Rhinitis — Frequently asked questions (FAQ)
1) What does this algorithm cover?
The algorithm guides the structured assessment of patients with nasal symptoms — rhinorrhoea, congestion, sneezing, itching and hyposmia/anosmia — starting with the exclusion of alarm signs and structural causes. It then differentiates an acute presentation, usually viral, from chronic or recurrent forms, and organises the decision-making process between allergic rhinitis and non-allergic rhinitis, including first-line treatment options, reassessment criteria and referral indications.
2) What are the main alarm signs requiring investigation or referral?
Signs such as persistent unilateral obstruction, recurrent epistaxis, severe localised facial pain, persistent high fever, suspicion of a mass or polyposis, and unilateral watery rhinorrhoea after trauma, suggesting a CSF leak, should be taken seriously. The presence of these findings should prompt a targeted medical assessment and, in the appropriate context, ENT referral, sometimes urgently.
3) How can acute viral rhinitis be differentiated from rhinosinusitis, whether post-viral or bacterial?
A presentation compatible with an upper respiratory tract infection or viral rhinitis is typically <10 days in duration and shows progressive improvement. Post-viral rhinosinusitis should be suspected when there is persistence for >10 days without improvement or worsening after initial improvement (double worsening). The possibility of bacterial aetiology or complication increases in the presence of persistent high fever, severe facial pain, marked purulent discharge and orbital or neurological signs, requiring reassessment and possible referral.
4) What treatment is recommended for probable viral rhinitis/upper respiratory tract infection?
Treatment is mainly symptomatic, including nasal washing with saline spray or irrigation and an analgesic/antipyretic as needed. A topical nasal decongestant may be used for a short period, ideally for a maximum of 5–7 days, to relieve obstruction. Antibiotics are not indicated in uncomplicated viral rhinitis; reassessment is required if there is persistence or worsening.
5) How is severity assessed in allergic rhinitis?
Severity should be based on functional impact, according to the ARIA concept, and not only on symptom intensity. It is considered mild if there is no impact on sleep, daily activities or school/work performance, and if symptoms are tolerable. It is considered moderate to severe when there is any impact in these domains or clearly troublesome symptoms.
6) What are the first-line treatment options for allergic rhinitis?
In mild disease, an antihistamine, oral or intranasal, may be started, along with avoidance measures when applicable, while maintaining nasal washing as an adjunctive measure. In moderate to severe disease or when congestion predominates, the treatment of choice is regular use of an intranasal corticosteroid. In uncontrolled cases, an intranasal combination, corticosteroid plus intranasal antihistamine, should be considered after confirming adherence and application technique.
7) When is it useful to review spray technique and treatment adherence?
Review of application technique and adherence should be performed whenever symptoms persist after 2–4 weeks of treatment. Many cases of therapeutic “failure” result from irregular use, insufficient dosing or incorrect application, such as directing the spray towards the septum, increasing irritation and epistaxis. Optimising these aspects should precede any treatment escalation.
8) How should non-allergic rhinitis be approached?
In non-allergic rhinitis, the priority is to identify precipitating factors, such as irritants, temperature changes, alcohol or meals, and to exclude specific causes such as rhinitis medicamentosa due to prolonged use of vasoconstrictors. Treatment should be guided by the predominant symptom: intranasal ipratropium when watery rhinorrhoea predominates, intranasal corticosteroid when congestion predominates, and intranasal antihistamine, with or without corticosteroid, in mixed symptoms.
9) What is rhinitis medicamentosa and how is it treated?
Rhinitis medicamentosa results from prolonged use of topical nasal decongestants, leading to persistent obstruction due to rebound effect. Treatment is based on stopping the vasoconstrictor, preferably by tapering, and starting or optimising an intranasal corticosteroid, combined with nasal washing and patient education to avoid continued use.
10) When should specific immunotherapy be considered?
Specific immunotherapy may be considered in patients with clinically relevant allergic rhinitis and documented sensitisation, particularly when symptoms persist despite optimised treatment, when there is significant functional impact or when the patient prefers to reduce long-term medication use. The decision should be individualised and, as a rule, framed within an Allergy and Clinical Immunology consultation.
11) When is imaging, such as CT, indicated in the approach to nasal symptoms?
Imaging is not necessary in most cases of rhinitis. It should be considered when there are alarm signs, suspicion of structural disease, complicated rhinosinusitis, orbital or neurological signs, or persistent symptoms with treatment failure, helping to guide the need for specialist assessment and a treatment plan.
12) Who is this content intended for?
The algorithm and this FAQ are intended for healthcare professionals. Clinical decision-making should integrate the individual context, comorbidities, concomitant medication, age, pregnancy and patient preferences, following applicable recommendations and guidelines.
