Causes and Treatment of Chronic Rhinitis
Rhinitis is defined as inflammation of the nasal mucosal membranes and is characterized by one or more of the following symptoms: anterior or posterior rhinorrhea (mucous drainage), nasal congestion, nasal itching, and sneezing.
Excluding infection, such as the common viral cold, there are two types of chronic rhinitis - allergic rhinitis (AR) and non-allergic rhinitis (NAR). In addition to the nasal symptoms, people with AR (sometimes referred to hay fever) frequently experience associated red and itchy eyes with excess tearing (conjunctivitis); a scratchy irritated throat; and occasional symptoms of sinus inflammation (sinusitis) causing headaches, facial pain, and congestion of the ears. Chronic AR with sinusitis can lead to loss of taste and smell. In contrast, NAR typically causes only the nasal symptoms.
Rhinitis can be seasonal or perennial. Seasonal rhinitis is most often due to allergies and NAR is usually perennial, although there are people with mixed AR and NAR.
AR is caused by a person being hypersensitive to environmental substances that result in an immunologic reaction whereby when exposed to an allergen, there is excessive production of IgE antibodies which attach to a class of white blood cells known as mast cells. When this occurs, the integrity of the mast cells is disrupted and inflammatory biochemicals, including histamine, are released systemically and this process mediates the symptoms described in AR. The identification of histamine’s involvement in this process lead to the development of the class of drugs known as antihistamines. These drugs can be beneficial for alleviating the symptoms of AR, but are usually not effective for treating NAR because this form of rhinitis is not caused by the immunological release of histamine.
Triggers for AR are numerous and ubiquitous depending on the season of the year. In general, the culprits in the spring are flowering trees and plants; in the summer various grasses; and in the fall a number of weeds. Of course, there are allergens that are present year around such as mold and mildew, dust mites, and animal dander, to name a few.
The cause of NAR is unknown but research has shown that some form of external irritant (not an allergen) causes the blood vessels in the nasal mucosa to dilate and these arteries become engorged with excess blood resulting in swelling of the nasal canals, thus the symptom of nasal congestion. An inflammatory process also occurs causing the production of excess mucous which flows anteriorly as a ‘drippy nose’ and posteriorly into the throat. Because of the increased blood flow, NAR is frequently referred to as vasomotor rhinitis.
Triggers of NAR are many but tend to fall in the following groups: a) Odors- such as perfumes and smoke; b) Weather Changes – particularly cold and dry conditions; c) Foods and Beverages – hot and spicy foods and alcoholic drinks; d) Medications – some blood pressure meds (amlodipine is notorious); NSAIDS – Advil and Alleve; e) Laryngopharyngeal acid reflux – often in the absence of esophageal symptoms. This should be strongly considered when the most prominent rhinitis symptom is that of posterior drainage that worsens when in a supine position.
OTC decongestant sprays (Afrin, Dristan) provide quick and remarkable relief of NAR because they constrict the arteries reducing the increased blood flow to the nasal mucosa which alleviates the congestion. However, in most people after only a few days of use, a rebound phenomenon occurs, whereby in-between sprays the congestion recurs more severe than originally, and increased frequency of use is required eventually leading to dependency.
Probably the most important and effective treatment for either type of rhinitis is saline nasal irrigations once or twice daily. To be effective it must be a lavage using a bulb syringe or a system like the Nedi-Pot that delivers adequate volumes (6-7 ounces) of buffered saline into each nostril with the solution exiting on the opposite side. This procedure flushes out irritants and thins the mucous soothing the nasal membranes. The saline solution is also bacteriostatic helping to prevent superimposed bacterial infections.
There are three types of nasal sprays, used individually or in combination, that are effective treatments for non-allergenic rhinitis.
Most commonly used are corticosteroid sprays (OTC Flonase or Nasacort) which are anti-inflammatory. Reducing inflammation decreases mucosal swelling and mucous production. For maximum benefit they should be used on a routine daily schedule, preferably after a saline lavage. Even though oral antihistamines are not beneficial for NAR, there are prescription antihistamine nasal sprays that are helpful and are synergistic when used simultaneously with the steroid sprays. Finally, there is a prescription spray called Atrovent which is an anticholinergic drug that is helpful for drainage but not congestion.
If these treatments fail, consult your primary healthcare provider or an ENT specialist to rule-out an anatomic disorder that may need surgical correction.
Dr. Tippett is the founder of Comprehensive Quality Healthcare Providers, a concierge internal medicine practice located at 1210 Commerce Dr. Suite 106, Greensboro, Ga. 30642. He can be reached at 706-510-3659. Visit his webpage at www.drtippett.com