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EN4.26 | Acute and Chronic Rhinitis — SDL Guide (Part 2)

Investigations and Differential Diagnosis

The investigation of rhinitis is guided by the clinical presentation and is directed toward confirming the aetiology, ruling out complications, and guiding management. In most cases, the history and examination are sufficient to diagnose acute viral rhinitis, acute bacterial rhinosinusitis, chronic hypertrophic rhinitis, and atrophic rhinitis — investigations serve to confirm and characterise rather than to make the primary diagnosis. The most important diagnostic discipline in rhinitis investigation is avoiding unnecessary testing: allergy tests are not indicated for atrophic rhinitis; CT PNS is not indicated for straightforward acute viral rhinitis; and biopsy is reserved for suspected granulomatous disease or malignancy. Targeted investigation based on clinical probability is both cost-effective and diagnostically superior to a blanket test panel.

For acute rhinitis, investigations are not required unless bacterial complications are suspected (acute rhinosinusitis). The key clinical diagnosis is distinguishing viral from bacterial — based on symptom duration and progression, not on the colour of the discharge.

For chronic rhinitis, the investigation panel is:
- Allergy testing (SPT or serum IgE): to identify or exclude an allergic driver — important because allergic rhinitis is often the underlying cause of chronic hypertrophic rhinitis.
- Nasal cytology: eosinophilia suggests allergic rhinitis or NARES; neutrophilia suggests chronic bacterial infection; no cells (acellular) may suggest atrophic rhinitis.
- CT PNS: for chronic rhinosinusitis, for staging of hypertrophic or polypoid disease, and for pre-surgical planning.
- Nasal swab for culture and sensitivity: in atrophic rhinitis to identify Klebsiella ozaenae and guide antibiotic therapy; in chronic bacterial rhinosinusitis.
- Serology and biopsy: in suspected granulomatous rhinitis (syphilis — VDRL/TPHA; tuberculosis — Mantoux, tissue AFB; rhinoscleroma — Klebsiella rhinoscleromatis culture; Wegener's granulomatosis — cANCA, renal function, biopsy).

Differential diagnosis for chronic crusting nasal discharge:
- Atrophic rhinitis vs specific granulomatous infections (rhinoscleroma, syphilis, TB, leprosy) — granulomatous infections produce nodular, friable, indurated mucosal lesions rather than smooth atrophy; biopsy shows characteristic histology (Mikulicz cells in rhinoscleroma, caseating granulomas in TB).
- Septal perforation — crusting localised to the septal margin; the perforation is visible on rhinoscopy.
- Intranasal drug use (cocaine, chromium) — history, septal perforation, urine toxicology.
- Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu) — epistaxis + telangiectasias on skin and mucosa.

Principles of Management Summary

The management of rhinitis is tailored to the specific type and stage. A clear aetiological diagnosis is the prerequisite for effective treatment — the same symptom of nasal obstruction has entirely different treatments depending on whether it is caused by acute viral rhinitis, chronic hypertrophic turbinate disease, or atrophic rhinitis. This module draws together the management principles for all types covered.

Acute viral rhinitis: Supportive — analgesics (paracetamol/ibuprofen), short-term topical decongestants (maximum 3–5 days), saline irrigation. No antibiotics unless bacterial superinfection is confirmed (symptoms worsening after 5 days, or 'double sickening' with purulent discharge, fever, and facial pain).

Acute bacterial rhinosinusitis: Amoxicillin (or amoxicillin-clavulanate) + intranasal saline irrigation + analgesics. Decongestants for symptom relief.

Chronic hypertrophic rhinitis: Treat the underlying cause first (allergy, vasomotor rhinitis, recurrent infection). For established fibrous hypertrophy unresponsive to medical therapy: inferior turbinate reduction surgery (submucosal diathermy, radiofrequency, partial turbinectomy).

Atrophic rhinitis / ozaena:
- Conservative: regular warm saline nasal irrigation (removes crusts, hydrates mucosa); glucose-glycerine drops; systemic antibiotics (ciprofloxacin or co-trimoxazole) targeting Klebsiella for acute infective exacerbations.
- Surgical (severe, refractory): Young's operation (partial obliteration of the anterior nares for 6 months, then reopened) is the classical surgical treatment — reduces airflow, allows mucosal rest and regeneration.
- Submucous injection of paraffin, cartilage, or synthetic grafts has been used historically to narrow the nasal passage by building up the lateral wall — largely replaced by Young's operation.

General principles applicable to all:
Saline nasal irrigation is safe, cheap, and beneficial in all forms of rhinitis — it clears secretions, removes allergens and irritants, and supports mucociliary clearance. It should be recommended as an adjunct in every patient regardless of rhinitis type.

Self-Assessment

Consider the following two contrasting cases before the quiz, as a test of your ability to distinguish the rhinitis spectrum from acute viral rhinitis to atrophic rhinitis:

Case A: A 28-year-old man comes on day 3 of a viral cold. His symptoms started with a dry, irritated nose, progressed to profuse watery discharge and sneezing, and he now has yellowish-green discharge from both nostrils. He has no facial pain, no fever, and feels slightly better than yesterday.

Case B: A 60-year-old man with a 25-year history of bilateral nasal obstruction and crusting. The crusts are thick and adherent; when removed, a wide, pink, smooth mucosal surface is seen. He has no sense of smell and his wife complains of a foul odour.

For each case: what is the diagnosis? What is the most important management step? What should NOT be done? For Case A: is antibiotic therapy indicated at this point?