“Rhino” from the Greek meaning nose and “Itis” from the Greek meaning inflammation, refers to an inflammation of the lining of the nose.
The most common symptoms found in rhinitis are:
When rhinitis is caused by an allergen, like the ones from animals (cats, dogs, horses, etc), there might be additional symptoms like:
In both cases, it is common for people to develop impaired or disturbed sleep, mainly due to a blocked nose.
Allergic rhinitis can present with symptoms in a particular season, mainly spring and summer, which will be associated with pollen allergy, often called “hay fever”.
If the symptoms are perennial, e.g. all year round, this can be due to an allergy to an animal, house dust mites or, less commonly, moulds.
Nevertheless, we need to consider non-allergic rhinitis, commonly associated with infections, mostly viral. Naturally, these will be more common during the autumn and winter months. When out of this season, many other conditions can be the culprit, and careful investigation by ENT should be sought.
Rhinitis, independently of its cause, leads to an increased risk of asthma and middle ear infection (also known as otitis media), often also associated with sinusitis. As there are 4 sinuses, namely the frontal, ethmoidal, maxillary and sphenoidal sinusitis, it is common for sufferers to also present with headaches.
It is important to note that allergic rhinitis can often lead to exacerbations of eczema in those who have atopic dermatitis.
Especially in cases when rhinitis progresses to persistent symptoms with resultant nasal congestion, which impacts on adjacent structures such as the sinuses, throat, middle ear and bronchial tubes, proper investigation and treatment by a specialist in ENT or allergy is warranted.
In the past, it was thought that one in four people in the UK suffered from allergic rhinitis, but more recent studies have shown that this number is much greater, reaching 49%.
It is also important to note that more than 40% of patients with allergic rhinitis will have asthma, and that allergy is the cause of asthma in about 80% of cases. Furthermore, according to the WAO, about 50% of asthmatics older than 30 years of age are concomitantly allergic. Younger asthmatics have an even higher incidence of allergies.
These numbers might increase, as a changing climate will mean changes in temperature and rainfall may lengthen the UK pollen season and potentially make pollen concentrations higher.
Climate change may lead to changes in the potency of pollen – a single pollen particle can have varying amounts of the allergy-causing agent on it.
The UK is also facing a threat from changes in the geographical distribution of allergenic plants, due to climate change, with invasive species such as ambrosia (common ragweed) being on the watch list. A single ragweed plant can produce a billion grains of pollen per season, and its pollen causes strong allergic reactions.
Allergic rhinitis is frequently ignored or regarded as trivial by family members, doctors and even sufferers themselves, as often its signs are mistaken for typical colds, as these are common, particularly in small children. This is a big mistake since not only does rhinitis reduce the quality of life, it can impair sleep and reduce school performance and attendance at work. Allergic children have been shown to have more infections and more problems with those infections.
Asthmatic children who get colds are 20 times more likely to be hospitalised due to their asthma if they are allergic and if they are exposed to high levels of their provoking allergens. Adequate treatment of the underlying allergic disease helps to diminish these problems. Allergic rhinitis may itself be the first manifestation of allergic disease, e.g. as hay fever in teenagers or adults.
Diagnosis rests on taking an adequate, detailed history and supplementing this by examination and, if necessary, specific allergy tests, mainly skin prick tests, although blood tests can also be helpful.
The timing of symptoms in relation to possible allergen exposure is of primary relevance.
Treatment of Allergic Rhinitis
This falls into 4 categories:
Avoidance of irritants such as smoke also helps to reduce symptoms. Simply washing out the nose with a saltwater solution can be very soothing. This can be achieved with a half-teaspoon of salt, a half-teaspoon of bicarbonate of soda (baking powder) added to a pint of lukewarm water, with gentle sniffing of the solution from the palm of the hand. Also, salt sprays and custom-designed salt douches are inexpensive and available from high street chemists.
More problematic and persistent rhinitis is better treated with a topical nasal corticosteroid administered by spray or, in the case of associated sinusitis and/or nasal polyps, by use of corticosteroid nasal drops. The new nasal corticosteroid sprays are not absorbed and can be used very safely in adults and children.
Appropriate technique is important, focusing on the avoidance of directing the spray towards the nasal septum (the partition in the middle of the nose) and the use of the nasal device without fiercely sniffing the spray into the back of the throat provides optimal benefit. Symptom relief is not immediate, and treatment may take several days or a week or two to be fully effective. Combinations of treatments may be needed – other potentially useful treatments include anti-leukotriene tablets (Singulair), chromones (Intal, Nedocromil) and ipratropium (Rhinatec).
The use of eye drops is also advised for those who also present with signs of allergic conjunctivitis. The most commonly used medications will either contain olopatadine, azelastine hydrochloride or sodium cromoglicate.
Immunotherapy is reserved for patients with one or two major problematic allergens and without chronic asthma who are not controlled by the above measures. Decision can and should be helped by following the stepwise treatment approach published by the ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines.
Injection (subcutaneous) or under the tongue (sublingual) immunotherapy is usually given regularly over 3 years, occasionally needing an extension up to 5 years. This form of treatment must only be prescribed initially by specialists in allergy.
Sublingual immunotherapy, once the first dose has been given under expert supervision, can be administered each day in the home. Sublingual reactions are very mild, mostly involving local itching and swelling in the mouth and throat, and short-term, lasting 1-2 weeks or less. Local side effects are to be expected and usually appear at the first dose, which should be given under supervision.
Side effects from injection immunotherapy may occasionally be more severe, so injections must take place in the presence of a trained physician in a setting where immediate resuscitation facilities are available.