Rhinitis, Conjunctivitis, and Sinusitis

Allergic Rhinitis and Conjunctivitis

Allergic rhinitis and allergic conjunctivitis are often concomitant diseases. Rhinitis is defined as inflammation of the nasal mucous membranes and encompasses a broad group of disorders with etiologies including the following:

• Allergic rhinitis (AR)

  • local AR

• Nonallergic rhinitis (NAR)

  • vasomotor

  • food-induced (gustatory/alcohol-induced)

  • infectious rhinitis

  • NAR with eosinophilia

  • occupational

  • atrophic

  • hormonal

  • rebound/chemical rhinitis (rhinitis medicamentosa)

  • geriatric rhinitis

Allergic rhinitis (hay fever) can be seasonal (occurring at a particular time of year) or perennial (present year-round). The diagnosis is usually made clinically based on history and physical exam and supported by skin prick and intradermal testing with environmental allergen extracts.

• Seasonal allergic rhinitis is caused by pollen from trees, grasses, and weeds; the timing of peak pollen counts varies by geographic area.

• Perennial allergic rhinitis is caused by indoor allergens, including dust mites, cockroaches, molds, and animal danders.

(Source: Photo courtesy of David Amrol, MD.)

(Source: Cobblestone Throat. Healthline 2019.)

Diagnosis

The following algorithm from the Joint Task Force on Practice Parameters for Allergy and Immunology demonstrates an approach to the evaluation and treatment of patients with suspected rhinitis:

(Reprinted from The Diagnosis and Management of Rhinitis: An Updated Practice Parameter. J Allergy Clin Immunol 2008. Copyright (2008), with permission from Elsevier.)

The diagnosis of rhinitis can be presumed based on clinical symptoms and exam and treated empirically. However, the identification of culprit allergens can help with allergen avoidance and has been associated with improved patient outcomes. Allergen-specific testing can be performed via skin-prick and intradermal testing (preferred) or by blood tests (allergen-specific immunoglobulin E [IgE]) to identify allergen triggers.

Differential diagnosis can include:

• chronic nonallergic rhinitis (see list above)

• chronic rhinosinusitis (with or without polyps)

• septal wall abnormalities (e.g., deviated septum)

• nasal valve collapse

• turbinate hypertrophy (with or without concha bullosa)

• adenoidal hypertrophy

• foreign body

• nasal tumors

• cerebrospinal fluid leak

• primary ciliary dyskinesia syndrome

• illicit drug use (e.g., intranasal cocaine)

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Management

Allergic rhinitis: The approach to managing allergic rhinitis depends on the frequency and severity of symptoms. The following figures summarize pharmacotherapy for episodic and persistent, mild, and moderate-to-severe symptoms. To help guide treatment, the 2020 Joint Task Force Practice Parameter Update recommends scoring symptoms using a visual analog scale (VAS) of 0-10 where 0 is no symptoms and 10 is worst possible symptoms.

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Nonallergic rhinitis: Treatment of infectious and chemical nonallergic rhinitis should target the underlying etiology. For all other nonallergic rhinitis, the following figures summarize pharmacotherapy for episodic and persistent, mild, and moderate-to-severe symptoms based on the VAS (0-10; 0 is no symptoms and 10 is worst possible symptoms).

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

(Source: Rhinitis 2020: A Practice Parameter Update. J Allergy Clin Immunol 2020.)

Allergen immunotherapy should be considered in patients with refractory symptoms despite medical management or if adverse effects from pharmacotherapy limit use.

• Allergen immunotherapy can be given as subcutaneous injections (allergy shots) or as sublingual tablets, which are only available for a limited number of allergens, such as grass and ragweed (ages ≥5 years) and dust mites (ages ≥18 years).

• Children with moderate-to-severe allergic rhinitis should be referred to an allergist because allergen immunotherapy has been shown to alter the progression of allergic disease and reduce the subsequent development of asthma.

Rhinosinusitis

Rhinosinusitis is inflammation of one or more of the paranasal sinuses and is often classified by duration as follows:

• acute rhinosinusitis: up to 4 weeks of symptoms

• subacute rhinosinusitis: 4-12 weeks of symptom duration

• chronic rhinosinusitis (CRS): symptoms lasting at least 12 weeks

  • CRS can be classified as:

    • CRS with nasal polyps (CRSwNP)

    • CRS without nasal polyps (CRSsNP)

    • allergic fungal rhinosinusitis (AFRS)

Management

Most acute sinus infections are caused by viruses and improve within 2 weeks without antibiotic treatment. A bacterial infection should be considered if symptoms worsen or fail to improve within 7-10 days. First-line antibiotics include amoxicillin and amoxicillin/clavulanate, but watchful waiting is often appropriate when follow up is assured. CT of the sinuses is not recommended for diagnosis of acute rhinosinusitis but is indicated in chronic, refractory, or recurrent rhinosinusitis. Patients with chronic sinusitis or recurrent acute rhinosinusitis should be assessed for chronic conditions that would modify management (e.g., asthma, cystic fibrosis, immunocompromised state, ciliary dyskinesia).

Chronic rhinosinusitis: Treatment typically includes nasal steroids and nasal saline lavage. See Medical Therapies for Adult Chronic Sinusitis (JAMA 2015, Figure 2) for an evidence-based approach to medical therapy for chronic sinusitis. The following three biologic agents are approved by the FDA for adults with chronic rhinosinusitis with nasal polyps, although biomarkers are not currently known to predict the most beneficial agent for a particular patient:

• dupilimab (demonstrated the most improvement in both subjective and objective measures in a review of phase II and phase III trial data)

• mepolizumab

• omalizumab