What is Rhinitis?

Rhinitis is the medical term for “Sensitive Nose”. It refers to inflammation of the nasal cavity. Rhinitis is a common condition, affecting almost 10% to 30% of the population worldwide. Some people may trivialise the significance of Rhinitis but numerous studies have shown that it has significant socioeconomic cost, adversely affects quality of life of the patients, work productivity and may worsen symptoms in patients with Asthma. In fact, Asthma and Rhinitis often co-exist, with approximately 80% of patients with Asthma suffering from Rhinitis and about 20-50% of patients with Rhinitis have concomitant Asthma. Treatment of rhinitis may improve asthma control and early treatment of allergies may prevent the development of asthma.

What are the types of Rhinitis?

The types of Rhinitis can be broadly divided into

a) Allergic Rhinitis (AR)

This is the most common form of Rhinitis and is caused by exposure to allergens which are proteins that trigger an allergic reaction. Common allergens include house dust mites, grass or tree pollens, animal danders, mold and cockroach. Traditionally, AR was classified as:

Seasonal – This occur in Spring and Autumn (Fall) when there is more pollen from trees, grass or weed causing the allergy

Perennial – This occurs all year round due to allergens that are present regardless of season. Common cause include House dust mites, animal danders, mold and cockroach.

The Allergic Rhinitis and its Impact on Asthma (ARIA) guideline has reclassified AR based on symptom frequency (“Intermittent” or “Persistent”) and symptom severity (“Mild”, “Moderate” or “Severe”). This classification provides a guide on the type of treatment required for Allergic Rhinitis.

b) Non-Allergic Rhinitis

This is Rhinitis that is not due to exposure to an allergen. Common causes include cigarette smoke, traffic fumes, perfume, strong odors, stress and a change of weather conditions. The symptoms are similar to Allergic Rhinitis.

c) Infectious Rhinitis

This is Rhinitis due to a viral infection. Cold and flu are common forms of infectious rhinitis.

What are the symptoms of Allergic Rhinitis?

Symptoms of Allergic Rhinitis include

Blocked nose

Clear runny nose

Sneezing

Itchiness in nose and eyes

Watery eyes

Mucous and phlegm in the throat (from “postnasal drip”)

What causes Allergic Rhinitis?

This is not completely understood. However, there is evidence of a hereditary cause and patients with family history of Allergic Rhinitis are more likely to have it than those who do not.

How do I tell if I have a cold and not Allergic Rhinitis?

Symptoms from Allergic Rhinitis can be similar to a cold. However, there are some differences and a cold tend to have more of the following symptoms:

Fever

Sorethroat

Coloured mucous (Yellow, green or brown)

Thick mucous or phlegm

Body ache and tiredness

Usually resolves within a week

Less itching of the nose and eyes

How is a cold different from Sinusitis?

Symptoms of sinusitis can be similar to a cold. However, sinusitis usually last longer than 10 days or the symptoms are not getting better after 5 days of infection. As sinusitis is usually caused by a bacterial infection, treatment with oral antibiotics is important. On the other hand, a cold is a viral infection and your body’s immune system should be able to fight it off. Antibiotics will not be helpful. Common symptoms of sinusitis include:

Facial pressure or pain

Nasal blockage

Nasal congestion (feeling of mucous stuck in the nose)

Coloured mucous (yellow, green or brown) or thick mucous/phelgm

Loss or decreased sense of smell

How is Allergic Rhinitis diagnosed?

The diagnosis of Rhinitis can be made from a suggestive clinical history and findings on nasoendoscopy. Nasoendoscopy is performed in the clinic and involves the passing of a small lighted tube into the nose and down the back of the throat (Fig 1a). On nasoendoscopy, the inferior turbinates may be enlarged (Fig 2a&b). A skin prick test (a form of Allergy Test) can be performed to help differentiate between Allergic and Non-Allergic rhinitis

What are the treatment options for Allergic Rhinitis?

Allergen Avoidance

The most common allergen amongst Singaporean is house dust mite. Hence, those with dust mite allergy should wash their bedsheets and pillow cases once a week with hot water (at least 60 degrees Celsius high) to get rid of the dust mite allergens. As it is not possible to avoid all allergens in the environment, you will need medications to keep your symptoms under control.

Medication

In patients with troubling symptoms from Rhinitis, the use of a nasal steroid spray is advised. Nasal steroid spray reduces inflammation in the nose and is effective in alleviating all symptoms of Allergic Rhinitis (Fig 4). While many people have concerns about the side effects of steroids, modern nasal steroid sprays have minimal absorption into the bloodstream. Hence the systemic side effects from the steroid is negligible. Some nasal steroid sprays can be used in children as young as 2 years old. Nasal steroid spray does take time to be effective (from days to 2 weeks for maximal effect) and has to be used on a daily basis. It is important that patients are diligent and comply with the use of nasal steroid spray before giving up this treatment modality. It is equally important that the correct application technique is used for the steroid to reach the correct areas in the nose. The patient should tilt his or her down, the spray into one nostril and aim the nozzle slightly away from the centre (towards the eye on the same side). Application of the spray should be timed with normal inhalation (a normal gentle breath in).

Immunotherapy

In immunotherapy, the patient is presented with the known allergen in a small dose repeatedly to desensitise the patient from that allergen. It can be given via an injection into arm (Subcutaneous Immunotherapy – SLIT) or sprayed under the tongue (Sublingual Immunotherapy – SLIT). In Singapore, immunotherapy is most commonly applied under the tongue (

Patients have to use SLIT for at 3 years as it takes time to change the body’s immune response to the allergen. However, improvement in symptoms can be expected after about 3-6 months of therapy.

Surgery

Surgery for Allergic Rhinitis is aimed at relieving the symptoms. It does not the disease process of Allergic Rhinitis. Most commonly, surgery is performed to relieve nasal obstruction. This is achieved by reducing the size of the inferior turbinates

There are many ways to reduce the size of inferior turbinates. Less aggressive procedures (e.g. radiofrequency or coblation of the inferior turbinates) can be done in the clinic setting under local anaesthesia while more aggressive procedures (e.g inferior turbinoplasty) has to be done in the operating theatre under general anaesthesia (patient asleep during the procedure).