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Wise et al.

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increased nasal resistance as measured by posterior rhinometry. In individuals with and without a history of smoke-induced rhinitis, prolonged exposure to moderate levels of smoke (15 ppm for 2 hours) also induced a congestive response lasting for an hour or longer. 134 Even though the objective response was short lived, patients reported symptoms lasting hours to days following exposure. Significant symptom overlap may exist, but a thorough history and allergy testing can help further differentiate smoke-induced rhinitis from AR. (See section VI.E. Risk factors for allergic rhinitis - Tobacco smoke for additional information on this topic.) III.C.6. Infectious rhinitis— Infectious rhinitis may be classified into acute and chronic forms, with both bacterial and viral etiologies. Physical findings and chronicity of symptoms play an important role in differentiating between different forms of rhinitis, including infectious, allergic, and the inflammation associated with CRS. Symptoms suggestive of a noninfectious etiology include nasal itching and sneezing, while findings of mucosal inflammation and rhinorrhea may be present in either infectious or noninfectious rhinitis. 26 Taken in isolation, dark or purulent rhinorrhea is not pathognomonic for bacterial rhinitis/ rhinosinusitis. Additional findings suggestive of infectious etiologies include associated pharyngeal inflammation or cervical lymphadenopathy. 135 Viral rhinitis typically manifests in an acute form, and accounts for up to 98% of infectious rhinitis in the young child. The incidence of viral rhinitis in young children is 6 episodes per patient-year. 136 In adult viral rhinitis, the incidence is 2 to 3 episodes per year. Symptoms associated with viral rhinitis include clear rhinorrhea, nasal obstruction, and often, fever. The responsible organisms of viral rhinitis can be rhinovirus, adenovirus, influenza virus, and parainfluenza virus. 81 Most viral rhinitis is self-limiting within 4 to 5 days, with prolonged symptoms lasting longer than 2 weeks suggestive of a noninfectious etiology or conversion to bacterial infection. There are instances when continued rhinitis beyond 10 days is felt to be due to worsening infection (ie, possible superimposed bacterial rhinosinusitis) and these patients should be treated more aggressively. 137 Approximately 2% of viral rhinitis episodes are secondarily infected by bacterial organisms such as Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis , with subsequent presentation of acute bacterial infection. 138 III.C.7. Rhinitis of pregnancy and hormonally-induced rhinitis— The development of a type of rhinitis unique to the pregnant patient has been referred to as rhinitis of pregnancy or pregnancy rhinitis. It occurs in about 22% of pregnancies 139 and, although symptoms may occur at any time, it typically starts after the second month of pregnancy and is most severe in the second trimester. 26,140 Rhinitis of pregnancy has been defined as nasal congestion in the last 6 or more weeks of pregnancy, without other signs of respiratory tract infection or allergic cause, followed by complete, spontaneous resolution of symptoms within 2 weeks after delivery. 141 The symptoms of rhinitis of pregnancy, like those of AR, include rhinorrhea and nasal congestion, which can be prominent and prolonged. Clinical history frequently elicits a prior history of chronic rhinitis, obscuring the extent to which pregnancy is a causal or

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.