Aaron Trinidade, FRCS (ORL-HNS)
Providing exceptional care for your ears, nose & throat
Helen Frankel: 07968312069
What is rhinitis?
Rhinitis is an inflammation (swelling) of the lining of the inside of the nose, called the mucosa, which results in the feeling of a blocked, runny nose. Mucosa lines the entire airways, from the nostrils right down to the lungs. In people with asthma, the mucosa in the lungs becomes inflamed. Rhinitis can therefore be thought of as asthma in the nose. Rhinitis is not an infection.
What causes it?
There are different types of rhinitis. If you have rhinitis then you will most likely fall into one of the following 6 categories:
This is commonly known as hayfever. People with allergic rhinitis tend to get symptoms when they are exposed to allergens. The most common allergens are the house dust mite and grass pollen. People with allergic rhinitis suffer from atopy and are said to be atopic. Atopy is an umbrella term for several allergic-type conditions including asthma, eczema and allergic rhinitis. Atopic people usually have a strong family history of one or more of these conditions and may have one or more themselves.
This type of rhinitis is called intrinsic becomes it ‘comes from within’, that it there are no identifiable triggers like allergies. Intrinsic rhinitis may be caused by a bad flu or viral upper respiratory tract infection. In these cases, the person is typically normal before the flu, but after the flu has passed, they cannot seem to shake the nasal blockage.
This is similar to intrinsic rhinitis but people tend to complain that their symptoms get worse during exercise or due to a change in temperature, like stepping into a warm room after being outside in the cold. This is because an already swollen nasal mucosa becomes engorged with blood and swells even more, resulting in nasal blockage.
The term ‘senile’ is used in this case to mean ‘elderly’. In the healthy nose, the mucosa moves mucus naturally to the back of the nose where it then passes into the throat and is swallowed and destroyed by acid in the stomach. The average adult swallows about 1 pint of mucus a day in this way. It is the nose’s way of cleaning itself. In senile rhinitis, the aging mucosa loses its ability to effectively clear mucus to the back of the nose and instead it drips out of the front of the nose causing a nuisance and embarrassment. People with senile rhinitis don’t always get nasal blockage as well.
This type of rhinitis is caused by abuse of nasal decongestants. Typically, it is caused in someone with another type of rhinitis who has been self-medicating the nose with a decongestant such as Otrivine, Sinex or another type of over the counter nose drop or spray. The medication clears the nose for short periods of time, which then quickly blocks up again, resulting in further use of the medication. Over time, the congestion becomes worse and worse (due to rebound congestion) until the person becomes dependent on decongestants.
This is uncommon and is usually a complication of previous nasal surgery. In this form of rhinitis, the patient suffers from an excessively dry nose that can result in crusting and blockage.
Who gets rhinitis?
Rhinitis can occur in all ages, except for senile rhinitis, which tends to occur in the elderly. Allergic rhinitis is more common in children, teenagers and young adult, while intrinsic rhinitis tends to occur in people in their 20s to 40s. Atopic people are more prone to developing allergic rhinitis.
What are the symptoms?
The main symptom is nasal blockage, with the feeling of being stuffed up at regular intervals or all the time. People may complain of a dripping or runny nose, or may experience catarrh (a dripping down the back of the nose, also called a postnasal drip). Especially in allergic rhinitis, there may be other hayfever symptoms such as sneezing fits and itchy eyes.
People often complain of difficulty sleeping at night, saying that when they lie on one side, one nostril blocks up and then switches to the other side when they turn over. This is an aggravation of the normal nasal cycle that happens in all people, but which people with rhinitis become abnormally aware of due to a more generally congested nose.
How is it diagnosed?
The diagnosis is based mainly on the symptoms. Examination of the nose will often show swelling of the inside lining (the mucosa). The front of the nose is examined with an instrument called a speculum and the back of the nose is examined with a nasendoscope, a type of telescope. The examination lasts about 1 to 2 minutes and is tolerated easily by most patients without an anaesthetic, but nose can be numbed with an anaesthetic spray if required. There are no tests specifically for rhinitis, but a skin prick allergy test can be performed if an allergic rhinitis is suspected. This will show which allergens, if any, you are allergic to.
What is the treatment?
Treatment is tailored to the type of rhinitis that you have. In all cases or rhinitis, a steroid spray in an integral part of treatment. This is usually in the form of Nasonex or Flixonase. When using these sprays, technique is crucial to ensure that you get maximal benefit (click here to see how to best apply a steroid spray into the nose). Steroid sprays take time to work and must be used daily for about 10 to 12 weeks before the full benefit can be seen. Together with a steroid spray, a salt water (saline) nasal wash (douche) may also be recommended. This helps to keep your nose clear of any irritants and crusting, and improves the overall hygiene and functionality of the nose. All patients with rhinitis should stop smoking as this severely affects the ability of your nose to clear mucus effectively and also aggravates swelling of the mucosa. Many people with rhinitis find that their symptoms are better when they take a shower because of the steam. If this helps, then you should consider the use of a humidifier in your room to help you sleep at night.
If you have allergic rhinitis, the addition of a regular oral antihistamine (such as fexofenadine) can help to dumb down the allergic response within your nose. An antihistamine spray (such as Dymista, which combines a steroid and an antihistamine) can also be useful. If you also have asthma, regular use of your steroid inhaler will also help your nose at the same time, and similarly, regular treatment of your nose will in turn help your asthma. Medications such as montelukast (a leukotriene inhibitor) may be of additional help. This should be discussed with your GP or asthma specialist. Allergens should be avoided where possible and if you have a pet that you have been shown to be allergic to, then keep its hair short, wash it regularly where possible and keep it out of your bed and bedroom. Cover mattresses and pillows in a hypoallergenic covering and keep carpets and fans free of dust. Sheets should be washed in hot water on a regular basis (at least once a week).
If you have developed a rhinitis medicomentosa due to decongestant abuse, then in addition to a steroid spray, you must stop all decongestants. This can be very difficult, especially at night when congestion can affect your ability to fall asleep. Nasal strips for snoring may help keep the nostrils open and a humidifier is very useful. Decongestants should be stopped altogether. This can be very difficult, but unfortunately, as long as you are using decongestants, no matter how little, your rhinitis medicomentosa wil not heal. A short course of oral steroids followed by steroid nasal drops can help you get over the worst of the withdrawal symptoms.
If your main issue is a dripping nose, as in senile rhinitis, and blockage is not really an issue, then a different spray, such as Rinatec may help. This contains ipratropium bromide, which acts on mucus-producing glands to reduce the amount of mucus that they produce. This can be used up to three times a day.
Are there any operations that can help rhinitis?
If all of the above measures have failed after 3 months of regular use, then surgery can be performed to try to reduce the swelling within the nose. The operation is called submucous diathermy of the inferior turbinates (called SMD for short). In this operation, the mucosa is shrunk down with diathermy (an electrical current), especially over the inferior turbinates (the main ridges within the nose) where it is usually most swollen.
The inferior turbinates may also be pushed outwards (inferior turbinate outfracture) to further increase room within the nostrils. In addition to reducing the size of the inferior turbinates, the nasal septum may also need to be straightened with a septoplasty if it is bent (deviated). This can also be done at the same time.
The operation is performed under a general anaesthetic, lasts about 20 minutes and is very safe with minimal risks. The main risk is a possible nose bleed (about 5%) that usually settles on its own within the first 24 hours, but occasionally results in the need to pack the nose if it is heavy and persistent. The success rate of the operation is modest at 75% and is not a cure for rhinitis, but is designed to make more physical room inside your nose so that steroid sprays can continue to be used in a more effective manner.
After the operation, the nose should be regularly douched with saline and Nasonex or Flixonase should be restarted after the first 24 hours.
This diagram shows the inside of the nose in someone with allergic rhinitis, but it is the same with most other types (see below) as well. The mucosa becomes swollen and inflamed, especially over the ridges within the nose (called the turbinates). It results in excessive mucus production and nasal blockage.
This shows how submucous diathermy (SMD) is performed. A diathermy instrument is passed into the nose and used to shrink the mucosa overlying the inferior turbinate where it causes the most obstruction.