2

What are the main forms of rhinitis?

Answer 2

● Allergic rhinitis

● Nonallergic rhinitis

Question 3

Allergic rhinitis reflects what type of Gell and

Coombs hypersensitivity?

Answer 3

Type I (anaphylactic/immediate) hypersensitivity with both
early and late-phase reactions occurring after re-exposure
to the antigen (see section on Allergy)

Question 4

What are the primary subtypes of allergic rhinitis?

Answer 4

● Seasonal allergic rhinitis
● Perennial allergic rhinitis
● Mixed allergic rhinitis

Question 5

What are the classic symptoms of allergic rhinitis?

Answer 5

● Sneezing
● Rhinorrhea
● Nasal congestion
● Pruritus (nasal, palatal, ocular)
● Watery eyes
● Postnasal drainage
● Anosmia/hyposmia

Question 6

Diagnosis of allergic rhinitis hinges most heavily

on what factor?

Answer 6

Clinical history

Question 7

What comorbidities are commonly associated

with allergic rhinitis?

Answer 7

Asthma, acute rhinosinusitis, otitis media with effusion,

sleep disordered breathing, and obstructive sleep apnea

Question 8

What treatments exist for allergic rhinitis?

Answer 8

Intranasal/oral corticosteroids, intranasal/oral antihist-
amines, leukotriene inhibitors, cromolyn sodium, immune
therapy (sublingual and injection)

Question 9

A patient presents with nasal congestion, rhinorrhea,
and postnasal drip but has a history of negative
allergy testing. What type of rhinitis does this most
likely represent? What are the major subtypes
associated with this condition?

Answer 9

● Nonallergic rhinitis:
○ Infectious rhinitis
○ Vasomotor rhinitis (60%)
○ Nonallergic rhinitis of eosinophilia syndrome (NARES)
○ Gustatory rhinitis
○ Occupational
○ Hormonally induced
○ Medication induced
○ Atrophic
○ Inflammatory/immune-related disorders

Question 10

What are the key symptoms associated with non-allergic rhinitis?

Answer 10

● Sneezing
● Rhinorrhea
● Nasal congestion
● Postnasal drainage

Question 11

True or False. Negative allergy testing is required

for the diagnosis of nonallergic rhinitis.

Answer 11

False

Question 12

Viral infections (rhinovirus, respiratory syncytial
virus, parainfluenza virus, adenovirus, influenza
virus, and enterovirus) can result in URI
symptoms, including congestion, rhinorrhea, and postnasal drip, but often they do not cause pruritic symptoms. The infection typically resolves within 7 to 10 days. What diagnosis does this describe?

Answer 12

Infectious rhinitis

Question 13

In what type of nonallergic rhinitis is there excess
parasympathetic tone resulting in vasodilation,
which can be triggered by cold temperatures and
strong smells?

Answer 13

Vasomotor rhinitis

Question 14

What are the characteristics of vasomotor

rhinitis?

Answer 14

It is a diagnosis of exclusion. Patients usually manifest this
condition in older age, with copious clear rhinorrhea that is
triggered by alcohol, temperature, or humidity changes or
exposure to odors.

Question 15

What are the common triggers for vasomotor

rhinitis?

Answer 15

Changes in temperature, change in relative humidity, odors
(e.g., perfumes, cleaning agents), second-hand tobacco
smoke, alcohol, sexual arousal, and emotional changes can
be triggers.

Question 16

What is the underlying pathophysiology

associated with vasomotor rhinitis?

Answer 16

This condition is poorly understood. It may be related to the
increased neural efferent input to mucosal vasculature.

Question 17

Though controversial, what surgical interventions
can be considered in patients with vasomotor
rhinitis?

Answer 17

Vidian neurectomy

Question 18

What type of nonallergic rhinitis manifests with
perennial symptoms including sneezing, watery
rhinorrhea, nasal pruritus, and intermittent
hyposmia/anosmia; demonstrates ~10 to 20%
eosinophils on nasal smear, and is associated with
negative in vivo and in vitro allergy testing?

Answer 18

NARES

Question 19

A 33-year-old man has profuse watery rhinorrhea
whenever he eats his favorite hot and spicy meals.
What is the likely diagnosis?

Answer 19

Gustatory rhinitis

Question 20

What is the underlying pathophysiology of

gustatory rhinitis?

Answer 20

Vagally (cholinergically) mediated vasodilation after eating

especially with hot or spicy foods

Question 21

What type of rhinitis is can be associated with (1) inhaled protein or chemical antigens that result in an IgE-mediated response (allergic rhinitis), (2) inhaled chemical respiratory sensitizers that cause an unknown immune response, or (3) exacerbation of rhinitis and is often associated with concurrent asthma?

Answer 21

Occupational rhinitis

Question 22

Pregnancy, puberty, menstruation, and
hypothyroidism can all be associated with what
type of rhinitis?

Answer 22

Hormonally induced rhinitis

Question 23

During pregnancy, hormone-induced vasodilation,
vascular pooling, and increased blood volume can contribute to congestion and rhinitis. Is it more common for this to occur as a new diagnosis of rhinitis or as an exacerbation of preexisting rhinitis?

Answer 23

1/3 of women = exacerbation
2/3 of women = de novo = typically resolves ~2 weeks after
delivery

Question 24

What are some common medications that can

cause rhinitis?

Answer 24

Angiotensin-converting enzyme (ACE) inhibitors, β-blockers and other antihypertensives, erectile dysfunction or pulmonary hypertension medications (i.e., sildenafil), oral contraceptives and aspirin in sensitive individuals. Ethanol in wine, beer, and other alcoholic beverages can result in vasodilation and rhinitis.

Question 25

What condition is associated with rebound nasal congestion secondary to using topical nasal decongestants (α-adrenergic) for more than 5 to 7 days?

Answer 25

Rhinitis medicamentosa

Question 26

What condition is associated with degeneration
of sinonasal sensory and autonomic nerve fibers
leading to mucosal gland involution, squamous metaplasia of the sinonasal epithelium, and significant alteration of mucociliary transport and can be either primary or secondary (after surgery or trauma)?

Answer 26

Atrophic rhinitis (also called rhinitis sicca or ozena)

Question 27

What organism commonly colonizes the nasal
mucosa in patients suffering from atrophic
rhinitis?

Answer 27

Klebsiella ozaenae

Question 28

What are the clinical examination findings

associated with atrophic rhinitis?

Answer 28

● Foul odor
● Yellow/green crusting
● Atrophic/fibrotic mucosa

Question 29

In addition to the categories of rhinitis included
above, what important inflammatory-immune
diseases are also associated with nonallergic
rhinitis?

Answer 29

● Granulomatous infections (rhinoscleroma,
rhinosporidiosis)
● Wegener granulomatosis
● Sarcoidosis
● Midline granuloma
● Churg-Strauss syndrome
● Relapsing polychondritis
● Amyloidosis
(Covered in the section on inflammatory/infectious nasal
masses and Systemic Disease sections of this chapter)

Question 30

What management options have demonstrated

utility in the management of nonallergic rhinitis?

Answer 30

● Intranasal glucocorticoids*
● Intranasal antihistamine (azelastine [Astelin, Astepro],
olapatadine [Patanase])*
● Intranasal ipratropium bromide (Atrovent)
● Nasal irrigation
● Adjunctive oral medications (antihistamines, decongest-
ants)
*Primary management: Use full dose daily, often in
combination (results are better with intranasal steroid and
antihistamine than with either alone).

Question 31

What specific feature of nonallergic rhinitis is the

target of ipratropium bromide intranasal spray?

Answer 31

Watery rhinorrhea

Question 32

What is the proposed reason an intranasal
antihistamine nasal spray would offer a benefit to
patients with nonallergic rhinitis?

Answer 32

Anti-inflammatory: Decreased eosinophil activation, ex-
pression of adhesion molecules, and cytokine production.
Potentially decreases neurogenic excitation from olfactory
stimuli.