rhinitis

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

If you have persistent nasal congestion, sneezing, or watery nasal discharge that lasts more than 2-3 weeks, you should consult an allergist or otolaryngologist and immediately undergo a series of diagnostic and therapeutic measures described below.

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Epidemiology

Epidemiological studies show that 5-10% of the population may periodically experience symptoms of a runny nose, especially during the cold season, but only a tenth of this group of people suffers from these phenomena constantly.

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Causes of a runny nose

The question of the etiological factor of rhinitis remains controversial in many respects: the mucous membrane is a biotope where a large amount of microflora persists; the effect of respiratory viruses can be of both exogenous and endogenous origin (persistence of rhinovirus, adenovirus, and various allergens in the epithelial cells of the nasal mucosa has been proven). The mechanisms that determine the persistence of microbial flora and viruses are quite complex. The leading factors activating their activity can be considered to be a weakening of mucociliary clearance, a decrease in non-specific humoral factors (secretory and cellular peptides, leukocyte interferon, etc.), a violation of non-specific cellular protection in the form of polymorphonuclear and monocytic phagocytosis, a violation of specific factors of general immunity, etc.

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How does a runny nose develop?

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

• Vasotonic stage (characterized by constant changes in vascular tone). Clinically manifested by intermittent nasal congestion, requires periodic use of decongestants.
• Stage of vasodilation. Nasal congestion is constant due to the dilation of the mucosal vessels, the patient often resorts to the use of decongestants, their effect becomes increasingly short-lived.
• Chronic edema stage. The nasal mucosa changes from pale marble to bluish, decongestants are no longer very effective, and nasal congestion is almost constant.
• Hyperplasia stage. The nasal mucosa grows, polyps are formed, paranasal sinuses are often involved in the process, secondary otitis develops, and a secondary infection almost always joins in.

Classification

The most complete classification is the classification by T.I. Garashchenko (1998). According to the nature of the course, acute and chronic rhinitis are distinguished. In the acute form, groups of infectious and non-infectious diseases are distinguished.

Infectious rhinitis

• Bacterial simple rhinitis.
• Bacterial rhinitis: specific and non-specific (gonorrheal, meningococcal, listeriosis, diphtheria, scarlet fever, yersiniosis, etc.).
• Viral rhinitis.
• Respiratory viral rhinitis.
• Epidemiological rhinitis (measles, chickenpox, rubella, mononucleosis, ECHO-coxsackie).
• Herpes rhinitis (herpes simplex virus types 1, 2, 6, CMV).
• HIV rhinitis.
• Fungal rhinitis.
• Rhinitis caused by protozoa (chlamydia, mycoplasma).

Acute non-infectious rhinitis.

• Traumatic.
• Toxic (including from passive smoking).
• Radiation.
• Medicinal.
• Neurogenic rhinitis (rhino neurosis).
• Allergic rhinitis.

Groups of acute forms according to the nature of the pathological process:

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

The course can be acute, subacute and protracted.

A distinction is made between infectious and non-infectious chronic rhinitis.

Infectious chronic rhinitis

• Specific bacterial rhinitis (tuberculous, syphilitic, leprosy, gonorrheal, ozena, etc.).
• Non-specific 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.
• Rhinosopathy
• Hypertensive-hypotensive rhinopathy.
• Hormonal rhinopathy.
• Occupational rhinitis,
• Toxic (ecopathology).
• Chronic rhinitis in systemic diseases (acetylsalicylic acid intolerance, Kartagener 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 (edematous-infiltrative, serous, exudative, eosinophilic non-allergic);
• purulent;
• productive;
• atrophic.

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

• superficial polypous;
• superficial papillary;
• cavernous; fibrous;
• bone hyperplastic.

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

• non-specific (constitutional, traumatic, hormonal, medicinal, iatrogenic).
• specific (atrophic rhinitis, ozena, Wegener's granulomatosis, outcome of specific tuberculous, syphilitic and leprosy granulomas).

Flow:

• latent;
• recurring; o continuously recurring.

Periods of acute and chronic form:

• spicy;
• exacerbation:
• convalescence; o remission;
• recovery.

The predisposing factor is most often hypothermia.

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How is rhinitis recognized?

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

Determination of immediate allergy mediators in nasal secretion, both after specific provocation and during the pollen season, may be of auxiliary importance for assessing the results of provocative tests. Significant difficulties arise in the diagnosis and differential diagnosis of year-round allergic rhinitis, when there is polyvalent sensitization to household and pollen allergens. In such combined pathology, the results of diagnostic tests and determination of allergen-specific IgE in the blood serum are usually of decisive importance in establishing the diagnosis.

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

How does rhinitis manifest itself?

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

Anamnesis

Contact with possible causative allergens

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

To conclude, it is necessary, first of all, to identify the seasonality of the disease, the occurrence or intensification of symptoms of a runny nose with direct contact with a particular chemical substance or allergen (contact with pollen, a pet, exacerbation when cleaning an apartment, connection with some professional factor, etc.), the presence or absence of an elimination effect, the influence of weather factors, food products, change of climate zone.

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Working and living conditions

Profession and work environment are known to play a decisive role in the development of rhinitis. Attention should be paid to the presence of possible industrial allergens, irritants, exposure to extreme temperatures, large amounts of dust, etc. Symptoms of rhinitis can greatly complicate professional activity (pilots, teachers, opera singers, etc.). Patients often have many carpets and books in their apartments, which contributes to constant close contact with allergens of house and library dust. The presence of pets is often a leading factor in the development of this disease.

Physical examination

During an external examination, the so-called classic symptoms attract attention - "allergic salute", "allergic glasses", puffiness under the eyes, a constantly open mouth, "sniffing" of the nose, redness of the skin around the wings of the nose.

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

It is necessary to visually assess the effect of local vasoconstrictor drugs.

Laboratory research

Skin testing and determination of total and allergen-specific IgE concentrations

Until now, none of the existing laboratory diagnostic methods can compare in their diagnostic importance with the method of skin diagnostic tests with water-salt extracts of allergens. However, this method has a number of limitations that complicate the correct interpretation of the results (urticarial dermographism, taking antihistamines and sedatives, the presence of a particular skin disease).

Determining the concentration of allergen-specific IgE in the blood serum is important, especially when skin testing is not possible. This method, like other methods of laboratory diagnostics of allergies, can only be a supplement and confirm the significance of a particular allergen. It should be specifically emphasized that it is impossible to make a diagnosis (and even more so to prescribe treatment) solely based on the concentration of allergen-specific IgE.

To conduct differential diagnostics of different types of rhinitis, markers of ECP (eosinophilic cationic protein) and the activity of tryptase released by mast cells after nasal provocation with histamine are studied.

Instrumental research

Provocative nasal tests (PNT) are methods that allow us to evaluate 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 causative allergens and mediators (histamine, acetylcholine and its analogues) that play a role in the development of allergic rhinitis. It is necessary to clearly define the place of PNT in the diagnosis of allergic rhinitis.

When to see a doctor if you have rhinitis?

Absolute indications for consultation with an otolaryngologist:

• complaint of distending pain in the area of the PPN;
• purulent discharge from the nose;
• throbbing headaches;
• unilateral symptoms of rhinitis;
• hearing loss, pain in the middle ear area.

Absolute indications for consultation with an allergist:

• prolonged runny nose with no apparent cause;
• seasonal nature of the runny nose;
• the connection between the occurrence of a runny nose and contact with a particular allergen;
• aggravated allergy history.