Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Rhinitis

Last updated: December 15, 2020

Summarytoggle arrow icon

Rhinitis is the irritation and swelling of the mucous membrane of the nose. There are two main types: allergic rhinitis and nonallergic rhinitis. Allergic rhinitis is caused by a type 1 hypersensitivity reaction that leads to inflammation of the nasal mucous membranes. Nonallergic rhinitis does not always involve an inflammatory process, and it includes infectious rhinitis, atrophic rhinitis, vasomotor rhinitis, drug-induced rhinitis, occupational rhinitis, gustatory rhinitis, hormonal rhinitis, and nonallergic rhinitis with eosinophilia syndrome (NARES). Infectious rhinitis is most often secondary to an upper respiratory tract infection that manifests as rhinosinusitis. Clinical manifestations of rhinitis include nasal congestion, rhinorrhea, and postnasal drip. Patients with allergic rhinitis typically also experience nasal itching, sneezing, and exacerbation of symptoms in certain seasons or with exposure to certain allergens (e.g., dust, animal dander, mold spores, or plant pollen). Atrophic rhinitis can be primary (idiopathic) or secondary (e.g., due to granulomatous diseases). This form of rhinitis commonly manifests with a foul-smelling, crust-filled nasal cavity and anosmia. Patients with NARES might present with nasal polyposis and hyposmia. Management of allergic rhinitis involves allergen and irritant avoidance, antiinflammatory (e.g., corticosteroids, antihistamines), and/or decongestant therapy (e.g., phenylephrine). Nasal lavage and surgical procedures can relieve symptoms in patients with atrophic and vasomotor rhinitis.

Clinical classification of allergic rhinitis
Classification criteria Definition
Temporal pattern of allergen exposure

Episodic

Exposure to allergens that are normally not a part of the individual's environment (e.g., visit to a farm)

Seasonal

Exposure to allergens that occur during certain seasons (e.g., hay fever, which is caused by exposure to pollen)

Perennial

Exposure to allergens that are normally a part of the patient's environment (e.g., allergic rhinitis caused by house dust)
Frequency

Intermittent

< 4 days/week OR < 4 weeks/year

Persistent

> 4 days/week OR > 4 weeks/year
Severity

Mild

Symptoms do not interfere with the quality of life.
Moderate/severe Symptoms interfere with the quality of life (e.g., co-existing asthma, decreased sleep, impaired school performance, the inability to carry out daily activities).

Intranasal steroids are considered the most effective maintenance treatment of seasonal allergic rhinitis.

Intranasal sympathomimetics should not be used for more than 3 days because of the risk of rebound nasal congestion (rhinitis medicamentosa).

  • Definition: acute or chronic rhinitis syndrome that is not IgE mediated
  • Classification
Types of nonallergic rhinitis [1]
Type Description Causes
Nonallergic rhinitis with eosinophilia syndrome (NARES) [9]
  • Unknown
Drug-induced rhinitis
  • Recurrent, nonallergic inflammation of the nasal mucosa associated with certain medications
Rhinitis medicamentosa
  • Rebound nasal congestion that is seen upon discontinuing intranasal sympathomimetics
  • Occurs 5–7 days after use of topical decongestants
  • Classically leads to increasing dose or frequency of decongestants (vicious cycle)
  • Discontinuation of intranasal sympathomimetics (e.g., phenylephrine, oxymetazoline, xylometazoline)
Hormonal rhinitis
Occupational rhinitis
  • Rhinitis as a result of exposure to irritants in a particular work environment
  • Most commonly seen in furriers, followed by bakers, breeders, veterinarians, farmers, cleaners, assemblers of electrical products, and laboratory employees
  • Irritants (e.g., fur, flour, paints, pesticides, dust, talc, detergents, chemicals)
  • Allergenic substances (e.g., rodent allergens, latex, guar gum, psyllium)
Gustatory rhinitis
  • Episodic rhinitis with diffuse watery rhinorrhea that is associated with certain foods
  • Spicy food
  • Alcohol
Atrophic rhinitis
Vasomotor rhinitis

Both allergic and nonallergic rhinitis manifest with postnasal drainage and nasal congestion. However, nasal itching and sneezing are only seen in allergic rhinitis.

  • Definition: chronic rhinitis associated with atrophy and sclerosis of the nasal mucosa
  • Etiology
  • Clinical features
    • Merciful anosmia: extremely foul-smelling nasal cavity but the patient is unaware of the foul smell (anosmia)
    • Nasal cavity is spacious, lacks turbinates, and is covered in yellowish-green crusts.
    • Epistaxis
  • Diagnostics
    • No specific diagnostic test is indicated.
    • Rhinoscopy, nasal cultures, and/or CT scans may be performed to evaluate the extent of the disease.
  • Treatment: aims to decrease the size and improve the blood flow of the nasal cavities and to promote regeneration and increase lubrication of the dry nasal mucosa but no form of treatment can completely eliminate the symptoms
    • Removal of nasal crusts
    • Surgical procedures that decrease the volume of the nasal cavity [10]
      • Modified Young's procedure
      • Insertion of Teflon paste, fat, or bone underneath the mucosa of the nasal cavity
      • No randomized clinical trials are available to confirm the efficacy of these measures.

Topical sympathomimetic drugs (e.g., xylometazoline) are contraindicated in atrophic rhinitis since they may decrease vascular perfusion of the nasal cavity and worsen symptoms.

References:[1]

Differential diagnosis of nasal congestion

Common differential diagnoses of nasal congestion
Allergic rhinitis Nasal polyps Deviated nasal septum Adenoid hypertrophy Foreign nasal body
Epidemiology
  • 10–30%
  • Usually starts in childhood (before the age of 20 years)
  • More common in those > 40 years old
  • Very common (∼ 80%)
  • Mostly young children (2–6 years)
  • Mostly young children (median age is 3 years)
Causes
  • Trauma (e.g., nasal injury during motor vehicle accidents)
  • Birth trauma (e.g., compression)
  • Congenital disorders (e.g., Marfan syndrome)
  • Insertion of foreign bodies into the nose
Onset
  • Gradual
  • Gradual
  • Gradual
  • Sudden in case of trauma
  • Gradual
  • Sudden
Clinical features
  • Difficulty breathing
  • Snoring or noisy breathing during sleep
  • Headaches or facial pain
  • Mouth breathing
  • Mucopurulent nasal discharge
  • Snoring
  • Impaired hearing
Nasal obstruction
  • Bilateral
  • Bilateral
  • Usually partial and unilateral
  • Unilateral
Olfactory function
  • Normal
  • Frequently impaired
  • Normal
  • Normal
  • Normal

For more info on nasal polyps, deviated nasal septum, and adenoid hypertrophy, see their respective articles.

Foreign nasal body

  • Epidemiology: mostly young children (2–5 years) [12]
  • Etiology: : organic (e.g., food items) or inorganic objects (e.g., pearls; , stones, small toys, button cell batteries) that are inserted into the nose
  • Clinical features
  • Diagnostics
    • Inspection of the nasal cavity with headlight or otoscope
    • Flexible fiberoptic endoscopy: if the foreign body is high up, in the posterior nasal cavity, or not visible with otoscopy
  • Treatment
    • Removal
      • Positive pressure techniques (first line)
      • Forceps
      • If the above fail: removal via endoscopy and anesthesia
    • Instrumentation under direct visualization and examination of the nasal cavity
  • Complications: Paired disc magnets and button cell batteries can lead to tissue necrosis and septal perforation (quick removal is essential).

The differential diagnoses listed here are not exhaustive.

  1. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020; 146 (4): p.721-767. doi: 10.1016/j.jaci.2020.07.007 . | Open in Read by QxMD
  2. Ellis AK, Keith PK. Nonallergic rhinitis with eosinophilia syndrome. Curr Allergy Asthma Rep. 2006; 6 (3): p.215-220. doi: 10.1007/s11882-006-0037-0 . | Open in Read by QxMD
  3. Matheson MC, Dharmage SC, Abramson MJ, et al. Early-life risk factors and incidence of rhinitis: Results from the European Community Respiratory Health Study—an international population-based cohort study. J Allergy Clin Immunol. 2011; 128 (4): p.816-823.e5. doi: 10.1016/j.jaci.2011.05.039 . | Open in Read by QxMD
  4. Cullinan P. Early allergen exposure, skin prick responses, and atopic wheeze at age 5 in English children: a cohort study. Thorax. 2004; 59 (10): p.855-861. doi: 10.1136/thx.2003.019877 . | Open in Read by QxMD
  5. Passali D, Cingi C, Staffa P, Passali F, Muluk NB, Bellussi ML. The International Study of the Allergic Rhinitis Survey: outcomes from 4 geographical regions. Asia Pacific Allergy. 2018; 8 (1). doi: 10.5415/apallergy.2018.8.e7 . | Open in Read by QxMD
  6. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol. 2008; 122 (2 Suppl): p.S1-S84. doi: 10.1016/j.jaci.2008.06.003 . | Open in Read by QxMD
  7. Stevens WW, Schleimer RP, Kern RC. Chronic Rhinosinusitis with Nasal Polyps. The Journal of Allergy and Clinical Immunology: In Practice. 2016; 4 (4): p.565-572. doi: 10.1016/j.jaip.2016.04.012 . | Open in Read by QxMD
  8. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg. 2015; 152 (1 Suppl): p.S1-S43. doi: 10.1177/0194599814561600 . | Open in Read by QxMD
  9. Dykewicz MS et al. Treatment of seasonal allergic rhinitis. Annals of Allergy, Asthma & Immunology. 2017; 119 (6): p.489-511.e41. doi: 10.1016/j.anai.2017.08.012 . | Open in Read by QxMD
  10. Dutt SN, Kameswaran M. The aetiology and management of atrophic rhinitis. The Journal of Laryngology & Otology. 2005; 119 (11): p.843-852. doi: 10.1258/002221505774783377 . | Open in Read by QxMD
  11. Kaliner MA. Nonallergic Rhinopathy (Formerly Known as Vasomotor Rhinitis). Immunol Allergy Clin North Am. 2011; 31 (3): p.441-455. doi: 10.1016/j.iac.2011.05.007 . | Open in Read by QxMD
  12. François M, Hamrioui R, Narcy P. Nasal foreign bodies in children.. Eur Arch Otorhinolaryngol. 1998; 255 (3): p.132-4. doi: 10.1007/s004050050028 . | Open in Read by QxMD
  13. RAPHAEL G et al.. Gustatory rhinitis: A syndrome of food-induced rhinorrhea. J Allergy Clin Immunol. 1989; 83 (1): p.110-115. doi: 10.1016/0091-6749(89)90484-3 . | Open in Read by QxMD
  14. Moscato G et al. Occupational rhinitis. Allergy. 2008; 63 (8): p.969-980. doi: 10.1111/j.1398-9995.2008.01801.x . | Open in Read by QxMD
  15. Varghese M et al.. Drug-induced rhinitis. Clinical & Experimental Allergy. 2010; 40 (3): p.381-384. doi: 10.1111/j.1365-2222.2009.03450.x . | Open in Read by QxMD