BSACI Guideline for the Diagnosis and Management of Allergic and Non-Allergic Rhinitis

Overview

This is a summary of the 2017 update of the British Society for Allergy and Clinical Immunology's guidance on diagnosis and management of rhinitis. It includes a useful treatment algorithm and indications for ENT referral.

This summary only includes recommendations pertinent to primary care settings. Please refer to the full guideline for recommendations on:

• intranasal decongestants
• oral decongestants (pseudoephedrine)
• ocular therapy
• immunotherapy (for example, subcutaneous injection immunotherapy, sublingual immunotherapy)
• treatment of non-allergic rhinitis
• rhinitis in pregnancy and during breastfeeding
• rhinitis in children.

Diagnosis of Rhinitis

Definitions/Classification

• Rhinitis is clinically defined by symptoms of nasal discharge, itching, sneezing and nasal blockage or congestion
• When the conjunctivae are also involved, the term rhinoconjunctivitis is more accurate. Involvement of the sinus linings in more widespread disease is known as rhinosinusitis
• Rhinitis has multiple phenotypes, usually divided into allergic, non-allergic, and infective as well as mixed forms

History

• A detailed history is required, including seasonality (pollen, moulds), indoors/outdoors location (dust mite, the presence of house pets), work location (occupational), improvement of holidays, and relationship to potential triggers which can impact on the patient’s quality of life. Symptoms of sneezing, nasal itching, itching of the palate are more likely to indicate allergic rhinitis (AR)

Rhinorrhoea

• Rhinorrhoea is either anterior, posterior, or both
• Clear—infection unlikely if continuously clear, although secretions are clear early in viral rhinitis
• Unilateral—is uncommon and cerebrospinal fluid (CSF) leak should be excluded
• Coloured:
  • yellow—allergy or infection; green—usually infection; blood tinged
  • unilateral—tumour, foreign body, nose picking, or misapplication of nasal spray
  • bilateral—misapplication of nasal spray, granulomatous disorder, bleeding diathesis, infection, nose picking

Nasal Obstruction

• Can be partial or complete; severity often correlates with systemic manifestations
• Bilateral—most likely rhinitis or nasal polyps but maybe septal (sigmoid) deviation
• Unilateral—usually septal deviation but also consider foreign body, antrochoanal polyp, and tumours
• Alternating—due to rhinitis exposing the nasal cycle

Nasal Crusting

• Severe crusting especially high inside the nose is an unusual symptom in rhinitis and requires further investigation
• Consider: chronic rhinosinusitis, nose picking, granulomatous polyangiitis, sarcoidosis or other vasculitides, cocaine abuse, ozaena, non-invasive ventilation. Topical steroids rarely cause crusting

Eye Symptoms

• Include intense itching, redness and swelling of the white of the eye, watering, lid swelling, and (in severe cases) periorbital oedema, which can be aggravated by eye rubbing

Lower Respiratory Tract Symptoms

• Cough, wheeze, shortness of breath—can occur with rhinitis alone since bronchial hyper-reactivity can be induced by upper airway inflammation
• Disorders of the upper and lower respiratory tract often coexist—80% of people with asthma have rhinitis

Other Symptoms

• Snoring, sleep problems, repeated sniffing, nasal intonation of the voice
• Pollen-food syndrome is triggered by ingestion of cross-reacting antigens in some fruits, vegetables, and nuts
• A proportion of patients suffering from allergic (mainly seasonal) rhinitis have an associated nasal hyper-reactivity which is generally not recognised/treated

Family History

• A diagnosis of AR is more likely when rhinitis is seasonal, or with a family history of AR. However, it can arise de novo

Social History

• Consider pets or other contact with animals, occupation or schooling

Drugs

• A number of drugs can cause or aggravate rhinitis symptoms. Therefore, a drug history should include details of the use of alpha and beta-blockers and other anti-hypertensives, aspirin and other non-steroidal anti-inflammatory drugs, oral contraceptives, as well as topical sympathomimetics. It is also important to enquire about the efficacy of previous treatments for rhinitis and details of how they were used and for how long

Examination

Visual Assessment

• Allergic salute and/or horizontal nasal crease across dorsum of nose and/or eye involvement supports a diagnosis of AR
• Chronic mouth breathing
• Allergic shiners
• An assessment of nasal airflow—for example, metal spatula misting in young children
• Depressed nasal bridge—post surgery, granulomatous polyangiitis, or cocaine misuse
• Widened bridge; polyps 
• Purple nasal tip due to sarcoidosis

Other Methods of Examination

• Anterior rhinoscopy
  • using otoscope:
    • check structure, mucosa, secretions
• Nasal endoscopy
• Check patient for asthma

Investigations

• Allergen-specific IgE can be detected with skin prick tests (SPTs) or by serum immunoassay

Skin Prick Tests

• Should be carried out routinely to determine if the rhinitis is allergic or non-allergic, and have a high negative predictive value. They should be interpreted in the light of the clinical history
• At least 15% of people with a positive SPT do not develop symptoms on exposure to the relevant allergen
• Prick-to-prick tests with fresh food can be used to diagnose oral allergy syndrome

Serum Total and Specific IgE

• Serum-specific immunoglobulin E (IgE) may be requested when skin tests are not possible or when the SPT together with the clinical history give equivocal results. Total IgE alone can be misleading but may aid interpretation of specific IgE. Currently available SPTs and allergen-specific IgE show similar sensitivity for house dust mite, but SPTs are more sensitive to other inhalant allergens such as cat epithelium, mould, and grass pollen

Laboratory Investigations

• Usually unnecessary, their use is guided by the history, examination, and results of skin prick tests. Examples include:
  • full blood count and differential white cell count, C-reactive protein, immunoglobulin profile, microbiological examination of sputum, and sinus swabs, when chronic infection is suspected
  • thyroid function tests in unexplained nasal obstruction
  • nasal secretions-asialotransferrin for CSF identification
  • urine toxicology when cocaine abuse is suspected

Other Investigations

• These include:
  • olfactory tests
  • cytology
  • exhaled nitric oxide 
  • nasal nitric oxide
  • radiology
  • nasal challenge
  • objective measures of nasal airway
  • tests for asthma—measurements of lung function should be considered in all patients with persistent rhinitis

ENT Referral

• Patients with:
  • unilateral symptoms
  • heavily blood stained discharge or pain
  • nasal blockage unrelieved by pharmacotherapy or structural abnormalities, such as septal deviation

Treatment

Non Pharmacological

• Treatment strategies include:
  • allergen avoidance
  • pet allergen exposure and sensitisation
  • saline irrigation
  • carbon dioxide washing

Pharmacotherapy

• For more information about administration and adverse events, please refer to the full guideline at bsaci.org and the summary of product characteristics for individual drugs
• Following diagnosis and classification according to disease severity, therapy using a stepwise pharmacotherapeutic approach should be undertaken. A combination of treatments is often needed for more severe disease, and it is here that the option of immunotherapy should also be considered

Algorithm 1: Rhinitis Treatment

Pharmacotherapy Effects on Individual Rhinitis Symptoms

• Oral H1-antihistamines: 
  • first-generation sedating antihistamines should be avoided as they worsen psychomotor retardation 
  • place in therapy:
    • first-line therapy for mild-to-moderate intermittent and mild persistent rhinitis
    • addition to intranasal steroids for moderate/severe persistent rhinitis uncontrolled on topical intranasal corticosteroids alone, particularly when eye symptoms are present 
  • act predominantly on neurally mediated symptoms of itch, sneeze and rhinorrhoea and have only a modest effect on nasal congestion
  • additionally, they reduce histamine driven symptoms such as itch at sites other than just the nose such as conjunctiva, palate, and skin
  • they should be used regularly rather than ‘as needed’ use in persistent rhinitis
  • acrivastine has the fastest onset of action, but needs to be used 8 hourly; fexofenadine is the least sedating oral antihistamine with a wide therapeutic index
• Nasal H1-antihistamines (for example, azelastine):
  • place in therapy: 
    • first-line for mild-to-moderate intermittent and mild persistent rhinitis
    • in combination with intranasal steroids used for moderate/severe persistent rhinitis, which care not controlled on topical intranasal corticosteroids alone 
  • superior to oral antihistamines in attenuating rhinitis symptoms, and in decreasing nasal obstruction, although they do not improve symptoms due to histamine at other sites, such as skin
  • rapid onset of action (15 minutes), faster than oral antihistamines, thus, the drug can be used on demand as rescue therapy for symptom breakthrough
  • continuous treatment is, however, more clinically effective than on demand use
  • they can be effective in patients who have previously failed oral antihistamines
• Intranasal corticosteroids (INS):
  • place in therapy
    • first-line therapy for moderate-to-severe persistent symptoms
    • first line of therapy if presenting with severe nasal obstruction, possibly combined with a short-term nasal decongestant. In severe nasal obstruction steroid drops or oral steroids should be used initially for up to 1 week
  • topical corticosteroids are the mainstay of anti-inflammatory intervention in AR. Factors which need consideration are systemic drug bioavailability, safety, and cost
  • unlike other treatments, INS reduce nasal congestion
  • onset of action is 6–8 hours after the first dose, clinical improvement may not be apparent for a few days and maximal effect may not be apparent until after 2 weeks
  • starting treatment 2 weeks prior to a known allergen season improves efficacy. Similar clinical efficacy for all INS, but bioavailability varies considerably
• INS and topical H1-antihistamine combination:
  • place in therapy:
    • combination of topical antihistamine (AH) with INS should be used in patients when symptoms remain uncontrolled on AH or INS monotherapy or on a combination of oral AH plus INS
  • azelastine and fluticasone propionate:
    • leads to greater symptom improvement than using either agent alone in seasonal AR
    • all symptoms of AR were significantly improved with onset of action by 30 minutes
    • combination approach leads to clinical improvement of symptoms days earlier than seen with azelastine or fluticasone propionate monotherapy
• Systemic glucocorticoids:
  • rarely indicated in the management of AR except for severe nasal obstruction
  • in order to obtain control, short-term rescue medication is used during severe exacerbation despite compliance on conventional pharmacotherapy
  • it is important to ensure intranasal steroid therapy is coadministered alongside oral steroids with or without a short-term decongestant spray to allow intranasal drug penetration
  • a suggested regimen for adults is 0.5 mg per kg for 5–10 days
  • oral preparations of steroids as a short course are recommended over depot injectable preparations, which have an adverse risk–benefit profile that cannot be removed if adverse effects occur
  • frequent oral steroid rescue should prompt immunotherapy as a treatment option
• Anti-leukotrienes:
  • place in therapy:
    • montelukast is licensed in the UK for those with seasonal AR who also have concomitant asthma (UK licence for age >6 months; zafirlukast UK licence >12 years)
• Topical anti-cholinergic (e.g. ipratropium bromide):
  • place in therapy:
    • patients with watery rhinorrhoea despite compliance with INS or INS plus antihistamine
• Chromones (e.g. sodium cromoglicate and nedocromil sodium):
  • place in therapy:
    • children and adults with mild symptoms only and sporadic problems in season or on limited allergen exposure
    • useful for individuals unable to take other medications, for example pregnant women
    • cromoglicate and nedocromil eye drops are useful in conjunctivitis as topical therapy
  • sodium cromoglicate is weakly effective in rhinitis with some effect on nasal obstruction. The spray needs to be used several times (3–4 times up to 6 times) per day

Surgery

• Surgery is offered in only a minority of cases. The indications for surgical intervention are as follows:
  • anatomical variations of the septum with functional relevance
  • drug-resistant inferior turbinate hypertrophy (poor objective evidence to support this indication other than in the short-term).