Chronic Rhinitis Treatment & Management

[Jeffrey Suh MD]
Chronic rhinitis is a very common condition. I think all of us at some point have had a runny nose for a number of reasons, whether it's from allergies, whether it's from being sick, or just any number of other causes, like just eating spicy food, causing our nose to run. It's a very common problem that affects a lot of different people. What's fascinating is that as an ENT, we don't really think very much of this condition. In fact, it's not as exciting as some of the other surgical conditions we treat, like chronic sinusitis, or even nasal obstruction but it's a problem with a very high prevalence that until recently didn't really have that many surgical options for our patients.

[Gopi Shah MD]
In terms of in your history, when a patient comes to you, what kinds of questions do you always ask them? What are you trying to tease apart? How do you distinguish chronic sinusitis from just chronic rhinitis? Sometimes to me, that can be difficult.

[Jeffrey Suh MD]
Yes, no, that's a great question. It's a really important thing for a surgeon to differentiate. There's so many different causes that have very similar symptoms in their nasal cavity in the sinuses. In order to offer the best treatment, we have to really get down to what's causing the symptoms. For rhinitis, which is basically runny nose, there can be any number of different causes for this condition. Each one can be treated differently.

For example, if you have chronic sinusitis, you can have drainage from your sinuses, you can have congestion obstruction, mucus in the nose and the treatment for chronic rhinitis options are very different. It could be using antibiotics, topical steroids, needing surgery in the sinuses, whether it's allergies. For allergies, it's really identifying the cause of the allergies, whether it's environmental, food, and then for some people, it's non-allergic causes of rhinitis, which is the focus of many of these surgical treatments that have been developed over the last five or six years.

[Gopi Shah MD]
We said certain risk factors are going to be allergies, non-allergic causes, can you get into some of the non-allergic causes that you're asking about?

[Jeffrey Suh MD]
The classic patient that I see that has non-allergic rhinitis, and it happens to all of us, are the fine eating spicy food then I love spicy food and my nose starts to run after I eat that is kind of a classic symptom of gustatory rhinitis, which is basically a non-allergic cause of a runny nose that's pretty common and affects a lot of us. Another one that I hear from my patients or the ones that are really active, that they run outside when the air is cold and their nose runs as they're running.

That can be bothersome, if they're running long distances, it can happen quite a bit for these people, and they're looking for a treatment option for this. The other classic patients that I see with non-allergic rhinitis are my elderly patients, the one that comes from nursing homes that are coming in on walkers or canes, and they're in their nursing home, they're saying that all the time their nose is running. They're distressed by this, they're distressed so much they want to go to the doctor's office and find a treatment option. Prior to cryotherapy or the other treatments that are now available surgically for us, we would just try to put them on sprays and the sprays were not that effective.

[Jeffrey Suh MD]
It all goes back to the first initial exam, the history, and then the physical exam. When I have residents that are with me in the clinic, it's always trying to understand the etiology of their symptoms, create a differential diagnosis, and then ideally pursuing medical therapy before recommending any types of surgery. There is some benefit for a CT scan, sometimes of the sinuses. If you see any signs of chronic inflammation, polyps, like you mentioned, or drainage from the sinuses, and standard medical therapy isn't ineffective, then sometimes radiology can give more insight into some things that might need to be addressed in the sinuses themselves.

Given the typical chronic rhinitis patient, everything being normal on the first nasal endoscopy, often it is trying to differentiate whether there might be some allergic triggers, so an allergic rhinitis versus a non-allergic. If there's something in the story that points toward an allergic rhinitis, then typically I think, seeing an allergist, understanding the triggers for their allergies, trying antihistamines, nasal steroid sprays would be beneficial. Then if it's purely non-allergic rhinitis, then there's a really great spray, which is Atrovent or ipratropium bromide, which I'll typically use as a litmus test for the benefits of seeing if maybe a surgery would work for this patient.

[Gopi Shah MD]
In a spray naïve patient, we'll say that for some reason they got to you without ever trying a spray. For the patient that doesn't have an allergy history, the nose doesn't look like an allergy, or maybe they had allergy testing and it was negative. Would you start with the ipratropium bromide, or would you start with something like the nasal steroid spray? Is there an algorithm? I feel like what I've always read is, well, for allergic or non-allergic rhinitis, we do the sprays and there's a nasal steroid spray, the antihistamine spray. Is there that algorithm or is it like, no, you don't have to do it that way and you can try this because I'm looking for this.

[Jeffrey Suh MD]
The nasal steroid sprays, they're quite effective and people do use them for non-allergic and allergic rhinitis, and I feel that if there's congestion, if there's signs of allergies like sneezing, itchy watery eyes, and other things, that would make me feel that there's allergic component, then the nasal steroid sprays are really effective. The biggest thing I try to teach my patients is these sprays generally have very little effect for the first few weeks. It's not a spray that's meant to be used just once and then see how it goes.
A lot of them have this feeling that they never work, and they usually don't work if they're not used long enough, so I say if you're going to try nasal steroid spray, such as Flonase, or Nasonex, or Nasacort, give it at least a month before you make a judgment if it's effective or not. For pure non-allergic rhinitis, I feel that Atrovent works phenomenally for just the drip.

If a patient comes in with symptoms that seem like they're very specific for just chronic rhinitis without an allergic component, then I find that the reason why the patients are drawn toward Atrovent is that there's not that buildup that we need with the Flonase or the nasal steroid spray. If you use Atrovent right now, then whatever trigger there would normally be, whether it's eating the spicy food, or running outside, it will stop that drip immediately.

The patient will just know that when they try the Atrovent if it works to prevent whatever the next trigger would be, it's likely to be non-allergic rhinitis. The only downside of the Atrovent spray is that it doesn't last for very long, it works for about two hours, three hours. It's really good to identify the potential cause of the rhinitis, but it's not necessarily the best long-term chronic rhinitis treatment option because the spray would've to be used pretty regularly.