Management of Rhinitis in Patients

with Asthma

Michael Schatz, MD, MSChief, Department of Allergy

Kaiser Permanente, San Diego, CA

• Rhinitis is a trivial illness.• All rhinitis is allergic.• All non-allergic rhinitis is

homogeneous.

Some Misconceptions About Rhinitis

Outline of Presentation

Practical classification of chronic rhinitis

Diagnostic approach in primary care Specific syndromes

Distinguishing features Treatment

Practical ClassificationPractical Classification

Allergic RhinitisAllergic Rhinitis Seasonal versus PerennialSeasonal versus Perennial FrequencyFrequency

Persistent (> 4 days/week for > 4 weeks/year)Persistent (> 4 days/week for > 4 weeks/year) Intermittent (less than above)Intermittent (less than above)

SeveritySeverity MildMild Moderate-severe (interference with sleep or Moderate-severe (interference with sleep or

daily activities or “troublesome symptoms”)daily activities or “troublesome symptoms”)

OtherOther

Practical Classification: Practical Classification: OtherOther

OtherOther Rhinitis medicamentosaRhinitis medicamentosa Septal deviationSeptal deviation Eosinophilic non-allergic rhinitisEosinophilic non-allergic rhinitis Nasal polypsNasal polyps Cholinergic rhinitisCholinergic rhinitis Vasomotor rhinitisVasomotor rhinitis GERD induced “post nasal drip”GERD induced “post nasal drip” Turbinate hypertrophyTurbinate hypertrophy Chronic sinusitisChronic sinusitis

Practical Classification: Practical Classification: Asthmatic PatientAsthmatic Patient

OtherOther Rhinitis medicamentosaRhinitis medicamentosa Septal deviationSeptal deviation Eosinophilic non-allergic rhinitisEosinophilic non-allergic rhinitis Nasal polypsNasal polyps Cholinergic rhinitisCholinergic rhinitis Vasomotor rhinitisVasomotor rhinitis GERD induced “post nasal drip”GERD induced “post nasal drip” Turbinate hypertrophyTurbinate hypertrophy Chronic sinusitisChronic sinusitis

1. History2. Physical Exam3. Tests

Chronic Rhinitis: Diagnostic Approach

Chronic Rhinitis: Diagnostic Chronic Rhinitis: Diagnostic TestsTests

Nasal smear (eosinophilic disease)Nasal smear (eosinophilic disease) Specific IgE (allergic versus non-allergic)Specific IgE (allergic versus non-allergic)

Skin testsSkin tests RAST (blood tests)RAST (blood tests)

Total IgE (AFS)Total IgE (AFS) Immunoglobulins G, A, M Immunoglobulins G, A, M

(hypogammaglobulinemia with chronic (hypogammaglobulinemia with chronic sinusitis)sinusitis)

Fungal precipitating antibodyFungal precipitating antibody Sinus radiologySinus radiology

Skin Tests versus Blood Skin Tests versus Blood TestsTests

Skin TestsSkin Tests Time-honored methodTime-honored method Results immediately availableResults immediately available More sensitive for some allergens or More sensitive for some allergens or

patientspatients Potential for systemic reactionsPotential for systemic reactions Antihistamines interfereAntihistamines interfere

Blood testsBlood tests Easier for patientEasier for patient May be more specificMay be more specific No interference by medications or potential No interference by medications or potential

for systemic reactionsfor systemic reactions

Outline of Presentation

Practical classification of chronic rhinitis

Diagnostic approach in primary care Specific syndromes

Distinguishing features Treatment

Allergic RhinitisAllergic Rhinitis Distinguishing FeaturesDistinguishing Features

Sneezing, itching, rhinorrhea prominentSneezing, itching, rhinorrhea prominent May be seasonalMay be seasonal Triggered by freshly cut grass, cleaning house, or Triggered by freshly cut grass, cleaning house, or

pet exposurepet exposure TreatmentTreatment

Indoor allergen avoidanceIndoor allergen avoidance Intermittent: Antihistamines, intranasal Intermittent: Antihistamines, intranasal

corticosteroids (INS) as neededcorticosteroids (INS) as needed Persistent: Regular INS; add antihistamines (oral Persistent: Regular INS; add antihistamines (oral

and/or intranasal) and montelukast if needed)and/or intranasal) and montelukast if needed) Consider immunotherapyConsider immunotherapy

ImmunotherapyImmunotherapy

Consider for patients with definite Consider for patients with definite allergic rhinitis not controlled by allergic rhinitis not controlled by other meansother means

Because of potentially life-Because of potentially life-threatening allergic reaction, it threatening allergic reaction, it should be carried out only by should be carried out only by specialists trained in its usespecialists trained in its use

Goal: symptom and/or medication Goal: symptom and/or medication reduction, not usually eradication or reduction, not usually eradication or cure cure

Immunotherapy 2Immunotherapy 2

Used less for rhinitis now than it Used less for rhinitis now than it used to be due to better medicationsused to be due to better medications

Less effectiveness data for mold and Less effectiveness data for mold and animal danderanimal dander

One year trialOne year trial If effective, continue for 3-5 years If effective, continue for 3-5 years

and then consider discontinuationand then consider discontinuation Sublingual immunotherapy (SLIT) Sublingual immunotherapy (SLIT)

now being studiednow being studied

Eosinophilic Non-Allergic Eosinophilic Non-Allergic RhinitisRhinitis

Distinguishing featuresDistinguishing features Prominent mucosal edemaProminent mucosal edema Nasal eosinophiliaNasal eosinophilia No relevant allergyNo relevant allergy

TreatmentTreatment Intranasal corticosteroidsIntranasal corticosteroids Oral antihistamine or antihistamine-Oral antihistamine or antihistamine-

decongestant combination if neededdecongestant combination if needed Oral prednisone for recalcitrant diseaseOral prednisone for recalcitrant disease

Nasal PolypsNasal Polyps Distinguishing FeaturesDistinguishing Features

Nasal obstructionNasal obstruction AnosmiaAnosmia Nasal polyps on examNasal polyps on exam

TreatmentTreatment Intranasal corticosteroidsIntranasal corticosteroids Course of doxycycline (20 days)Course of doxycycline (20 days) Oral corticosteroidsOral corticosteroids Treatment of complicating infectionTreatment of complicating infection Consider montelukastConsider montelukast Surgery (polyp, sinus)Surgery (polyp, sinus)

GERD Induced “Post Nasal GERD Induced “Post Nasal Drip”Drip”

Distinguishing featuresDistinguishing features Feeling of post-nasal drip or mucus in Feeling of post-nasal drip or mucus in

throat with minimal or no other nasal throat with minimal or no other nasal symptomssymptoms

May be associated with hoarseness, throat May be associated with hoarseness, throat clearing, cough, pyrosis, regurgitationclearing, cough, pyrosis, regurgitation

May be worse after eatingMay be worse after eating TreatmentTreatment

Reflux precautionsReflux precautions Protein pump inhibitorsProtein pump inhibitors

Practical Classification: Practical Classification: OtherOther OtherOther

Rhinitis medicamentosaRhinitis medicamentosa Septal deviationSeptal deviation Eosinophilic non-allergic rhinitisEosinophilic non-allergic rhinitis Nasal polypsNasal polyps Cholinergic rhinitisCholinergic rhinitis Vasomotor rhinitisVasomotor rhinitis GERD induced “post nasal drip”GERD induced “post nasal drip” Turbinate hypertrophyTurbinate hypertrophy Chronic sinusitisChronic sinusitis

Symptoms Suggestive of Symptoms Suggestive of Chronic SinusitisChronic Sinusitis

Nasal congestion Nasal congestion Pain or pressure around the Pain or pressure around the

forehead, nose, or eyesforehead, nose, or eyes Discolored nasal discharge or Discolored nasal discharge or

discolored mucus in the throatdiscolored mucus in the throat Reduced sense of smell Reduced sense of smell Symptoms for > 12 weeks by Symptoms for > 12 weeks by

definitiondefinitionTomassen P, et al. Allergy 2011; 66:556

Allergy and Chronic Allergy and Chronic SinusitisSinusitis

Conflicting data regarding increased Conflicting data regarding increased prevalence of chronic sinusitis in allergic prevalence of chronic sinusitis in allergic patientspatients

Data suggests chronic sinusitis may be Data suggests chronic sinusitis may be more severe in allergic patientsmore severe in allergic patients

Appropriate to aggressively treat allergic Appropriate to aggressively treat allergic rhinitis in patients with coexistent chronic rhinitis in patients with coexistent chronic sinusitissinusitis

Immunotherapy not convincingly shown Immunotherapy not convincingly shown to improve sinusitis in allergic patients to improve sinusitis in allergic patients

Medical Approach to Medical Approach to Chronic SinusitisChronic Sinusitis

Saline lavageSaline lavage Intranasal corticosteroidsIntranasal corticosteroids Treat acute infectionsTreat acute infections Treat coexistent allergic rhinitisTreat coexistent allergic rhinitis Rule out hypogammaglobulinemiaRule out hypogammaglobulinemia Medical treatment of hyperplastic Medical treatment of hyperplastic

eosinophilic sinusitiseosinophilic sinusitis Post operative treatment of Allergic Post operative treatment of Allergic

Fungal SinusitisFungal Sinusitis

Chronic Hyperplastic Chronic Hyperplastic Eosinophilic Sinusitis Eosinophilic Sinusitis

Eosinophilia does not indicate Eosinophilia does not indicate allergyallergy

Associated with nasal polyps, Associated with nasal polyps, asthma, aspirin sensitivityasthma, aspirin sensitivity

Poorer prognosis after surgeryPoorer prognosis after surgery Consider montelukastConsider montelukast Aspirin desensitization for patients Aspirin desensitization for patients

with aspirin sensitivitywith aspirin sensitivity

Allergic Fungal Sinusitis: Allergic Fungal Sinusitis: Diagnostic CriteriaDiagnostic Criteria

Radiologic evidence of sinusitisRadiologic evidence of sinusitis Allergic mucin in the sinusAllergic mucin in the sinus Fungal hyphae in the mucin or Fungal hyphae in the mucin or

positive sinus fungal culturepositive sinus fungal culture Absence of diabetes, Absence of diabetes,

immunodeficiency, or immunodeficiency, or immunosuppressive therapyimmunosuppressive therapy

Absence of fungal invasionAbsence of fungal invasion

Allergic Fungal Sinusitis: Allergic Fungal Sinusitis: Immunologic FindingsImmunologic Findings

Elevated total IgE level (67-74 %)Elevated total IgE level (67-74 %) May correlate with course of diseaseMay correlate with course of disease Increases ≥ 10 % provides high sensitivity Increases ≥ 10 % provides high sensitivity

for disease progression but lower specificityfor disease progression but lower specificity Atopy (76-100 %)Atopy (76-100 %) Specific IgE against fungus (58-100 % Specific IgE against fungus (58-100 %

positive skin tests)positive skin tests) Precipitating antibody against fungus (8-Precipitating antibody against fungus (8-

89 %)89 %)

Allergic Fungal Sinusitis: Allergic Fungal Sinusitis: ManagementManagement

SurgerySurgery Post-operative prednisonePost-operative prednisone

0.5 mg/kg daily for 14 days0.5 mg/kg daily for 14 days 0.5 mg/kg every other day, tapered over 0.5 mg/kg every other day, tapered over

3 months to 5 mg every other day3 months to 5 mg every other day Continue 5 mg every other day for at Continue 5 mg every other day for at

least 12 months least 12 months Intranasal steroidsIntranasal steroids ? Antifungal agents? Antifungal agents

ConclusionsConclusions

Rhinitis is NOT a trivial illnessRhinitis is NOT a trivial illness All rhinitis is NOT allergicAll rhinitis is NOT allergic All non-allergic rhinitis is NOT All non-allergic rhinitis is NOT

homogeneoushomogeneous Appropriate diagnosis and management Appropriate diagnosis and management

(medical and surgical) can substantially (medical and surgical) can substantially improve the quality of life of patients improve the quality of life of patients with chronic rhinitis or sinusitis and with chronic rhinitis or sinusitis and improve asthma control as wellimprove asthma control as well