Rhinitis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fatimo Biobaku M.B.B.S [2]

Overview

Rhinitis is a very common disease that is frequently overlooked or undertreated. It is associated with several comorbidities which can have significant impact on the quality of life. It can also be the initial presentation of overt systemic illnesses which can be potentially fatal. It is important to differentiate rhinitis from other conditions micmicking the symptoms of rhinitis such as intranasal foreign bodies, cerebrospinal fluid rhinorrhea, nasal polyps and tumors.

Differential Diagnosis

The following conditions can present with symptoms that are similar to those found in rhinitis:

• Nasal polyps
• Mechanical/structural factors such as:

1. Deviated nasal septum/septal wall anomalies
2. Adenoidal hypertrophy
3. Nasal tumors (benign and malignant)
4. Foreign bodies- Unilateral, mucopurulent rhinorrhea in children could be as a result of insertion of foreign objects into the nostril.
5. Trauma
6. Anatomical variants in the ostiomeatal complex
7. Choanal atresia
8. Cleft palate
9. Pharyngeal reflux (laryngopharyngo-nasal reflux)
10. Metabolic conditions such as acromegaly

• Cerebrospinal fluid rhinorrhea: In cases where CSF rhinorrhea is suspected, the rhinorrhea can be evaluated for beta-2 transferrin (beta-2 transferrin is an endogenous marker of CSF leakage).
• Ciliary dyskinesia syndrome: Chronic rhinitis with mucopurulent secretion which manifests from birth could be suggestive of primary ciliary dyskinesia.

Disease	History	Physical examination	Laboratory or radiological findings
Acute viral nasopharyngitis	Symptoms start with sore throat Nasal congestion and runny nose Cough that may persist after the resolution of the other symptoms Fever is not common	Nasal mucosa is congested and hyperemic Pharynx is typically normal	Diagnosis is usually clinical and lab tests are rarely needed The virus can be cultured on human lung cells but results take time PCR is rapid and accurate test but done only in immunocompromised patients when the virus strain needs to be known
Allergic rhinitis	Characterized by repeated paroxysms of rhinorrhea, sneezing and cough. Symptoms may be related to a specific season of the year, hence the name “seasonal allergies”.	Rhinorrhea fluid is usually clear and watery. Examination of the nose reveals a crease below the nasal bridge from repeated pulling of the nose secondary to irritation. Edema in the area below the eye if associated conjunctivitis is present.	Skin testing using intradermal prick skin tests to determine the specific allergens causing allergic rhinitis. Serum immune assays to determine IgE levels in the serum.
Acute sinusitis	Presents with symptoms similar to URTIs (sneezing, cough and runny nose) Symptoms last for a longer time (about 10 days) with the peak of symptoms between 4th and 6th days. Usually, acute sinusitis is not associated with fever	Inspection may show erythema and edema over the involved sinus Palpation of sinuses shows tenderness on palpation Transillumination of the sinuses may show opacity.	X ray and CT may show air fluid level or bubbles in the affected sinus. Culture of the nasal secretions is of limited use in acute sinusitis as nasal secretions may be contaminated by nasal flora.
Infectious mononucleosis	Symptoms of pharyngitis: sore throat and difficult swallowing Fever Fatigue Lymphadenopathy especially in the posterior cervical region	Abdominal examination reveals splenomegaly Maculopapular rash may be present	Positive monospot test Elevated liver enzymes