Rhinitis, Immunotherapy, and Biologics

1

What is rhinitis?

Rhinitis is inflammation of the nasal passages resulting in one of the following: nasal congestion, rhinorrhea, sneezing or nasal pruritus. It affects both children and adults and is categorized as allergic or non-allergic. Rhinitis may be inflammatory, non-inflammatory or structural in nature.

2

What are the causes of inflammatory rhinitis?

Inflammatory rhinitis may be allergic, drug-induced, infectious or irritant. Allergic rhinitis affects 10-30% of adults and 40% of children in the United States. Causes of allergic rhinitis are commonly pollens (trees, grasses and weeds), animal dander, dust mites, cockroaches and molds. Skin prick testing in these patients is typically positive, although an entity called local allergic rhinitis may also be present in which allergen specific IgE is only present in the nasal mucosa. This condition may occur in up to 25% of patients with rhinitis and can be confirmed through a nasal allergen provocation challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin can induce an acute inflammatory reaction involving the nasal mucosa in patients with aspirin exacerbated respiratory disease (AERD) along with symptoms of acute asthma. Infectious rhinitis is most commonly due to viral upper respiratory tract infections. However, in patients who are immunocompromised, fungal infections should be considered. Patients who are susceptible to infectious rhinitis include those with anatomic abnormalities, ciliary dysfunction, chronic rhinosinusitis with nasal polyps, cystic fibrosis, primary immunodeficiency and children. Irritant rhinitis can occur due to exposure to an airborne irritant such as solvents, chemicals, fumes, construction materials and workplace irritants (occupational rhinitis).

3

What are the causes of non-inflammatory rhinitis?

There are a variety of causes of non-inflammatory rhinitis, including vasomotor rhinitis, gustatory rhinitis, medication-induced rhinitis, NARES, atrophic rhinitis and rhinitis of pregnancy. Vasomotor rhinitis is triggered by cold air, temperature changes, exercise, strong odors and/or airborne irritants. Gustatory rhinitis involves clear rhinorrhea following ingestion of spicy or hot foods. Rhinitis medicamentosa is characterized by severe rebound nasal congestion caused by chronic or frequent use of intranasal decongestants. Other medications such as NSAIDs, alpha antagonists, oral contraceptives and antihypertensive agents can also cause non-inflammatory rhinitis. Non-allergic rhinitis with eosinophilia (NARES) is a condition characterized by high eosinophil numbers on nasal smear. Atrophic rhinitis may occur in some patients due to multiple sinus or nasal surgeries, systemic disease or infection. Finally, rhinitis of pregnancy is a common cause of non-inflammatory rhinitis due to hormonal changes.

4

What are causes of structural rhinitis?

In patients who report their primary complaint as nasal obstruction, causes such as septal deviation, turbinate or adenoid hypertrophy, nasal polyposis, sinonasal tumors, and foreign bodies should be considered. Foreign bodies are most common in younger patients. The likelihood of nasal polyps increases if the patient complains of a lack of sense of smell and sensitivity to aspirin or other NSAIDs. For patients who report primarily rhinorrhea, CSF leak should be considered, and history should be obtained regarding sinus surgery and head trauma. CSF leaks tend to be unilateral and can be diagnosed by measurement of beta2-transferrin in the nasal discharge, as this should be present in CSF only.

5

What are the treatment options for rhinitis?

Topical corticosteroids remain the mainstay of rhinitis therapy. Patients with chronic rhinitis, both allergic and non-allergic, may benefit from topical antihistamine nasal sprays, such as azelastine and olopatadine. First-generation antihistamines are discouraged for treatment of rhinitis. In addition, leukotriene receptor antagonist therapies (LTRAs) are also not recommended as initial treatment of chronic rhinitis. Use of intranasal decongestants should be limited due to concern for rhinitis medicamentosa. Intranasal cromolyn can be offered as a therapy for patients with allergic rhinitis and should be taken prior to allergen exposure. For vasomotor and gustatory rhinitis, Ipratropium nasal sprays can be useful.

6

What are the surgical options for rhinitis?

I would not change this section but would like to get Dr. Ramakrishnan’s opinion on updates here.

7