Pediatric Annals

Special Issue Article 

Badly Behaving Noses in Children: Rhinitis, Sinusitis, or Neither?

Jordan Smallwood, MD; Julie L. Wei, MD

Abstract

Every pediatrician has likely experienced frustration with cases of chronic nasal symptoms that either do not seem to get better or do show improvement but then worsen again. Often, this leads to the diagnosis of allergic rhinitis or sinusitis and subsequent prescription of medication(s) that may or may not be warranted. This article discusses the various causes of rhinitis, both allergic and nonallergic. Recommendations for treatment place special focus on nasal irrigation and the role that a child's diet can have on chronic nasal symptoms, with the hope of reducing excessive and sometimes unnecessary medication use. [Pediatr Ann. 2016;45(11):e384–e387.]

Abstract

Every pediatrician has likely experienced frustration with cases of chronic nasal symptoms that either do not seem to get better or do show improvement but then worsen again. Often, this leads to the diagnosis of allergic rhinitis or sinusitis and subsequent prescription of medication(s) that may or may not be warranted. This article discusses the various causes of rhinitis, both allergic and nonallergic. Recommendations for treatment place special focus on nasal irrigation and the role that a child's diet can have on chronic nasal symptoms, with the hope of reducing excessive and sometimes unnecessary medication use. [Pediatr Ann. 2016;45(11):e384–e387.]

One of the more common and potentially frustrating patients for any pediatrician or specialist to see is the child with acute or chronic symptoms of runny nose and nasal congestion. The challenge in treating these children comes from the physician knowing, even before going into the examination room, that in the majority of young children symptoms may reflect either allergic rhinitis or acute viral upper respiratory infection rather than bacterial infection; however, distinguishing between these diagnoses can be difficult. Despite the fact that most nasal symptoms in children are not due to malignancy or other serious medical conditions, parents are often concerned and distressed about their child's chronic nasal congestion, runny nose, or both. Parental concerns focus on the chronic nature of their child's symptoms—persistent daily congestion for months on end, repeated courses of antibiotics for treatment of presumed acute sinus infections, and quality-of-life issues such as absence from school and sleep disturbance. Parents and caretakers of these patients expect a diagnosis and a treatment plan that typically includes prescriptions for antibiotics, antihistamines, steroids, or decongestants. In their minds, physicians should make diagnoses and provide treatments; to parents, failure to do so either suggests incompetence or insensitivity. Herein lies the problem, because often the empirically prescribed medications provide minimal benefit or do not work at all, despite the clinician's best intentions.

Rhinitis

Rhinitis is defined as inflammation of the nasal mucosa, and it is often identified by the presence of some or all of the following: nasal discharge, nasal congestion, nasal or ocular itching, and sneezing.1 Acute rhinitis is a global health problem in both pediatric and adult populations, affecting approximately 25% of the population of westernized countries.1 Patient questionnaires, such as the Rhinoconjunctivitis Quality of Life Questionnaire and the Medical Outcomes Study Short-Form, can reveal significant impairment in daily quality of life in patients suffering from rhinitis. Rhinitis also has significant economic impact, with costs often only reflecting the direct impact while failing to capture indirect costs such as missed days of school and work.

Differential Diagnosis

Although the differential diagnosis for rhinitis is extensive, clinicians tend to consider only a few causes—most cases are ascribed either to allergies or to some form of infection, be it bacterial or viral. When treatment for those few diagnoses fails, then referral to an allergist and/or otolaryngologist is often the next clinical recommendation. Both subspecialists are likely seeing the same group of otherwise healthy children, and have the goal of providing the most likely diagnosis based on history, examination, and appropriate testing, such as for allergies to rule-in or rule-out allergic rhinitis, which is often viewed as a “guilty-until-proven-innocent” suspect.

For pediatric allergists, the most common history from parents and caretakers is something like “my child has nasal congestion and the doctor says it's allergies.” This diagnosis is often a safe bet, as up to 40% of pediatric patients are affected by allergic rhinitis.2 However, when a diagnosis of allergic rhinitis is considered, it is important that the patient history contain some evidence for atopy, such as nasal itching, ocular itching, or seasonal variation in symptoms related to outdoor environmental pollens. A patient without red eyes, ocular and nasal itching, and sneezing occurring in the right season is less likely to have allergic rhinitis. For pediatric otolaryngologists, a frequent history from parents and caretakers is “my child has nasal stuffiness or congestion” and “always has sinus infections.” A detailed patient history often reveals that symptoms occur daily, which rules out an acute infectious process.

A common assumption is that the presence of dark circles underneath the eyes (“allergic shiners”), with or without accompanying nasal symptoms, is a sign of allergic sensitization. These dark circles are caused by vascular congestion and frequently accompany nasal and sinus congestion. Subsequent rubbing of the eyes only furthers their darkened appearance. Although it is true that dark circles underneath the eyes can be caused by allergic rhinitis, it should be remembered that lack of sleep, as well as any conditions causing nasal congestion, including adenoid hypertrophy and chronic nasal obstruction, may also cause dark circles. Therefore, dark circles under the eyes should not automatically result in a diagnosis of allergic rhinitis.

More and more patients are undergoing specific immunoglobulin E (IgE) testing by their primary care physician to diagnose an “allergy.” Although this test may be useful in the diagnosis and treatment of allergy, its specificity is approximately 80% to 90% with sensitivity of 80% to 85%,3 implying that there is a substantial possibility for error and consequent misdiagnosis. The possibility of error increases in patients with significantly elevated total IgE, such as patients with severe eczema, because the elevated IgE contributes to the possibility of a false-positive result. (I often explain this concept to parents/caregivers using this metaphor: if you could win a contest by pulling a red marble out of a jar, it's going to be a lot easier to win if that jar is full of red marbles.) Unfortunately, few parents appreciate the operator characteristics of IgE-based allergy testing assays. Clinicians who order allergy IgE testing must keep in mind the context of the patient's clinical history. IgE-based allergy testing cannot be interpreted in isolation, as this leads to overdiagnosis of allergic sensitivity. A frequent example of overdiagnosis of allergic sensitivity based on specific IgE testing occurs when parents inform us that their child is no longer eating specific foods based on results of testing, even though the child has enjoyed those same foods prior to testing, having never exhibited symptoms of allergy. As physicians, we must remind ourselves to treat patients on the basis of history and examination findings, not merely on laboratory results.

The majority of children with frequent runny noses can be managed appropriately by their primary care physicians, and they require neither allergy testing nor subspecialty referral. Based on the 2015 clinical practice guidelines for allergic rhinitis by the American Academy of Otolaryngology–Head and Neck Surgery,2 pediatricians and pediatric subspecialists should offer children with allergic rhinitis trials of intranasal steroid and oral antihistamines. It is unnecessary for most children with frequent runny noses to be subjected to skin testing or referred to an allergist, otolaryngologist, or both. Only when a child has persistent symptoms, despite the consistent use of nasal steroids and antihistamines, should they be referred for subspecialty evaluation.

Nonallergic Rhinitis

Nonallergic rhinitis should be a diagnosis of exclusion. Nonallergic rhinitis should be considered when appropriate, specific IgE or skin testing has been completed and the results are negative. To parse through the many causes of nonallergic rhinitis occurring with or without intermittent or chronic rhinorrhea, clinicians must obtain a thorough clinical and environmental history.1

Differential Diagnosis

Nonallergic rhinitis can be caused by exposure to strong irritant odors and strong fragrances, such as tobacco smoke, perfumes, air fresheners, car exhaust, and cleaning products.1

Vasomotor rhinitis. Vasomotor rhinitis is characterized by intermittent symptoms of congestion or watery nasal discharge. Vasomotor rhinitis is most commonly triggered by exposure to cold, dry air, as may occur when walking into an air-conditioned room from outside.1

Gustatory rhinitis. Gustatory rhinitis presents with prominent watery rhinorrhea that occurs as a result of a vagally mediated reflex that is most often associated with ingestion of hot or spicy foods.1

Rhinitis medicamentosa. Rhinitis medicamentosa is a common cause of recurrent nasal congestion that occurs after prolonged (and frequently, inappropriate) use of topical decongestant vasoconstricive catecholamines (phenylephrine) and imidazoles (oxymetazoline). Rhinitis medicamentosa will not be uncovered by the physician unless an adequate medication history, including prescription and over-the-counter medications, is obtained.1

Other medications commonly implicated in nasal congestion include alpha-blockers such as clonidine, as well as antihypertensives, antidepressants, and nonsteroidal anti-inflammatory drugs.

Anatomic and physical obstruction. Anatomic and physical obstruction of the nares are possible factors contributing to chronic rhinitis and will not be alleviated by traditional medications. Examples include enlarged turbinates, adenoid hypertrophy, foreign bodies, choanal atresia, and septal deviation.1

Postural reflex nasal congestion.Postural reflex nasal congestion, demonstrated by increased nasal congestion with supine position, is a normal nasal reflex unrelated to any disease process. Postural reflex nasal congestion is often reported as nasal symptoms that are worse immediately on awakening but that resolve once the patient is upright for a short period of time.1

Pregnancy. Pregnant adolescents may experience rhinitis of pregnancy. Rhinitis of pregnancy is attributed to increased overall blood volume during pregnancy, as well as to increased estrogen, which causes vascular congestion of mucous membranes. Nasal congestion with or without clear rhinorrhea may occur anytime during pregnancy but is typically at its worst during the first trimester.1

Sneezing on exposure to dramatic temperature extremes or bright light. Sneezing on sudden exposure to dramatic temperature extremes as well as to sudden exposures to bright light (such as stepping outside on a sunny day) is also a normal nasal reflex. Because these symptoms often occur when stepping outside, they are often inappropriately attributed to pollen exposure.1

Excessive consumption of sugar.It has been observed that there are associations between chronic cough, nasal congestion, and rhinorrhea in preschool-aged children who consume excessive amounts of food and beverages high in sugar, which can increase risk of gastroesophageal reflux or laryngopharyngeal reflux.4 Excessive consumption of sugar, along with fats, caffeine, carbonation, and acids may lead to prolonged gastric emptying and greater acidic stomach contents, both of which may potentiate reflux and vagally mediated rhinorrhea and congestion experienced during emesis. Habitual late-night eating or milk and/or snacks at bedtime may also lead to similar symptoms.4

When a parent states that their child has a “normal diet,” we do not always push for further details, especially when there does not appear to be overt obesity. However, the amount of sugar a child may be consuming on a daily basis through beverages and food can be sobering for both physicians and parents. This is a good opportunity for physicians to ask questions about a child's daily eating and drinking habits.

Management

It is the opinion of the authors that patients who are experiencing chronic nasal symptoms with no evidence of atopy or anatomic obstruction, should take the steps outlined in Table 1.


            Symptom Management for Children with Chronic Nasal Issues with No Atopy or Anatomic Obstruction

Table 1.

Symptom Management for Children with Chronic Nasal Issues with No Atopy or Anatomic Obstruction

Although nasal irrigation is rarely recommended by pediatricians, studies have demonstrated the clinical efficacy of regular nasal irrigation for the treatment of rhinosinusitis.5,6 A 2014 study by Pham et al.6 demonstrated that saline irrigation in children, when performed daily for up to 6 weeks for treatment of computed tomography (CT)-proven mucosal thickening and chronic rhinosinusitis, was highly effective, led to symptom resolution, reversal of mucosal thickening on CT scans, and improved scores on the Sinus and Nasal Quality of Life survey. Furthermore, of the entire group treated with saline irrigation, only 10% required functional endoscopic sinus surgery due to persistent and unresolved symptoms. Nasal irrigation can be an effective first-line therapy for symptoms that recur during or after acute viral upper-respiratory tract illnesses. When taught the proper technique, children as young as age 4 years can use nasal irrigation. Not all children or families are willing to try nasal irrigation, and some may give up after initial efforts, but most patients appear to be able to tolerate irrigation after a few days and even report enjoyment after getting used to it. Efficacy of saline irrigation has been demonstrated in numerous studies, especially in adults, to be cost-effective with minimal risk and to reduce unnecessary testing and medication use, thereby avoiding rhinitis medicamentosa. Nasal irrigation also provides parents and caretakers a relatively simple method to treat symptoms. Parents who are looking for a more “natural” approach to their child's medical care often find nasal irrigation to be an appealing solution.

As pediatric allergists and otolaryngologists, we welcome the referrals for otherwise healthy children with “badly behaving” noses. By the time these patients come to us, they have often already used several medications. With allergist consultation, the next clinical steps usually include skin testing or specific IgE testing to determine if immunotherapy may be of benefit. As part of the consultation with an otolaryngologist, an office rhinoscopy/nasal endoscopy is often considered to rule out anatomic obstruction, potential nasal polyposis, and adenoid hypertrophy, and to assess for surgical treatment options should a nasal obstructive problem be identified.

Summary

Rhinitis is irritation or inflammation of the mucous membrane in the nose, and manifests clinically as congestion and nasal discharge. The medical and surgical differential diagnosis of rhinitis is extensive; therefore, reflexive diagnosis of allergic rhinitis or bacterial rhinitis/sinusitis discredits the intelligence and capability of pediatricians and subspecialists, and, more importantly, may be a wrong diagnosis, ultimately leading to overmedication of young children.

References

  1. Adkinson NF Jr, Bochner BS, Burks AW, , eds. Middleton's Allergy: Principles and Practice. 7th ed. London, UK: Mosby; 2009.
  2. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 Suppl):S1–43. doi:10.1177/0194599814561600 [CrossRef]
  3. Bernstein IL, Li JT, Bernstein DI, et al. American Academy of Allergy, Asthma, and ImmunologyAmerican College of Allergy, Asthma, and Immunology. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008;100(3 Suppl 3):S1–S148.
  4. Wei JL. A Healthier Wei: Reclaiming Health for Misdiagnosed and Overmedicated Children. Orlando, FL: A Healthier Wei, LLC; 2012.
  5. Wei JL, Sykes KJ, Johnson P, He J, Mayo M. Safety and efficacy of once daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis. Laryngoscope. 2011;121(9):1989–2000.
  6. Pham V, Sykes KJ, Wei JL. Long-term outcome of once daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis. Laryngoscope. 2014;124(4):1000–1007. doi:10.1002/lary.24224 [CrossRef]
  7. American Academy of Pediatrics. Committee on Nutrition. The use and misuse of fruit juice in pediatrics. http://pediatrics.aappublications.org/content/107/5/1210. Accessed October 21, 2016.
  8. Price D, Kemp L, Sims E, et al. Observational study comparing intranasal mometasone furoate with oral antihistamines for rhinitis and asthma. Prim Care Respir J. 2010;19(3):266–273. doi:10.4104/pcrj.2010.00040 [CrossRef]

Symptom Management for Children with Chronic Nasal Issues with No Atopy or Anatomic Obstruction

Children Younger than Age 4 Years <list-item>

Reduce sugary beverages and replace with water

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Limit juice to 4–6 ounces once per day (in keeping with guidelines from the American Academy of Pediatrics7)

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Limit milk consumption to 14 ounces per day in toddlers older than age 2 years and eliminate consumption of dairy products before bedtime if possible

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Avoid snacks for at least 1 hour before bedtime

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Children Age 4 Years or Older <list-item>

Apply the same dietary restrictions as in children younger than age 4 years

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Trial of once-daily nasal irrigation using a sinus rinse bottle, with the child learning to do the irrigations

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If symptoms persist despite dietary restrictions and nasal irrigation, then add intranasal steroid (randomized clinical trials of treatment of allergic rhinitis showed greater efficacy of intranasal steroids when compared to oral antihistamines8)

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If intranasal steroids fail to resolve persistent nasal obstruction/congestion, then add a second agent, such as an oral antihistamine

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If patient symptoms persist despite treatment, refer to an allergist for testing

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Authors

Jordan Smallwood, MD, is the Section Chief, Division of Allergy/Immunology, Nemours Children's Hospital; and an Assistant Professor, University of Central Florida College of Medicine. Julie L. Wei, MD, is the Division Chief, Division of Otolaryngology, Nemours Children's Hospital; and a Professor, Otolaryngology Head and Neck Surgery, University of Central Florida College of Medicine.

Address correspondence to Jordan Smallwood, MD, Division of Allergy/Immunology, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL 32827; email: jordan.smallwood@nemours.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20161011-01

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