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World Journal of Otorhinolaryngology - Head and Neck Surgery logoLink to World Journal of Otorhinolaryngology - Head and Neck Surgery
. 2025 Jul 6:10.1002/wjo2.70034. Online ahead of print. doi: 10.1002/wjo2.70034

Variations in the Severity of Rhinitis Symptoms: A Systematic Review and Meta‐Analysis

Asher T Ripp 1,2, Pranav A Patel 1, Shaun A Nguyen 1,✉, Isabella V Schafer 1, Alexander N Duffy 1, Zachary M Soler 1, Rodney J Schlosser 1
PMCID: PMC13399166  PMID: 42500067

ABSTRACT

Objective

Key rhinitis symptoms include nasal obstruction, rhinorrhea, sneezing, and nasal itching. Different subtypes of rhinitis can have varying presentations, making it difficult to diagnose and categorize. The objective of this review is to characterize the baseline presentation of rhinitis and highlight differences in the presentation of various subtypes.

Data Sources

PubMed (National Library of Medicine), Scopus (Elsevier), and CINAHL (EBSCO).

Methods

A literature search was conducted from database inception to August 2024 for articles reporting baseline symptoms for adult patients with rhinitis. Specific questionnaires of interest were the Total Nasal Symptom Score (TNSS) and Visual Analog Scale (VAS) equivalents of the four TNSS items. Rhinitis types included allergic (AR) and nonallergic rhinitis (NAR); allergic rhinitis was further subcategorized by intermittent (IAR) and persistent (PER) symptomatology. Primary outcome measures included proportions (%) and mean difference/proportion difference (Δ) with 95% confidence intervals.

Results

A total of 89 studies (N = 14,448 patients) were included for meta‐analysis. Nasal congestion was the most severe symptom (2.03 [95% CI 1.91–2.15]) across all patients. Rhinorrhea was the symptom reported as moderate/severe (score of 2–3) at the highest frequency (93.2%). AR patients had higher total TNSS scores (7.31 vs. 5.22 [95% CI 1.84–1.91]), rhinorrhea and sneezing scores (p < 0.0001) than NAR patients. NAR patients, however, had more severe nasal congestion (2.04 vs. 1.99 [95% CI 0.04–0.05]). PER patients recorded higher total TNSS scores than IAR patients (7.20 vs. 6.85 [95% CI 0.25–0.45]), but IAR patients reported more severe individual symptoms scores for congestion, rhinorrhea, and nasal itching (all p < 0.0001).

Conclusion

Nasal congestion is the most severe symptom at baseline presentation for all subtypes of rhinitis. Allergic status and symptom duration influence both overall disease severity and individual symptom scores.

Keywords: adults rhinology, allergy/rhinology, quality of life

Summary

  • Congestion and rhinorrhea represent the most severe presenting symptoms among adults with rhinitis

  • Patients with allergic rhinitis tend to have a more severe presentation than patients with nonallergic rhinitis

  • Symptom duration does not clinically differentiate patients with persistent allergic symptoms versus those with intermittent allergic symptoms

1. Introduction

Rhinitis is a heterogeneous disease that is characterized by inflammation of the nasal mucosa, leading to symptoms of nasal congestion, rhinorrhea, sneezing, and nasal itching [1]. Chronic rhinitis is estimated to affect up to 30% of the global population, with allergic rhinitis (AR) afflicting over 500 million people worldwide [2, 3]. However, this estimate has been limited in part due to the difficulty in establishing a diagnosis.

Diagnosing and classifying rhinitis is a vital step in initial patient management, as it will influence treatment plans and the clinical suspicion of comorbid diagnoses such as asthma or chronic rhinosinusitis (CRS) with or without nasal polyps (CRSwNP and CRSsNP, respectively) [3]. A large part of diagnosis relies on subjective symptom reporting. The Total Nasal Symptom Score (TNSS) is a validated four‐item questionnaire used to assess the severity of nasal obstruction, rhinorrhea, sneezing, and nasal itching [4]. The relative severity of each respective symptom ideally aids in classifying the specific subtype of rhinitis the patient is suffering from. The most basic dichotomy within rhinitis is between AR and nonallergic rhinitis (NAR), with AR being further subclassified as intermittent (IAR) or persistent (PER), depending on symptom chronology [2]. NAR tends to be a less well‐defined disease than AR and lacks the same level of robust epidemiologic data [3]. The two conditions can be difficult to distinguish clinically, as NAR is often a diagnosis of exclusion and has an overlapping presentation with AR [3, 5].

Characterizing variations in individual symptom severity provides pivotal supporting information for arriving at the correct diagnosis and targeting the most bothersome symptoms. This is especially helpful when dealing with diagnoses of exclusion, such as NAR. The ability to properly classify patients helps guide clinicians toward the appropriate treatment path [3, 6]. Having a precise measure of symptoms at baseline lastly helps physicians track symptom improvement over time.

This systematic review and meta‐analysis aims to provide a comprehensive summary of the most bothersome symptoms experienced by rhinitis patients. Additionally, we aim to highlight any significant discrepancies in how different rhinitis subtypes experience these symptoms. These baseline scores will serve as a template to aid physicians in supplementing available laboratory testing to arrive at the correct rhinitis diagnosis. This, in turn, will enable patients to receive the most appropriate treatment, and allow them to track their response over time. The authors hypothesize that certain symptoms will present more severely, and there will be clinically meaningful differences in how various rhinitis subtypes present.

2. Methods

2.1. Research Question

This systematic review and meta‐analysis intends to answer the question: “How do adults with rhinitis present at baseline, and do these symptoms vary by rhinitis subtype?” We hypothesize that we will observe differences in symptom severity and prevalence between rhinitis subtypes, as measured by the four‐item TNSS questionnaire.

2.2. Search Criteria

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) [7]. A comprehensive literature search was conducted on PubMed (National Library of Medicine), Scopus (Elsevier), and CINAHL (EBSCO). The initial search strategy was designed for PubMed and included keywords and medical subjected headings (MeSH) relating to rhinitis, TNSS, and nasal drainage. The PubMed search strategy was subsequently adapted for SCOPUS and CINAHL as necessary. The complete search strategy can be found in the Supporting Information S1. Following completion of the literature search, articles were uploaded to Covidence systematic review software.

2.3. Study Selection

Two authors (A.T.R. and P.A.P.) independently reviewed articles by title and abstract for initial inclusion into the study. Relevant articles then underwent full‐text screening for final inclusion into the study. Following each stage of screening, discrepancies between reviewers were mediated by a third party (S.A.N.). Inclusion criteria were studies that included (1) adult populations with a diagnosis of rhinitis and (2) itemized responses to the TNSS survey or VAS questionnaires. Exclusion criteria were (1) animal studies, (2) studies without an available English translation, (3) case studies, (4) review articles, (5) non‐itemized questionnaire data, (6) non‐standardized questionnaire data, (7) non‐extractable data, and (8) pediatric populations < 16 years of age.

2.4. Study Appraisal

Included studies were assigned a level of evidence based on the criteria set forth by the Oxford Center for Evidence‐Based Medicine [8]. Randomized control and comparative studies were assessed for bias using the Revised Cochrane risk‐of‐bias tool for randomized trials (RoB‐2), and nonrandomized studies were appraised with the Risk of Bias in Non‐Randomized Studies—of Interventions (ROBINS‐I) assessment tool [9, 10]. For cross‐sectional, case series, and case–control studies, the Joanna Briggs Institute (JBI) Critical Appraisal Tool checklist was utilized to test for risk of bias [11]. Two study authors (A.T.R. and I.V.S.) independently assessed each study for risk of bias using the appropriate tool, with any disagreements being reconciled by a third party (S.A.N.). For studies utilizing the RoB‐2 and ROBINS‐I risk of bias tools, response options were “high risk,” “low risk,” or “unclear.” The JBI responses included “yes,” which equated to a score of 1, or “no,” “not applicable,” or “unclear,” which received a score of zero. Case series and case–control studies were scored out of 10; any score above 5 signified that a study had a low risk of bias. Similarly, cross‐sectional studies were scored based on an 8‐item checklist, with any score above 4 equating to a low risk of bias. Only studies that were classified as having a low risk of bias were included in the final analysis.

2.5. Data Extraction

Two authors (A.T.R. and P.A.P.) independently extracted data into a spreadsheet designed for the patient population of interest. Any disagreements or inaccuracies were resolved by a third party (S.A.N.). Relevant data included author name, country of publication, year of publication, study design, sample size, study population and specific subgrouping of rhinitis, patient demographics, patient comorbidities, and intervention, when applicable. Outcome data included the 4‐item TNSS and total symptom score, which are scored from 0 to 3 and 0 to 12, respectively. VAS equivalents of the four TNSS items were simultaneously extracted when TNSS data were not available. These items included runny nose, nasal obstruction, itchy nose, and sneezing. VAS scores were standardized to a 0–10 cm scale to allow consistency in measurements. Lastly, 0–3 and 0–10 scoring for postnasal drip (PND) and hyposmia were collected when available. To compare measurements across different VAS questionnaires, the following terms were equated to runny nose: “rhinorrhea” and “nasal discharge.” Similarly, the terms “congestion,” or “nasal congestion,” were equated to the VAS item nasal obstruction. Rhinitis subtypes included allergic (AR) and nonallergic rhinitis (NAR); allergic rhinitis was further subcategorized by intermittent (IAR) and persistent (PER) symptomatology. Studies which included a mixture of patients with AR and NAR but did not stratify their results by rhinitis subtype were classified as rhinitis (unstratified). These seventeen studies were included in the overall analysis but were excluded from the subgroup analysis.

The minimal clinically important difference (MCID) is an important concept in assessing differences in quality‐of‐life measurements. It is defined as the lowest change in a score which correlates with a noticeable change in the patients’ symptoms [12]. The MCID for the TNSS scoring has been heavily debated, with more recent distribution‐based methods calculating a value between 0.23 and 0.28 [13]. The VAS MCID falls between 0.9 and 1.3 depending on the symptom being measured [14, 15].

2.6. Statistical Analysis

Meta‐analysis of continuous measures (age, symptom duration, BMI, TNSS scores, VAS scores) and meta‐analysis of proportions (gender, patient comorbidities and characteristics, symptom prevalence) were performed by Comprehensive Meta‐Analysis version 4 (Biostat Inc., Englewood, NJ, USA). Meta‐analysis of mean difference (baseline and post‐surgery) was performed by Cochrane Review Manager (RevMan) version 5.4 (The Cochrane Collaboration 2020, United Kingdom). Each measure (mean/proportion (%)/ANOVA and 95% confidence interval (CI) was weighted according to the number of patients affected. As some studies reported the outcomes in median (first quartile, third quartile), the quantile estimation (QE) method was deployed to calculate the pooled estimates as specified by Cochrane Review [16, 17, 18]. Heterogeneity among studies was assessed using χ 2 and I 2 statistics with fixed effects (I 2 < 50%) and random effects (I 2 > 50%). In addition, a comparison of means and proportions, expressed as difference (Δ) and 95% CI, was done to compare outcomes between two groups. Finally, potential publication bias was evaluated by visual inspection of the funnel plot and Egger's regression test, which statistically examines the asymmetry of the funnel plot [19, 20]. A p value of < 0.05 was considered to indicate a significant difference for all statistical tests.

3. Results

3.1. Search Results and Study Characteristics

The literature search produced 1715 studies. After removal of 356 duplicates, 1359 unique results remained for title and abstract screening. A full‐text review was performed on 526 studies, of which, 436 were excluded. Reasons for exclusion included pediatric population, no itemized TNSS or VAS scoring, non‐extractable data, no translation available, wrong questionnaire used, wrong outcomes, lack of baseline data, wrong patient population, incorrect study design, lack of full text or translation, overlapping data, and high risk of bias. At the conclusion of the review, 89 studies met the inclusion criteria and were included in the analysis [21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110]. A PRISMA diagram illustrating this process is available in Figure 1. A summary of included studies can be found in Table 1.

Figure 1.

Figure 1

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PRISMA systematic review flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐analysis.

Table 1.

Summary of included studies.

Author OCEBM level of evidence Subgroup Total patients (n) Age, mean (range) (years) Outcomes
Abtahi (2013) 2 AR 50 26.7 TNSS
Akhavan (2015) 2 AR 140 30.3 VAS
Alyasin (2016) 2 AR 62 36.6 (25–60) TNSS
Andaloro (2023) 2 IAR 40 37.7 TNSS
Banhiran (2010) 3 Rhinitis (unstratified) 28 43.5 (30–71) VAS
Banhiran (2015) 2 Rhinitis (unstratified) 84 46.2 VAS
Bernstein (1996) 2 IAR 239 35.7 TNSS
Bousquet (2013) 3 AR 979 41.8 (18–94) TNSS
Caffier (2011) 3 AR 40 40 VAS
Cantone (2015) 2 NAR 60 73.5 VAS
Caruso (2018) 2 AR 26 41.2 (24–54) VAS
Chang (2021) 2 AR 60 32.7 (20–80) VAS
Chen (2008) 2 PER 160 39.2 (19–61) VAS
Cingi (2010) 3 AR 100 27.2 (18–49) TNSS
Del Signore (2022) 2 Rhinitis (unstratified) 133 55.2 TNSS
Di Lorenzo (2011) 4 Rhinitis (unstratified) 1511 35 TNSS
Du (2024) 3 AR 33 32.8 VAS
Ellis (2016) 2 IAR 222 39 TNSS
Gao (2021) 4 AR 20 37.1 VAS
Gariuc (2020) 2 AR 50 37.9 VAS
Gelardi (2015) 4 AR 83 34.7 VAS
Gerka Stuyt (2021) 4 Rhinitis (unstratified) 24 60.0 (25–90) TNSS
Golding‐Wood (1996) 3 PER 25 40.7 (16–64) VAS
Gomes (2016) 4 IAR 10 — TNSS
Guilemany (2012) 2 PER 27 31.9 TNSS
Hajiheydari (2017) 2 AR 71 32.7 VAS
Hoang (2023) 2 AR 262 31.3 TNSS
Hou (2018) 4 AR 75 36.2 VAS
Hwang (2017) 3 Rhinitis (unstratified) 27 53.3 TNSS
Jiang (2020) 2 PER 705 36.2 VAS
Jin (2022) 2 Rhinitis (unstratified) 103 41.5 TNSS
Jo (2022) 2 PER 40 42.2 TNSS
Jung (2011) 2 PER 59 26.4 (19–48) TNSS
Juvekar (2024) 3 AR 388 39.9 TNSS
Kang (2020) 2 PER 84 33.5 TNSS
Kim (2022) 3 AR 2670 54.4 TNSS
Kubavat (2011) 3 AR 220 35.8 (18–75) TNSS
Kim (2016) 4 Rhinitis (unstratified) 40 38.7 TNSS
Kim (2024) 4 Rhinitis (unstratified) 300 47.4 VAS
Kirtsreesakul (2010) 3 AR 69 30.8 (16–52) TNSS
Krug (2005) 2 IAR 165 26.4 (18–52) TNSS
Lee (2024) 3 Rhinitis (unstratified) 129 57.8 TNSS
Liang (2023) 3 PER 109 29.5 TNSS
Lin (2010) 4 AR 101 29.1 VAS
Lin (2011) 4 PER 120 58.5 SNOT
Liu (2009) 2 PER 90 37.5 (18–59) VAS
Liu (2023) 2 IAR 152 41.1 VAS
Lumry (2003) 2 Rhinitis (unstratified) 105 36.9 (19–71) TNSS
Maniaci (2023) 2 AR 11 32.4 VAS
Masieri (2016) 3 IAR 20 47 (26–70) VAS
McFadden (2000) 2 PER 54 30 (19–51) VAS
Meng (2019) 2 AR 38 31.4 TNSS
Meng (2021) 3 PER 104 37 VAS
Mi (2020) 2 PER 229 37.6 TNSS
Mo (2021) 2 PER 28 34 TNSS
Moffa (2023) 3 PER 60 44.7 (24–73) TNSS
Mori (1999) 3 AR 120 25.9 TNSS
OnerciCelebi (2023) 2 PER 47 31 TNSS
Parida (2011) 3 IAR 70 (20–45) VAS
Perić (2021) 2 AR 96 39.4 (18–65) VAS
Qian (2019) 3 AR 29 23.7 TNSS
Qiao (2022) 3 Rhinitis (unstratified) 36 36.8 TNSS
Reh (2023) 4 IAR 20 62.8 TNSS, VAS
Schäper (2009) 3 AR 120 32.2 (19–65) TNSS
Shi (2023) 4 AR 160 29.6 TNSS
Song (2022) 4 Rhinitis (unstratified) 116 29.3 TNSS
Stolovitzky (2021) 2 AR 89 57.5 TNSS
Suojalehto (2014) 4 NAR 44 33 VAS
Takashima (2024) 2 Rhinitis (unstratified) 104 57.3 TNSS
Tamasauskiene (2021) 4 Rhinitis (unstratified) 65 32.6 TNSS
Tang (2014) 3 AR 36 (23–45) VAS
Tatar (2012) 3 AR 150 30.6 (17–53) Score prevalence
Tosun (2005) 4 NAR 20 29.2 (20–40) VAS
Tungsukruthai (2018) 2 AR 64 — VAS
Türk (2018) 3 Rhinitis (unstratified) 59 37.3 (18–67) VAS
Valero (2011) 4 AR 360 36.3 TNSS
Wang (2016) 4 AR 30 28.5 VAS
Wang (2020) 4 AR 77 32.8 (22–51) VAS
Wang (2021) 4 AR 70 26.9 TNSS
Wanjun (2018) 4 AR 65 29.1 VAS
Xu (2020) 4 IAR 153 32.4 (18–52) VAS
Yamamoto (2012) 2 AR 148 29.4 VAS
Yamprasert (2020) 2 AR 80 33.1 TNSS
Yu (2015) 4 NAR 35 75.5 (65–89) VAS
Yu (2023) 4 AR 494 33.2 TNSS
X. Zhang (2022) 3 AR 200 28.1 TNSS
Y. Zhang (2022) 2 Rhinitis (unstratified) 206 36.1 TNSS
Zheng (2023) 3 AR 160 26.8 TNSS
Zhong (2019) 2 AR 66 43.3 VAS
Zhu (2016) 3 AR 25 22.1 TNSS
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Abbreviations: AR, allergic rhinitis; IAR, intermittent allergic rhinitis; NAR, nonallergic rhinitis; OCEBM, Oxford Centre for Evidence‐Based Medicine; PER, persistent allergic rhinitis; TNSS, total nasal symptom score; VAS, visual analog scale.

Studies included in the final analysis were published between 1996 and 2024. Descriptive features of included studies, such as author name, year of publication, and rhinitis subtype can be found in Table 1. Following critical appraisal, all included studies were considered to have an acceptably low risk of bias. For randomized trials, potential sources of bias were due to lack of clear allocation concealment during randomization, lack of blinding, and missing outcomes data. Non‐randomized studies were occasionally subject to bias due to confounding, missing data, and selective reporting. Case series, cross‐sectional, and case–control studies were similarly at risk of bias due to confounding, and for using different criteria to recruit cases versus controls. However, each study design scored higher than 5, 4, or 5 for their respective scoring system. RoB‐2 risk assessments can be found in Figure 2; ROBINS‐I and JBI risk assessments can be found in Supporting Information: S1.

Figure 2.

Figure 2

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RoB‐2 risk of bias.

A funnel plot with Egger's test produced a value of 0.51 ([95% CI: −0.26 to 1.29], p = 0.19), with 83 out of 89 studies falling within the funnel plot with minimal asymmetry, indicating a low risk for publication bias (Supporting Information S1).

3.2. Patient Characteristics

The study population comprised 14,448 adult patients with rhinitis with a mean age of 38.0 ± 1.2 years (range: 16–94). Patients were evenly divided by sex and mean symptom duration was 7.3 years. Most had AR with significant numbers of both IAR and PER as shown in Table 2.

Table 2.

Patient characteristics.

Patient characteristics Proportion (%) 95% CI
Male 47.3 45.39–49.22
AR 93.0 88.09–96.68
NAR 6.4 3.03‐–10.99
IAR 36.9 22.6–52.39
PER 62.5 46.29–77.36
Asthma 10.4 0.29‐32.27
Smoking history 10.2 3.94–18.90
Prior sinus surgery 7.5 1.83–16.52
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Abbreviations: AR, allergic rhinitis; IAR, intermittent allergic rhinitis; NAR, nonallergic rhinitis; PER, persistent allergic rhinitis.

3.3. Severity of Symptoms

A comprehensive breakdown of symptom severity in adults with rhinitis as assessed by the TNSS and VAS surveys, including data stratified by rhinitis type, can be found in Table 3. Among all patients with rhinitis, nasal congestion and rhinorrhea were reported at the highest severity in the TNSS, with scores of 2.03 [95% CI: 1.91–2.15] and 2.01 [95% CI: 1.90–2.13], respectively. Sneezing and nasal itching represented the two less severe symptoms, with scores of 1.79 [95% CI: 1.62–1.95] and 1.69 [95% CI: 1.52–1.86], respectively (Figure 3). This pattern of disease severity remained consistent among VAS equivalents of the TNSS.

Table 3.

Overall symptom severity by rhinitis subtype.

Metric Group Total patients Mean score 95% CI
TNSS total Overall 9048 7.07 6.61–7.54
AR 7750 7.10a 6.53–7.67
NAR 444 5.22 3.72–6.72
IAR 457 6.85 4.36–9.33
PER 706 7.20b 6.69–7.70
TNSS congestion Overall 9595 2.03 1.91–2.15
AR 8290 1.99 1.85–2.13
NAR 432 2.04c 1.61–2.46
IAR 818 2.23d 2.04–2.41
PER 792 2.16 1.99–2.32
TNSS rhinorrhea Overall 9478 2.01 1.90–2.13
AR 8394 1.96a 1.82–2.09
NAR 417 1.61 1.32–1.90
IAR 818 2.05d 1.80–2.31
PER 792 2.03 1.91–2.15
TNSS sneezing Overall 9128 1.79 1.62–1.95
AR 8295 1.86a 1.69–2.04
NAR 193 1.00 ‐0.30–2.29
IAR 818 1.72 1.32–2.13
PER 792 1.88b 1.73–2.03
TNSS nasal itching Overall 8939 1.69 1.52–1.86
AR 8073 1.79 1.61–1.97
NAR — — —
IAR 818 1.93d 1.62–2.25
PER 732 1.72 1.58–1.85
VAS nasal obstruction Overall 3194 5.88 4.79–6.98
AR 2646 5.68 4.48–6.89
NAR 295 6.44c 5.16–7.72
IAR 243 5.74 4.89–6.60
PER 1057 7.65b 6.30–8.99
VAS runny nose Overall 3275 5.49 4.56–6.43
AR 2735 5.43 4.28–6.58
NAR 287 5.97c 4.52–7.42
IAR 243 6.34 3.55–9.14
PER 1145 6.76b 6.35–7.18
VAS sneezing Overall 2976 5.37 4.26–6.47
AR 2547 5.42 4.03–6.81
NAR 176 5.54c 4.05–7.03
IAR 243 6.57d 4.01–9.14
PER 1120 6.48 6.08–6.87
VAS itchy nose Overall 2179 4.19 3.37–5.02
AR 1988 5.34a 4.32–6.36
NAR 155 2.68 2.43–2.92
IAR 173 4.63 1.44–7.83
PER 795 6.52b 5.67–7.38
VAS PND Overall 280 4.95 3.87–6.03
AR 125 3.92 2.75–5.09
NAR — — —
IAR — — —
PER — — —
VAS hyposmia Overall 360 3.79 2.07–5.50
AR 332 3.84 1.94–5.73
NAR — — —
IAR — — —
PER 130 4.74 2.86–6.62
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Abbreviations: AR, allergic rhinitis; IAR, intermittent allergic rhinitis; NAR, nonallergic rhinitis; PER, persistent allergic rhinitis; TNSS, total nasal symptom score; VAS, visual analog scale.

a

AR group more severe.

b

PER group more severe.

c

NAR group more severe.

d

IAR group more severe.

Figure 3.

Figure 3

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TNSS sub‐item severity overall. *statistical significance. **clinical significance.

Although postnasal drip and hyposmia are not included within the traditional 4‐item TNSS, several studies included baseline VAS data on these symptoms. With a score of 4.95 [95% CI: 3.87–6.03], PND was the fourth‐most severe symptom, ranking in‐between sneezing (5.37) and itchy nose (4.19). Hyposmia was the mildest symptom at baseline, with a score of 3.79 [95% CI: 2.07–5.50].

3.4. Symptom Prevalence

A total of five studies (N = 532) included data on TNSS symptom prevalence, allowing us to record the most frequently reported score for each item on the survey [39, 42, 44, 48, 69]. Score distributions were stratified into “mild” (0–1) and “severe” (2–3). Rhinorrhea was severe in 93.2% of patients, and nasal congestion was severe in 87.2%. Sneezing and nasal itching were severe in only half of patients (Figure 4).

Figure 4.

Figure 4

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Symptom score prevalence.

3.5. AR Versus NAR

When stratifying by allergic status, patients with AR presented with more severe baseline disease than NAR patients, highlighted by a higher TNSS (7.10 vs 5.22 [95% CI: 1.84–1.91], p < 0.0001). AR patients also had worse individual TNSS scores for rhinorrhea (mean difference: 0.34 [95% CI: 0.22–0.45]), nasal itching (mean difference: 1.35 [95% CI: 0.68–2.02]), and sneezing (mean difference: 1.36 [95% CI: −0.51−3.23]). These findings were replicated in VAS scoring, with runny nose, itchy nose, and sneezing scores being worse among AR patients; itchy nose and sneezing achieved both statistical and clinical significance. Supporting Information S1 depicts a graphical score comparison between AR and NAR patients; these findings are further illustrated through forest plots in Figure 5 and Supporting Information S1.

Figure 5.

Figure 5

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Forest plot highlighting differences in TNSS scores between allergic and nonallergic rhinitis patients. AR, allergic rhinitis; NAR, nonallergic rhinitis; TNSS, Total Nasal Symptom Score.

3.6. IAR Versus PER

Patients with AR were further stratified into IAR and PER cohorts. All baseline scores of the TNSS were significantly different between IAR and PER patients; however, the differences in scores ranged from 0.07 to 0.22, falling below the threshold for clinically meaningful differences. When comparing VAS scores, only two symptoms achieved both statistical and clinical significance—PER patients experienced more severe nasal obstruction (7.65 vs 5.74, mean difference 1.90 [95% CI: 1.81–1.99], p < 0.0001) and itchy nose (6.52 vs 4.63, mean difference 1.89 [95% CI: 1.76–2.02], p < 0.0001) (Supporting Information S1). Focusing on the order of symptom severity, IAR patients reported sneezing (mean 6.57 [95% CI: 4.01–9.14]) and runny nose (mean 6.34 [95% CI: 3.55–9.14]) as their most severe symptoms, which contrasts with every other rhinitis cohort reporting congestion and rhinorrhea as their most burdensome symptoms.

4. Discussion

Rhinitis has a significant global burden, with AR affecting one in every six Americans, and NAR occurring in over 10% of the global population [111, 112]. Several existing reviews have measured changes in the TNSS following medical or surgical management [113, 114, 115, 116]. However, rarely do these reviews record quantitative itemized baseline data for the four individual TNSS items. Further, these reviews tend to focus on a single subset of rhinitis, limiting the potential for direct comparison between allergic and nonallergic patients, or those with intermittent versus persistent symptoms. Therefore, much of the knowledge regarding rhinitis classification and management is derived from clinical experience, with limited data characterizing its presentation among adult populations, particularly in NAR patients [112]. Our study was able to quantify itemized symptom severity at baseline presentation. Symptoms fell into two clear categories: congestion and rhinorrhea represented the most severe symptoms, while sneezing and nasal itching encompassed the mild symptoms. Further, we found that AR patients have more severe presentation than NAR patients; symptom duration, however, did not play a clinically meaningful role in differentiating within allergic patients. These findings aid in filling the gap in population‐level epidemiological data among NAR patients. Additionally, the categorization and quantification of specific symptom severity will assist physicians in quickly achieving an accurate diagnosis and assigning treatment, while also being able to closely monitor patients’ response.

Discriminating isolated rhinitis from diseases affecting the paranasal sinuses, such as CRS is extremely difficult as the two often manifest similarly [117]. Nasal drainage and obstruction, the two most severe symptoms in our study population, are also two of the four cardinal symptoms for CRS. Standard CRS surveys, such as the SNOT‐22, devote multiple questions to characterizing nasal obstruction and drainage, focusing on both anterior and posterior symptoms [117]. Conversely, rhinitis questionnaires, such as the TNSS, solely collect anterior symptoms like rhinorrhea [118]. The absence of PND on standard rhinitis symptom questionnaires is puzzling, as patients with rhinitis experiencing rhinorrhea most often have accompanying PND [119]. Our rhinitis population reported rhinorrhea as one of their most severe symptoms, while PND, though infrequently reported, was scored as the fourth‐most severe symptom. This is in stark contrast to CRS patients, who have been shown to report PND as their most severe nasal drainage symptom [120]. Routinely monitoring posterior and anterior symptoms through standardized questionnaires may help differentiate rhinitis patients from those with comorbid sinus disease.

Obstructive symptoms were a prominent aspect of patient presentations among our study population. Nasal obstruction occurs in many disease states, and several studies have highlighted differences in how patients perceive and report congestion compared to otolaryngologists [121, 122]. Patients tend to focus on pressure and mucus‐related symptoms, while physicians strictly define congestion in obstructive terms [122]. These discrepancies are not currently accounted for in rhinitis surveys, which can negatively impact patient satisfaction and outcomes [123]. Furthermore, nuances in patient perceptions of congestion may provide clues to the underlying pathology, which would ultimately influence the appropriate treatment options, as different medications and surgeries exist for nasal obstruction depending on etiology [121]. Nasal obstruction, as demonstrated by this meta‐analysis, is an immensely burdensome symptom for patients suffering from rhinitis, but likely requires additional survey items to specify its etiology and impact.

This study was able to demonstrate significant score differences between AR and NAR patients at presentation. In clinical practice, distinguishing between these two subtypes can be challenging—AR diagnosis typically requires both symptoms and serum IgE measurements or skin‐prick tests (SPT), while NAR is frequently a diagnosis of exclusion [5]. Being able to clinically distinguish between AR and NAR is vital, as up to half of all primary care facilities may not have access to the requisite lab tests for diagnosis [124]. Further, these tests are not foolproof—up to 14% of AR patients who have their disease defined by SPT or serum IgE may have nonallergic etiologies or inaccurate allergen diagnoses [125]. Some subtypes of NAR may have lab values indicating an allergic process, while certain AR phenotypes can have negative allergy testing [126, 127]. In addition, many patients have rhinitis with both allergic and nonallergic triggers. Keeping this in mind, a stronger emphasis on clinical indicators may be preferable in initial patient encounters for rhinitis [126]. Our findings of more severe nasal itching, rhinorrhea, and sneezing in AR patients can help stratify patients upon their initial presentation, allowing more streamlined care and lowering healthcare costs. These findings fit into a contentious area of the literature, with existing studies conflicting on the relative severity of AR versus NAR [5, 128]. In practice, identifying severe baseline TNSS scores, with a focus on nasal itching, sneezing, and rhinorrhea, can help point physicians towards a diagnosis of AR, allowing more appropriate disease management.

The distinction between IAR and PER was first introduced in the 2001 Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines [2]. Our findings did not indicate that the presentations between these two groups are clinically different. However, due to slight variations in management, otolaryngologists should elicit the duration and pattern of patients’ symptoms in order to choose the most appropriate treatment plan.

A strength of this study is its ability to collate itemized baseline data across a large population, spanning a wide breadth of different rhinitis subtypes. However, this review has several limitations which should be addressed. Not all the studies had a washout period before obtaining baseline measurements, meaning that some patients had been on various treatment regimens at the time of data collection. Additionally, patients with AR were not always studied during their allergy season, potentially leading to lower‐than‐expected symptom scores at baseline. Many studies solely reported the overall TNSS without itemization, limiting our sample size. Those that did include itemized data occasionally combined sneezing and nasal itching into a composite score, excluding us from collecting all four symptom scores and preventing collection of the TNSS composite, which would no longer range from 0 to 12. Few studies collected data on PND or hyposmia, limiting its analysis by subgroup. A paucity of patient‐level data precluded us from performing more detailed subgroup analyses by comorbidities such as asthma. Several subtypes of AR and NAR were unable to be analyzed, such as local AR (LAR) or NAR with eosinophilia (NARES), due to a lack of stratified data. These limitations showcase the shortcomings of the presently available data and highlight necessary areas for further research. Future studies may benefit from additional patient level data to isolate the effect of comorbidities and more specific rhinitis subtypes on symptom presentation. Additionally, future reviews should highlight the impact of treatment on itemized symptom outcomes.

5. Conclusion

Our findings suggest that rhinitis symptoms can be classified into two categories, with congestion and rhinorrhea presenting severely, and nasal itching and sneezing presenting mildly. Patients with AR have a more severe presentation than NAR patients, but symptom duration does not lead to clinically meaningful differences in AR patients.

Author Contributions

Asher T. Ripp, Pranav A. Patel, Shaun A. Nguyen, and Isabella V. Schafer provided substantial contributions to the conception and design, acquisition of data, analysis and interpretation of data; Shaun A. Nguyen, Alexander N. Duffy, Zachary M. Soler, and Rodney J. Schlosser gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

Zachary M. Soler: OptiNose (consultant), Sinusonic (consultant), Regeneron (consultant), Sanofi (consultant). Rodney J. Schlosser: OptiNose (consultant), Sinusonic (consultant), Aerin (consultant), Stryker (consultant). Professor Shaun A. Nguyen is a member of World Journal of Otorhinolaryngology – Head & Neck Surgery (WJOHNS) editorial board and is not involved in the peer review process of this article.

Supporting information

Supplementary materials (4).

WJO2-9999-0-s001.docx (1.6MB, docx)

Acknowledgments

The authors have nothing to report.

Meeting: Submitted to The Triological Society for COSM 2025.

Data Availability Statement

Data are available from the authors upon reasonable request.

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