Primary care

Rhinitis

Samantha Walker, head of research ^a, Aziz Sheikh, NHS R&D national primary care training fellow ^b. 

^a National Respiratory Training Centre, 10 Church Street, Warwick CV34 4AB, ^b Department of General Practice and Primary Health Care, Imperial College School of Medicine, London W6 8RP

Correspondence to: S Walker s.walker{at}nrtc.org.uk

A woman presents in early summer with a history of progressively worsening symptoms of a constant runny nose and frequent sneezing bouts. She was prescribed antihistamine tablets many years ago, which were helpful but made her drowsy. Lately, she has used "over the counter" decongestant nasal sprays, which, although initially helpful, now do not relieve symptoms. Tired and upset, she wants to know what else might help.

	What issues you should cover

Top What issues you should... What you should do

• Is this really rhinitis? Rhinitis is defined as two or more of the following symptoms, which must last for an hour or more on most days: nasal blockage, sneezing, rhinorrhoea, and nasal itch.
• Does the problem disrupt work and sleep? Does it interfere with relationships or cause social embarrassment?
• What is the underlying cause? Does the patient have a personal or family history of allergy? Allergy is by far the commonest cause of chronic symptoms. If it is seasonal (hay fever), pollens and fungal spores are the most likely triggers; perennial symptoms are typically due to house dust mite or pet allergy. Other causes of symptoms of rhinitis include infection (viral or bacterial), structural problems of the nose, and less commonly endocrine problems (hypothyroidism) and iatrogenic disease (for example, the combined contraceptive pill).
• Ask about associated symptoms. Springtime symptomsindicating tree pollen allergymay be associated with oral allergy syndrome (swelling or tingling of the lips after eating uncooked stoned fruits); symptoms during the peak hay fever seasonconjunctival inflammation and cough, wheezing, and chest tightnessare more common features of hay fever. Nasal polyposis, asthma, and hypersensitivity to aspirin often coexist. Sinusitis and otitis media with effusion are recognised complications of rhinitis.
• Be alert to "alarm symptoms" (unilateral nasal blockage and bloodstained nasal discharge), which may suggest nasopharyngeal carcinoma.
• Ask about previous drug use for symptoms of rhinoconjunctivitis and about response to treatment. Was compliance poor, and, if so, was this related to side effects of treatment? Could symptoms be due to side effects from other drugs? Prolonged use of decongestants causes rebound worsening of symptoms.

	What you should do

Top What issues you should... What you should do

• Patients with alarm symptoms warrant urgent referral to a specialist.
• Treat the underlying cause if possible. Viral and bacterial infections are usually self limiting, although the latter may require systemic antibiotics. Seasonal wheezing may indicate asthma. Structural nasal problems will usually require a surgeon's opinion.
• For chronic allergic rhinitis prescribe a daily nasal corticosteroid spray (not drops as they increase systemic absorption). Advise patients with severe seasonal allergic rhinitis (hay fever) to begin treatment a few weeks before the anticipated start of symptoms and continue treatment throughout the pollen season.
• If symptoms remain uncontrolled and the patient also has conjunctival symptoms, consider adding a non-sedating systemic antihistamine.
• Consider other options if combined treatment fails: allergen avoidance measures, topical mast cell stabilisers, topical antihistamine nasal sprays, and oral steroidsfor example, 20 mg prednisolone daily for five daysalthough evidence supporting these interventions is limited. Depot triamcinolone is no longer recommended in Britain for treating hay fever. Consider immunotherapy at a specialist centre for those with severe hay fever not responding to medical treatment.

	Footnotes

The series is edited by Ann McPherson and Deborah Waller

   Competing interests: AS has received reimbursement from GlaxoWellcome, Allan & Hanbury's, and 3M for attending symposiums, and honorariums for attending meetings organised by Schwarz Pharmaceuticals. SW has received financial support from the drug company ALK-Abelló, Denmark, and reimbursement from ALK-Abelló UK, Schering-Plough, Schwarz Pharmaceuticals, and Allan & Hanbury's for lectures and meetings.

An algorithm for managing rhinitis is on bmj.com