Rhinitis, Conjunctivitis, and Sinusitis

Rhinitis is defined as inflammation of the nasal mucous membranes and encompasses a broad group of disorders with etiologies including:

• Allergic rhinitis (AR)

  • local AR

• Nonallergic rhinitis (NAR)

  • vasomotor

  • atrophic

  • hormonal

  • food-induced (gustatory/alcohol-induced)

  • occupational

  • rebound/chemical rhinitis (rhinitis medicamentosa)

  • infectious rhinitis

  • NAR with eosinophilia

  • geriatric rhinitis

Allergic Rhinitis and Conjunctivitis

Allergic rhinitis and allergic conjunctivitis are often concomitant diseases. Allergic rhinitis (hay fever) can be classified temporally as intermittent or persistent along with mild or moderate-to-severe symptoms. It can also be characterized as 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. Skin testing or specific immunoglobulin E (IgE) levels can help confirm the diagnosis.

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

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

The following table describes the symptoms and physical exam findings for allergic rhinitis and conjunctivitis.

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

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

(Source: Cobblestone Throat. Healthline 2019.)

Diagnosis and Management of Rhinitis

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

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

Allergic rhinitis typically requires several years of allergen exposure for a patient to develop symptoms and therefore is uncommon in children younger than 2 years. Sensitization usually first occurs to allergens present in the home environment (e.g., dust mites, insects, dander). Data from one birth cohort indicated that even the youngest children required at least two seasons of pollen exposure before development of allergic symptoms.

Diagnosis

The diagnosis of rhinitis can be suspected clinically 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 testing (preferred) with optional subsequent intradermal skin testing (associated with higher sensitivity but only used in older children with ongoing symptoms who can tolerate this procedure well) or by blood tests (allergen-specific 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)

Management

The approach to managing allergic rhinitis depends on the frequency and severity of the symptoms, age of the patient, and comorbidities.

In children younger than 2 years, allergic rhinitis is uncommon given the need for repeated exposures/sensitization to seasonal allergens, and alternative diagnoses should be considered before considering medical management.

In children older than 2 years, severity and persistence of symptoms determine management.

• Mild/episodic symptoms:

  • Glucocorticoid nasal spray, such as mometasone furoate, fluticasone furoate and triamcinolone acetonide (approved in patients aged 2 years and older) and fluticasone propionate (approved for patients aged 4 years and older) are most effective when taken regularly or for several days before/after exposure to known allergen.

  • Second-generation antihistamines (daily or as needed) include cetirizine (approved in patients aged ≥6 months), fexofenadine (approved in patients aged 2 years and older), or loratadine (approved in patients aged >2 years).

  • Antihistamine nasal sprays include azelastine (approved in patients aged >5 years) or olopatadine (approved in patients aged >12 years).

• Moderate/severe/persistent symptoms:

  • Glucocorticoid nasal sprays are recommended as the first-line pharmacologic therapy. These include mometasone furoate, fluticasone furoate, and triamcinolone acetonide (approved for patients >2 years); fluticasone propionate (approved for patients aged 4 years and older); and budesonide nasal spray (approved for patients aged ≥6 years). They are most effective when taken regularly or for several days before/after exposure to known allergen.

  • Antihistamine nasal sprays include azelastine (approved for patients aged >5 years), or olopatadine (approved for patients aged >12 years). Combination nasal sprays with both a glucocorticoid and antihistamine are available as well.

  • For patients not controlled on an intranasal glucocorticoid, the addition of an intranasal antihistamine is synergistic.

  • Second-generation antihistamines, including cetirizine (approved for patients aged >6 months) and loratadine or fexofenadine (approved for patients aged >2 years), can be used daily or as needed.

• For patients with allergic conjunctivitis, consider antihistamine eye drops such as olopatadine or azelastine. (Children aged ≥3 years and adolescents can refer to adult dosing.) Ketotifen, a mast-cell stabilizer, can also be effective. (Children aged ≥3 years and adolescents can refer to adult dosing.)

• Patients with asthma may benefit from a leukotriene-receptor antagonist such as montelukast, but this is not a recommended first-line medication for allergic rhinitis and patients and caregivers should be warned about potential adverse effects of mood-changing behavior.

• Isotonic and hypertonic saline solutions are of modest benefit for reducing symptoms of allergic rhinitis and are less effective than intranasal glucocorticoids.

For management of rhinitis in patients aged 12 years and older, please refer to the treatment algorithms found in Rhinitis 2020: A Practice Parameter Update.

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

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

Sinusitis

Acute bacterial rhinosinusitis is inflammation of one or more of the paranasal sinuses lasting at least 10 days without improvement and is often classified by duration as follows:

• acute bacterial sinusitis: <30 days of symptoms

• subacute bacterial rhinosinusitis: ≥30 and <90 days’ symptom duration

• recurrent acute rhinosinusitis: at least three episodes of symptoms lasting <30 days separated by at least 10 symptom-free days in a 6-month period or four episodes in 12 months

(Source: Acute Bacterial Sinusitis in Children. N Engl J Med 2012.)

Treatment

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. Untreated bacterial rhinosinusitis may result in serious complications such as orbital involvement or intracranial extension.

First-line antibiotics include amoxicillin and amoxicillin/clavulanate, but watchful waiting is often appropriate. CT of the sinuses is not recommended for diagnosis of acute rhinosinusitis but is indicated in chronic, refractory, or recurrent rhinosinusitis.

(Source: Acute Bacterial Sinusitis in Children. N Engl J Med 2012.)

Chronic rhinosinusitis is inflammation of one or more of the paranasal sinuses lasting >90 days. Pediatric patients should be evaluated for noninfectious etiologies such as exposure to environmental allergens or irritants, cystic fibrosis, ciliary dyskinesia, or gastroesophageal reflux.