Download One must rule out all known allergic, infectious and known causes of

One must rule out all known allergic, infectious and known causes of chronic rhinitis
to come to a diagnosis of Idiopathic Rhinitis (IR) (Desrosiers et al., 2011; Kaliner et
al., 2009; Van Rijswijk, Blom, & Fokkens, 2005; Wallace et al., 2008; Wilder, 2012).
See Desrosiers et al. for two useful algorithms you should consult. The first goes
through the clinical symptoms, diagnosis, treatment and referral triggers for Acute
Bacterial Rhinosinusitus (ABRS). This is important as the infectious causes of
rhinitis are the ones likely to need urgent referral to acute care with more severe
and rapid progression possible.
So, once ABRS has been ruled out and/or it is a more chronic presentation [ at least
2 symptoms from the list of a) facial congestion, b) facial pain, c) nasal obstruction,
d) purulent nasal discharge, e) impaired smell for at least 8-12 weeks plus
documented inflammation] Desrosiers et al. (2011) provide an algorithm to help
diagnose, treat and again referral triggers for patients with Chronic Rhinosinusitus.
Once all known causes of rhinitis have been excluded one can consider the catch all
diagnosis of IR. Van Rijswijk et al. (2005) present several possible etiologies for IR
but are clear that there is no convincing or adequate evidence to prove any of them.
That said, it seems like chronic inflammatory disorders, noradrenergic
noncholinergic or peptidergic neural system dysfunction, neurogenic,
parasympathic/sympathetic neural dysbalans, hyperthesia or dysthesia at the CNS
level and the presence of nitric oxide synthase in nasal tissue may all be possible
mechanisms to explain IR.
Kaliner et al. (2009) present the primary symptoms of IR as a) nasal congestion and
b) rhinorrhea. Other associated upper respiratory and sinus symptoms may be
present. (Wilder, 2012) suggests that obstructive rather than irritative symptoms
are more common in IR versus allergic rhinitis. A detailed medical, occupational
and social history are needed to rule out various causes of rhinitis. Hypereactivity
to non-allergic stimuli including cold air, climate changes, smoke, strong smells,
exercise, chemicals and alcohol have also been considered a factor in IR (Kaliner et
al., 2009).
Physical exam findings to support the diagnosis of IR mostly consist of pertinent
negatives including a) An important thing to note is the lack of purulent discharge
suggestive (Wilder, 2012) b) erythematous versus characteristic pale nasal mucosa
of allergic rhinitis c) often normal nasal mucosa without signs of inflammation. One
would see evidence of nasal congestion and clear watery nasal discharge (Van
Rijswijk et al., 2005; Wilder, 2012).
There is no test for IR but rather a few things to help rule out other causes of
rhinitis. Testing for nasal eosinophils and skin testing for allergic IgE, cold dry air
(CDA) provocation are some of the few tests but it is symptoms and lack of other
diagnosis that gets one to IR (Van Rijswijk et al., 2005; Wilder, 2012).
Treatments for IR is focused on symptoms and treatments do not cure. Capsaicin
has been used with some success with 5 treatments in a day but first line should
probably be a 6 week trial of topical steroids (Van Rijswijk et al., 2005). Other
treatments include topical or systemic sympathomimetics though they should not
be used for longer than a week and provide only short term improvement often with
rebound of symptoms. Antihistamines are not often effective but may be tried when
all else fails. Lastly there are surgical options that focus on increasing the size of the
nasal air passage and or denervating the autonomic nerves to the nares (Van
Rijswijk et al., 2005; Wilder, 2012). Other than that avoidance of triggers is the
main goal .
Health teaching for this patient would be focused on proper use of prescribed
medications and being aware of triggers or signs that would suggest some other
reason for the rhinitis where treatment might be more appropriately tailored
(Wilder, 2012).
References
Desrosiers, M., Evans, G. A., Keith, P. K., Wright, E. D., Kaplan, A., Bouchard, J., …
Witterick, I. J. (2011). Canadian clinical practice guidelines for acute and
chronic rhinosinusitis. Allergy, Asthma & Clinical Immunology, 7(1), 2.
doi:10.1186/1710-1492-7-2
Kaliner, M. A., Baraniuk, J. N., Benninger, M., Bernstein, J. A., Lieberman, P., Meltzer,
E. O., … Farrar, J. R. (2009). Consensus Definition of Nonallergic Rhinopathy,
Previously Referred to as Vasomotor Rhinitis, Nonallergic Rhinitis, and/or
Idiopathic Rhinitis. World Allergy Organization Journal, 2(6), 119.
doi:10.1097/WOX.0b013e3181a8e15a
Van Rijswijk, J. B., Blom, H. M., & Fokkens, W. J. (2005). Idiopathic rhinitis, the
ongoing quest. Allergy, 60(12), 1471–1481. doi:10.1111/j.13989995.2005.00975.x
Wallace, D. V., Dykewicz, M. S., Bernstein, D. I., Blessing-Moore, J., Cox, L., Khan, D. A.,
… Tilles, S. A. (2008). The diagnosis and management of rhinitis: An updated
practice parameter. Journal of Allergy and Clinical Immunology, 122(2,
Supplement), S1–S84. doi:10.1016/j.jaci.2008.06.003
Wilder, A. (2012). Rhinitis. In Primary Care A Collaborative Practice - Pageburst
Retail. (4th ed.). Mosby Inc.