NONALLERGIC RHINITIS DEFINITION

Rhinitis :
Inflammatory disease of the nasal mucous membrane Characterized by one or more the following symptoms: nasal congestion rhinorrhea sneezing itching post nasal drainage
1

Classification

: allergic rhinitis non allergic rhinitis

Non allergic rhinitis is rhinitis not caused by IgE-mediated immunopathologic events

EPIDEMIOLOGY
Over the last two to three decades: Incidence : Urbanization and environmental pollution may play a role.
Clinician became equipped to approach rhinitis knowledgeably and systematically in order to permit accurate diagnoses and effective therapeutic intervention
3

Introduction
Rhinitis contributes to associated medical problems, including asthma and rhinosinusitis Morbidity : Deterioration of the patient quality of life (QOL) (headache, fatigue, cognitive impairment, side effects of medication)

CLASSIFICATION
Infectious rhinitis Hormonal rhinitis Vasomotor rhinitis Nonallergic Rhinitis with Eosinophilia Syndrome Occupational rhinitis Drug-induced rhinitis Gustatory rhinitis Atrophic rhinitis Rhinitis among children

Adapted from Newlands SD. Nonallergic Rhinitis. Bailey BJ. Head & Neck Surgery Otolaryngology. Third Editions. 2001.

CLASSIFICATION
Syndromes of known etiology
Infectious Bacterial Fungal immunodeficiencies immotile cilia syndrome cystic fibrosis Syndromes of unknown Etiology Vasomotor rhinitis NARES Other, undefined sydromes Atrophic rhinitis Excessive surgery ozena

Metabolic conditions Pregnancy Hypothyroidsm Vasculitides/autoimmune Churg-Strauss Lupus Sjogrens Granulomatous disease Sarcoidosis Wageners granulomatosis Drug-induced Antihypertensives Reserpine Guanethidine Methyldopa Prazosin Beta blockers Neoplasm

Anatomic abnormalities aspirin/NSAIDs nasal decongestants ophtalmic beta blockers bromocriptine estrogen/ oral contraceptives

Syndromes related to physical and chemical factors/exposures Dry air-induced rhinitis Gustatory rhinitis Bright light exposure Pollutant-induced rhinitis Occupational rhinitis (chemical sensitizers)

Adapted from Mygind N, et al. Non-allergic Rhinitis. Allergic and Non-Allergic Rhinitis. 1993. 6

Infectious Rhinitis
Acute rhinitis Caused by viral infection (upper respiratory tract infection): - Rhinovirus - Respiratory syncitial virus - Parainfluenza virus - Influenza virus - Adenovirus Symptoms : Nasal obstruction, clear rhinorrhea, fever, sneezing, edema obstruct the ostia of the sinuses facial pain, superinfected with bacteria bacterial rhinosinusitis

Hormonal Rhinitis
Etiology : Hypotyroidism Pregnancy elevated estrogen level Contraceptives Menstrual cycle Pregnancy-induced rhinitis occurs in 20% of pregnancies, frequent onset in second trimester of pregnancy Swollen, pale, edematous turbinate

Hormonal Rhinitis
HIGH LEVEL OF ESTROGEN
ACETYLCHOLINE PRODUCTION in the parasympathetic ganglia

ACETYL CHOLINESTERASE ACTIVITY

EDEMA HYPERSECRETION VASCULAR ENGORGEMENT OF NASAL MUCOSA

Adapted from Newlands SD. Nonallergic Rhinitis. Bailey BJ. Head & Neck Surgery Otolaryngology. Third Editions. 2001.
9

Vasomotor Rhinitis
Perenial nonallergic rhinitis, Idiopathic rhinitis, Nonallergic rhinitis without eosinophilia Primary symptoms : congestion and rhinorrhea without sneezing and pruritus Low nasal eosinophil counts and negative skin results for allergy Etiology : abnormal functioning of parasympathetic input to the turbinate and septal mucosa

10

Vasomotor Rhinitis
Rhinitis develops in response to environmental conditions including cold air, high humidity, stress or irritants such as alcohol, bleach, solvents, air pollutions, and smoke Surgical procedure to correct vasomotor rhinitis : - Eliminate turbinate edema & hypersecretion (by means of targeting the suspected neurologic source vidian neurectomy) - Eliminate the affected mucosa of the inferior & middle turbinate

11

Nonallergic Rhinitis with Eosinophilia Syndrome

Clinically similar to allergic rhinitis but lacks of the immunoglobulin E-mediated immunopathologic events Clinical syndrome is a perennial course of watery rhinorrhea and nasal pruritus with paroxysms of sneezing The incidence of these disease is unknown, many cases are diagnosed as allergic The cause is unknown aspirin sensitivity

12

Occupational Rhinitis
This diagnosis overlaps between allergic and vasomotor rhinitis Define as nasal discharge or congestion due to exposure to an airborne substance at work This reaction can be either allergic or nonallergic Patients report worsening of symptoms while at work and improvement away from work Common non allergic irritants : * cold air * tobacco smoke * industrial chemical * cosmetic
13

Occupational Rhinitis
Common allergic triggers :
* laboratory animal * food products * wood dust * latex

Confirm diagnosis : * skin testing with suspected allergen

* specific test for allergic or nonallergic source is to challenge the patient with the suspected irritant or allergen and document a change in symptoms or nasal resistance by rhinomanometry

Management : Identification the irritants and avoidance it

14

Drug-induced Rhinitis
Caused by systemic drugs that have effect on nasal mucosa or by topical drugs Induced rhinitis systemic drugs : reserpine, guanethidine, phentolamine, methyl dopa, prazosin, chlorpromazine, beta blocker, angiotensin- converting enzym classes Fairly mild-symptoms isolated congestion/rhinorrhea Complex symptoms rhinosinusitis/nasal polyposis/ asthma Induced rhinitis topical drugs : cocaine, oxymetazoline hydochloride, phenylephrine hydrochloride

15

Drug-induced Rhinitis
Rhinitis medicamentosa refractory vasodilatation of mucosal blood vessels or excessive mucosal edema Diagnosis : considered of any patient using the causative medicine for more than 7 days Therapy : * cessation of topical administration of a vasoconstrictor * replacement of this drug with saline nasal spray mobilizes and loosens secretions and keeps the recovering mucosa hydrated

16

Drug-induced Rhinitis
Therapy :
* acute nasal obstruction after nasal spray withdrawal high burst of prednisone with a rapid tapper * allergic rhinitis patients daytime course of oral vasoconstrictor or oral antihistamine at night * patient with concurrent allergy corticosteroid nasal spray during the previous oral regimen
17

Gustatory Rhinitis
Rhinitis can be caused by food allergy,resulting in IgE-mediated rhinitis Allergy mediates reaction is suspected and can be confirmed with skin testing Histamines-containing foods (provoke pseudo-allergic reaction) : cheese, poorly kept fish, certain wine Consumption of alcoholic drinks also can cause rhinitis dilating nasal vasculature Hot or spicy food can cause profuse rhinorrhea through vagally mediated mechanism

18

Atrophic Rhinitis
Atrophic rhinitis or Rhinitis sicca Characterized by atrophic mucosa on the septum, turbinates, or lateral nasal mucosa Symptoms : * subjective nasal congestion * constant foul-smelling odor despite lack of objective evidence of obstruction Primary atrophic rhinitis occurs among elderly patients More prevalent in eastern Europe, Egypt, India, China

19

Atrophic Rhinitis
Atropic rhinitis with ozena manifest as thick, adherent, green or yellow nasal crust, usually has a bad odor Primary form of this disease may be caused by infection with Klebsiella ozaenae Bacterial strains (K.ozaenae, toxic form of C.diphtheriae) grow opportunistically in ozena nasal crust and giving role in pathogenesis of atrophic rhinitis Secondary form of the disease is caused by over-aggressive nasal surgery, chronic rhinosinusitis, granulomatous disease of nasal cavity or radiation

20

Rhinitis among Children

Rhinitis is a common problem for children Children 2 to 6 y.o have viral rhinitis about six times a year Chronic bacterial rhinitis caused by an immunologic disorders, cystic fibrosis or structural defects, cleft palate Nasal polyposis in a child should initiate an evaluation for cystic fibrosis Purulent unilateral rhinorrhea foreign body Nasal obstruction is more common among children than among adults because of the incidence of adenoidal hypertrophy

21

Differentiating nonallergic from allergic rhinitis

Differential Diagnosis
History

Spesific tests (for exclusion of allergic rhinitis)

Allergic

Nonallergic

Temporal pattern of symptoms

Type of symptoms

perenial

sneezing, pruritus congestion congestion rhinorrhea rhinorrhea posterior drainage posterior drainage sinus pressure sinus pressure

seasonal or perennial with seasonal exacerbations

Allergy Skin Testing Detection of specific IgE in patients serum

Age of onset Precipitating factors

70% >>20 y.o non specific irritants not present not frequent

70%<<20 y.o specific antigens + non speciific irritants frequently present frequent
Adapted from Mygind N, et al. Non-allergic Rhinitis. 22 Allergic and Non-Allergic Rhinitis. 1993.

Other atopic disease

Family history of rhinitis

Differential Diagnosis
Allergic Rhinitis
Allergic rhinitis is often accompanied by allergic conjunctivitis, malaise, weakness and fatigue Twenty percent of patients have asthma Other clues to the diagnosis : atopic eczema a family history of ectopy a temporal relation between exposure to potential allergens & symptoms Clinical significant positive skin test results or detection of specific IgE serum antyibodies confirm the diagnosis
23

Differential Diagnosis
Mast cells
Histamine Leukotrienes Prostaglandin Bradykinin PAF Immediate rhinitis Symptoms itch, sneezing watery discharge nasal congestion

Allergen

IgE B lymphocytes IL-4

T lymphocytes (mast cells)

VCAM-1 IL-3 IL-5 GM-CSF Eosinophils

Chronic ongoing Rhinitis nasal blockage loss of smell nasal hypereactivity

Figure 6.1 Hypothesis on mechanism of allergic rhinis

Adapted from Mechanism and treatment of allergic rhinitis. Scott-Browns Otolaryngology. Sixth Edition.1997

24

Differential Diagnosis
Rhinosinusitis
Symptoms
acute or chronic and bilateral or unilateral decreasing order of frequency, nasal congestion, purulent nasal discharge, post-nasal discharge with cough, foul-smelling discharge, facial pressure or pain, and olfactory changes

Mucormycosis :
patients with poorly managed diabetes pale (early)/dark (late) area in lateral nasal walls

Invasive aspergillosis (Aspergillus)

granulomatous lesions in paranasal sinus

Management :
wide surgical debridement tight control of diabetes reversal of immunosuppresion
25

Differential Diagnosis
Anatomic Nasal Obstruction
Choanal atresia Adenoid hypertrophy Septal deflection Turbinate enlargement Nasal neoplasia Congestion Rhinorrhea Nasal obstruction

Nasal polyposis 10%-15% patients with allergic rhinitis but frequent without allergy caused by chronic rhinosinusitis or cystic fibrosis, part of Samters syndromes( asthma, nasal polyposis and aspirin sensitivity)

26

Differential Diagnosis
Systemic Disease
Wegeners granulomatosis Sarcoidosis Relapsing polychondritis Rhinoscleroma Klebsiella rhinoscleromatis Infections that cause granulomatous obstruction of the nasal cavity include tuberculosis, leprosy, sporotrichiosis, blastomycosis, histoplasmosis and coccidiodomycosis

27

Clinical Evaluation
History
General medical history History or family history of immunodeficiency, ciliary dyskinesia, or cystic fibrosis History of drug abused Family history of allergic rhinitis Initial onset of the disease Frequency of the symptoms Presence of any factors that trigger acute symptoms

28

Clinical Evaluation
Physical Examination
Allergic shinners Mouth breathing Serous otitis media Retraction of the tympanic membrane Allergic conjunctivitis Allergic salute Saddle nose deformity Collapse of nasal valve Character and color nasal mucosa Discharge Anterior septal deflections Turbinate hypertrophy
General obsevation Otologic examination External nasal examinations Internal nasal examinations
29

Clinical Evaluation
Special Diagnostic Techniques CT scan :
Imaging of the nasal cavity and paranasal sinuses Indicated to diagnose or to evaluate recurrent acute or chronic rhinosinusitis To examine abnormal finding at nasal endoscopy To evaluate atypical facial pain

30

Clinical Evaluation
Rhinomanometry and Acoustic Rhinometry :
To document severity of nasal obstruction Rhinomanometry measure resistance to airflow Acoustic rhinometry mapping the volume & dimensions

Serum IgE and Serum Eosinophil Levels : Nasal Cytologic Examinations :

31

Management
Management of allergic rhinitis :
Avoidance of inciting allergens Pharmacotherapy Desentization

Mainstay of therapy for non allergic rhinitis :

Pharmacotherapy Avoidance of inciting factors is the therapy for drug-induced and gustatory rhinitis

Therapy for acute viral rhinitis

Largely symptomatic Annual influenza vaccination
32

Antihistamines
Oral antihistamines are effective in reducing the symptoms of itching, sneezing and rhinorrhea in allergic rhinitis Classic first-generation antihistamines produce sedation Second-generation H1 antagonist astemizole, terfenadine Newer nonsedating antihistamines cetirizine, fexofenadine, loratadine Having no efficacy in the management of nonallergic rhinitis Systemic antihistamines effective for allergic conjuctivitis Intra nasal antihistamines relieve nasal congestion bitter taste

33

Decongestants
Oral decongestants pseudoephedrine phenylephrine phenylpropanoamine Topical decongestants phenyleprine oxymetazoline xylometazoline

Alfa-adrenergic agonist

Oral decongestants agents are most efficacious used alone to manage vasomotor rhinitis and infectious rhinitis

34

Corticosteroids
Nasal steroids are effective in controlling the congestion, rhinorrhea, itching, sneezing of allergic rhinitis Nasal steroids are first-line therapy for rhinitis medicamentosa low effective dosage, localized site of action, minimal systemic circulations, metabolized rapidly once absorbed systemically Oral corticosteroids are used to reduce edematous nasal mucosa and gain control over sinonasal polyposis before surgical excision or prolonged therapy with a nasal steroid spray Oral administration of corticosteroids should be performed in a high burst with a rapid tappering of dosage Contraindication : diabetes, tuberculosis, pregnancy, peptic ulcer, renal disease, emotional instability, hypertensions

35

Intranasal cromolyn sodium

Cromolyn sodium inhibits degranulation of mast cells Useful in the prevention of allergic rhinitis when used before exposure to an allergen seasonal allergic rhinitis Safely used in pregnancy and by small children Not useful in the management of nonalllergic rhinitis

36

Intranasal anticholinergic
Intranasal anticholinergic agents are poorly absorbed systemically Useful in management of rhinorrhea caused by increase cholinergic activity management of parasympathetically mediated rhinitis and allergic rhinitis Ipratropium bromide contraindicated : narrow-angle glaucoma pateients or patient who are taking anatheranticholinergic agents (prostatic hypertrophy or bladder neck obstruction)

37

Non-allergic rhinitis
treatment

Non-surgical non-pharmacological
Stop smoking Non-specific irritants should be avoided Avoid sprays Avoid high concentrations of dust Certain drugs, such as blood pressure Medication, may cause vasomotor rhinitis symptoms During periods of heavy pollution, drive your car With the windiws and vents closed .
38 WAO

Non-allergic rhinitis Treatment : surgery

Nasal obstruction Turbinate Submucosal diathermy Cryosurgery Laser cautery Partial excision Submucosal turbinectomy Total turbinectomy

Turbinate resection

Rhinorrhea Vidian neurectomy

Excision of vidian nerve Diathermy Cryotherapy

39 ARIA

Highlights
Nonallergic rhinitis is a common problem in otolaryngology, but the precise diagnosis often is elusive Pregnancy-induced rhinitis commonly occurs during the second trimester Vasomotor rhinitis is a conditions of unknown causation characterized by congestion and rhinorrhea without sneezing or pruritus Occupational rhinitis is diagnosed when symptoms of congestion and rhinorrhea occur when the patients enters the work environment but resolve when the patients leaves the environment

40

Highlights
Rhinitis medicamentosa most commonly is caused by extended use of over-the-counter topical decongestants Therapy for rhinitis depends on the cause. The diagnosis must be made before initiation of treatment for the best results. Antihistamines are efficacious only in the management of allergic rhinitis Oral decongestants are useful in the management of vasomotor, infectious, and allergic rhinitis Nasal corticosteroids are most useful in the management of allergic rhinitis and nonallergic rhinitis with eosinophilia

41

Thank You

42