Rhinitis is a term implying inflammation of the nasal mucosa. There is generalised swelling of the mucosa, increased volume and viscosity of nasal secretions and impairment of normal ciliary function. Clinically, rhinitis is defined by the onset of two or more of the following symptoms - nasal discharge, sneezing, nasal itching and congestion.
Rhinitis is the most common cause of nasal obstruction but other less common conditions should be borne in mind when considering the diagnosis.
This is an overarching record, summarising the conditions one should consider when confronted with a patient who has nasal obstruction. See also separate Allergic Rhinitis, Non-allergic Rhinitis, Nasal Polyps, Nasal Injury and Nasal Foreign Bodies and Sinusitis articles.
Rhinitis is a common condition and is likely to become more common with the ageing of the population. The prevalence varies according to the cause and it affects around 13% of the adult population. Some experts even quote the prevalence of chronic rhinitis in the general population to be as high as 40%.
The causes of nasal obstruction are:
- Infective rhinitis: acute rhinitis is often infective in origin:
- Viral rhinitis is one of the most frequent causes of nasal obstruction. Rhinoviruses, respiratory syncytial virus, parainfluenza and influenza viruses and adenoviruses are among the viruses most commonly identified.
- Bacterial rhinitis may begin spontaneously or as a sequel to viral rhinitis. It causes a mucopurulent nasal discharge. Bacteria most often implicated are Streptococcus pneumoniae, group A beta-haemolytic streptococci and Haemophilus influenzae.
- Fungal rhinitis is most often found (but rarely) in immunocompromised patients. Candida spp., Aspergillus spp., Cryptococcus spp. and fungi of the class Zygomycetes (also previously called Phycomycetes) are most often implicated.
- Infection by Nocardia spp. can also cause rhinitis in immunocompromised patients.
- Allergic rhinitis.
- Non-allergic rhinitis.
- Foreign bodies in the nose:
- These are most commonly seen in patients aged 6 months to 5 years.
- There is persistent unilateral nasal obstruction and discharge, which may be bloody and accompanied by an offensive odour.
- Serous otitis media on the same side often accompanies the nasal obstruction when the foreign material has been present for any length of time.
- Nasal radiography may be required.
- Nasal septum abnormalities:
- Nasal septal deviation (congenital or acquired), haematoma (trauma) or perforation (eg, trauma, nose picking, cocaine abuse).
- Occlusion of the nasal valve:
- The valve is at the narrowest part of the nose and is the apex where the septum and the upper lateral cartilage meet.
- Causes of occlusion include septal deviation, ageing and nasal valve scarring after nasal surgery.
- Turbinate hypertrophy:
- This may be idiopathic or caused by long-standing allergic rhinitis (seasonal and perennial), inflammation (eg, rhinitis caused by the common cold) and long-term use of over-the-counter (OTC) vasoconstrictive nasal sprays.
- The enlarged turbinates lose their ability to expand and shrink and therefore result in nasal obstruction.
- Patients with this condition often present with complaints of continuous nasal obstruction unrelieved by nose drops, antihistamines, or allergic desensitisation.
- Examination with a nasal speculum reveals enlargement of the inferior turbinate.
- Treatment consists of alleviating symptoms with a steroid nasal spray and antihistamines for allergies, discontinuing habitual use of OTC vasoconstrictive nasal sprays, and surgical procedures to shrink the turbinates.
- Adenoid hypertrophy:
- This is more common in children than it is in adults.
- It occurs when excessive adenoid tissue blocks the nasopharynx and results in snoring, nasal obstruction, postnasal drainage and infections.
- In children, the condition can be expected to regress over time.
- Adenoidectomy may be required for significant functional impairment (hearing and speech).
- Nasal polyps.
- Neoplasm - for example, inverted papilloma, sarcoma, lymphoma, juvenile nasopharyngeal angiofibroma and squamous cell carcinoma:
- The possibility is suggested by unilateral epistaxis.
- Inverted papilloma, although histologically benign, is locally invasive and may produce bone erosion.
- Other neoplastic lesions that produce nasal obstruction include sarcoma, lymphoma and juvenile nasopharyngeal angiofibroma. Primary malignant tumours in the nasal cavity, which are relatively rare, are unilateral and are generally squamous cell carcinoma.
- Choanal atresia - see separate Congenital Nasal Problems article.
- Symptoms vary according to the aetiology but can include itching, sneezing, nasal obstruction, purulent, bloody or clear discharge and impairment of smell.
- Chronic stuffy nose can impair normal breathing, force patients to breathe through the mouth, or cause a persistent cough, headaches and a feeling of fullness in the face.
- Simple tasks such as eating, drinking and speaking may become difficult and uncomfortable.
- Newborn infants must breathe through the nose and so nasal congestion may cause severe difficulties, especially when feeding.
- Prolonged nasal congestion in older children can interfere with hearing and speech development.
- Significant congestion may also cause snoring and episodes of sleep apnoea.
Investigation and management
Investigations are not usually required but may include:
- Allergy tests.
- X-rays: adenoid, sinus.
- CT scan.
- Nasal manometry (a method of measuring nasal airflow during respiration) may be helpful in some patients).
Management is dealt with in the separate, individual articles.
Dr Hayley Willacy draws your attention to the updated guideline from the BSACI on the diagnosis and management of allergic and non-allergic rhinitis. The updated version of the guideline takes into account new evidence in the understanding of how rhinitis may be controlled and emphasises that:
- Rhinitis is diagnosed by history and examination, and supported by specific allergy tests.
- Rhinitis is a risk factor for the development of asthma.
- Topical nasal corticosteroids are the treatment of choice for moderate-to-severe allergic rhinitis and that the addition of intranasal antihistamine may further improve control.
- Immunotherapy is highly effective when a specific allergen is the responsible driver for the symptoms.
Further reading and references
Poddighe D, Gelardi M, Licari A, et al; Non-allergic rhinitis in children: Epidemiological aspects, pathological features, diagnostic methodology and clinical management. World J Methodol. 2016 Dec 266(4):200-213. doi: 10.5662/wjm.v6.i4.200. eCollection 2016 Dec 26.
Jaksha AF, Weitzel EK, Laury AM; Recent advances in the surgical management of rhinosinusitis. F1000Res. 2016 Sep 265. pii: F1000 Faculty Rev-2377. eCollection 2016.
Wandalsen GF, Mendes AI, Matsumoto F, et al; Acoustic Rhinometry in Nasal Provocation Tests in Children and Adolescents. J Investig Allergol Clin Immunol. 201626(3):156-60. doi: 10.18176/jiaci.0036.
BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis; British Society for Allergy and Clinical Immunology (July 2017)