Pregnancy Rhinitis

Rhinitis in Primary Care

Rhinitis affects a significant portion of the world population and increases the cost of health care by billions of dollars in treatment costs and missed days of work. Allergic rhinitis is the most common cause. Rhinitis is primarily a clinical diagnosis which can be confirmed with specific testing as indicated to ascertain causative agents. Initial treatment includes using topical agents like intranasal corticosteroids and inhaled antihistamines as the first-line therapies for both allergic rhinitis and chronic rhinitis. Therapy can evolve in a stepwise manner depending on the primary symptom complaint prior to referral for advanced therapies such as allergen immunotherapy.

Objective Measurements of Nasal Obstruction and Eustachian Tube Function in Pregnant Women

Background: Hormonal changes during pregnancy have a substantial effect on the swelling of the mucous membrane in the nasal cavity, resulting in rhinitis and Eustachian tube dysfunction. The aim of the study was to assess subjective and objective changes in nasal cavity and Eustachian tube patency in the third trimester of pregnancy. Materials and Methods: The study group included fifty 18-41 year-old women in the third trimester of pregnancy. The control group consisted of 25 females aged 25 to 31 who were not pregnant. The Eustachian tube and nasal cavity patency examination was carried out using a rhinomanometer, a tympanometer and a SNOT-22 Questionnaire. Results: The SNOT-22 showed that subjective nasal obstruction was assessed as strong or worse by 42% of the study group, which was significantly higher than in the control group and confirmed with rhinomanometry. A total of 68% of the study group reported a subjective ear fullness which correlated with the week of pregnancy. The tympanometry showed that all pregnant women exhibited a type A tympanogram, but tympanometry values decreased at higher weeks of pregnancy, and statistical analysis confirmed a significant difference between the study group and the control group in tympanometry for both ears. Conclusions: The results highlight the substantial impact on both subjective and objective measurements of nasal and Eustachian tube patency. Almost every woman in the third trimester of pregnancy experiences nasal obstruction, and nearly 70% struggle with ear fullness. Recognizing and addressing these challenges are pivotal for ensuring the well-being of pregnant individuals and enhancing the quality of antenatal care.

Why Female Smokers Have Poorer Long-Term Health Outcomes than Male Smokers: The Role of Cigarette Smoking During Pregnancy

Objectives: Women's health status is better than men but the opposite is true for female smokers who usually have poorer long-health outcomes than male smokers. The objectives of this study were to thoroughly reviewed and analyzed relevant literature and to propose a hypothesis that may explain this paradox phenomenon. Methods: We conducted a search of literature from three English databases (EMBASE, MEDLINE, and Google Scholar) from inception to 13 November 2023. A combination of key words and/or subject headings in English was applied, including relevant terms for cigarette smoking, sex/gender, pregnancy, and health indicators. We then performed analysis of the searched literature. Results: Based on this review/analysis of literature, we proposed a hypothesis that may explain this paradox phenomenon: female smokers have worse long-term health outcomes than male smokers because some of them smoke during pregnancy, and the adverse effects of cigarette smoking during pregnancy is much stronger than cigarette smoking during non-pregnancy periods. Conclusion: Approval of our pregnancy-amplification theory could provide additional evidence on the adverse effect on women's long-term health outcomes for cigarette smoking during pregnancy.

Effects of Climate Change and Air Pollution on Perinatal Health

Climate change is often framed as an environmental concern; however, the burning of fossil fuels both directly and indirectly impacts air quality and, thus, human health. Gas byproducts of combustion lead to increased levels of atmospheric ozone and carbon dioxide, which in turn elevate surface temperatures of the earth. This process exposes individuals to respiratory irritants and contributes to increased frequency of natural disasters such as wildfires, negatively impacting respiratory health. Normal physiologic changes in the respiratory system make pregnant people particularly vulnerable to the effects of air pollution. Asthma and allergic rhinitis are 2 common respiratory diseases that can be triggered by poor air quality. Solutions to limit the impact of climate change on respiratory disease include risk mitigation and reduction of fossil fuel consumption on individual, organization, and community levels. Midwives are well positioned as clinicians to educate people about individual strategies to reduce environmental exposure to respiratory irritants and advocate for policy changes to limit future health effects of climate change.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Redefining Pregnancy-Induced Rhinitis

BACKGROUND

Pregnancy-induced rhinitis (PIR) is a form of chronic non-allergic rhinitis not present before pregnancy that manifests itself during pregnancy with complete resolution of symptoms after delivery.

OBJECTIVE

The objective of this ambidirectional longitudinal cohort study is to evaluate the prevalence of PIR and to investigate the appearance and character of its symptoms, and its impact on the quality of life.Methodology: Six hundred eighty-one (681) women were recruited in the study. They completed questionnaires about nasal symptoms a day after delivery and each woman with nasal symptoms was interviewed 30 days later and data on symptom duration and quality were recorded.

RESULTS

The prevalence of PIR was 31.86% (N = 217), 47.14% (N = 321) women had no nasal symptoms and 21% (N = 143) of participants had prior sinonasal disease. The clinical presentation of pregnancy rhinitis included nasal obstruction as the most common symptom, followed by rhinorrhea, postnasal secretion, nose itching, sneezing, and hyposmia. The median duration of PIR was 4 months with their complete resolution of symptoms between 2th and 16th day after delivery in the majority of respondents. PIR was diagnosed significantly more often if the women carried a female child. PIR affected their quality of life during pregnancy in 53,9% women (N = 117), with an average VAS score of 8. It seems that pregnancy may affect the course of previously present sinonasal disease (allergic rhinitis, chronic rhinosinusitis, nonallergic rhinitis, or non-infectious rhinitis prior to the pregnancy).

CONCLUSIONS

PIR is a common clinical entity with a wide range of symptoms with a direct impact on the quality of life in pregnancy. We propose a new definition of pregnancy-induced rhinitis.

Anatomical and physiological alterations of pregnancy

The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.

Rhinitis and Sinusitis

Rhinitis is defined as inflammation of the nose, which can extend into and affect the sinuses. The term rhinosinusitis is used to describe inflammation of both the nose and the sinuses. An example of rhinitis is allergic rhinitis, caused by sensitization and exposure to aeroallergens, which, along with other allergic diseases, such as asthma, affect up to one-third of women in the childbearing age. The most common type of rhinosinusitis is infectious, either acute or chronic, which commonly occurs secondarily to a viral respiratory tract infection. Both rhinitis and rhinosinusitis significantly affect the quality of life. The purpose of this chapter is to introduce and describe the differential diagnosis and treatment of these two common clinical entities during pregnancy.

Pregnancy rhinitis in Turkish women: Do gestational week, BMI and parity affect nasal congestion?

Objective:

To determine the cumulative incidence of pregnancy rhinitis along with prevalence in different trimesters and to find out whether gestational age, BMI and parity have any effect on pregnancy related nasal congestion.

Methods:

In the prospective protocol at the obstetrics outpatient clinic, 167 pregnant women were enrolled consecutively. According to exclusion criteria, 67 of them were excluded. Visual-Analogue-Scale (VAS), Nasal-Obstructive-Symptom-Evaluation (NOSE) scale and Discharge-Inflammation-Polyps/Oedema (DIP) scoring were utilized for diagnosis of pregnancy rhinitis. Besides, weight, length, age, parity and week of pregnancy were recorded.

Results:

Total prevalence of pregnancy rhinitis was 17.17% and cumulative incidence was 38.89%. Our study revealed significant relation of NOSE score with both gestational week (r=0.474, p=0.001) and BMI (r=0.301, p=0.003). VAS score was significantly related with gestational week (r=0.409, p=0.001) and BMI (r=0.270, p=0.007). DIP score was found to be correlated only with gestational week (r=0.375, p=0.001).

Conclusion:

Cumulative incidence of pregnancy rhinitis was 38.89%. Nasal congestion was significantly associated with BMI and gestational week. Patients should be informed about unfavorable fetal and maternal outcomes of pregnancy related nasal congestion which is triggered by obesity and excessive weight gain in pregnancy.

WITHDRAWN: Nasal saline irrigations for the symptoms of chronic rhinosinusitis

Review withdrawn from Issue 4, 2016. Review replaced by 'Saline irrigation for chronic rhinosinusitis' (Chong 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.

Rhinitis and pregnancy: literature review

Introduction

There is a controversy concerning the terminology and definition of rhinitis in pregnancy. Gestational rhinitis is a relatively common condition, which has drawn increasing interest in recent years due to a possible association with maternal obstructive sleep apnea syndrome (OSAS) and unfavorable fetal outcomes.

Objective

To review the current knowledge on gestacional rhinitis, and to assess its evidence.

Methods

Structured literature search.

Results

Gestational rhinitis and rhinitis “during pregnancy” are somewhat similar conditions regarding their physiopathology and treatment, but differ regarding definition and prognosis. Hormonal changes have a presumed etiological role, but knowledge about the physiopathology of gestational rhinitis is still lacking. Management of rhinitis during pregnancy focuses on the minimal intervention required for symptom relief.

Conclusion

As it has a great impact on maternal quality of life, both the otorhinolaryngologist and the obstetrician must be careful concerning the early diagnosis and treatment of gestational rhinitis, considering the safety of treatment measures and drugs and their current level of evidence.

Rhinitis in pregnant women with asthma is associated with poorer asthma control and quality of life

OBJECTIVE

To describe the pattern and severity of rhinitis in pregnancy and the impact rhinitis has on asthma control and quality of life (QoL) in pregnant women with asthma.

METHODS

Two hundred and eighteen non-smoking pregnant women with asthma were participants in a randomised controlled trial of exhaled nitric oxide guided treatment adjustment. Rhinitis was assessed using a visual analogue scale (VAS) scored from 0 to 10 and classified as current (VAS > 2.5), moderate/severe versus mild (VAS > 6 vs <5), atopic versus non-atopic and pregnancy rhinitis. At baseline, women completed the 20-Item Sino-Nasal Outcome Test (SNOT20), asthma-specific (AQLQ-M) QoL questionnaires and the Six-Item Short-Form State Trait Anxiety Inventory (STAI-6). Asthma control was assessed using the asthma control questionnaire (ACQ). Perinatal outcomes were collected after delivery.

RESULTS

Current rhinitis was present in 142 (65%) women including 45 (20%) women who developed pregnancy rhinitis. Women with current rhinitis had higher scores for ACQ (p = 0.004), SNOT20 (p < 0.0001) and AQLQ-M (p < 0.0001) compared to women with no rhinitis. Current rhinitis was associated with increased anxiety symptoms (p = 0.002), rhinitis severity was associated with higher ACQ score (p = 0.004) and atopic rhinitis was associated with poorer lung function (p = 0.037). Rhinitis symptom severity improved significantly during gestation (p < 0.0001). There was no impact on perinatal outcomes. Improved asthma control was associated with improvement in rhinitis.

CONCLUSION

Rhinitis in pregnant women with asthma is common and associated with poorer asthma control, sino-nasal and asthma-specific QoL impairment and anxiety. In the context of active asthma management there was significant improvement in rhinitis symptoms and severity as pregnancy progressed.

Commentary on gender differences in prevalence, treatment, and quality of life of patients with chronic rhinosinusitis

Objective:

To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS).

Methods:

Review of the literature and expert opinion.

Results:

From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men.

Conclusions:

Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.

The effects of pregnancy on nasal physiology

BACKGROUND

Nasal congestion that is not present before pregnancy represents a distinct clinical entity called pregnancy rhinitis. The aim of this study is to evaluate the clinical characteristics of nasal physiology over the course of pregnancy.

METHODS

The study was conducted with 85 pregnant women and 26 nonpregnant controls. We measured nasal airway patency objectively via acoustic rhinometry (ARM) and anterior rhinomanometry (RMM) and subjectively via the Nasal Obstruction Symptom Evaluation (NOSE) scale in each trimester and compared the results to those of the controls.

RESULTS

The NOSE scores of control and pregnant women showed no difference (p = 0.866). Minimal cross-sectional area (MCA1; minimal cross sectional area at nasal valve and MCA2; minimal cross sectional area at the level where the head of inferior turbinate is placed) decreased significantly between the first and third trimesters: first trimester 0.37 cm(2), third trimester 0.31 cm(2). There was no difference between each trimester with regard to total nasal resistance. The correlation analysis between the NOSE score and both total volume and MCA1 in all patients showed no significance (r = -0.10, p = 0.318; r = -0.04, p = 0.654, respectively).

CONCLUSION

Pregnancy affects nasal physiology adversely and impairs nasal breathing in some women. However, based on the findings of this study, we concluded that this clinical entity may not be considered as a disease without complementary symptoms despite the presence of objective changes in nasal parameters.

Diagnosing rhinitis during pregnancy

Chronic rhinitis is a common medical condition to affect pregnant women. Uncontrolled rhinitis during pregnancy may have a significant adverse effect on quality of life and may have an effect on coexisting asthma. This article reviews the most common causes of rhinitis to occur during pregnancy as well as treatment options for pregnant women.

Hormonal changes causing rhinitis in pregnancy among Malaysian women

Objectives:

To investigate the aetiology of rhinitis occurring in pregnancy, by (1) describing the relationship between pregnancy rhinitis and serum oestrogen, progesterone, placental growth hormone and insulin-like growth factor, and (2) assessing the prevalence of pregnancy rhinitis among Malaysian women.

Methods:

Prospective study involving 30 pregnant women followed at an ante-natal clinic for 14 months. Hormone levels were analysed during pregnancy and the post-partum period.

Results:

Levels of all four hormones were elevated in the third trimester, compared with first trimester and post-partum values. Rhinitis patients had higher levels of oestrogen and insulin-like growth factor 1 in the third trimester than non-rhinitis patients, although these differences were not statistically significant. The prevalence of rhinitis was 53.3 per cent, with most cases occurring in the third trimester. Patients with pregnancy rhinitis had a higher prevalence of female babies, compared with non-rhinitis patients (p = 0.003).

Conclusions:

Pregnancy rhinitis was significantly more common in women giving birth to female babies. Women with pregnancy rhinitis had a non-significant elevation in oestrogen and insulin-like growth factor 1 levels, compared with those without rhinitis.

Review on the impact of pregnancy and obesity on influenza virus infection

A myriad of risk factors have been linked to an increase in the severity of the pandemic H1N1 2009 influenza A virus [A(H1N1)pdm09] including pregnancy and obesity where death rates can be elevated as compared to the general population. The goal of this review is to provide an overview of the influence of pregnancy and obesity on the reported cases of A(H1N1)pdm09 virus infection and of how the concurrent presence of these factors may have an exacerbating effect on infection outcome. Also, the hypothesized immunologic mechanisms that contribute to A(H1N1)pdm09 virus severity during pregnant or obese states are outlined. Identifying the mechanisms underlying the increased disease severity in these populations may result in improved therapeutic approaches and future pandemic preparedness.

Pott's puffy tumour and intracranial complications of frontal sinusitis in pregnancy

Introduction:

A Pott's puffy tumour is a subperiosteal abscess and osteomyelitis of the frontal bone secondary to frontal sinusitis. Intracranial complications are seen in approximately 40 per cent of cases and are potentially life-threatening; such complications have not previously been reported in pregnancy.

Case report:

A 21-year-old woman at 35 weeks' gestation presented with a history of frontal headaches and swelling, periorbital oedema, pain and chemosis. Imaging confirmed Pott's puffy tumour with right-sided epidural empyema and periorbital cellulitis. A multidisciplinary team was involved in the patient's management. Intravenous antibiotics were commenced and initial percutaneous drainage through the frontal sinus skin was performed, followed by endoscopic sinus drainage. A caesarean section was performed 3 days later. Complete resolution of the sinus and intracranial collections was noted on imaging performed six weeks later.

Conclusion:

This case highlights the challenges of managing rare intracranial complications of sinusitis in pregnancy, and the importance of multidisciplinary care.

Rhinosinusitis-Related Quality of Life during Pregnancy

Background

Pregnancy rhinitis manifests as nasal congestion, with resolution of symptoms after delivery. Eighteen to 30% of pregnant patients report symptoms of rhinitis. Pregnancy rhinitis may have an adverse effect on quality of life (QOL) and may cause obstructive sleep apnea (OSA), which in turn may adversely affect the outcome of pregnancy. Previous examinations of the prevalence of pregnancy rhinitis during different stages of pregnancy have been inconclusive. This study aimed to determine rhinosinusitis-specific QOL during different stages of pregnancy.

Methods

A cross-sectional observation study of patients in the second and third trimesters of pregnancy using the 22-item Sino-Nasal Outcome Test (SNOT-22) was conducted in the obstetric clinic at McGill University Health Center in Montreal, Canada. Seventy-six low- risk pregnant patients were included in the study. Thirty-two patients were in the second trimester of pregnancy and 44 patients were in the third trimester.

Results

Average item scores for the entire questionnaire were significantly higher (p = 0.041), indicating more severe impairment of QOL, in the third trimester in comparison with the second trimester. A comparison between women with and without preexisting allergic rhinitis, in both the second and the third trimesters, shows significantly higher SNOT-22 scores for the allergic group (p = 0.007). QOL was lower in the third trimester than in nonrhinosinusitis patients (p = 0.011).

Conclusion

Rhinosinusitis-specific QOL is lower in the third trimester of pregnancy in comparison with the second trimester and also in comparison with nonrhinosinusitis patients. Increased awareness may enhance the QOL of pregnant patients, prevent OSA, and thereby positively influence the outcome of pregnancy.

Asthma and rhinitis during pregnancy

Pregnancy may be complicated by new-onset or preexisting rhinitis, or asthma. This article reviews the recognition and management of rhinitis and asthma during pregnancy, as well as general principles of medication use during pregnancy. Asthma is one of the most common potentially serious medical problems to complicate pregnancy, and chronic rhinitis is even more common in pregnant women. Both conditions may substantially affect maternal quality of life and directly or indirectly affect the pregnancy. Optimal management of asthma and rhinitis during pregnancy is thus important for both mother and baby. This article reviews the assessment and management of rhinitis and asthma in pregnant women.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Nasal saline irrigations for the symptoms of chronic rhinosinusitis

BACKGROUND

The use of nasal irrigation for the treatment of nose and sinus complaints has its foundations in yogic and homeopathic traditions. There has been increasing use of saline irrigation, douches, sprays and rinsing as an adjunct to the medical management of chronic rhinosinusitis. Treatment strategies often include the use of topical saline from once to more than four times a day. Considerable patient effort is often involved. Any additional benefit has been difficult to discern from other treatments.

OBJECTIVES

To evaluate the effectiveness and safety of topical saline in the management of chronic rhinosinusitis.

SEARCH STRATEGY

Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006). The date of the last search was November 2006.

SELECTION CRITERIA

Randomised controlled trials in which saline was evaluated in comparison with either no treatment, a placebo, as an adjunct to other treatments or against treatments. The comparison of hypertonic versus isotonic solutions was also compared.

DATA COLLECTION AND ANALYSIS

Trials were graded for methodological quality using the Cochrane approach (modification of Chalmers 1990). Only symptom scores from saline versus no treatment and symptom and radiological scores from the hypertonic versus isotonic group could be pooled for statistical analysis. A narrative overview of the remaining results is presented.

MAIN RESULTS

Eight trials were identified that satisfied the inclusion criteria. Three studies compared topical saline against no treatment, one against placebo, one as an adjunct to and one against an intranasal steroid spray. Two studies compared different hypertonic solutions against isotonic saline. There is evidence that saline is beneficial in the treatment of the symptoms of chronic rhinosinusitis when used as the sole modality of treatment. Evidence also exists in favour of saline as a treatment adjunct. No superiority was seen when saline was compared against a reflexology 'placebo'. Saline is not as effective as an intranasal steroid. Some evidence suggests that hypertonic solutions improve objective measures but the impact on symptoms is less clear.

AUTHORS' CONCLUSIONS

Saline irrigations are well tolerated. Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis.