Rhinitis

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Rhinitis
Other namesCoryza
Misc pollen.jpg
Pollen grains from a variety of common plants can cause hay fever.
Pronunciation
Specialty Infectious disease, allergy and immunology

Rhinitis, also known as coryza, [3] is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, sneezing, and post-nasal drip. [4]

Contents

The inflammation is caused by viruses, bacteria, irritants or allergens. The most common kind of rhinitis is allergic rhinitis, [5] which is usually triggered by airborne allergens such as pollen and dander. [6] Allergic rhinitis may cause additional symptoms, such as sneezing and nasal itching, coughing, headache, [7] fatigue, malaise, and cognitive impairment. [8] [9] The allergens may also affect the eyes, causing watery, reddened, or itchy eyes and puffiness around the eyes. [7] The inflammation results in the generation of large amounts of mucus, commonly producing a runny nose, as well as a stuffy nose and post-nasal drip. In the case of allergic rhinitis, the inflammation is caused by the degranulation of mast cells in the nose. When mast cells degranulate, they release histamine and other chemicals, [10] starting an inflammatory process that can cause symptoms outside the nose, such as fatigue and malaise. [11] In the case of infectious rhinitis, it may occasionally lead to pneumonia, either viral or bacterial. Sneezing also occurs in infectious rhinitis to expel bacteria and viruses from the respiratory tract.

Rhinitis is very common. Allergic rhinitis is more common in some countries than others; in the United States, about 10–30% of adults are affected annually. [12] Mixed rhinitis (MR) refers to patients with nonallergic rhinitis and allergic rhinitis. MR is a specific rhinitis subtype. It may represent between 50 and 70% of all AR patients. However, true prevalence of MR has not been confirmed yet. [13]

Types

Rhinitis is categorized into three types (although infectious rhinitis is typically regarded as a separate clinical entity due to its transient nature): (i) infectious rhinitis includes acute and chronic bacterial infections; (ii) nonallergic rhinitis [14] includes vasomotor, idiopathic, hormonal, atrophic, occupational, and gustatory rhinitis, as well as rhinitis medicamentosa (rebound congestion); (iii) allergic rhinitis, triggered by pollen, mold, animal dander, dust, Balsam of Peru, and other inhaled allergens. [15]

Infectious

Rhinitis is commonly caused by a viral or bacterial infection, including the common cold, which is caused by Rhinoviruses, Coronaviruses, and influenza viruses, others caused by adenoviruses, human parainfluenza viruses, human respiratory syncytial virus, enteroviruses other than rhinoviruses, metapneumovirus, and measles virus, or bacterial sinusitis, which is commonly caused by Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis . Symptoms of the common cold include rhinorrhea, sneezing, sore throat (pharyngitis), cough, congestion, and slight headache. [16] [ citation needed ]

Nonallergic rhinitis

Nonallergic rhinitis refers to rhinitis that is not due to an allergy. The category was formerly referred to as vasomotor rhinitis, as the first cause discovered was vasodilation due to an overactive parasympathetic nerve response. As additional causes were identified, additional types of nonallergic rhinitis were recognized. Vasomotor rhinitis is now included among these under the more general classification of nonallergic rhinitis. [17] The diagnosis is made upon excluding allergic causes. [18] It is an umbrella term of rhinitis of multiple causes, such as occupational (chemical), smoking, gustatory, hormonal, senile (rhinitis of the elderly), atrophic, medication-induced (including rhinitis medicamentosa), local allergic rhinitis, non-allergic rhinitis with eosinophilia syndrome (NARES) and idiopathic (vasomotor or non-allergic, non-infectious perennial allergic rhinitis (NANIPER), or non-infectious non-allergic rhinitis (NINAR). [19]

    In vasomotor rhinitis, [20] [21] certain nonspecific stimuli, including changes in environment (temperature, humidity, barometric pressure, or weather), airborne irritants (odors, fumes), dietary factors (spicy food, alcohol), sexual arousal, exercise, [22] and emotional factors trigger rhinitis. [23] There is still much to be learned about this, but it is thought that these non-allergic triggers cause dilation of the blood vessels in the lining of the nose, which results in swelling and drainage.

    Non-allergic rhinitis can co-exist with allergic rhinitis, and is referred to as "mixed rhinitis". [24] The pathology of vasomotor rhinitis appears to involve neurogenic inflammation [25] and is as yet not very well understood. The role of transient receptor potential ion channels on the non-neuronal nasal epithelial cells has also been suggested. Overexpression of these receptors have influence the nasal airway hyper-responsiveness to non-allergic irritant environmental stimuli (e.g., extremes of temperature, changes in osmotic or barometric pressure). [26] Vasomotor rhinitis appears to be significantly more common in women than men, leading some researchers to believe that hormone imbalance plays a role. [27] [28] In general, age of onset occurs after 20 years of age, in contrast to allergic rhinitis which can be developed at any age. Individuals with vasomotor rhinitis typically experience symptoms year-round, though symptoms may be exacerbated in the spring and autumn when rapid weather changes are more common. [17] An estimated 17 million United States citizens have vasomotor rhinitis. [17]

    Drinking alcohol may cause rhinitis as well as worsen asthma (see alcohol-induced respiratory reactions). In certain populations, particularly those of East Asian countries such as Japan, these reactions have a nonallergic basis. [29] In other populations, particularly those of European descent, a genetic variant in the gene that metabolizes ethanol to acetaldehyde, ADH1B, is associated with alcohol-induced rhinitis. It is suggested that this variant metabolizes ethanol to acetaldehyde too quickly for further processing by ALDH2 and thereby leads to the accumulation of acetaldehyde and rhinitis symptoms. [30] In these cases, alcohol-induced rhinitis may be of the mixed rhinitis type and, it seems likely, most cases of alcohol-induced rhinitis in non-Asian populations reflect true allergic response to the non-ethanol and/or contaminants in alcoholic beverages, particularly when these beverages are wines or beers. [29] Alcohol-exacerbated rhinitis is more frequent in individuals with a history of rhinitis exacerbated by aspirin. [31]

    Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), particularly those that inhibit cyclooxygenase 1 (COX1), can worsen rhinitis and asthma symptoms in individuals with a history of either one of these diseases. [32] These exacerbations most often appear due to NSAID hypersensitivity reactions rather than NSAID-induced allergic reactions. [33]

    The antihistamine azelastine, applied as a nasal spray, may be effective for vasomotor rhinitis. [34] Fluticasone propionate or budesonide (both are steroids) in nostril spray form may also be used for symptomatic treatment. The antihistamine cyproheptadine is also effective, probably due to its antiserotonergic effects.

    A systematic review on non-allergic rhinitis reports improvement of overall function after treatment with capsaicin (the active component of chili peppers). The quality of evidence is low, however. [35]

    Allergic

    Allergic rhinitis or hay fever may follow when an allergen such as pollen, dust, or Balsam of Peru [36] is inhaled by an individual with a sensitized immune system, triggering antibody production. These antibodies mostly bind to mast cells, which contain histamine. When the mast cells are stimulated by an allergen, histamine (and other chemicals) are released. This causes itching, swelling, and mucus production.

    Symptoms vary in severity between individuals. Very sensitive individuals can experience hives or other rashes. Particulate matter in polluted air and chemicals such as chlorine and detergents, which can normally be tolerated, can greatly aggravate the condition.[ citation needed ]

    Characteristic physical findings in individuals who have allergic rhinitis include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, lateral crease on the nose, swollen nasal turbinates, and middle ear effusion. [37]

    Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. [38] Many people who were previously diagnosed with nonallergic rhinitis may actually have local allergic rhinitis. [39]

    A patch test may be used to determine if a particular substance is causing the rhinitis.

    Rhinitis medicamentosa

    Rhinitis medicamentosa is a form of drug-induced nonallergic rhinitis which is associated with nasal congestion brought on by the use of certain oral medications (primarily sympathomimetic amine and 2-imidazoline derivatives) and topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) that constrict the blood vessels in the lining of the nose. [40]

    Chronic atrophic rhinitis

    Chronic rhinitis is a form of atrophy of the mucous membrane and glands of the nose.

    Rhinitis sicca

    Chronic form of dryness of the mucous membranes.

    Polypous rhinitis

    Chronic rhinitis associated with polyps in the nasal cavity.

    Pathophysiology

    Pathological changes in non-allergic rhinitis Neural abnormalities.tif
    Pathological changes in non-allergic rhinitis
    Mechanism of non-allergic rhinitis: Imbalance between sympathetic and parasympathetic components in the nasal mucous membrane Non-allergic rhinitis mechanism.tif
    Mechanism of non-allergic rhinitis: Imbalance between sympathetic and parasympathetic components in the nasal mucous membrane

    Most prominent pathological changes observed are nasal airway epithelial metaplasia in which goblet cells replace ciliated columnar epithelial cells in the nasal mucous membrane. [26] This results in mucin hypersecretion by goblet cells and decreased mucociliary activity. Nasal secretion are not adequately cleared with clinical manifestation of nasal congestion, sinus pressure, post-nasal dripping, and headache. Over-expression of transient receptor potential (TRP) ion channels, such as TRPA1 and TRPV1, may be involved in the pathogenesis of non-allergic rhinitis. [41]

    Association between rhinitis and asthma

    Neurogenic inflammation produced by neuropeptides released from sensory nerve endings to the airways is a proposed common mechanism of association between both allergic and non-allergic rhinitis with asthma. This may explain higher association of rhinitis with asthma developing later in life. [42] Environmental irritants acts as modulators of airway inflammation in these contiguous airways. Development of occupational asthma is often preceded by occupational rhinitis. Among the causative agents are flours, enzymes used in processing food, latex, isocyanates, welding fumes, epoxy resins, and formaldehyde. Accordingly, prognosis of occupational asthma is contingent on early diagnosis and the adoption of protective measures for rhinitis. [43]

    Diagnosis

    The different forms of rhinitis are essentially diagnosed clinically.[ clarification needed ] Vasomotor rhinitis is differentiated from viral and bacterial infections by the lack of purulent exudate and crusting. It can be differentiated from allergic rhinitis because of the absence of an identifiable allergen. [44]

    Evidence has been published from a few health apps for mobile devices that show potential to assist in the diagnosis of rhinitis and rhinosinusitis and to evaluate management and treatment adherence. While this shows promise for clinical management, as of 2022 few had been validated in the scientific literature, and even fewer included considerations for multimorbidity. [45] [46]

    Management

    The management of rhinitis depends on the underlying cause.

    For allergic rhinitis, intranasal corticosteroids are recommended. [47] For severe symptoms intranasal antihistamines may be added. [47]

    Pronunciation and etymology

    Rhinitis is pronounced /raɪˈnaɪtɪs/ , [48] while coryza is pronounced /kəˈraɪzə/ . [49]

    Rhinitis comes from the Ancient Greek ῥίςrhis, gen.: ῥινόςrhinos, "nose". Coryza comes through Latin from Ancient Greek κόρυζα. According to physician Andrew Wylie, "we use the term [coryza] for a cold in the head, but the two are really synonymous. The ancient Romans advised their patients to clean their nostrils and thereby sharpen their wits." [50]

    Related Research Articles

    <span class="mw-page-title-main">Allergy</span> Immune system response to a substance that most people tolerate well

    Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic dermatitis, allergic asthma, and anaphylaxis. Symptoms may include red eyes, an itchy rash, sneezing, coughing, a runny nose, shortness of breath, or swelling. Note that food intolerances and food poisoning are separate conditions.

    An allergen is an otherwise harmless substance that triggers an allergic reaction in sensitive individuals by stimulating an immune response.

    <span class="mw-page-title-main">Allergic rhinitis</span> Nasal inflammation due to allergens in the air

    Allergic rhinitis, of which the seasonal type is called hay fever, is a type of inflammation in the nose that occurs when the immune system overreacts to allergens in the air. It is classified as a type I hypersensitivity reaction. Signs and symptoms include a runny or stuffy nose, sneezing, red, itchy, and watery eyes, and swelling around the eyes. The fluid from the nose is usually clear. Symptom onset is often within minutes following allergen exposure, and can affect sleep and the ability to work or study. Some people may develop symptoms only during specific times of the year, often as a result of pollen exposure. Many people with allergic rhinitis also have asthma, allergic conjunctivitis, or atopic dermatitis.

    <span class="mw-page-title-main">Aspirin-exacerbated respiratory disease</span> Chronic inflammatory disease affecting the sinuses and lungs

    Aspirin-exacerbated respiratory disease (AERD), also called NSAID-exacerbated respiratory disease (N-ERD) or historically aspirin-induced asthma and Samter's Triad, is a long-term disease defined by three simultaneous symptoms: asthma, chronic rhinosinusitis with nasal polyps, and intolerance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Compared to aspirin tolerant patients, AERD patients' asthma and nasal polyps are generally more severe. Reduction or loss of the ability to smell is extremely common, occurring in more than 90% of people with the disease. AERD most commonly begins in early- to mid-adulthood and has no known cure. While NSAID intolerance is a defining feature of AERD, avoidance of NSAIDs does not affect the onset, development or perennial nature of the disease.

    <span class="mw-page-title-main">Allergen immunotherapy</span> Medical treatment for environmental allergies

    Allergen immunotherapy, also known as desensitization or hypo-sensitization, is a medical treatment for environmental allergies and asthma. Immunotherapy involves exposing people to larger and larger amounts of allergens in an attempt to change the immune system's response.

    <span class="mw-page-title-main">Nasal congestion</span> Partial or complete blockage of nasal passages

    Nasal congestion is the partial or complete blockage of nasal passages, leading to impaired nasal breathing, usually due to membranes lining the nose becoming swollen from inflammation of blood vessels.

    <span class="mw-page-title-main">Post-nasal drip</span> Medical condition

    Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.

    <span class="mw-page-title-main">Rhinorrhea</span> Filling of the nasal cavity with fluid mucus

    Rhinorrhea, also spelled rhinorrhoea or rhinorrhœa, or informally runny nose is the free discharge of a thin mucus fluid from the nose; it is a common condition. It is a common symptom of allergies or certain viral infections, such as the common cold or COVID-19. It can be a side effect of crying, exposure to cold temperatures, cocaine abuse, or drug withdrawal, such as from methadone or other opioids. Treatment for rhinorrhea may be aimed at reducing symptoms or treating underlying causes. Rhinorrhea usually resolves without intervention, but may require treatment by a doctor if symptoms last more than 10 days or if symptoms are the result of foreign bodies in the nose.

    Acute severe asthma, also known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and corticosteroids. Asthma is caused by multiple genes, some having protective effect, with each gene having its own tendency to be influenced by the environment although a genetic link leading to acute severe asthma is still unknown. Symptoms include chest tightness, rapidly progressive dyspnea, dry cough, use of accessory respiratory muscles, fast and/or labored breathing, and extreme wheezing. It is a life-threatening episode of airway obstruction and is considered a medical emergency. Complications include cardiac and/or respiratory arrest. The increasing prevalence of atopy and asthma remains unexplained but may be due to infection with respiratory viruses.

    <span class="mw-page-title-main">Azelastine</span> Chemical compound

    Azelastine, sold under the brand name Astelin among others, is a H1 receptor-blocking medication primarily used as a nasal spray to treat allergic rhinitis (hay fever) and as eye drops for allergic conjunctivitis. Other uses may include asthma and skin rashes for which it is taken by mouth. Onset of effects is within minutes when used in the eyes and within an hour when used in the nose. Effects last for up to 12 hours.

    Allergies to cats, a type of animal allergy, are one of the most common allergies experienced by humans. Among the eight known cat allergens, the most prominent allergen is secretoglobin Fel d 1, which is produced in the anal glands, salivary glands, and, mainly, in sebaceous glands of cats, and is ubiquitous in the United States, even in households without cats. The second most common is Fel d 2, this type is triggered by the cats dead skin flakes (dander) that are floating in the air as well as in the smell of cat urine.

    <span class="mw-page-title-main">Salicylate sensitivity</span> Medical condition

    Salicylate sensitivity is any adverse effect that occurs when a usual amount of salicylate is ingested. People with salicylate intolerance are unable to consume a normal amount of salicylate without adverse effects.

    Vocal cord dysfunction (VCD) is a condition affecting the vocal cords. It is characterized by abnormal closure of the vocal folds, which can result in significant difficulties and distress during breathing, particularly during inhalation.

    <span class="mw-page-title-main">Pathophysiology of asthma</span> Medical condition

    Asthma is a common pulmonary condition defined by chronic inflammation of respiratory tubes, tightening of respiratory smooth muscle, and episodes of bronchoconstriction. The Centers for Disease Control and Prevention estimate that 1 in 11 children and 1 in 12 adults have asthma in the United States of America. According to the World Health Organization, asthma affects 235 million people worldwide. There are two major categories of asthma: allergic and non-allergic. The focus of this article will be allergic asthma. In both cases, bronchoconstriction is prominent.

    Alcohol-induced respiratory reactions, also termed alcohol-induced asthma and alcohol-induced respiratory symptoms, are increasingly recognized as a pathological bronchoconstriction response to the consumption of alcohol that afflicts many people with a "classical" form of asthma, the airway constriction disease evoked by the inhalation of allergens. Alcohol-induced respiratory reactions reflect the operation of different and often racially related mechanisms that differ from those of classical, allergen-induced asthma.

    NSAIDhypersensitivity reactions encompass a broad range of allergic or allergic-like symptoms that occur within minutes to hours after ingesting aspirin or other NSAID nonsteroidal anti-inflammatory drugs. Hypersensitivity drug reactions differ from drug toxicity reactions in that drug toxicity reactions result from the pharmacological action of a drug, are dose-related, and can occur in any treated individual. Hypersensitivity reactions are idiosyncratic reactions to a drug. Although the term NSAID was introduced to signal a comparatively low risk of adverse effects, NSAIDs do evoke a broad range of hypersensitivity syndromes. These syndromes have recently been classified by the European Academy of Allergy and Clinical Immunology Task Force on NSAIDs Hypersensitivity.

    Nonallergic rhinitis is rhinitis—inflammation of the inner part of the nose—not caused by an allergy. Nonallergic rhinitis displays symptoms including chronic sneezing or having a congested, drippy nose, without an identified allergic reaction with allergy testing being normal. Other common terms for nonallergic rhinitis are vasomotor rhinitis and perennial rhinitis. The prevalence of nonallergic rhinitis in otolaryngology is 40%. Allergic rhinitis is more common than nonallergic rhinitis; however, both conditions have similar presentation, manifestation and treatment. Nasal itching and paroxysmal sneezing are usually associated with nonallergic rhinitis rather than allergic rhinitis. Other symptoms that are more specific to non-allergic rhinitis include ear plugging or discomfort with eustachian tube dysfunction, headaches, sinus pressure, and muffled hearing. Common triggers for non-allergic rhinitis include irritants such as tobacco smoke, cleaning agents, or abrupt changes in ambient temperature.

    <span class="mw-page-title-main">Asthma trigger</span> Factor that provokes symptoms of asthma

    Asthma triggers are factors or stimuli that provoke the exacerbation of asthma symptoms or increase the degree of airflow disruption, which can lead to an asthma attack. An asthma attack is characterized by an obstruction of the airway, hypersecretion of mucus and bronchoconstriction due to the contraction of smooth muscles around the respiratory tract. Its symptoms include a wide range of manifestations such as breathlessness, coughing, a tight chest and wheezing.

    Asthma phenotyping and endotyping is a novel approach to asthma classification inspired by precision medicine. It seeks to separate the clinical presentations or clusters of signs and symptoms of asthma, known as asthma phenotypes, from their underlying etiologies or causes, known as asthma endotypes.

    Anti-allergic agents are medications used to treat allergic reactions. Anti-allergic agents have existed since 3000 B.C in countries such as China and Egypt. It was not until 1933 when antihistamines, the first type of anti-allergic agents, were developed. Common allergic diseases include allergic rhinitis, allergic asthma and atopic dermatitis with varying symptoms, including runny nose, watery eyes, itchiness, coughing, and shortness of breath. More than one-third of the world's population is currently being affected by one or more allergic conditions.

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