Chronic rhinitis denotes a prolonged course of nasal mucous membrane inflammation and its main symptoms - rhinorrhea and nasal congestion. Because several forms of rhinitis are recognized (infectious, allergic, atrophic, etc.), various additional symptoms may be observed, which is why patient history, together with a thorough ear, nose and throat examination, is vital to make the diagnosis.
The clinical presentation of rhinitis somewhat varies depending on the underlying cause, but all patients report nasal congestion and rhinorrhea in the initial stages of the disease. One of the most common subtypes, allergic rhinitis, can be further classified into seasonal, perennial, and occupational, each manifesting by nasal complaints, but also constitutional symptoms - malaise, fatigue, and headaches [1]. Persistent need for mouth breathing and sneezing may be encountered as well, while chronic symptoms often cause frequent rubbing of the nose and the appearance of an "allergic crease" across the nasal bridge due to persistent irritation [2]. Exposure to a specific allergen during a particular time of the year (tree pollens in the spring or grass pollens in the summer), an environmental irritant (tobacco, formaldehyde, hair spray, etc) or an indoor allergen (dust mites, molds) can induce typical symptoms and lead to their prolongation in the absence of a diagnosis and appropriate therapy [1] [3]. Allergic conjunctivitis, eczema, and even asthma may accompany rhinitis in such patients [1]. On the other hand, infectious pathogens (both bacterial and viral) can present with nasal obstruction, frequent and recurrent epistaxis and purulent rhinorrhea in the setting of a bacterial infection [4]. Atrophic rhinitis, another form of non-allergic inflammation of the nasal mucosa, can cause a chronic cough, excessive mucus production (known as the nasal drip), and dryness, while patients frequently complain of nasal crusting, as well as dense and thick secretions that induce the need to clear the throat [5]. Furthermore, it is not uncommon for patients to suffer from chronic inflammation of the nasal and sinus mucosa (known as chronic rhinosinusitis), in which symptoms last for more than 12 weeks [6]. Vasomotor rhinitis, characterized by an intermittent appearance of chronic watery rhinorrhea and sneezing, is also an important cause of chronic rhinitis, but its etiology remains to be determined [4].
The diagnosis can often be made solely through obtaining a thorough patient history and performing a detailed physical examination, as the clinical presentation is highly specific for rhinitis [1] [2] [4]. Patients should be asked about the timing and onset of symptoms that may reveal seasonal or occupational factors that can provoke them, while the use of medications is important as well since drug-induced rhinitis is also described in the literature [1]. Angiotensin-converting enzyme (ACE) inhibitors, phentolamine, methyldopa, prazosin, beta blockers, oral contraceptives, chlorpromazine, decongestants and nonsteroidal anti-inflammatory drugs (NSAIDs) are all potential causes of medication-induced rhinitis [1]. A full ear, nose, and throat (ENT) exam (with a particular emphasis on anterior rhinoscopy and observation of discharge) can confirm the diagnosis. Pale, pink, or bluish swelling of the nasal mucosa and accompanying watery eye discharge and conjunctival swelling are highly suggestive of allergic rhinitis [2]. Conversely, purulent nasal secretion strongly points to a bacterial etiology, in which case cultivation of the smear may be recommended. Apart from clinical criteria, percutaneous and immunoglobulin E (IgE) testing for allergens are frequently employed in the setting of chronic rhinitis [1], while imaging studies, such as computed tomography (CT) and upper airway endoscopy, may be quite important if the diagnosis remains unresolved [3].