Chronic Rhinitis: Clinical Guidelines

List of Abbreviations

ATC – Anatomical Therapeutic Chemical classification

VAS – visual analog scale

VR – vasomotor rhinitis

CT – computed tomography

kDa – kilodalton (unit of molecular mass measurement)

ICD-10 – International Statistical Classification of Diseases and Related Health Problems (10th Revision)

INN – International Nonproprietary Name (of a medicinal product)

NAR – non-allergic rhinitis

CR – chronic rhinitis

NARES – non-allergic rhinitis with eosinophilia syndrome

Terms and Definitions

Chronic rhinitis is any inflammation of the nasal mucosa characterized by the presence of at least two of the following symptoms manifesting daily for 1 hour or more: nasal congestion (obstruction), nasal discharge (rhinorrhea), sneezing, nasal itching. In modern literature, chronic rhinitis generally encompasses all types of chronic rhinitis except allergic rhinitis, and the term nonallergic rhinitis is used [1–9].

Disease (rhinitis) phenotype – a set of organism characteristics and clinical manifestation features of a disease developing as a result of the interaction between genetic factors and the environment [6,9].

Endotype – a disease subtype defined by a distinct pathobiological mechanism [6,9].

Level of evidence (LoE) – the ranking of study designs based primarily on their internal validity. This criterion is used to determine the persuasiveness of a study.

Level of Evidence (LoE) – the degree of certainty in the reliability of the intervention's effect and that following the recommendations will bring more benefit than harm in a specific situation.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Chronic rhinitis – any inflammation of the nasal mucosa characterized by the daily presence for 1 hour or more of at least two of the following symptoms: nasal congestion (obstruction), nasal discharge (rhinorrhea), sneezing, nasal pruritus.

When diagnosing chronic rhinitis, it is important that two nasal symptoms are present for at least 1 hour daily for a minimum of 12 weeks per year [1-9].

Vasomotor rhinitis (idiopathic rhinitis or non-allergic rhinopathy) – the most common phenotype of chronic rhinitis in the general population, diagnosed by excluding other etiological factors (infection, allergy, and other forms of chronic rhinitis). A key feature of patients with idiopathic non-allergic rhinitis is the impairment of neuro-reflex regulation of microcirculation and transcapillary exchange in the nasal mucosa [1-10].

Hypertrophy of the inferior nasal conchae (Hypertrophic rhinitis) – an irreversible increase in the size of the inferior nasal conchae developing as a manifestation of chronic rhinitis, less frequently due to enlargement of the bone base, clinically manifesting as persistent nasal breathing difficulty [11-14].

Hormonal rhinitis – a phenotype of chronic rhinitis associated with thyroid pathology (hypothyroidism) or changes in sex hormone levels (primarily estrogen and progesterone) occurring against the background of pregnancy, menopause, during certain periods of the menstrual cycle in females, as well as during puberty in adolescents [1-9,15,16].

Rhinitis of pregnancy (gestational rhinitis) – a type of hormonal rhinitis manifesting clinically as persistent nasal obstruction absent before pregnancy, arising during pregnancy (most commonly in the second or third trimester) and lasting for 6 weeks or more, in the absence of signs of respiratory infection and allergy, and resolving completely within 2 weeks postpartum [1,3-9,17].

Drug-induced rhinitis – a phenotype of chronic rhinitis based on changes in the nasal mucosa caused by the use of systemic and topical (nasal) drug formulations.

Medication-induced rhinitis (rhinitis medicamentosa) – the most common type of drug-induced rhinitis in the general population, associated with the prolonged use of nasal decongestants. Until recently, the terms "drug-induced rhinitis" and "medication-induced rhinitis" were considered interchangeable. However, in recent consensus documents on chronic rhinitis, it has been proposed to use the term "medication-induced rhinitis" to refer exclusively to forms of chronic rhinitis caused by the prolonged use of nasal decongestants [9,18-20].

Occupational rhinitis – an inflammatory disease of the nose characterized by intermittent or permanent nasal symptoms caused by causes and conditions associated with a specific working environment. Occupational rhinitis is considered a variant of non-allergic chronic rhinitis in mucosal inflammation caused by the non-immunological action of a low-molecular-weight chemical irritant with a molecular weight of less than 5 kDa. High-molecular-weight compounds more frequently cause IgE-mediated inflammation, in which occupational rhinitis is regarded as a type of allergic rhinitis [9,21].

Smoker's rhinitis – essentially a variant of occupational rhinitis, where tobacco smoke acts as the low-molecular-weight chemical substance with an irritant effect on the nasal mucosa, and a bad human habit replaces occupational activity [9].

Gustatory rhinitis – a phenotype of chronic rhinitis manifested by watery rhinorrhea upon consumption of spicy/hot food or alcoholic beverages (alcohol-induced rhinitis). Unlike food allergy manifestations, gustatory rhinitis is not accompanied by such nasal symptoms as sneezing/nasal pruritus, cutaneous symptoms, and signs of bronchial obstruction [9].

Rhinitis of the elderly (senile rhinitis) – a phenotype of chronic rhinitis observed in individuals over 65 years of age, whose main symptom is watery rhinorrhea intensified by various trigger factors [1,4-9]. A number of authors also attribute dryness in the nose and crusting to the symptoms of senile rhinitis, which complicates differential diagnosis with atrophic rhinitis.

Non-allergic rhinitis with eosinophilia syndrome (NARES) – a phenotype of chronic rhinitis based on eosinophilic inflammation of the nasal mucosa with negative allergy tests [6,8,9].

Atrophic rhinitis – a form of chronic rhinitis characterized by atrophic changes in the nasal mucosa, manifesting with symptoms such as nasal congestion, sensation of dryness in the nose, crusting, and epistaxis. Primary and secondary atrophic rhinitis (arising as a result of an obvious causative factor) are distinguished [9].

Chronic catarrhal rhinitis – one of the forms of chronic rhinitis according to the morphological classification (Dainyak L.B., 1966), characterized by constant catarrhal (non-purulent) inflammation of the nasal mucosa, caused by a combination of factors of both infectious and non-infectious nature. This diagnosis continues to be used by some physicians practicing in the former USSR countries when working with patients presenting with mixed rhinitis phenotypes [67,68].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The diagnosis of "chronic rhinitis" encompasses a group of diseases with significant differences in etiology and, in most cases, poorly understood pathogenesis. Conventionally, the authors of recent consensus documents on chronic rhinitis propose distinguishing 2 endotypes: inflammatory and neurogenic. States of the inflammatory endotype are characterized directly by an inflammatory reaction of the nasal mucosa. In the neurogenic endotype, the basis of pathogenesis is a dysfunction of the autonomic nervous system and an imbalance of a number of biologically active substances that determine the regulation of vascular tone and the function of the secretory glands of the nasal mucosa [9,22-24].

Certain types (phenotypes) of chronic rhinitis are based on the impact of a significant factor. Thus, various pharmacological substances lead to the development of drug-induced rhinitis through different pathogenetic mechanisms due to the specific features of their pharmacological properties (see Table 1).

Table 1. Substances causing drug-induced rhinitis [9,18]

A similar situation is observed regarding occupational rhinitis, where the chemical properties of the substance acting on the nasal mucosa determine the nature of pathogenetic changes (see Table 2).

Table 2. Main substances provoking the development of occupational rhinitis [9]

The pathogenesis of such conditions as hormonal rhinitis, gustatory rhinitis, and non-allergic rhinopathy is considered insufficiently studied and quite complex [9, 22].

All forms of chronic rhinitis (except for atrophic rhinitis) share the presence of nasal mucosa hyperreactivity to external non-specific triggers, although to a lesser extent compared to allergic rhinitis [25].

The etiology and pathogenesis of primary atrophic rhinitis are poorly understood. It is known that the disease usually manifests in individuals over 50 years of age, though isolated cases in childhood have been described. The disease is predominantly prevalent in certain ethnic groups (peoples of southern regions of Asia and Africa), but exceptions may occur. A certain role is played by a bacterial infection associated with Klebsiella ozaenae. The infectious process is secondary and develops against the background of pre-existing atrophic changes in the nasal mucosa [9]. Secondary atrophic rhinitis is most often the consequence of rhinosurgical interventions (primarily on the inferior nasal turbinates); less commonly, the cause may be the use of topical nasal medications, head and neck radiation therapy, or a manifestation of systemic autoimmune granulomatous polyangiitis (e.g., granulomatosis with polyangiitis) [9].

1.3 Epidemiology of the Disease or Condition

Despite the availability of publications on the epidemiology of chronic rhinitis, experts acknowledge that the data do not reflect the true prevalence of the disease. In most cases of mixed forms of rhinitis, practitioners diagnose allergic or infectious rhinitis (rhinosinusitis), ignoring chronic rhinitis as a comorbid condition. Studies on the epidemiology of rhinitis based on healthcare utilization data often fail to capture patients with mild disease who do not seek medical care [1-9, 25-27].

Data from recent epidemiological studies on non-allergic chronic rhinitis in the general population indicate that this pathology affects 10.9% to 28% of individuals [24, 26]. According to experts from the Russian Rhinologic Society, there are about 100,000 patients with CR in Russia [3]. It is undisputed that chronic rhinitis predominantly affects adults, although the disease may also be observed in children. Many phenotypes of CR frequently encountered in adulthood do not occur in pediatric practice. By definition, children cannot suffer from senile rhinitis; cases of occupational rhinitis, gustatory rhinitis, rhinitis of pregnancy, medicamentosa rhinitis, and non-allergic eosinophilic rhinitis are isolated in pediatric practice. Children most frequently face the problem of drug-induced rhinitis and vasomotor rhinitis (non-allergic rhinopathy), and somewhat less frequently various forms of hormonal rhinitis [2].

Regarding the epidemiology of individual CR phenotypes, there are data on the prevalence of vasomotor rhinitis in the adult population: about 7% in the USA and 9.6% in Europe. It is noted that women suffer from this pathology 2–3 times more often than men [9]. To date, there are no large population-based studies on the prevalence of vasomotor rhinitis in Russia.

Drug-induced rhinitis is the second most frequent CR phenotype, accounting for about 15% according to recent studies [24]. A survey published in Russian sources, conducted by the Russian Public Opinion Research Center, showed that about 4% of people (sample of 1,600 respondents) admitted to the regular use of decongestant drops/sprays [3, 18].

According to Russian experts, occupational rhinitis affects from 30% to 60% or more (depending on work experience and the nature of damaging factors in various industrial environments) of workers in professions associated with an increased risk of technogenic impact on the upper respiratory tract [21].

According to data published in foreign literature, rhinitis of pregnancy affects 22% to 32% of women [9, 17]. There are currently no exact data on the prevalence of nasal symptoms in individuals with hypothyroidism and acromegaly.

There are no exact epidemiological data on senile rhinitis, partly due to discrepancies in diagnostic criteria for this condition among various experts [9]. Similarly, there are no epidemiological data for such CR phenotypes as NARES, gustatory rhinitis, and drug-induced rhinitis [1, 6, 8, 9]. According to individual experts, NARES accounts for 5% to 15% of all chronic rhinitis cases (including allergic rhinitis) in adults and 1% to 5% in children [8].

The epidemiology of chronic rhinitis in children is practically unstudied, especially regarding the prevalence of individual CR phenotypes. Published isolated data from foreign experts indicate that the approximate ratio of the prevalence of allergic-to-non-allergic rhinitis in the pediatric population is 3-4:1 [9, 28].

There are no epidemiological data for atrophic rhinitis [9].

1.4 Features of Coding the Disease or Condition

J30.0 – Vasomotor rhinitis

J31.0 – Chronic rhinitis

J34.3 – Hypertrophy of nasal turbinate

1.5 Classification of the disease or condition

There is no single universally accepted classification of CR. Taking into account the probable causal factor, the main phenotypes of CR are distinguished [1, 3-9]:

• Rhinitis of the elderly (senile rhinitis).

• Occupational rhinitis (including smoker's rhinitis as a separate subtype of occupational rhinitis).

• Drug-induced rhinitis.

• Medicamentosa rhinitis (isolated as a separate phenotype from drug-induced rhinitis).

• Hormonal rhinitis (including rhinitis of pregnancy as a separate subtype of hormonal rhinitis).

• Gustatory rhinitis.

• Non-allergic rhinitis with eosinophilia syndrome (NARES).

• Vasomotor rhinitis (synonyms: idiopathic rhinitis or non-allergic rhinopathy).

• Atrophic rhinitis (primary and secondary, including empty nose syndrome).

However, in real practice, an individual patient does not always clearly fit into a single CR phenotype. According to recent studies, about 20% of patients with chronic rhinitis are classified by physicians as unclassified or mixed forms [6, 24, 26].

As with allergic rhinitis, to substantiate treatment tactics, CR is classified by the nature of the course into:

• intermittent – symptoms are present less than 4 days a week or less than 4 weeks a year;

• persistent – symptoms are present more than 4 days a week and more than 4 weeks a year [5, 6, 8, 9].

Also, in clinical practice, experts recommend using the CR classification by severity, extrapolated from the analogous classification for allergic rhinitis [5, 6, 8, 9]:

• mild – the patient has mild symptoms of rhinitis that do not disrupt daytime activity and sleep;

• moderate – rhinitis symptoms interfere with work, study, sports, and disrupt the patient's sleep;

• severe – symptoms significantly impair the patient's quality of life; without therapy, the patient cannot normally work, study, or play sports; nighttime sleep is significantly disturbed.

In adults and adolescents, the severity of CR may be determined using a 10-point visual analogue scale (VAS), where "0" represents no impact of symptoms on sleep and daily activities, and "10" represents the maximum negative impact. The interpretation of VAS results is generally twofold: less than 5 points – mild CR; 5 points or more – moderate/severe CR [6, 8, 9] (Appendix G1).

1.6 Clinical presentation of the disease or condition

None of the CR phenotypes have pathognomonic symptoms. Except for atrophic rhinitis, all CR phenotypes are characterized to varying degrees by non-specific rhinological symptoms: nasal obstruction (nasal congestion), anterior and posterior rhinorrhea (nasal discharge and post-nasal drip), sneezing/nasal itching, and hyposmia. However, the dominant symptom most frequently observed in a specific phenotype and having the greatest impact on the patient's quality of life may vary across different forms of CR (see Table 3).

Table 3. Symptom features in various forms of CR [5, 8, 9, 24]:

Nasal symptoms in chronic rhinitis (CR) are usually exacerbated by trigger factors. However, the effect of triggers in CR is considered less pronounced compared to allergic rhinitis [25]. Also, unlike patients with allergic rhinitis, ocular symptoms are not characteristic of CR [9]. The persistence of CR symptoms can vary significantly depending on the phenotype. For instance, senile rhinitis, NARES, drug-induced rhinitis, and severe forms of occupational rhinitis are characterized by permanent symptoms. In mild forms of occupational rhinitis and in patients with gustatory rhinitis, symptoms appear only upon exposure to the etiological factor. The manifestations of drug-induced rhinitis depend on the administration regimen and the duration of the drug course. Vasomotor rhinitis and hormonal rhinitis typically have a "fluctuating" course associated with the patient's physical condition [1-9].

The symptomatology of atrophic rhinitis differs from the manifestations of other CR phenotypes. In patients with atrophic rhinitis, prominent symptoms include a feeling of dryness/irritation in the nasal cavity, nasal crusting, and episodes of epistaxis. Patients with atrophic rhinitis generally complain of nasal congestion and hyposmia. In severe atrophic rhinitis, patients report complete nasal obstruction (not relieved by topical decongestants) and anosmia. Nasal mucosal hyperreactivity is not characteristic of atrophic rhinitis, although exposure to certain triggers may cause an increased sensation of nasal mucosal irritation. Primary atrophic rhinitis and secondary atrophic rhinitis associated with systemic autoimmune granulomatous polyangiitis are the most severe forms. In these cases, atrophic changes often affect not only the nasal mucosa but also involve cartilaginous and bony structures, potentially leading to nasal septum perforation with changes in the shape of the external nose and nasal concha sequestration. Primary atrophic rhinitis is extremely rare in children, usually manifesting in individuals over 50 years of age. Secondary atrophic rhinitis is significantly more common in children, though pediatric cases are overall less frequent than adult cases [9].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Due to the significant heterogeneity of conditions generalized by the term "chronic rhinitis," there are currently no clear diagnostic criteria for establishing this diagnosis [1,4-9].

Except for atrophic rhinitis, other CR phenotypes are "secondary diagnoses" considered only after ruling out infectious or allergic etiologies of rhinitis. At the same time, there are criteria for defining specific CR phenotypes where the diagnostic algorithm follows this formula: identification of periodic or constant symptoms of rhinitis and corresponding patient complaints + confirmation of a link to exposure to specific exogenous or endogenous factors (excluding infection and allergy) causing the onset/exacerbation of disease symptoms. Only a few phenotypes have a chronometric criterion clearly defining the minimum duration of nasal symptoms and corresponding patient complaints.

Criteria for diagnosing "pregnancy rhinitis" or "gestational rhinitis":

• presence, based on patient complaints and medical history, of nasal congestion absent prior to pregnancy;

• persistence of symptoms for 6 weeks or more;

• exclusion of allergic and infectious causes of inflammation based on a combination of clinical examination and laboratory test data;

• complete resolution of symptoms within 2 weeks postpartum (this item is used only as a criterion in retrospective history analysis).

Criteria for diagnosing "medicamentosa rhinitis":

• confirmation by the patient (or their representatives) of the need for regular daily use of nasal decongestants outside of cold episodes to improve nasal breathing.

Criteria for diagnosing "drug-induced rhinitis":

• confirmation by the patient (or their representatives) of the onset of rhinitis symptoms (primarily nasal congestion) outside of cold episodes during the use of certain classes of drugs (see Table 2); symptoms completely resolve as the drug wears off.

Criteria for diagnosing "occupational rhinitis":

• patient complaints of intermittently occurring or constant rhinitis symptoms while at the workplace (in the absence of rhinitis symptoms before arriving at work) or exacerbation of nasal symptoms while at work;

• symptoms diminish or completely resolve upon leaving the workplace;

• exclusion of allergic rhinitis.

Criteria for diagnosing "elderly rhinitis (senile rhinitis)":

• patient complaints of constant nasal discharge (most often of a mucous nature) or the sensation of mucus dripping down the back of the throat;

• patient age over 65 years;

• exclusion of allergic rhinitis and other causes of rhinorrhea based on otorhinolaryngological examination.

Criteria for diagnosing "gustatory rhinitis":

• patient complaints (or those of their representatives) of rhinitis symptoms arising during the intake of spicy food and subsiding as the intake ceases;

• exclusion of allergic rhinitis;

• absence of rhinitis symptoms at the start of the meal.

Criteria for diagnosing "non-allergic rhinitis with eosinophilia syndrome (NARES)":

• eosinophilia greater than 25% in the cytological analysis of smears from the surface of the upper respiratory tract mucosa (nasal cavity);

• exclusion of allergic rhinitis;

• persisting rhinitis symptoms with pronounced olfactory impairment.

Criteria for diagnosing "vasomotor (idiopathic) rhinitis":

• patient complaints of intermittently occurring or constant rhinitis symptoms (in adult patients, most commonly alternating nasal obstruction of the right and left nasal cavities, onset of nasal congestion on the corresponding side when lying on one's side) with no clear correlation with exogenous and endogenous factors (no data supporting other CR phenotypes);

• exclusion of allergic rhinitis;

• exclusion of other causes of nasal symptoms based on an examination by an otorhinolaryngologist.

There are no universally accepted criteria for diagnosing "hormonal rhinitis." This diagnosis may be valid in patients with confirmed endocrine pathology (hypothyroidism, acromegaly) who complain of persistent rhinitis symptoms (primarily nasal congestion) when other causes of rhinological symptoms are ruled out. Additionally, a diagnosis of "hormonal rhinitis" may be considered in patients complaining of rhinitis symptoms arising during certain transitory physiological states, such as menstruation or puberty, when other causes of nasal symptoms are excluded [1,6,8,9].

Criteria for diagnosing "atrophic rhinitis":

• detection of signs of mucosal atrophy (crusts, dryness of the nasal mucosa);

• patient complaints of intermittent or constant sensations of "nasal dryness," nasal congestion ± worsening/complete loss of smell, or an unpleasant odor of nasal discharge;

  and/or

• patient complaints of recurrent epistaxis.

Practicing physicians should remember that mixed forms of rhinitis exist. The identification of anamnestically and clinically signs, including those confirmed by laboratory tests, for an infectious or allergic cause of nasal inflammation does not rule out the possibility of a particular CR phenotype in the patient [9].

2.1 Complaints and Anamnesis

Complaints and medical history: the medical history should clarify the duration of the disease, what the patient believes triggered the onset of the disease, and the dynamics of the symptoms and clinical manifestations of the disease (including their impact on sleep, daily activities, educational or professional activities), ongoing treatment, and its effect (including adverse events likely associated with the treatment). It is important to clarify the presence of disease symptoms and their severity outside of acute respiratory infection episodes. The severity of clinical symptoms at the time of examination is noted separately in comparison with the severity of symptoms previously.

The personal history clarifies the presence of concomitant diseases in patients (primarily allergies). If concomitant diseases are present, it should be determined whether the patient is being monitored by a specialist for them, what treatment they are receiving, and whether surgical treatment stages are planned. Data on previous rhinosurgical interventions and manipulations in the nasal cavity are of great importance.

2.2 Physical Examination

Comments: a general physical examination is performed for all patients upon presentation to an otorhinolaryngologist in an outpatient setting, as well as upon admission of the patient to an inpatient otorhinolaryngology department.

2.3 Laboratory Diagnostics

Comments: due to low specificity and sensitivity, this study is not advisable to perform in the routine diagnosis of other chronic rhinitis phenotypes [5,6,8,9].

2.4 Instrumental Diagnostics

Comments: cone-beam computed tomography is a type of computed tomography and is considered as an imaging option with lower radiation exposure.

2.5 Other Procedures

Comments: the detection of allergic rhinitis does not rule out the probability of pathogenetic mechanisms underlying chronic rhinitis in an individual patient, which, according to many experts, justifies the presence of so-called mixed forms of rhinitis [1,4-9]. In patients with diagnosed allergic rhinitis, identifying individual chronic rhinitis phenotypes as a concomitant pathology is advisable in case of a dissociation between the detected sensitization to respiratory allergens and the clinical course of the disease (e.g., year-round clinical manifestations of rhinitis in a patient sensitized only to a limited spectrum of seasonal pollen allergens), or in the absence/incomplete control of rhinitis symptoms with the maximum possible treatment of allergic rhinitis while ruling out other rhinological pathology.

Comments: the clinical picture of hypothyroidism in adults varies significantly depending on the severity and duration of thyroid hormone deficiency, the patient's age, and concomitant diseases. The most common symptoms of hypothyroidism include: severe fatigue, drowsiness, dry skin, hair loss, slowed speech, puffiness of the face, fingers, and toes, constipation, memory impairment, feeling cold, hoarseness, depressed mood.

Comments: in addition to congenital hypothyroidism, it is advisable to refer pubertal girls with symptoms of chronic rhinitis for a pediatric endocrinologist consultation when more common causes of nasal symptoms have been excluded: adenoid hypertrophy and adenoiditis, allergic rhinitis, drug-induced rhinitis [32].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

In view of the currently limited data on the etiology and pathogenesis of most chronic rhinitis phenotypes, the treatment of this pathology in children and adults is a rather difficult task with a difficult-to-predict outcome. In most cases (except for hypertrophic rhinitis), chronic rhinitis is not a disease that initially requires surgical treatment, and unjustified surgical intervention in the nasal cavity often harms the patient. Even in the case of justified surgical intervention, the attending physician must explain to the patient that regarding chronic rhinitis, surgery is only a symptomatic method of treatment, the result of which may be improved nasal breathing with extremely minor or no impact on other rhinitis symptoms—rhinorrhea, sneezing attacks, nasal itching, and olfactory impairment. The key direction in the treatment of chronic rhinitis is the elimination/minimization of the causal factor's impact, if one can be identified. If there are no obvious causes or they cannot be effectively addressed, it is advisable to consider available conservative treatment methods. However, most of these treatment methods are merely symptomatic, and the efficacy of many of them has the lowest level of evidence, as it is based not on clinical trial data, but on personal experience and expert opinion [3,6-8].

All forms of chronic rhinitis (except for certain types of atrophic rhinitis) are not regarded as diseases that threaten the patient's life or carry a high risk of severe complications resulting in grievous harm to the patient's health. Therefore, conservative treatment of patients with chronic rhinitis is carried out on a scheduled basis in outpatient clinics and/or hospital consultative departments. If there are indications for surgical treatment, it is performed on a scheduled basis in an otorhinolaryngology department of a hospital or a short-stay hospital.

3.1 Conservative Treatment

Comments: the therapeutic and health-improving regimen in patients with chronic rhinitis implies adherence to certain rules and the organization of daily routine aimed at eliminating or at least reducing the impact of causal factors and nonspecific triggers. The most socially significant triggers whose impact can be limited are tobacco smoke and electronic cigarette vapor. The patient must also be informed that sudden changes in air temperature, high air dustiness, strongly scented substances, spices, and alcoholic beverages can act as exogenous triggers. Exacerbation of chronic rhinitis symptoms can be caused by sleep and rest disturbances, physical inactivity, and emotional stress.

Comments: there are various expert opinions regarding the frequency of washing, duration of the treatment course, and sodium chloride concentration in the solution. At the current stage of our understanding of the problem, it is advisable that the method of elimination and irrigation therapy, frequency of application, choice between iso- or hypertonic solution, and duration of the treatment course be determined by the attending physician for each individual patient depending on the chronic rhinitis phenotype and the clinical course of the disease.

Comments: beclometasone** should be administered at the minimum dose required to achieve effective symptom control. Patients should be warned about the risk of epistaxis during treatment with this group of drugs [37]. Corticosteroids should not be used in patients with clinical and anamnestic signs of nasal mucosa atrophy, including patients with atrophic rhinitis.

Comments: there is currently no data on the expediency of a longer course of azelastine preparations (ATC code: R01AC03) in the treatment of vasomotor rhinitis.

Comments: the use of nasal decongestants (sympathomimetics; ATC code: R01AA) helps reduce only the symptom of nasal obstruction; there are no data regarding the effect of this group of drugs on other rhinitis symptoms.

Given the presence of nasal hyperreactivity in patients with chronic rhinitis and to minimize the ciliotoxic effect mediated by antiseptic preservatives [44–46], it is advisable to prefer nasal preparations without antiseptic preservatives.

Comments: a medical prescription requiring the immediate withdrawal of a nasal decongestant (sympathomimetic) is often not followed by the patient. To increase the likelihood of discontinuing nasal decongestants (sympathomimetics), a gradual withdrawal is necessary, initially decreasing the frequency of application per day and the single dose.

Comments: it is permissible to prescribe only homeopathic remedies registered in the Russian Federation as medicinal products in situations specified in the "indications for use" section of the product labeling.

Comments: when Klebsiella ozaenae is isolated based on microbiological diagnostics in patients with primary atrophic rhinitis, systemic antibacterial therapy is indicated. The choice of drug is based on the results of susceptibility testing of the isolated pathogen to antibacterial and/or other medicinal products.

3.2 Surgical Treatment

To date, there is no evidence supporting the consideration of surgical treatment for such chronic rhinitis phenotypes as hormonal rhinitis, rhinitis of pregnancy, gustatory rhinitis, and drug-induced rhinitis. Surgical treatment is performed in all patients with an established diagnosis of "hypertrophic rhinitis". Surgical treatment, when properly justified, is usually performed in patients with vasomotor rhinitis, medicamentosa rhinitis, NARES, and in rare cases, in patients with senile rhinitis, occupational rhinitis, and atrophic rhinitis. Currently, there are no universally accepted absolute indications for surgery in chronic rhinitis. Since chronic rhinitis is not a life-threatening condition in the long term, the main guiding factor for recommending surgical intervention is the impact of rhinitis symptoms on the patient's quality of life. Surgical intervention for chronic rhinitis is indicated if adequate medical therapy administered for 6–12 months fails to improve the patient's quality of life, or if surgical intervention can significantly improve quality of life compared to the outcome of conservative treatment [3, 4].

The principle of surgical treatment for chronic rhinitis depends on the rhinitis phenotype and the dominant symptom. However, all surgical interventions must be performed while adhering to the principle of minimal trauma to the nasal mucosa [3].

Before any surgical intervention for chronic rhinitis, the patient must be warned about the likely relative instability of the surgical outcome and the potential need for repeated interventions in some cases [3].

Comments: in chronic rhinitis with a dominant symptom of nasal congestion (excluding atrophic rhinitis), various options for inferior turbinate surgery are usually considered: conchotomy (anterior and/or posterior), video-assisted endoscopic inferior turbinoplasty, submucosal vasotomy of the inferior nasal conchae [3, 12–14, 57, 58]. According to several domestic studies, inferior turbinoplasty using high-energy laser technologies (laser correction, coagulation vasotomy) yields good results [73, 74].

Although there are no formal age restrictions for surgical intervention in the pediatric population, the majority of physicians adhere to a conservative approach in preschool and early school-age children [77, 105]. In pediatric patients, regardless of the technical equipment chosen for the surgery, all manipulations in the inferior turbinate area must be performed within the submucosal layer [11]. Submucosal vasotomy of the inferior nasal conchae with simultaneous lateralization of the bone part of the concha can be performed using cold instruments, microdebriders, radiofrequency or coblation devices, etc. Preserving the integrity of the mucosa minimizes complications related to mucociliary clearance impairment, synechia formation, and crusting in the nasal cavity [63, 76].

Comments: if the patient has a pronounced symptom of nasal obstruction, it is advisable to consider performing this intervention simultaneously with other types of surgery on the inferior nasal conchae. This type of treatment is not advisable in patients with clinical and anamnestical signs of atrophic rhinitis.

Comments: excessive or total resection of the inferior nasal conchae disrupts the distribution of airflows in the nasal cavity, contributes to the prolonged formation of crusts in the nasal cavity, increases the risk of infection of the traumatized nasal mucosa, and significantly increases the risk of developing the so-called "empty nose syndrome". Despite the fact that this condition does not have a specific code in the ICD, it is widely covered in the international scientific literature [63].

Comments: surgical intervention in primary atrophic rhinitis is exclusively palliative in nature and aims to remove sequestered structures of the nasal cavity. Given the very small number of patients with this pathology, information on the specifics of surgical treatment in this category of patients is extremely limited.

3.3 Treatment after interventions on the inferior nasal turbinates

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not indicated.

5. Prevention and Dispensary Observation

Specific prevention for pregnancy rhinitis, hormonal rhinitis, elderly rhinitis, non-allergic rhinitis with eosinophilia syndrome (NARES), and vasomotor rhinitis is absent.

Comments: the highest risk of developing drug-induced rhinitis is observed in patients who already have chronic inflammatory diseases of the nasal cavity and paranasal sinuses. For this group of patients, the duration of nasal decongestant use is best limited to 3 days [42].

6. Organization of Medical Care

Diagnosis and conservative treatment of patients with chronic rhinitis are carried out on an elective basis in out-patient settings and/or consultative departments of hospitals. If there are indications for surgical treatment, it is performed on an elective basis in the otorhinolaryngology department of a hospital or a short-stay hospital.

Indications for elective hospitalization in a medical organization for surgical treatment:

1) in vasomotor and drug-induced rhinitis (less commonly in severe cases of NARES, hormonal, occupational, or senile rhinitis), if adequate medical therapy carried out for 6-12 months fails to improve the patient's quality of life, or if surgical intervention can significantly improve the quality of life compared to the existing result of conservative treatment.

2) Hypertrophic rhinitis caused by an enlarged bone framework of the inferior nasal concha, accompanied by persistent severe nasal breathing difficulty and a significant decrease in the patient's quality of life.

3) Severe primary atrophic rhinitis.

4) Severe iatrogenic atrophic rhinitis accompanied by clinical manifestations of empty nose syndrome.

Indications for discharging a patient from a medical organization:

1) Surgical treatment performed to the necessary extent.

2) Satisfactory general condition of the patient after the performed surgical treatment, absence of local and systemic acute inflammatory processes caused by an infectious agent.

7. Additional Information

The features of clinical manifestation and prognosis of the disease course are largely determined by its etiology and the presence and nature of comorbid pathology.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Yunusov A.S., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Zyabkin I.V., MD, Member of the National Medical Association of Otorhinolaryngologists, President of the National Association of Rhinosurgeons, no conflict of interest.

Korneeva O.V., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Karpova E.P., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Tulupov D.A., PhD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Ryazantsev S.V., MD, DSc, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Nosulya E.V., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Gurov A.V., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Polyakov D.P., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest

Svistushkin V.M., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Kim I.A., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Nikiforova G.N., MD, PhD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Vakhrushev S.G., MD, PhD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

The methodology for developing clinical guidelines is based on a comprehensive analysis of the current state of the problem, literature data, and regulatory legal acts, followed by discussion within the professional community and amendments based on the results of resolutions of conferences and national congresses, provided they are approved by the Ministry of Health.

The clinical guidelines summarize the authors' experience in the diagnosis and treatment of patients with adenoid hypertrophy and palatine tonsil hypertrophy. The clinical guidelines contain information necessary for the diagnosis, differential diagnosis, and selection of treatment methods for patients with adenoid hypertrophy and palatine tonsil hypertrophy.

Target audience for these clinical guidelines:

1. otorhinolaryngologists;

2. otorhinolaryngologist-audiologists;

3. city (district) pediatricians;

4. district pediatricians;

5. adolescent general practitioners;

6. general practitioners (family physicians).

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for evaluating the levels of убедительности рекомендаций (LoR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The update mechanism for clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific conditions, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Russian Ministry of Health No. 606n dated November 7, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Allergology and Immunology'."

2. Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On Approval of the Procedure and Deadlines for the Development and Revision of Clinical Guidelines, Their Standard Form, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines."

3. Guidelines for the development of physician action algorithms. Ministry of Health of the Russian Federation, 2016.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

The attending physician must convey the following information to the patient:

1. Chronic rhinitis is a collective term encompassing a fairly common group of acquired nasal cavity diseases that sometimes differ significantly in etiology, clinical manifestations, and disease prognosis.

2. In most cases, the diagnosis of chronic rhinitis is established by excluding other, more frequent causes of inflammatory pathology in the nasal cavity (infection and allergy). At the same time, a specific patient may simultaneously have several causes of rhinitis. The scope of examination required to establish a diagnosis is determined individually for each patient by an otorhinolaryngologist.

3. The treatment of most forms of chronic rhinitis is based on eliminating or at least minimizing the patient's exposure to probable external causative factors, including non-specific triggers, and/or treating the patient's comorbid conditions that affect the clinical manifestations of rhinitis. Treatment of comorbid somatic pathology is carried out by the relevant specialist physicians.

4. Pharmacotherapeutic agents for chronic rhinitis in the vast majority of cases only alleviate the symptoms of the disease rather than cure the patient. The list of medicinal products required to control disease symptoms, their dosage regimen, and the duration of the course are determined by the attending physician based on the likely causes of chronic rhinitis, symptom severity, patient age, and the presence of comorbidities. All medicinal treatments for chronic rhinitis must be used in accordance with the instructions for use. If questions arise regarding the drug therapy for chronic rhinitis, the patient should consult a physician.

5. Indications for surgical treatment of chronic rhinitis are determined by the otorhinolaryngologist. Surgical treatment of chronic rhinitis is elective. The physician must explain and justify to the patient in understandable terms the necessity of the surgery, the expected outcome, and the probable risks of surgical treatment. The final decision on whether to consent to surgery for chronic rhinitis is made by the patient based on the information provided by the otorhinolaryngologist recommending the surgical treatment stage.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1.

Russian title: Visual Analog Scale (VAS).

Original title (if available): Visual Analog Scale.

Source (official developer website, validation publication): Hayes M. H. S., Patterson D. G. (1921). Experimental development of the graphic rating method. Psychol. Bull. 18, 98–99.

Type (underline): rating scale.

Purpose: intended for measuring pain intensity.

Content (template): it is a continuous scale in the form of a horizontal or vertical line 10 cm long with two extreme points located on it: "no pain" and "worst pain imaginable".

Key (interpretation): the patient is asked to make a mark on it corresponding to the intensity of pain they are currently experiencing. The distance between the start of the line ("no pain") and the mark made is measured in centimeters and rounded to the nearest whole number. Each centimeter on the line corresponds to 1 point. A mark up to 2 cm classifies the pain as mild, from 2 to 4 cm as moderate, from 4 to 6 cm as severe, from 6 to 8 cm as very severe, and up to 10 cm as excruciating.