TOPIC 36: Rhinitis – Understand the Differential Diagnosis, Evaluation, and Management of a Child with Persistent Rhinitis

MOCA-PBR – 2025 Edition TOPIC 36: Rhinitis – Understand the Differential Diagnosis, Evaluation, and Management of a Child with Persistent Rhinitis

OFFICIAL ABP TOPIC:

Understand the differential diagnosis, evaluation, and management of a child with persistent rhinitis

BACKGROUND

Persistent rhinitis is a common and often underappreciated condition in children that can significantly impact quality of life. Chronic nasal inflammation and irritation can lead to bothersome symptoms, sleep disturbance, and decreased school performance.

DIFFERENTIAL DIAGNOSIS

DIAGNOSIS 

KEY SYMPTOMS 

DIAGNOSTIC CLUES 

Allergic Rhinitis 

Sneezing, itching, clear rhinorrhea, nasal congestion; often seasonal 

Positive skin prick or specific IgE tests to allergens 

Chronic Nonallergic Rhinitis 

Chronic nasal congestion and rhinorrhea without allergic triggers 

No allergic sensitization 

Adenoiditis 

Nasal obstruction, mouth breathing, snoring 

Enlargement of adenoids on lateral neck X-ray or endoscopy 

Chronic Sinusitis 

Purulent nasal discharge, cough, facial pain >12 weeks 

Opacification or mucosal thickening on CT sinuses 

Rhinitis Medicamentosa 

Chronic use of decongestant sprays, rebound nasal congestion when medication stopped 

Withdrawal of medication ultimately improves symptoms after initial worsening 

Foreign Body 

Unilateral foul nasal discharge 

Object visible on exam or imaging 

Cystic Fibrosis 

Chronic productive cough, nasal polyposis, failure to thrive 

Positive sweat chloride test 

Primary Ciliary Dyskinesia 

Neonatal respiratory distress, chronic wet cough, recurrent otitis 

Abnormal ciliary motion on biopsy; situs inversus 

CSF Rhinorrhea 

Clear, unilateral nasal discharge; worsens with straining or leaning forward 

History of head trauma or surgery; beta-2 transferrin testing confirms CSF 

Nasal Tumors 

Unilateral nasal obstruction, epistaxis, facial deformities 

Imaging (CT/MRI) reveals mass; biopsy confirms diagnosis 

Fungal Infections 

Persistent nasal discharge, pain, or tissue destruction 

Biopsy or culture confirms diagnosis; consider in immunocompromised children or endemic areas 

Other rarer causes of persistent rhinitis include immunodeficiencies, sarcoidosis, and granulomatosis with polyangiitis (Wegener’s granulomatosis).

EVALUATION OF PERSISTENT RHINITIS

HISTORY

  • Age of onset and evolution of symptoms
  • Pattern (seasonal vs perennial) and severity
  • Triggers (allergens, irritants, weather changes)
  • Associated symptoms: sneezing, itching, congestion, rhinorrhea, postnasal drip
  • Impact on sleep, activities, school performance
  • Personal or family history of atopy: asthma, eczema, allergies
  • Medication use and response to prior therapies
  • Any history of head trauma or surgery (consider CSF rhinorrhea)

PHYSICAL EXAM

  • Nasal mucosa: Boggy, edematous turbinates, more often pale in allergic rhinitis and erythematous in nonallergic rhinitis
  • Nasal polyps: Raises concern for CF or chronic sinusitis
  • Enlarged adenoids: Observed by posterior pharynx exam or lateral neck X-ray
  • Signs of atopy: Allergic shiners, transverse nasal crease, atopic dermatitis
  • Wheezing or other lower airway involvement
  • Unilateral mass, facial deformity (consider nasal tumor)

ALLERGY TESTING

  • Skin prick testing or serum-specific IgE measurement to common aeroallergens
  • Indicated if allergic rhinitis is suspected based on history/exam

IMAGING

  • Lateral neck X-rays if adenoid hypertrophy is suspected
  • Sinus CT for chronic sinusitis, unilateral symptoms, or concerns for complications
  • CT/MRI if nasal tumor is suspected based on exam findings
  • Avoid routine imaging for uncomplicated allergic rhinitis

ADDITIONAL TESTS TO CONSIDER FOR ALTERNATIVE DIAGNOSES

  • Sweat chloride test (if CF is suspected)
  • Ciliary biopsy (for primary ciliary dyskinesia)
  • Beta-2 transferrin testing (to confirm CSF rhinorrhea)
  • Biopsy or culture (if fungal infection suspected)
  • Immune function testing (for recurrent infections)

RED FLAGS

  • Unilateral foul purulent drainage: Foreign body, tumor
  • Clear unilateral drainage worsened by straining/leaning forward: CSF leak
  • Mucopurulent drainage >10–14 days: Bacterial sinusitis
  • Nasal polyps: Consider cystic fibrosis
  • Unilateral obstruction, epistaxis, facial deformity: Nasal tumor
  • Persistent discharge with pain/tissue destruction: Fungal infection
  • Severe refractory symptoms: Reevaluate diagnosis; consider referral to ENT

MANAGEMENT OF PERSISTENT RHINITIS

PHARMACOTHERAPY OPTIONS

CLASS 

EXAMPLES 

INDICATIONS 

KEY CONSIDERATIONS 

Intranasal Corticosteroids (INCS) 

– Fluticasone

– Mometasone

– First-line for moderate-severe persistent symptoms           

– Monitor growth in children

Oral 2nd Gen Antihistamines 

– Cetirizine

– Loratadine

– Sneezing, itching, rhinorrhea; less effective for congestion

– Minimal adverse effects

Intranasal Antihistamines 

– Azelastine

– Olopatadine

– Effective for congestion; faster onset than oral antihistamines 

– Bitter taste

– Sedation

Oral Decongestants 

Pseudoephedrine 

– Short-term congestion relief 

– Avoid in young children

– Insomnia

– Irritability

Intranasal Decongestants 

Oxymetazoline 

– Very short-term use only (≤3 days) 

– Rebound congestion (rhinitis medicamentosa)

Leukotriene Receptor Antagonists

Montelukast 

– NOT first-line; may be helpful for allergic rhinitis + comorbid asthma 

– Neuropsychiatric events rarely reported

Rhinitis caused by acute bacterial rhinosinusitis should be treated with amoxicillin-clavulanate, while initial treatment for chronic rhinosinusitis lasting more than 12 weeks is usually an extended trial of intranasal corticosteroids and intranasal saline.

Intermittent allergic rhinitis: Intranasal antihistamine or 2nd-gen oral antihistamine

Persistent allergic rhinitis: INCS first-line, but can also consider intranasal antihistamine or 2nd-gen oral antihistamine as alternative monotherapy or in combination with INCS depending on severity of symptoms and patient preference

NON-PHARMACOLOGIC STRATEGIES

  • Allergen avoidance/environmental control if specific triggers are identified
  • Nasal saline irrigation for symptoms of congestion, rhinorrhea

Mild chronic nonallergic rhinitis: INCS or intranasal antihistamine

Moderate/severe chronic nonallergic rhinitis: INCS and intranasal antihistamine

Allergen immunotherapy should be offered to children with allergic rhinitis who are unable to avoid exposure to allergens, have symptoms poorly controlled with pharmacotherapy, or have comorbidities such as asthma.

For rhinitis medicamentosa, stop decongestant sprays after advising family that symptoms may initially worsen; consider trial of INCS until symptoms improve.

INDICATIONS FOR REFERRAL

  • Allergist: Moderate-severe persistent rhinitis, multiple suspected allergens, immunotherapy candidate
  • ENT: Severe nasal obstruction, suspected adenoiditis, anatomic abnormalities
  • Pulmonologist: Concern for cystic fibrosis or primary ciliary dyskinesia based on history and screening tests
  • Immunologist: Frequent, severe sinopulmonary infections
  • Neurosurgeon: Confirmed or suspected CSF leak

REFERENCES

https://publications.aap.org/pediatricsinreview/article/44/10/537/194016/Allergic-Rhinitis 

https://www.uptodate.com/contents/chronic-nonallergic-rhinitis 

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