rhinitis is the inflammation of the mucous lining of the nose , and it can lead to symptoms including rhinorrhea , nasal obstruction , post - nasal drip , itching , and sneezing .
the etiologies of rhinitis include infection , anatomical anomalies , immunological disorders , hormonal imbalance , and ciliary defects [ 1 , 2 ] .
similar nasal symptoms can be caused by different etiologies , making the diagnosis and treatment of rhinitis difficult .  
methods for management of rhinitis include environmental control , pharmacotherapy , immunotherapy , surgical interventions , nasal irrigation , complementary , and alternative medicine .
the surgical indications for rhinitis include drug - resistant inflammatory mucosal hypertrophy , anatomical anomalies , and sinus drainage obstruction . complementary or alternative medicines such as traditional chinese medicine ( tcm ) , acupuncture , herbs , and probiotics are also being used for the treatment of rhinitis [ 46 ] .
recently , evidence - based guidelines with several algorithm - guided therapeutic schemes for the treatment of rhinitis are available [ 2 , 7 , 8 ] . yet , to our knowledge
, no studies have been conducted to determine the factors associated with the use of different treatment modalities .
therefore , the aim of this study was to investigate the factors associated with the use of treatment among patients with rhinitis in taiwan .
patients with physician - diagnosed rhinitis from the outpatient department of otolaryngology in taichung veterans general hospital , a medical center in central taiwan , were invited to participate in this cross - sectional survey study .
the diagnosis of rhinitis was based on patients ' reports of typical nasal symptoms persisting for two weeks or more and rhinoscopy examination .
typical nasal symptoms include rhinorrhea , nasal obstruction , postnasal dripping , itching , and sneezing .
physical examination with anterior rhinoscopy or nasal endoscopy was performed by two rhinologists ( rsj and kll ) .
all enrolled patients revealed signs of nasal inflammation including mucosal edema , nasal polyp , polypoid swelling , discharge ( purulent , mucous or serous ) , or crust .
the study was approved by the institutional review board of taichung veterans general hospital , and all participants gave written informed consent .
each patient completed a questionnaire with questions on sociodemographic status , lifestyle , general health status , disease - specific quality of life , and previous use of treatment modalities for rhinitis .
the treatment modalities were classified into four main categories : pharmacology , surgical intervention , tcm , and nasal irrigation .
the disease - specific quality of life was assessed using the chinese version of the 31-item rhinosinusitis outcome measure ( crsom-31 ) .
the crsom-31 is a validated instrument translated from the widely used rhinosinusitis outcome measure ( rsom-31 ) .
it contains seven domains including nasal symptoms ( 6 items ) , eye symptoms ( 3 items ) , sleep ( 3 items ) , ear symptoms ( 5 items ) , general symptoms ( 7 items ) , practical problems ( 4 items ) , and emotional consequences ( 3 items ) for evaluation of the rhinitis or rhinosinusitis - related impact on the quality of life . for each symptom
, there are two response scales : magnitude ( 0 to 5 ) and importance ( 1 to 4 ) .
the crsom-31 symptom - impact score is the product of the magnitude and importance scores , with higher scores indicating worse disease - specific quality of life .
continuous data were expressed as mean  standard deviation ( sd ) , and categorical data were expressed as frequencies and percentages .
univariate logistic regression analyses were conducted to assess the odds ratios and 95% confidence intervals for each of the treatment modalities with the independent variables , including sex , age , body mass index ( bmi ) , marital status , educational level , alcohol use , smoking , regular exercise , general health status , crsom-31 symptom - impact scores , and four etiologies of rhinitis .
multivariate logistic regression analyses with backward stepwise selection method were used to evaluate the independent factors associated with the use of each of the treatment modalities . in all regression analyses ,
bmi was calculated as weight ( in kilograms ) divided by height ( in meters ) squared .
based on the definition from the bureau of health promotion , department of health , taiwan , the respondents were categorized as underweight ( bmi < 18.5  kg / m ) , normal weight ( bmi 18.523.9  kg / m ) , overweight ( bmi 24.026.9  kg / m ) , or obese ( bmi  27.0  kg / m ) .
educational levels were divided into elementary school or lower ( grade 1 to grade 6 ) and high school or above .
general health status of the patients was grouped into three levels ( poor or fair , good , and very good or excellent ) . crsom-31
a total of 279 patients with acute or chronic rhinosinusitis , allergic or nonallergic rhinitis were successfully interviewed between july and september 2011 .
the basic characteristics of the study participants are summarized in table 1 .   in terms of the use of treatment modalities ,
85.7% of the patients had used pharmacology ( 77.1% had used oral medications and 65.9% had used topical medications ) , 38.4% had used surgical intervention , 34.4% had used tcm , and 34.1% had used nasal irrigation ( table 2 ) . in addition , 19 ( 6.8% ) patients had not used any treatment modalities , and 56 ( 20.1% ) , 63 ( 22.6% ) , 77 ( 27.6% ) , 36 ( 12.9% ) , and 28 ( 10.0% ) patients had used 1 , 2 , 3 , 4 , and 5 treatment modalities , respectively . regarding the severity of the rhinitis , since only 56 patients ( 20% ) used only a single treatment modality , there are too few individuals to provide statistically meaningful comparisons between the five treatment modalities .
nonetheless , when the total number of modalities ( 0 to 5 ) used by the patients was compared , we found that the crsom-31 scores in patients who had used all five modalities ( 269.4  130.3 ) significantly higher compared to those who had used fewer modalities .
no significant differences in crsom-31 scores were observed among those patients who had used 4 ( 196.6  107.1 ) , 3 ( 173.7  85.8 ) , 2 ( 162.6  93.3 ) , 1 ( 148.3  101.4 ) , or no ( 125.7  88.7 ) treatment modalities . 

table 2 also showed the results of univariate logistic regression analyses for each of the six treatment modalities with all the independent variables .
furthermore , six separate multivariate logistic regression analyses were conducted to assess the association between each of the treatment modalities and their independent and significant factors ( table 3 ) .
educational levels of elementary school or below were significantly associated with the use of pharmacology treatment modality and also with the use of subgroup of pharmacology treatment modality ( oral or topical medications ) .
fair or poor general health status was significantly associated with the use of pharmacology treatment modality and especially with the use of topical medications , whereas very good or excellent general health status was inversely associated with the use of surgical intervention .
worse disease - specific quality of life ( crsom-31 symptom - impact score ) was significantly associated with the use of pharmacology treatment modality , oral medications , and traditional chinese medicine . in terms of the etiologies of rhinitis
finally , chronic rhinosinusitis , both with or without nasal polyps , was significantly associated with the use of topical medications , surgical intervention , and the use of nasal irrigation .
rhinitis and rhinosinusitis are common health problems that impact on the quality of life of their sufferers [ 11 , 12 ] .
the world health organization proposed a stepwise treatment for allergic rhinitis in the allergic rhinitis and its impact on asthma ( aria ) guideline .
oral antihistamine and topical corticosteroid are recommended for the first - line treatment for mild and moderate - severe allergic rhinitis by the aria guideline .
our results showed that most rhinitis patients had received pharmacological treatments ( 85.7% ) which included the uses of oral medications ( 77.1% ) and topical medications ( 65.9% ) , indicating that guideline - directed rhinitis treatment is widely adopted by both physicians and patients in taiwan .
in addition , our data showed that approximately a third of the patients ( 34.1% ) had used nasal irrigation to relieve their rhinitis symptoms .
nasal irrigation is used for various sinonasal condition and postoperative care after nasal surgery [ 1416 ] .
the mechanisms of nasal irrigation include physical cleaning , enhancement of mucociliary function , and removal of local inflammatory mediators .
although it is widely recommended and commonly used in taiwanese patients , there was no data reporting the proportion of nasal irrigation use in clinical settings .  
about one third of our patients ( 34.4% ) had used tcm for their rhinitis symptoms .
the relatively common use of it could partly be explained by the health care system of taiwan because tcm services are fully reimbursed by the national health insurance program .
based on the results of an analysis of tcm outpatient reimbursement claims from 1996 to 2001 in taiwan , diseases of the respiratory system were found to rank at the top of the major disease categories for tcm visits , which accounted for 27% of all tcm visits .  
understanding the factors associated with the use of different treatment modalities for rhinitis can be helpful for clinicians when they are considering the choice of treatment for their patients .
our results demonstrated that sex , educational levels , general health status , smoking habit , alcohol use , and disease - specific quality of life were independent factors associated with different treatment modalities .
these associations had been adjusted for the etiologies of rhinitis and remained statistically significant . in particular , male patients were more likely to receive surgical interventions , while lower educational levels were associated with the use of oral and topical medications .
patients with poor or fair general health status were associated with the use of topical medications .
a possible reason is that the occurrence of drug - to - drug interactions is relatively rare with topical medications and therefore , suitable for patients who were on medications for their other diseases .
it is of interest to note that very good or excellent general health status was inversely associated with surgical intervention . since surgery for rhinitis
is typically performed under local anesthesia , the general health status of a patient should not be a contraindication for surgery .
the reasons for the association between the use of surgical intervention and general health status will require further investigations .   nasal irrigation is a method to relieve sinus symptoms by rinsing the nasal cavity with isotonic or hypertonic saline .
a cochrane systematic review on eight randomized controlled trials concluded that the use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis . in our study , smoking was significantly associated with the use of nasal irrigation .
nasal irrigation has been claimed as a method to remove nicotine and tar buildup in the nasal passages for smokers , and this might explain the association between nasal irrigation and smoking observed in this study .
previous large - scale population studies have revealed that cigarette smoking and chronic rhinitis were associated in a dose - dependent manner .
in addition , past and current secondhand tobacco smoke exposure was reported to be a risk factor for allergic rhinitis .
subjects with secondhand tobacco smoke exposure and allergic rhinitis were significantly more likely to use nasal decongestants . however , no studies have specifically investigated whether smoking was associated with increased use of nasal irrigation .  
finally , worse disease - specific quality of life , assessed by the use of crsom-31 , was found to be associated with the use of oral medications and tcm .
since it is likely that the chronicity of rhinitis symptoms is associated with a worse quality of life , patients with worse quality of life might seek alternative therapies including tcm as a way to minimize the adverse effects of chronic use of conventional medications .
the association between crsom-31 and the use of oral medications could be explained by the fact that oral medication is often used for moderate or severe cases not responsive to topical medications , which are likely to be cases with worse quality of life .
nevertheless , we have included crsom-31 symptom - impact scores in our multivariate analyses as a proxy to control for the effect of severity of rhinitis .
second , all patients were recruited from one medical center , and most of them had previously been treated for rhinitis by their primary care physicians .
results from the present study indicated that common treatment modalities in taiwanese patients with rhinitis included oral medications , topical medications , surgical intervention , tcm , and nasal irrigation .
the use of different treatment modalities among taiwanese patients with rhinitis was associated with different factors including sex , educational levels , general health status , smoking habit , alcohol use , and disease - specific quality of life , adjusting for etiologies of rhinitis .
 rhinitis is a common upper airway disease and can have great impact on patients ' quality of life . 
 factors associated with the use of common treatment modalities among 279 taiwanese rhinitis patients from the outpatient department of otolaryngology in a medical center were investigated using a cross - sectional survey study . 
 results from multiple logistic regression analysis , adjusted for etiologies of rhinitis , revealed that males were associated with surgical intervention ( or  =  2.11 , p = 0.009 ) . 
 lower educational level was associated with oral ( or = 2.31 , p = 0.024 ) and topical medications ( or  =  2.50 , p = 0.005 ) . 
 poor or fair general health status was associated with topical medications ( or  =  4.47 , p = 0.001 ) , whereas very good or excellent general health status was inversely associated with surgical intervention ( or  =  0.32 , p = 0.002 ) . 
 smoking was associated with the use of nasal irrigation ( or  =  2.72 , p = 0.003 ) . 
 worse disease - specific quality of life was associated with oral medications ( or  =  2.46 , p = 0.010 ) and traditional chinese medicine ( or  =  5.43 , p < 0.001 ) . in conclusion , 
 the use of different treatment modalities for rhinitis was associated with different combinations of independent factors . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusions