ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Allergic rhinitis, the most common type of rhinitis, generally can be differentiated from the numerous types of nonallergic rhinitis through a thorough history and physical examination. Allergic rhinitis may be seasonal, perennial, or occupational. The most common cause of nonallergic rhinitis is acute viral infection. Other types of nonallergic rhinitis include vasomotor, hormonal, drug-induced, structural, and occupational (irritant) rhinitis, as well as rhinitis medicamentosa and nonallergic rhinitis with eosinophilia syndrome. Since 1998, three large expert panels have made recommendations for the diagnosis of allergic and nonallergic rhinitis. Allergy testing (e.g., percutaneous skin testing, radioallergosorbent testing) is not necessary in all patients but may be useful in ambiguous or complicated cases.
Vasomotor Rhinitis - Article
ABSTRACT: Vasomotor rhinitis affects millions of Americans and results in significant symptomatology. Characterized by a combination of symptoms that includes nasal obstruction and rhinorrhea, vasomotor rhinitis is a diagnosis of exclusion reached after taking a careful history, performing a physical examination, and, in select cases, testing the patient with known allergens. According to a 2002 evidence report published by the Agency for Healthcare Research and Quality (AHRQ), there is insufficient evidence to reliably differentiate between allergic and nonallergic rhinitis based on signs and symptoms alone. The minimum level of diagnostic testing needed to differentiate between the two types of rhinitis also has not been established. An algorithm is presented that is based on a targeted history and physical examination and a stepwise approach to management that reflects the AHRQ evidence report and U.S. Food and Drug Administration approvals. Specific approaches to the management of rhinitis in children, athletes, pregnant women, and older adults are discussed.
ABSTRACT: Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory practice. Although often caused by viruses, it sometimes is caused by bacteria, a condition that is called acute bacterial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which makes accurate clinical diagnosis difficult. Because two thirds of patients with acute bacterial rhinosinusitis improve without antibiotic treatment and most patients with viral upper respiratory infection improve within seven d antibiotic therapy should be reserved for use in patients who have had symptoms for more than seven days and meet clinical criteria. Four signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis: purulent nasal discharge, maxillary tooth or facial pain (especially unilateral), unilateral maxillary sinus tenderness, and worsening symptoms after initial improvement. Sinus radiography and ultrasonography are not recommended in the diagnosis of uncomplicated acute bacterial rhinosinusitis, although computed tomography has a role in the care of patients with recurrent or chronic symptoms.
ABSTRACT: Rhinosinusitis can be divided among four subtypes: acute, recurrent acute, subacute and chronic, based on patient history and a limited physical examination. In most instances, therapy is initiated based on this classification. Antibiotic therapy, supplemented by hydration and decongestants, is indicated for seven to 14 days in patients with acute, recurrent acute or subacute bacterial rhinosinusitis. For patients with chronic disease, the same treatment regimen is indicated for an additional four weeks or more, and a nasal steroid may also be prescribed if inhalant allergies are known or suspected. Nasal endoscopy and computed tomography of the sinuses are reserved for circumstances that include a failure to respond to therapy as expected, spread of infection outside the sinuses, a question of diagnosis and when surgery is being considered. Laboratory tests are infrequently necessary and are reserved for patients with suspected allergies, cystic fibrosis, immune deficiencies, mucociliary disorders and similar disease states. Findings on endoscopically guided microswab culture obtained from the middle meatus correlate 80 to 85 percent of the time with results from the more painful antral puncture technique and is performed in patients who fail to respond to the initial antibiotic selection. Surgery is indicated for extranasal spread of infection, evidence of mucocele or pyocele, fungal sinusitis or obstructive nasal polyposis, and is often performed in patients with recurrent or persistent infection not resolved by drug therapy.
ABSTRACT: Although most cases of acute rhinosinusitis are caused by viruses, acute bacterial rhinosinusitis is a fairly common complication. Even though most patients with acute rhinosinusitis recover promptly without it, antibiotic therapy should be considered in patients with prolonged or more severe symptoms. To avoid the emergence and spread of antibiotic-resistant bacteria, narrow-spectrum antibiotics such as amoxicillin should be used for 10 to 14 days. In patients with mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are options. Second-line antibiotics should be considered if the patient has moderate disease, recent antibiotic use (past six weeks), or no response to treatment within 72 hours. Amoxicillin-clavulanate potassium and fluoroquinolones have the best coverage for Haemophilus influenzae and Streptococcus pneumoniae. In patients with beta-lactam hypersensitivity who have moderate disease, a fluoroquinolone should be prescribed. The evidence supporting the use of ancillary treatments is limited. Decongestants often are recommended, and there is some evidence to support their use, although topical decongestants should not be used for more than three days to avoid rebound congestion. Topical ipratropium and the sedating antihistamines have anticholinergic effects that maybe beneficial, but there are no clinical studies supporting this possibility. Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and has no serious adverse effects. Nasal corticosteroids also may be beneficial in treating chronic sinusitis. Mist, zinc salt lozenges, echinacea extract, and vitamin C have no proven benefit in the treatment of acute bacterial rhinosinusitis.
ABSTRACT: Saline nasal irrigation is an adjunctive therapy for upper respiratory conditions that bathes the nasal cavity with spray or liquid saline. Nasal irrigation with liquid saline is used to manage symptoms associated with chronic rhinosinusitis. Less conclusive evidence supports the use of spray and liquid saline nasal irrigation to manage symptoms of mild to moderate allergic rhinitis and acute upper respiratory tract infections. Consensus guidelines recommend saline nasal irrigation as a treatment for a variety of other conditions, including rhinitis of pregnancy and acute rhinosinusitis. Saline nasal irrigation appears safe, with no reported serious adverse events. Minor adverse effects can be avoided with technique modification and salinity adjustment.
Principles of Appropriate Antibiotic Use: Part III. Acute Rhinosinusitis - Practice Guidelines
AHRQ Releases Review of Treatments for Allergic and Nonallergic Rhinitis - Practice Guidelines
Sinus and Allergy Health Partnership Releases Report on Adult Chronic Rhinosinusitis - Practice Guidelines