Rhinitis

Rhinitis is a prolonged inflammatory process in the nasal mucosa that occurs as a result of exposure to microbial agents, environmental factors (dust, gases, moist air), various allergens.

With constant nasal congestion, sneezing, watery discharge of their nose, continuing for more than 2-3 weeks, you should consult an allergist and an otolaryngologist and urgently need to perform a number of the following diagnostic and treatment measures.

[1], [2], [3], [4], [5], [6]

Epidemiology

Data from epidemiological studies show that 5-10% of the population can periodically experience symptoms of a common cold, especially during the cold season, but only a tenth of this group of people suffers from these phenomena all the time.

[7], [8], [9], [10], [11]

Causes of a cold

The question of the etiologic factor of the common cold remains largely controversial: the mucous membrane of the biotope, where a large number of microflora persist; the impact of respiratory viruses can be either exogenous or endogenous (persistence in epithelial cells of the nasal mucosa of the rhinovirus, adenovirus, various allergens has been proven). The mechanisms that determine the persistence of microbial flora and viruses are quite complex. Leading factors in the activation of their activity include mucociliary clearance, reduction of nonspecific humoral factors (secretory and cellular peptides, leukocyte interferon, etc.), violation of nonspecific cell defense in the form of polymorphonuclear and monocytic phagocytosis, violation of specific factors of general immunity, etc.

[12], [13], [14], [15], [16]

How does the cold develop?

As a result of the effect of the etiological factor, an acute inflammatory process develops in the nasal mucosa, while such protective mechanisms as sneezing and secretion of mucous secretions do not lead to elimination of the allergen.

• Vasotonic stage (characterized by constant changes in vascular tone). Clinically manifested by inconstant nasal congestion, requires periodic use of decongestants.
• Stage vozodilatatsiya. Nasal congestion is constant due to the expansion of the vessels of the mucosa, the patient often resorts to the use of decongestants, their action becomes more and more short-lived.
• Stage of chronic edema. The mucous nasal from pale-marble becomes cyanotic, decongestants are already ineffective, the stuffiness of the nose is almost constant.
• Stage of hyperplasia. There is an overgrowth of the nasal mucosa, polyps are formed, often the process involves the accessory sinuses of the nose, secondary otitis develops, almost always secondary infection is attached.

Classification

The most complete classification is the classification according to T.I. Garashchenko (1998). The nature of the flow distinguish between acute and chronic rhinitis. In acute form, groups of infectious and non-infectious diseases are isolated.

Infectious rhinitis

• Bacterial simple rhinitis.
• Bacterial rhinitis: specific and nonspecific (gonorrhea, meningococcal, listeriosis, diphtheria, scarlet fever, yersiniosis, etc.).
• Viral rhinitis.
• Respiratory-viral rhinitis.
• Epidemiological rhinitis (measles, chickenpox, rubella, mononucleosis, ECHO-coxsack).
• Rhinitis of the herpetic group (herpes simplex virus of 1-, 2-, 6-th types, CMV).
• HIV - rhinitis.
• Fungal rhinitis.
• Rhinitis caused by protozoa (chlamydia, mycoplasma).

Acute noninfectious rhinitis.

• Trammatic.
• Toxic (including from passive smoking).
• Radiation.
• Medicated.
• Neurogenic rhinitis (rhinoneurosis).
• Allergic rhinitis.

Groups of acute forms by the nature of the pathological process:

• catarrhal (serous, exudative, hemorrhagic, edematous-infiltrative);
• purulent;
• purulent-necrotic.

The course can be acute, subacute and protracted.

There are infectious and non-infectious chronic rhinitis.

Infectious chronic rhinitis

• Specific bacterial rhinitis (tubercular, syphilitic, leprosy, gonorrhea, ozona, etc.).
• Nonspecific bacterial rhinitis (caused by pathogenic and opportunistic microflora).
• Viral rhinitis (herpetic, CMV, HIV, etc.).
• Fungal.
• Rhinitis caused by protozoa (chlamydia, mycoplasma, etc.).

Non-infectious chronic rhinitis

• Rhinoneurosis.
• Rinovazopathy
• Hypertensive-hypotensive rhinopathy.
• Hormonal rhinopathy.
• Professional rhinitis,
• Toxic (ecopathology).
• Chronic rhinitis in systemic diseases (intolerance to acetylsalicylic acid, Kartagener's syndrome, cystic fibrosis, Wegener's granulomatosis, lupus erythematosus, etc.).
• Allergic rhinitis (seasonal and year-round).

Chronic rhinitis by the nature of the course of the pathological inflammatory process:

• catarrhal (edema-infiltrative, serous, exudative, eosinophilic non-allergic);
• purulent;
• productive;
• atrophic.

In productive chronic inflammation (actually hypertrophic rhinitis), hypertrophy (diffuse, limited) can be distinguished with clarification:

• superficial-polypous;
• superficial-papillary (papillary);
• cavernous; fibrous;
• bone-hyperplastic.

Both infectious and non-infectious chronic rhinitis may occur with a tendency to atrophy, therefore the atrophic form of pathological inflammation can be:

• nonspecific (constitutional, traumatic, hormonal, drug, iatrogenic).
• specific (atrophic rhinitis, ozena, Wegener's granulomatosis, the outcome of specific tubercular, syphilitic and leprosy granules).

Flow:

• latent;
• recurrent; o continuously recurrent.

Periods of acute and chronic form:

• acute;
• exacerbation:
• convalescence; about remission;
• recovery.

The predisposing factor is more often hypothermia.

[17], [18], [19],

How is rhinitis recognized?

Diagnosis of rhinitis in most cases is established already at the stage of collection of anamnesis and rhinoscopic examination. The data of cytological examination and the provocative nasal test can be of decisive importance. Moreover, the diagnostic value of this test increases significantly when using the objective method of evaluating the results of rhinometry.

The determination in the nasal secret of mediators of immediate allergy, both after a specific provocation, and during the dusting season, may have an auxiliary value for evaluating the results of provocative samples. Significant difficulties arise in the diagnosis and differential diagnosis of year-round allergic rhinitis, when there is polyvalent sensitization to household and pollen allergens. With such a combined pathology, the results of diagnostic tests and the determination of allergen-specific IgE in the blood serum are usually crucial in establishing the diagnosis.

The greatest difficulty is the differential diagnosis of year-round rhinitis of a non-allergic nature. Allergic rhinitis must be differentiated from infectious rhinitis and, most difficult, from vasomotor or non-allergic rhinitis, which, like allergic rhinitis, can be year-round in nature, but it is not based on allergic inflammation. Frequent use of symptomatic agents (vasoconstrictive drops) leads to thickening, hypertrophy of the nasal mucosa, resulting in a permanent nasal congestion that does not respond to any medications. Differential diagnosis is complicated by the fact that approximately 50-80% of patients with an allergic rhinitis and especially year-round its form have vasomotor phenomena.

How is rhinitis manifested?

• paroxysmal sneezing;
• permanent nasal congestion;
• rhinorrhea;
• itching in the nasal cavity;
• anosmia;
• change voice timbre;
• feeling of bursting in the area of the paranasal sinuses:
• a decrease in the quality of life.

Anamnesis

Contact with possible cause-significant allergens

Often, in order to correctly diagnose and prescribe the treatment, it is sufficient to establish a causative factor causing a runny nose during a conversation with the patient.

For the total, it is first of all necessary to identify the seasonality of the disease, the onset or intensification of the symptoms of the common cold with direct contact with a particular chemical substance or allergen (contact with pollen, domestic animals, exacerbation of cleaning the apartment, communication with any professional factor, etc.), the presence or absence of the elimination effect, the influence of weather factors, food products, climate change.

[20], [21], [22],

Working and living conditions

Profession, as well as the working environment, as you know, can play a decisive role in the development of the common cold. Attention should be paid to the presence of possible production allergens, irritants, exposure to extreme temperatures, large amounts of dust, etc. Symptoms of the common cold can greatly impede professional activity (pilots, teachers, opera singers, etc.). In the apartment patients often have a lot of carpets, books, which contributes to a constant close contact with allergens of home and library dust. The presence of pets often serves as a leading factor in the development of this disease.

Physical examination

With the external examination, attention is drawn to the so-called classic symptoms - "allergic salute", "allergic eyewear", swelling under the eyes, constantly ajar, "sniffing" the nose, redness around the wings of the nose.

With rhinoscopy, attention should be paid to the condition of the nasal septum, the color of the mucous membrane (pale pink, bright red, Voyachek spots), the nature of the discharge, the presence of polyps.

It is necessary to visually evaluate the effect of local vasoconstrictive drugs.

Laboratory research

Skin testing and determination of the concentration of the total and allergen specific IgE

Until now, according to its diagnostic importance, none of the existing methods of laboratory diagnosis can be compared with the method of setting skin diagnostic tests with water-salt extracts of allergens. However, this method has a number of limitations that make it difficult to correctly interpret the results (urticarial dermographism, the administration of antihistamines and sedatives, the presence of a skin disease).

Determination of the concentration of allergen-specific IgE in serum of the croup is important, especially when it is impossible to conduct skin testing. This method, like other methods of laboratory diagnosis of allergy, can only be complementary and confirming the significance of an allergen. It should be specially emphasized that it is impossible to diagnose (and even less prescribe treatment) solely on the basis of their concentration of the allergen specific IgE.

For the differential diagnosis of various types of rhinitis, ECP markers (eosinophilic cationic protein) and tryptase activity released by mast cells are examined after a nasal provocation with histamine.

Instrumental research

Provocative nasal tests (PNT) refer to methods that allow you to assess the allergic inflammatory process in the nasal mucosa and characterize the functional state of the shock organ. The most important in this group of tests are provocative nasal tests with cause-significant allergenemia mediators (histamine, acetylcholine and its analogues) that play the role and development of an allergic rhinitis. It is necessary to clearly define the place of PNT in the diagnosis of an allergic rhinitis.

When to see a doctor if you have rhinitis?

Unconditional indications for consultation of an otorhinolaryngologist:

• Complaint with raspiashchie pain in the area of PPN;
• purulent discharge from the nose;
• head throbbing pains;
• unilateral symptoms of the common cold;
• hearing loss, pain from the middle ear area.

Unconditional indications for allergist consultation:

• a prolonged runny nose for no apparent reason;
• seasonal character of the common cold;
• connection of the onset of a cold with contact with a particular allergen;
• weighed allergic anamnesis.