Nasal Conditions: Rhinitis, Sinusitis & Congestion

Nasal Congestion

• Blocked / stuffy nose; severity varies

• Common accompanying Sx: rhinorrhoea, post-nasal drip, facial pain, anosmia, sneezing, itching, crusting

• Key causes: nasal deformity, foreign body, mucosal swelling/inflammation, infection (sinusitis), allergy (hay fever)

• Core symptomatic Tx:

  • Steam inhalation (± menthol / eucalyptus)

  • Saline: sprays, drops, irrigation

  • Intranasal corticosteroid sprays (e.g. Beclometasone)

  • Decongestants: oral (pseudoephedrine) or intranasal (xylometazoline) — limit duration to avoid rebound

  • Oral antihistamines when allergic component

Rhinitis

• Inflammation of nasal mucosa; allergic vs non-allergic

• Cardinal Sx: sneezing, congestion, rhinorrhoea, itch, post-nasal drip, cough, ocular Sx

Allergic Rhinitis

• IgE-mediated; histamine + mediator release

• Patterns:

  • Seasonal, Perennial

  • Intermittent (<4 days/wk or <4 consecutive wks) vs Persistent (>4 days/wk & >4 wks)

  • Occupational

• Triggers: pollen, house-dust mites, animal dander, moulds, workplace allergens

• Diagnosis: bilateral Sx, atopy history, onset after exposure; exclude infective / non-allergic forms

• Management hierarchy:

  • Allergen avoidance + saline irrigation

  • Pharmacotherapy:
    • Antihistamines – oral (cetirizine, loratadine) or intranasal (azelastine)
    • Intranasal cromones (sodium cromoglicate)
    • Intranasal decongestants (xylometazoline ≤7 days)
    • Intranasal anticholinergic (ipratropium) – for rhinorrhoea
    • Leukotriene receptor antagonist (montelukast)
    • Intranasal corticosteroids – first-line for persistent Sx

Key Drug Notes

• Cetirizine 10\,\text{mg} OD; halve dose if eGFR<60, avoid if <15

• Loratadine 10\,\text{mg} OD; alternate-day in hepatic impairment

• Azelastine: 1 spray BD, age \ge6

• Sodium cromoglicate: 1 spray 2–4 ×/day, safe in pregnancy

• Xylometazoline: max 5–7 days; cautions – HTN, CVD, DM, glaucoma, BPH

• Ipratropium: 2 sprays 2–3 ×/day (age \ge12); avoid eyes

• Montelukast 10\,\text{mg} nocte (age \ge15); neuro-psych ADRs; multiple CYP inducers interact

Non-Allergic Rhinitis – Principal Causes

• Temp / humidity change, viral URTI, irritants (smoke, perfume), exercise, alcohol/spicy food, meds (α-blockers, ACEI, NSAIDs, cocaine), hormonal (pregnancy, HRT), rebound from decongestants, structural/systemic disorders

Sinusitis (Rhinosinusitis)

• Inflammation of nasal cavity + paranasal sinuses

• Acute: <12 wks, often post-viral; recurrent ≥4 attacks/yr

• Chronic: >12 wks continuous Sx

Core Sx

• Nasal blockage or purulent discharge, facial pain/pressure, hyposmia; ± cough, nasal voice, tenderness over sinuses

Aetiology

• Viral URTI (most), bacterial, asthma, allergic rhinitis, smoking, anatomical defects, immunocompromise

Complications (rare but serious)

• Orbital: cellulitis, abscess, cavernous sinus thrombosis

• Intracranial: meningitis, abscess, venous thrombosis

• Osteomyelitis; progression to chronic disease; sleep & QoL impact

Management – Acute

• Admit if systemic, orbital, or intracranial signs

• <10 days: no antibiotics; self-care (analgesia, fluids)

• ≥10 days persistent/worsening:
  • High-dose intranasal corticosteroid 14 days
  • Back-up or delayed antibiotic if no improvement after 7 days
  • Refer if recurrent, treatment failure, anatomical defect, immunocompromised, polyps

Management – Chronic

• Nasal irrigation

• Intranasal corticosteroid up to 3 months

• Avoid triggers, stop smoking, dental hygiene; refer if persistent, unilateral, impacting QoL, polyps, need for prophylaxis

Pharmacological Options

• Analgesia: paracetamol, NSAIDs, ± weak opioids

• Intranasal corticosteroids (age \ge12): beclometasone, mometasone, fluticasone
  • Contra-indications: untreated infection, recent surgery/trauma, pulmonary TB
  • Local ADRs: dryness, epistaxis; systemic rare
  • Technique: blow nose, shake, head slightly forward, spray while inhaling gently; avoid sniffing; breathe out via mouth

• Antibiotics (if indicated):
  • Phenoxymethylpenicillin 500\,\text{mg} QDS 5 days
  • Amoxicillin 500\,\text{mg} TDS 5 days (up to 1\,\text{g} severe)
  • Co-amoxiclav 500/125\,\text{mg} TDS 5 days for persistent Sx
  • Macrolides – clarithromycin 500\,\text{mg} BD 5 days (QT caution); erythromycin in pregnancy
  • Doxycycline 100\,\text{mg} BD first day then OD 6 days (contra in <12 yrs, pregnancy)

Antibiotic Safety Highlights

• Penicillins: hypersensitivity, GI upset; adjust dose in renal impairment

• Co-amoxiclav: cholestatic jaundice risk; avoid if previous jaundice/ hepatitis

• Macrolides: QT prolongation, CYP3A4 interactions (statins, warfarin, etc.)

• Doxycycline: photosensitivity, hepatotoxicity; interacts with antacids, warfarin, CYP inducers

• Hormonal contraception: efficacy NOT reduced by penicillins, macrolides, tetracyclines; advise extra precautions only if vomiting/diarrhoea

Key Guidelines for Reference

• NICE CKS: Allergic Rhinitis; Sinusitis

• AWMSG & Local PHW antimicrobial guidance

• BNF monographs for listed drugs