Desktop Helper No. 19 - A practical guide to improve rhinitis diagnosis in primary care - online version

Rhinitis is inflammation of the nasal mucosa, characterized by at least 2 symptoms, more than one hour per day on most days:

1. runny nose (rhinorrhoea)
2. blocked/stuffy nose (congestion)
3. sneezing
4. itchy nose
5. itchy throat
6. itchy eyes*

* This is a symptom of allergic conjunctivitis, which is present in at least 50% of the patients with AR

There are three widely accepted distinct rhinitis subgroups: allergic rhinitis (AR); non-allergic, non-infectious rhinitis (NAR); and infectious rhinitis.(10) AR refers to symptoms triggered by an immune-mediated response following exposure to allergens, while NAR refers to symptoms without allergic sensitisation.(11) Sometimes both types (NAR and AR) coexist at the same time (mixed rhinitis). Identifying the cause of rhinitis is important for successful management.

Allergic rhinitis (AR) is caused by aeroallergens, including exposure to occupational allergens. According to Allergic Rhinitis and its Impact on Asthma (ARIA) https://www.euforea.eu/aria/ it is classified based on the duration and severity of symptoms (Table 1). At least 50% of patients have persistent symptoms, and 40-60% have moderate-to-severe AR, which markedly impacts their quality of life. The diagnostic approach to AR is similar across all age groups. AR typically starts appearing in children around 4–6 years old, with incidence peaking at 14–16, but it can develop at any time in life.(12,13) NAR is less common in children, except for infection-related NAR.

AR is often underdiagnosed or misdiagnosed, and is frequently untreated.(14) As the presenting symptoms are similar to other conditions, especially viral (e.g. common cold, rhinosinusitis, influenza, COVID-19, NAR), people with AR may think they have an infection or another respiratory condition.(15,16) This may lead them to expect an antibiotic prescription from their GPs17 (see below). In addition, people with AR often self-diagnose and self-manage with OTC treatment at community or online pharmacies for symptom relief without seeing their GP.(18) This can lead to medication overuse, lack of established diagnosis, inadequate treatment, poor medication adherence, and poor self-management.(19) OTC requests are an opportunity for pharmacists to identify probable rhinitis and to advise or direct individuals to a primary care consultation, where the diagnosis can be based on clinical and family history, physical examination and, in selected cases, referral.

History taking

Taking a detailed personal and family history is essential in the evaluation of AR, and questions should focus on the types of symptoms, their onset, duration and frequency, suspected exposures, exacerbating/alleviating factors, and seasonality [see questions list below]. History should also assess for associated conditions such as allergic conjunctivitis, asthma, atopic dermatitis, sleep-disordered breathing, rhinosinusitis, and otitis media.

Questions to help identify AR:

• Are you aware of anything or any place that triggers your symptoms? For example, house dust or pollen exposure, contact with animals, certain tasks at work or home or school, or exposure to chemicals.
• What symptoms are causing you the most trouble? (check for rhinorrhoea, sneezing, itchy nose, nasal congestion, loss of smell, watery or itchy eyes).
• How long have you had these symptoms? Did you have the same this time last year?
• Has any member of your family ever had similar symptoms?
• Were they ever diagnosed with allergic rhinitis (patients may know it as hay fever), allergic conjunctivitis, asthma or atopic dermatitis?
• Do your symptoms come and go, or are they always present? Can you relate symptoms to a particular season / time of the year?
• Is your nasal discharge clear and watery?
• Are you experiencing any wheezing or shortness of breath? (“Yes” may indicate asthma, but may also indicate difficulty in breathing through the nose).
• Do you have an earache or any pain in your face? (“Yes” may indicate otitis media or rhinosinusitis. This does not indicate bacterial infection, but is due to a combination of increased mucus production, accompanied by reduced drainage, leading to pressure (pain) in the middle ear or sinus (see above).

Physical examination

Findings may include clear, sticky mucus and pale, swollen inferior turbinates. Mouth breathing, frequent sniffing and/or throat clearing are often apparent, together with signs such as dark circles under the eyes ("allergic shiners"), infraorbital skin fold, and a transverse nasal crease (from the “allergic salute”, which is more common in children). It is important to exclude other causes of  nasal obstruction, such as significant septal deviation, polyps, or sinonasal masses and, especially in children, foreign bodies, characterised by unilateral smelly nasal discharge. The sinuses might be tender to touch in people with chronic symptoms.

Red flags

Certain ‘red flags’ warrant immediate attention and indicate the need for referral to an otolaryngologist and/or allergist. These include persistent unilateral nasal obstruction, progressive blood-stained discharge, malodorous nasal discharge, persistent sinus pain or nasal polyps (suggested by severe persistent nasal congestion and anosmia). Such signs suggest more serious underlying conditions that require further evaluation.

Evaluation

If history taking and clinical assessment suggest AR, and this is supported by a positive response to empiric treatment with a nonsedating H1-antihistamine and/or a nasal glucocorticoid (or a fixed combination of nasal glucocorticoid and nasal antihistamine in moderate to severe cases), history driven allergen confirmation is possible with either serum testing for allergen-specific immunoglobulin E (SIgE) or allergy skin prick testing, although these tests are usually negative in local allergic rhinitis.(26,27) Local allergic rhinitis is typified by good treatment response but negative detection of systemic IgE, as this resides only in the nasal mucosa. Serum testing (SigE) is frequently available in primary care, does not require trained technicians, and does not require antihistamine cessation. Skin prick testing requires a trained professional to perform testing and interpret findings. It is rarely available in primary care, however results are available immediately. These tests are best reserved when there is diagnostic uncertainty or non-response to treatment, but also if allergen immunotherapy is to be considered.(28,29).

Radiographic imaging is not recommended for the diagnosis of AR.(20)

Practical tips:(30)

• People may experience acute symptoms without having AR or NAR, most often as a result of incidental, momentary and non-pathological exposure to environmental irritants (e.g., extreme cold during winter, exposure to cigarette smoke or perfume). These causes frequently do not require medical care and will resolve once the cause is removed.
• Environmental causes of AR vary widely on a global scale as allergen exposures differ by region. Moreover, climate change is making aeroallergen patterns increasingly unpredictable. Therefore, all patients should be assessed based on local climatic conditions and allergen exposure.
• Symptoms suggestive of AR (when related to allergen exposure) are 2 or more of the following for >1h on most days:
  • Runny nose
  • Sneezing, especially paroxysmal
  • Nasal obstruction
  • Nasal itch
  • Ocular symptoms like itch, redness or tearing (think of allergic conjunctivitis)
• Symptoms less suggestive of AR:
  • Unilateral symptoms
  • Discoloured secretions
  • Facial or nasal pain
  • Recurrent epistaxis
  • Smell disorder (anosmia)
  • Posterior rhinorrhoea (post-nasal drip) with thickened mucus
  • Isolated rhinorrhoea
  • Snoring / sleep apnoea