Chronic Rhinitis vs Sinusitis: Symptoms, Diagnosis & Treatment

[Dr. Ashley Agan]
How do chronic rhinitis patients initially present to you? Is your practice a tertiary, quaternary care type, or is it more community, private practice-based?

[Dr. Omar Ahmed]
It is a tertiary, quaternary care-type practice. Even with that, I still get, on average, probably 30 rhinitis patients a week. Part of the reason is a lot of patients have sinus symptoms. Just because they have sinus symptoms doesn't necessarily mean they have sinusitis. Actually, majority of these patients have some form of rhinitis, whether it's allergic, mixed, or non-allergic rhinitis. I actually get a lot of these patients that are referred by PCPs, by allergists, by other ENTs as well. I've developed quite a niche in this area. I also do the surgical treatments for rhinitis, including video neurectomies and posterior nasal neurectomies as well. I get referrals for that.

Again, I see probably 20 to 30 rhinitis patients alone a week, and it's a big portion of my patients. I really get patients both from primary cares, allergists, patients that are self-referred, and other ENTs as well.

[Dr. Ashley Agan]
When you're saying rhinitis, is that specifically the runny nose patient, or are there other symptoms that patients are presenting with? How do you think about that when you're just purely taking the history?

[Dr. Omar Ahmed]
There's one group of patients that have a pure vasomotor rhinitis. Traditionally, that's what we thought these procedures were geared toward. What we realized is that majority of the patients actually have a mixed rhinitis. There's also patients with purely allergic rhinitis. Our research and our understanding of this is changing, and it's dramatically changed over the past 10 years, actually. One of my colleagues and mentors at Johns Hopkins Hospital actually is looking at pollution, environment, temperature, and all these other factors that trigger inflammation.

We know that whatever form of rhinitis a patient has, it's often multifactorial. Our understanding that, "Oh, this is a pure vasomotor, or this is a pure allergic rhinitis patient," I think is changing. I think a majority of patients are actually truly mixed rhinitis. I'm looking at all the different types of rhinitis patients. I think these treatment options actually are beneficial to all these groups of patients.

[Dr. Ashley Agan]
To tease out, for example, your chronic rhinosinusitis from your rhinitis patients, are there surveys or are there specific-- I know there's the SWAT spot 22 and all that, we think, usually for a CRS, but do you use those same surveys for these patients or are there other surveys for the rhinitis patients?

[Dr. Omar Ahmed]
Yes. We have a very sophisticated system to gather patient report outcome measures. We have iPads for all our patients as soon as they walk in. There is a specific question algorithm that they go through to answer your questions. Based on how they answer the questions, they're either given a SWAT 22, TNSS is another very common total nasal symptoms score. There is also some other quality of life measures. We actually have teamed up with a couple of other institutions to collect the same data point. Us, the University of Washington in Seattle, and actually, now I think WashU in St. Louis is also joining, but what we're trying to do is create a big consortium and collaboration between a lot of institutions. We're all collecting the same data points in our patients and every time they visit.

Again, how do you distinguish a rhinitis patient from a sinusitis patient? You can't do it alone from these patient-report outcome measures. You have to evaluate the patient. I think from almost all my patients, I scope them. In some patients, the scope alone is not enough. We actually have an in-office CT scanner, which I think is very beneficial. I'd say about 25%, 30% of patients where you scope them and you don't see any evidence of sinusitis, you pick up on a CT scanner. I think you need some objective evidence. I think it's very easy to miss sinusitis patients. Really, I think either a scope or a scan are needed.

[Dr. Gopi Shah]
For your management, just for the typical rhinitis patient, are you starting with nasal sprays? I feel like Atrovent or Ipertropium sprays-- it's what comes to mind when you think of particularly a vasomotor chronic rhinitis patient.

[Dr. Ashley Agan]
Do you start with nasal steroid sprays and saline, the standard?

[Dr. Gopi Shah]
It depends what type of rhinitis they have. If they have pure vasomotor, then I think Atrovent is the way to go. Drainage is the biggest issue for them, I think Atrovent is the way to go. I'll typically use Atrovent at the higher dose, not only for treatment but for diagnosis. There's actually a great paper with John Craig and P. Batra out of Henry Ford and Rush that they looked at atrophic response and how does that predict success with some of these procedures. They found that an Atrovent response to rhinorrhea specifically helped predict rhinorrhea response or drainage to ClariFix.

I'm sure you can apply that to RhinAer or any of the devices. I think if it's vasomotor or the drainage is the issue, I will spray our ipratropium bromide and I'll go with the 0.06%. The issue is when they complain of post-nasal drip. You can try to use ipratropium bromide as a screening tool. My concern is a lot of patients do not get response. The question is, is it really drainage or is the ipratropium bromide not getting posterior enough to really target the posterior parasympathetic aspects of the nose? It's not as good of a screening tool for that.

We actually looked at our own patients where we did RhinAer for the primary symptom of post-nasal drip. Basically a lot of these are sent by our laryngologist who have said, "We've done everything. They have this post-nasal drip. Just try something." We looked at our outcomes and atrium response was not predictive for the post-nasal drip response to RhinAer. Again, it's used for anterior rhinorrhea, but I don't think it could be used effectively for posterior rhinorrhea.

[Dr. Ashley Agan]
Yes. You're saying that if a patient's primary complaint is post-nasal drainage, that whether or not they respond to Atrovent is not predictive of whether or not they would respond to a posterior nasal nerve ablation.

[Dr. Omar Ahmed]
Especially if they have tight anatomy where the spray is not able to get back to that location. We're doing a study where we're using a different delivery device to see if we can get further back there and see if we can potentially use that to predict post-nasal drip response.

[Dr. Gopi Shah]
Meaning that some of these post-nasal drainage patients may actually benefit from a posterior nasal nerve ablation, even if they didn't respond to Atrovent. Is that what you're saying?

[Dr. Omar Ahmed]
Yes. These are patients where they've been tried on reflux, they've seen GI. Usually, those are patients where they're sent by the laryngologist because they've been tried on some type of reflux gourmet or some type of alginate therapy. They've been tried on PPIs, they've been seeing the GI doctor. They've seen the laryngologist who was like, "I don't know, clearly not--" They don't think it's a sensory phenomenon. Then they've sent those patients to me. At that point, I tell the patients, "Hey, this is an option. I think the success rate-- there's still a good chance for success."

We looked at our patients. There was about 70% of our patients, we had a sample of 70 patients that did report an improvement. I think the primary symptom is post-nasal drip, though some of those patients can still benefit from posterior nasal nerve ablation.

[Dr. Gopi Shah]
What is your Atrovent dosing and how long do you try it for to see if there's a response?

[Dr. Omar Ahmed]
You can do a trial for two weeks, honestly, that's all you need really. I go with the higher doses because I say, "Okay, I could rule out--" It's more of a diagnostic test to rule out, "Okay, are you responding to this at all?" I'll go three times a day. Speaking of post-nasal drip, we just published something looking at all the RhinAer clinical data and looking at post-nasal drip and cough. These are in patients who also had significant rhinitis. Their TNSSs were greater than a six. TNSS is on a scale of zero to 12, anything greater than six is considered moderate to severe.

All those patients were enrolled and we looked at the outcomes and almost, I think, 90% of patients had a significant improvement in chronic cough and post-nasal drip. There is definitely an indication, I think, again, it's tough to tease out when the only symptom is post-nasal drip, but if they're in conjunction with rhinitis, it's shown to help.

[Dr. Gopi Shah]
Prior to these in-office devices to treat the posterior nasal nerve, you had mentioned at the beginning doing surgery, posterior nasal neurectomy. Can you talk a little bit about that before we move on to the office procedures?

[Dr. Omar Ahmed]
I do probably about three or four video neurectomies a year still. I do probably about one or two posterior nasal neurectomies a month. These are patients who have failed. I think in this day and age, you have to try the in-office option first because it's saving time, saving money, saving for the patient, for the hospital system. Since basically if you look at all the data, their responding rate is anywhere from 70% to 95%. Again, leaves anywhere from 5% to 30% of patients that don't get a benefit. Typically I will do these procedures if they have failed other therapies and sometimes even failed two separate treatments.

[Dr. Ashley Agan]
I was going to ask you, do you repeat the in-office procedure before you jump to those?

[Dr. Omar Ahmed]
Definitely. I've had a lot of patients, they've tried ClariFix and it failed. Then I tried RhinAer, had success, and so you don't need to do a procedure. If you've failed everything, then you have to think that we're just not-- at least in my thought process is we're not targeting the posterior nasal nerves. It's much more complicated than we initially thought. We thought all the nerves are right in front of the middle turbine attachment. You hit it there, you're good, but when you look at anatomical data, it's much more intricate. There are branches that come posterior to the middle turbinate right in front of the Eustachian tube opening.

There are branches that go even close to the floor of the nose. There's actually a recent paper that looked at parasympathetic innervation that travel along the anterior ethmoid artery. Again, I think our understanding is going to continue to evolve. I think when we are not successful, we're missing the nerve. A video neurectomy is 100% you're going to get the nerve, but again, almost all my patients have dry eyes.

There are some patients who are so desperate that are just like, "I want something done." Posterior nasal neurectomy is advantageous compared to video neurectomy because it's basically finding all the small parasympathetic branches in the posterior middle meatus, but also further posterior to that, and actually lysing each of the branches. Actually doing a lot of those has helped me understand the anatomy much better because you see all these tiny wispy parasympathetic fibers and you're like, "Oh, I usually--" At least when I first started doing this, I was like, "Oh, I usually don't treat that area with the RhinAer. Maybe I should start treating that area." Our understanding has changed.