Rhinitis, Acute: (Runny Nose)

Presentation

In allergic rhinitis , patients typically complain of rhinorrhea (“runny nose”), nasal congestion, sneezing, nasal itching, and “itchy eyes.” There may be a problem with sleep disturbance (from nasal congestion), malaise, fatigue, irritability, and neurocognitive deficits.

Typically patients with allergic rhinitis have clear discharge, swollen turbinates, and bluish or pale mucosa. There may be “allergic shiners”—infraorbital darkening thought to be caused by chronic venous pooling—or an “allergic salute” in children who rub their noses upward because of nasal discomfort, sometimes producing a persistent horizontal crease across the nose. Mild bilateral conjunctivitis with nonpurulent discharge is strongly suggestive of an allergic cause when it is accompanied by pruritus. The patient with a “summer cold” lasting a full month is likely to have allergic rhinitis.

Precipitating factors may be known or may be elicited from the patient. Common allergens include airborne dust-mite fecal particles, cockroach residues, animal danders (especially cats and dogs), molds, and pollens (hence the origin of the term hay fever ).

Vasomotor (idiopathic) rhinitis may occur in response to environmental conditions such as changes in temperature or relative humidity, odors (e.g., perfume or cleaning materials), passive tobacco smoke, alcohol, sexual arousal, or emotional factors.

Drug-induced rhinitis may be caused by oral medications, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, various antihypertensive agents, chlorpromazine, aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and oral contraceptives as well as topical α-adrenergic decongestant sprays that have been used for more than 5 to 7 days (rhinitis medicamentosa). Repeated use of intranasal cocaine and methamphetamines may also result in rebound congestion and, on occasion, nasal septal erosion and perforation.

In viral rhinitis (the common cold) , patients generally complain of an annoying, persistent mucoid nasal discharge accompanied by nasal and facial congestion, along with a constellation of viral symptoms, including low-grade fever, myalgias, and sore throat. These patients generally seek care because they feel miserable, cannot sleep, and want relief. They often believe that antibiotics are needed to cure their problem.

On physical examination, there is only nasal mucous membrane congestion, which may appear erythematous, along with cloudy nasal secretions, which may become somewhat yellow and thick after several days. Resolution occurs within 10 days to 2 weeks.

Always keep in mind that young children may place intranasal foreign bodies (e.g., beads or beans) in the nose, leading to foul-smelling, purulent, unilateral nasal discharge (see Chapter 30 ).