General Medical Information

Recognition and Management of Complicating Factors

Richard L. Mabry

Despite the contention of many patients to the contrary, not all that makes them sneeze is an allergen. However, even when a nasal allergy is present, it can be complicated by other types of rhinitis. Clinicians must constantly assess the clinical status of patients with rhinitis and adjust therapy accordingly. If a patient with an allergy who has done well on a regimen has problems without associated allergen overload, the physician should consider the presence of other types of rhinitis before changing therapy.

The typical patient with vasomotor rhinitis has rhinorrhea as a result of temperature extremes, eating, stress, or exposure to irritants. Nasal congestion often accompanies this rhinorrhea and frequently is worse when the patient assumes a recumbent position. Acute situational stress can cause nasal symptoms that can be mistaken for an allergy. Because both allergic and vasomotor rhinitis are not uncommon, the two conditions are expected to coexist among some patients. Besides avoidance of causative factors, therapy for vasomotor rhinitis is mainly symptomatic.

Nasal and sinus infections can occur among patients with underlying nasal allergy. Such problems must be recognized not only to institute appropriate antibiotic therapy but also because infection often alters the patient’s response to allergen immunotherapy. It causes unacceptable local skin reactions to injections. Allergy injections should be deferred until antibiotics have become effective, especially if the patient is febrile.

Excessive use of decongesting nose drops or sprays can complicate rhinitis and cause rebound rhinitis. Unless it is determined by asking the patient that this has occurred and the process is reversed, response to therapy will be inadequate. A number of medications, especially b-adrenergic blocking agents and some antihypertensive agents, can produce nasal congestion as a side effect. The physician must establish that this has occurred and withdraw the offending medication for relief.

When a female patient becomes pregnant, nasal congestion can complicate the clinical signs and symptoms. Numerous causes can account for rhinitis of pregnancy, more properly called rhinitis during pregnancy. Although therapy for allergic rhinitis during pregnancy demands careful attention by the physician, the problem can be controlled without compromising the health of the mother or the fetus.