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BackTable / ENT / Article
Navigating Chronic Rhinitis: Patient Assessment & Classification
Taylor Spurgeon-Hess • May 24, 2023 • 97 hits
Chronic rhinitis, characterized by a persistently runny or congested nose, presents a significant burden to a large number of individuals. A crucial step in managing this condition is an accurate patient assessment and classification. Dr. Stan McClurg sheds light on the changing landscape of patient presentations, notably the increasing trend of individuals directly seeking assistance for chronic rhinitis or post-nasal drip. A common treatment, ipratropium bromide, not only offers relief but also predicts a patient's response to innovative in-office procedures such as RhinAer. Further, allergy testing plays a pivotal role in guiding treatment decisions, with RhinAer proving beneficial for patients with varying rhinitis diagnoses. The discussion also explores the complexities in accurately diagnosing chronic rhinitis and underscores strategic management methods that aim to improve patients' quality of life.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Chronic rhinitis presents with consistent runny nose symptoms for more than four weeks in diverse patients and can vary in cause, with allergic rhinitis, non-allergic rhinitis, and a mix of both contributing.
• Ipratropium bromide is a common treatment that also provides predictive value for the patient's response to in-office procedures like RhinAer.
• Procedures like RhinAer can be beneficial for both allergic and non-allergic rhinitis patients.
• The role of allergy testing, especially skin testing, can significantly influence treatment decisions in patients with chronic rhinitis.
• Patients with negative allergy tests but seasonal symptom variations are often treated like those with allergic rhinitis and can be excellent candidates for in-office procedures.
• The diagnosis of chronic rhinitis can be challenging and may require tools like rigid nasal endoscopy and CT scans, and management strategies like reflux treatment trials and ipratropium bromide challenges.
• Treatment approaches aim to improve the patient's quality of life, even if they don't result in complete symptom resolution.
Table of Contents
(1) Chronic Rhinitis Presentation and the “Runny Nose” Patient
(2) The Role of Allergy Testing in Chronic Rhinitis
(3) Diagnosing and Managing Chronic Rhinitis
Chronic Rhinitis Presentation and the “Runny Nose” Patient
Chronic rhinitis, marked by a constant runny nose for more than four weeks, affects a diverse patient population and can be a significant burden. In Dr. Stan McClurg's practice, he's noticed an evolution of patient presentations, from those with persistent rhinitis symptoms after other issues like sinus infections and allergies have been resolved, to patients directly seeking help for chronic rhinitis or post-nasal drip. Treatment can vary, with ipratropium bromide being a common intervention that also helps predict a patient's response to in-office procedures like RhinAer.
Chronic rhinitis can stem from various causes, with around 43% attributable to allergic rhinitis, 23% to non-allergic rhinitis, and the rest being a mix. Importantly, a procedure like RhinAer can be beneficial for both allergic and non-allergic rhinitis patients, suggesting that an initial workup to identify the type of rhinitis can optimize treatment. Additionally, while around half the patients also report nasal obstruction, the others present solely with a runny nose, a symptom that may be mistakenly normalized in certain social circles. Lastly, patients with vasomotor rhinitis, triggered by specific situations like eating or exercising, are also considered for treatment, depending on the severity of their symptoms.
[Ashley Agan MD]
Well, awesome. You're going to talk to us today. We're going to focus the conversation on chronic rhinitis. Just to kick things off, maybe we can just talk about what this looks like when these patients are coming to your practice and what symptoms there are, and what questions you're asking, that sort of thing.
[Stan McClurg MD]
I've actually found that the type of patients that are presenting with this has shifted. Initially, it was patients that presented after everything else had been fixed, like a patient with chronic sinus infection or allergies or something else would fix all the other issues, and then they still have this pesky runny nose or postnasal drip. Then we'd just throw ipratropium bromide at it and be done with it. Then more recently, I've actually been getting patients sent directly to me for chronic rhinitis or post-nasal drip.
...
[Stan McClurg MD]
Yes. It actually works pretty well. Interestingly, and I'll probably talk about this a little later, but I actually use that as a criteria to see if they'll benefit from an in-office procedure such as RhinAer. If they respond to those nasal sprays, I find that they have a much higher likelihood of responding to the procedures.
[Gopi Shah MD]
These are patients that have a runny nose, but that maybe do have allergies or don't have allergies. How do you think of it as you're categorizing patients?
[Stan McClurg MD]
Yes. Actually, the definition of chronic rhinitis is constant runny nose for greater than four weeks. It can be from multiple different sources. One study showed that of the patients that have chronic rhinitis, about 43% have allergic rhinitis, and then non-allergic is about 23%, and there's a mixed varietal in there of about 34%. Initially, as I was working with these patients, I wasn't really thinking of allergic rhinitis as a potential patient that could be fixed with a procedure like this.
[Gopi Shah MD]
Do all the people with chronic rhinitis-- not all the people, what percent also just have a clogged nose too? Do those go hand in hand or you've already helped them open their-- it's not a blockage, but it's just their runny?
[Stan McClurg MD]
I would say probably about half and half, probably about 50% of patients will present and say, "I have a runny nose, but I also have nasal obstruction." Then there's these other patients, about half of them that say, "I only have runny nose, I can breathe fine."
[Ashley Agan MD]
You have your patients who have a vasomotor rhinitis picture where it's like they have runny nose when they eat or something.
[Stan McClurg MD]
Yes, so vasomotor rhinitis I think is a different animal. I usually give patients the ipratropium bromide to try out. It really depends on how significant their problems are.
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The Role of Allergy Testing in Chronic Rhinitis
The approach to allergy testing in patients with chronic rhinitis can significantly influence treatment decisions. Dr. Stan McClurg leans toward skin testing due to its higher sensitivity and the ability to identify specific allergens. However, in-vitro testing is a suitable alternative for patients who can't undergo skin testing. A notable challenge arises with patients who exhibit negative allergy test results but experience seasonal variations in their symptoms. Despite a formal diagnosis of non-allergic rhinitis, these patients are often managed similarly to those with allergic rhinitis, with treatments like intranasal steroids and Azelastine. It's important to note that such patients, unable to pursue interventions like allergy shots or sublingual immunotherapy, could be excellent candidates for in-office procedures. Recent studies suggest these patients derive similar benefits from procedures like RhinAer as those with allergic rhinitis or chronic runny nose.
[Ashley Agan MD]
Yes, that makes sense. Before choosing the medical therapies, when you're doing your allergy testing, do you have a preference on whether it's skin testing or in-vitro testing?
[Stan McClurg MD]
I usually prefer skin testing. I think it's more sensitive, and you can find a little bit more specifics on what types of allergens the patient have. Then you can follow it up with intradermal testing in that scenario as well. For some people that potentially can't do skin testing, then I think that in-vitro testing is fine.
...
[Ashley Agan MD]
What do you think about patients who have negative allergy testing, but they come to you and have seasonal variations and their runny nose?
[Stan McClurg MD]
I treat them just like they have allergic rhinitis. If it's seasonal, there's something out there that they just weren't tested for, or they had a negative test at that time, but I treat them with the same intranasal steroids and possibly Azelastine if they need that. It's a difficult thing to say. "Yes, you've been diagnosed with non-allergic rhinitis, but you do have an allergy out there, so we're going to treat you like if you have allergies."
...
[Stan McClurg MD]
Potentially, those patients would actually be pretty good candidates for an in-office procedure, because they don't have the option to get allergy shots or sublingual immunotherapy. Some of the more recent studies have shown that patients with allergic rhinitis have a similar benefit to patients with just chronic rhinitis, runny nose, to these procedures. Those are actually probably people you should be talking to about potentially doing a procedure like this.
Diagnosing and Managing Chronic Rhinitis
When diagnosing chronic rhinitis, clinicians often face challenges distinguishing it from other conditions, such as chronic rhinosinusitis (CRS), according to Dr. Gopi Shah and Dr. Stan McClurg. In such situations, a rigid nasal endoscopy can be instrumental in visualizing any purulence, polyps, or other indicative signs. Patients with chronic rhinitis tend to report a constant, clear runny nose with no fluctuations or accompanying symptoms like facial pressure or pain. Asking patients about the color of their postnasal drip can provide valuable insights, with clear mucus suggesting rhinitis over sinus infections. A CT scan can also rule out chronic mucosal inflammation. In the case of persistent postnasal drainage, a multipronged approach involving a reflux treatment trial, an ipratropium bromide challenge, and potential referral to laryngology might be necessary. Ipratropium bromide, an anticholinergic nasal spray, can simulate the effect of nerve ablation procedures and help predict patient response to treatments like RhinAer. The ultimate goal is to improve the patient's quality of life, even if the treatment doesn't result in complete symptom resolution.
[Gopi Shah MD]
Okay. I was just going to say one last question, in terms of that initial patient coming into your clinic, sometimes I feel like the chronic rhinitis diagnosis can be difficult to make. Do you have ways where you clinically say, "No, this is just rhinitis, this isn't necessarily something else going on,"?
[Stan McClurg MD]
Postnasal drip is a tough one, but I think the scope is key. When you do the rigid nasal endoscopy, you can see pretty much everywhere up there. You're looking for any purulence, polyps, or anything like that. Quite honestly, most patients that have chronic rhinitis only, they'll tell you that they don't get sinus infections. It's just a constant runny nose that never goes away and it never fluctuates.
...
[Gopi Shah MD]
Do you spray, decongest the nose before you take a look or do you never decongest to take a look or what's your thoughts on that?
[Stan McClurg MD]
I used to spray everybody but then when COVID hit, I stopped, just because I was terrified of mucosal atomization of the COVID virus. I stopped spraying but I still needed to scope. I found that patients really didn't have any change on whether or not they could tolerate the scope or not. I think the key is actually using a small endoscope.
...
[Ashley Agan MD]
Before we move on too far, you mentioned the postnasal drainage patients. I do think that is a tricky group because if the complaint is postnasal drainage, and when you scope them, you don't necessarily see thick drainage coming back from the nose into the throat. How do you take that apart and figure out what's going on?
[Stan McClurg MD]
It's a very frustrating patient. The postnasal drip can come from about a thousand different sources, so you have to delineate where it's coming from. Doing reflux treatment potentially, and trial there to see if it improves, I'll do a ipratropium bromide challenge for them.
...
[Ashley Agan MD]
With your ipratropium challenge, you choose that nasal spray as opposed to Flonase or Azelastine or some other nasal spray because it's an anticholinergic and it-
[Stan McClurg MD]
Yes. It actually recreates what we would potentially do with a procedure such as rhinorrea ClariFix.
...
[Stan McClurg MD]
That's actually a change in mindset of a lot of surgeons. A lot of surgeons will say, "I'm only going to do a procedure if it's going to fix it 100%". When you start dealing with chronic rhinitis and these in-office procedures, you have to be okay that treating something very good is enough. That's the end result is that you're going to help it get better. It may not be 100% but you're going to actually make things better. It's a change in mindset in thinking of the surgeon.
[Gopi Shah MD]
That's a good point. Some of it's what we're doing is quality of life. If we can make the quality of life better and it's not like you have an alternative to "fix it." It is an improvement, which is good.
Podcast Contributors
Dr. Stan McClurg
Dr. Stan McClurg is a private practice rhinologist at Ascentist Healthcare in Kansas City.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2022, November 15). Ep. 77 – In-Office Procedures for Chronic Rhinitis [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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