What’s worse than a runny nose?
A runny nose and stuffy nose at the same time. Both symptoms let you know your nasal cavity is inflamed.
Whether you have a cold or something else, doctors call these symptoms “rhinitis.”
ENT expert David Gudis, MD, chief of the Division of Rhinology and Anterior Skull Base Surgery at Columbia University Vagelos College of Physicians and Surgeons discusses these distinct problems and how to cure and prevent them.
What is rhinitis?
Rhinitis is a general term for inflammation of the nasal cavity.
The nasal cavity is much larger and extends further back than most people realize.
At the front of the nose inside the nostril, also known as the nasal vestibule, is the area most people can reach with a tissue (or finger). That’s where the nasal cavity starts. It extends about 8 cm (about 3 inches) into the head.
What causes rhinitis?
There are several types of rhinitis, each with different causes. The most common:
Allergic rhinitis, caused by an inflammatory reaction to environmental allergens, including tree pollen, grasses, dust mites, animal dander, and many others. Symptoms typically include stuffy nose, clear watery nasal discharge, itching, and sneezing.
Vasomotor rhinitis, caused by dysregulation of the nerves that supply the nasal cavity. Vasomotor rhinitis is characterized by clear, watery nasal discharge that usually occurs in response to certain triggers, like eating or changes in temperature when stepping inside or outside.
Who gets rhinitis?
Allergic rhinitis is very common, affecting 15% to 20% of the population. It often runs in families and is far more common in people who have other similar disorders, like asthma or eczema.
Vasomotor rhinitis usually occurs in older people without a significant history of sinus or nasal problems. For unknown reasons, dysregulation of the nerves that control nasal discharge seems to worsen with age.
Here’s good news for some of us: People who grow up in rural areas, especially near farms with livestock, are much less likely to develop allergic rhinitis.
Our best understanding is that modern hygiene reduces our exposure to countless microorganisms and environmental molecules.
People exposed to more environmental microorganisms throughout childhood, as the immune system is developing, tolerate them better as adults.
If childhood exposure to environmental microorganisms is limited, the adult immune system sees them as threats and mounts a robust inflammatory attack.
A similar process explains why asthma is also less common in people who grow up on farms near animals.
Unfortunately for people who did not grow up in rural areas, moving to a farm later in life does not have the same effect.
How do you know if you have rhinitis (or something else)?
Notice your nasal congestion and discharge (fluid running out of your nose).
If you have nasal congestion, clear watery nasal discharge, itchy nose, throat, eyes, or ears, and/or sneezing, then there is a good chance you have rhinitis. Nosebleeds are another symptom of rhinitis.
If your nasal discharge is thick or discolored or the symptoms are unilateral (on only one side) or there are other associated symptoms like sinus pain or pressure, then other diagnoses should be considered.
Should you go to a doctor if you have a stuffy or runny nose or something else related to rhinitis?
Yes. Talk to your primary care doctor if symptoms have not resolved after three weeks. While you wait, you can try over-the-counter nasal sprays, like saline (salt water) or fluticasone (a corticosteroid).
How do you treat rhinitis?
Over-the-counter and prescription treatments, including nasal sprays, are very effective at reducing the symptoms of rhinitis.
But it can be difficult to distinguish between types of rhinitis, and a therapeutic trial of anti-inflammatory nasal sprays can help clarify the diagnosis. This is important because treatments are different.
It’s also important that your doctor is aware of any new medical issues or treatments, even over-the-counter, you are taking. That way they can determine the correct diagnosis and help you reduce the risk of drug interactions.
For allergic rhinitis
Topical nasal sprays are the most effective and safest first-line treatment, even before oral antihistamines.
I always have patients start a combination of an intranasal corticosteroid spray, like fluticasone, with an intranasal antihistamine spray, like azelastine.
Most patients will improve significantly in response to those treatments alone. If needed, I will add an oral antihistamine.
If those treatments fail, consider formal allergy testing to find out which specific allergens you should avoid. Once determined, you can consider allergy shots (immunotherapy).
For vasomotor rhinitis
An anticholinergic nasal spray such as ipratropium bromide is a very effective treatment option.
For chronic rhinitis
There are great new treatment options for chronic rhinitis, used after routine medical treatment fails.
These treatments target the posterior nasal nerve, which carries the fibers that stimulate most of the nasal discharge and congestion.
For some patients, a quick office procedure under local anesthesia can be performed to freeze, or “cryoablate,” the nerve. For others, surgery in the operating room can be performed to disrupt the nerve fibers.
Can you hurt yourself using a nasal spray?
Yes. Certain nasal sprays can dry out the nose and lead to nosebleeds. Nasal decongestant sprays like oxymetazoline can cause “rebound congestion” and leave people worse than they started.
This is actually another form of rhinitis, called “rhinitis medicamentosa,” caused by overuse of medication. However, a trial of over-the-counter fluticasone for rhinitis symptoms is safe in the vast majority of people.
Can rhinitis be prevented?
For allergic rhinitis, preventive measures are extremely important: Reduce the number of allergens in your environment.
Dusting, vacuuming, wiping down surfaces, and keeping bed sheets and pillowcases clean are very important.
Air purifiers and using air-conditioning instead of window ventilation during peak allergy season can also be very helpful.
I also advise patients to shower before going to bed, so that they do not spend all night rolling around in the allergens on their body.
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