Clinical guide - Rhinitis
This guidance replaces that left at the beginning of 2012 titled ‘Simple Rhinitis and Rhinosinusitis’. It does not replace a good understanding of the underlying pathology of rhinosinusitis or its medical management and these must be studied separately.
Chronic rhinosinusitis (CRS) is diagnosed when a patient has a blocked nose with facial discomfort, discoloured nasal mucus and loss of smell. The symptoms will have been there for more than three months. Polyps may or may not be present on both sides. Unilateral polyps are treated separately.
CRS is common and may be related to smoking, allergic rhinitis, HIV and dental disease.
Patients with CRS sometimes get acute rhinosinusitis as well.
Rhinitis is an inflammation of the nose and causes blockage, clear rhinorrhoea, itching, sneezing and loss of sense of smell. It may be allergic or non-allergic. A good clinical history will help decide which the patient has but laboratory testing is not available to you. Sometimes it will not be obvious which type of rhinitis that the patient has and you will have to use common sense and experience to decide upon treatment.
A general note on medications.
Modern oral antihistamines are quite good at treating clear rhinorrhoea, itching and sneezing. They are not very helpful in patients with a blocked nose.
Use fexofenadine and cetirizine as these are associated with fewest side effects and drug interactions.
Nasal steroids are good at treating all of the symptoms of rhinitis including blockage as long as the technique of usage is good and the patient uses them every day. There are no drug interactions.
How are these drugs used in rhinitis?
If the patient complains of discharge, itch and sneeze then you should start with an antihistamine. This will probably work if the patient has allergic rhinitis but it probably won’t if they have non-allergic rhinitis.
If antihistamines fail to work change the patient to a nasal steroid spray. Stop the antihistamine. Steroid sprays are good at treating many forms of rhinitis.
If steroids alone fail then use a mixture of nasal steroids plus an antihistamine.
The above treatment will treat the majority of cases. If it doesn’t, refer the patient to the hospital; they may require surgery
Flixonase can be used once daily from the age of 4.
Nasonex is also once daily but is not suitable under the age of 12.
Saline is made from: 0.5l saline with 1 teaspoon each of salt, sugar and bicarbonate of soda