Acute Viral Rhinitis

Acute viral rhinitis (the common cold) is a self-limiting viral infection of the nasal mucosa with sneezing, nasal discharge and obstruction, with or without pharyngitis and cough. Adults have 2 to 4 episodes per year and school children 6 to 8 (up to 12), and symptoms usually last 7 to 10 days (up to 14 days in children).

• Over 200 viruses cause it: rhinoviruses (30 to 50% of cases, with over 160 types), coronaviruses (10 to 15%), respiratory syncytial virus, influenza and parainfluenza viruses, adenoviruses, human metapneumovirus, and enteroviruses.
• Transmission is by aerosol, respiratory droplets and direct contact with contaminated surfaces and hands (the nose and eye are the main portals). The incubation period is 1 to 3 days, and the patient is infectious from 1 day before symptoms until about 5 to 7 days after onset.
• Highest incidence is in autumn and winter, in children (daycare and school), and in crowded spaces. Risk factors: smoking, stress, poor sleep, immunosuppression, and exposure to children.
• Mechanisms of symptoms: viral infection of the nasal epithelium induces inflammatory mediators (bradykinin, interleukin-8, histamine, leukotrienes), vasodilation, increased vascular permeability, glandular secretion and nerve stimulation, rather than direct cell destruction.
• Complications: acute bacterial rhinosinusitis in about 0.5 to 2% of cases, acute otitis media (especially in children), exacerbation of asthma or COPD, lower respiratory tract infection, pneumonia, and bacterial pharyngitis.

• Onset with throat irritation, malaise and sneezing, followed in 1 to 2 days by nasal discharge (watery, then thick and mucopurulent) and nasal obstruction, with peak symptoms at 2 to 4 days. Associated features: sore throat, cough (in 40 to 60%), hoarseness, mild headache, low grade fever (more common in children), and mild malaise.
• Change of mucus colour to yellow or green reflects neutrophil enzymes and does not indicate bacterial infection.
• Examination: red, swollen nasal mucosa with clear or mucopurulent secretions, mildly inflamed pharynx, and possible conjunctivitis. There are no focal signs in the chest and no marked fever in adults.
• Differential diagnosis: allergic rhinitis, influenza (abrupt onset, high fever, myalgia, prostration), COVID-19, acute bacterial sinusitis, streptococcal pharyngitis, infectious mononucleosis, pertussis, nasal foreign body in a child with unilateral discharge, rhinitis medicamentosa, vasomotor rhinitis, and medicine induced rhinitis.
• Red flags: fever above 39 C persisting beyond 3 days, symptoms lasting more than 10 days without improvement, a double worsening pattern (improvement then deterioration), severe unilateral facial pain, periorbital swelling, double vision, neck stiffness, severe headache, difficulty swallowing or drooling, stridor, breathlessness, ear pain with discharge or hearing loss, and an infant under 3 months with fever.

• Clinical diagnosis, based on the typical symptoms and the season, with no routine testing. Laboratory tests are not needed.
• Rapid or molecular testing for influenza, COVID-19 or respiratory syncytial virus is done when the result changes treatment or infection control (for example, in high risk people, outbreaks or hospital care).
• Rapid antigen test or throat swab for group A streptococcus when sore throat is prominent with fever, tonsillar exudate, tender anterior cervical nodes, and no cough.
• Examine the ears in children with ear pain, the sinuses in adults with persistent symptoms, and the chest in those with cough or breathlessness.
• Consider chest X-ray, sinus imaging or blood tests only for complicated or prolonged illness, or for red flags.

• Explain that the illness is viral and self-limiting, lasts 7 to 10 days, and that antibiotics do not shorten it or prevent complications. Cough may last up to 3 weeks.
• Supportive therapy (all patients):
  • Rest, adequate fluids and a balanced diet. Avoid smoking and alcohol. Humidified air and warm drinks relieve symptoms.
  • Saline nasal irrigation or spray (0.9% sodium chloride, 2 sprays into each nostril 3 to 4 times daily, or 120 to 240 mL irrigation once or twice daily) to loosen secretions, which also reduces symptoms in children.
  • Honey for cough (children over 1 year: 2.5 to 5 mL at night).
  • Gargling with warm salt water, or sucking lozenges for sore throat.
• Analgesic and antipyretic therapy:
  • Paracetamol 1 g orally every 6 hours (maximum 4 g per day, with 3 g in adults weighing under 50 kg and 2 g in chronic liver disease), or ibuprofen 400 mg orally every 8 hours with food (maximum 1.2 g per day without prescription supervision).
  • Child: paracetamol 15 mg/kg every 4 to 6 hours (maximum 60 mg/kg per day), or ibuprofen 5 to 10 mg/kg every 6 to 8 hours (maximum 40 mg/kg per day, in children over 3 months), for fever or discomfort.
• Nasal decongestion (short course):
  • Oxymetazoline 0.05% nasal spray, 2 sprays into each nostril every 12 hours for a maximum of 3 days (up to 5 days), or xylometazoline 0.1% nasal spray, 1 to 2 sprays into each nostril 2 to 3 times daily for 5 days at most (child 6 to 11 years 0.05% strength, 1 spray 2 to 3 times daily). Longer use causes rebound congestion (rhinitis medicamentosa). Do not use in children under 6 years (0.05% strength in children under 12 only on medical advice).
  • Pseudoephedrine 60 mg orally every 6 hours (maximum 240 mg per day) for 3 to 5 days. Avoid in hypertension, heart disease, hyperthyroidism, glaucoma, urinary retention, pregnancy (first trimester), and with monoamine oxidase inhibitors, and avoid in children under 12 years.
  • Phenylephrine oral tablets are not effective for nasal congestion and are not advised.
• Antihistamine and anticholinergic therapy:
  • First generation antihistamine such as chlorphenamine 4 mg orally every 4 to 6 hours (maximum 24 mg per day) gives a small benefit for sneezing and rhinorrhoea in the first 2 days, at the cost of drowsiness and dry mouth. Avoid in older adults, glaucoma, and prostatic enlargement, and in children under 2 years.
  • Ipratropium bromide nasal spray 0.06% (42 micrograms per spray), 2 sprays into each nostril 3 to 4 times daily for up to 4 days, reduces rhinorrhoea and sneezing. Dry nose and nose bleeding are adverse effects.
  • Non-sedating antihistamines (cetirizine, loratadine) do not help a cold, and are used only for allergic rhinitis.
• Cough and sore throat:
  • Dextromethorphan 10 to 20 mg orally every 4 to 6 hours (maximum 120 mg per day), or codeine linctus 15 to 30 mg every 6 hours for a few days in adults only, for a dry cough disturbing sleep.
  • Throat lozenges or benzydamine 0.15% oral rinse or spray, 15 mL gargled every 1.5 to 3 hours for a maximum of 7 days (adults and children over 12 years).
• Complementary options with limited evidence: zinc lozenges (zinc acetate or gluconate, 75 mg daily of elemental zinc, in divided doses, started within 24 hours and used for up to 5 to 10 days, which may shorten the illness by about 1 day, with nausea and a bad taste as adverse effects, and avoid long term use because of copper deficiency); vitamin C taken regularly (200 mg or more daily) slightly reduces the duration, and does not help when started during the illness; and echinacea, with inconsistent evidence. Antibiotics, oral steroids and antivirals have no role in simple colds.
• Treat complications:
  • Acute bacterial rhinosinusitis: symptoms for more than 10 days without improvement, or a double worsening pattern, or severe features (fever above 39 C with purulent discharge and facial pain for at least 3 to 4 days). Give amoxicillin 500 mg orally 8 hourly for 5 to 7 days (child 25 to 30 mg/kg 8 hourly), or doxycycline 100 mg orally 12 hourly for 5 to 7 days (adults and children over 8 years) in penicillin allergy, with intranasal steroid and saline.
  • Acute otitis media: analgesia, and amoxicillin 500 mg orally 8 hourly for 5 to 7 days (child 25 to 30 mg/kg 8 hourly, 40 mg/kg 12 hourly in higher risk) if age under 2 years, bilateral disease, discharge or severe symptoms, otherwise watchful waiting for 48 hours.
  • Group A streptococcal pharyngitis: phenoxymethylpenicillin 500 mg orally every 6 hours (or 1 g every 12 hours) for 10 days (child 10 to 15 mg/kg per dose 12 hourly). Penicillin allergy: azithromycin 500 mg once daily for 3 days, or clarithromycin 250 to 500 mg 12 hourly for 5 days.
  • Asthma or COPD exacerbation: increase bronchodilator therapy, with prednisolone 30 to 40 mg orally once daily for 5 days.
  • Pneumonia: arrange a chest X-ray; give amoxicillin 500 mg to 1 g orally 8 hourly for 5 days when mild, and admit if severe.
• Prevention and infection control: regular hand washing with soap for 20 seconds or alcohol rub (60% or more), avoiding touching the face, respiratory hygiene (cough into the elbow, disposable tissues), avoiding close contact with sick people, stopping smoking, and staying at home when feverish. Masks help in some settings. Vaccines apply to influenza and COVID-19 only.
• Special groups:
  • Infants and young children: nasal saline drops and gentle suction, upright positioning, small frequent feeds, paracetamol or ibuprofen for distress and fever, and avoidance of cough and cold medicines under 6 years. Examine for fast breathing (above 60 per minute in infants under 2 months, above 50 for 2 to 11 months, above 40 for 1 to 5 years), recession, poor feeding, and apnoea in young infants, which need urgent review. Refer infants under 3 months with fever.
  • Pregnancy: paracetamol, saline, steam inhalation, honey, and lozenges. Oxymetazoline for 3 days at most. Avoid pseudoephedrine in the first trimester and avoid ibuprofen from 20 weeks. Chlorphenamine is acceptable. Get influenza vaccination.
  • Breastfeeding: paracetamol and ibuprofen are compatible. Avoid pseudoephedrine in large doses because it can reduce milk supply.
  • Elderly: avoid first generation antihistamines and decongestants where possible, and monitor for secondary pneumonia and confusion.
  • Hypertension and heart disease: avoid oral decongestants, and use saline and short topical decongestants with caution.
  • Asthma, COPD and immunosuppression: lower threshold for review and for treatment of complications, and give influenza and pneumococcal vaccination as appropriate.
  • Renal impairment: avoid NSAIDs (use paracetamol), and reduce doses of cetirizine and other renally cleared drugs.
  • Hepatic impairment: restrict paracetamol to 2 g per day.
• Follow up: none needed for uncomplicated illness. Advise return if symptoms exceed 10 days without improvement, if there is worsening after initial improvement, or for red flags (high fever, breathlessness, ear pain, facial swelling, neck stiffness, drooling, stridor). Refer to ENT for recurrent complicated sinusitis or otitis media.