Update on Non Allergic Rhinitis DILYANA VICHEVA

The Diagnostic Dilemma of Allergic and Non-Allergic Rhinitis The Journal of Asthma Research. Vol. 14. No. 1. October, 1976 The Diagnostic Dilemma of Allergic and Non-Allergic Rhinitis Vincent Fontana

The term Non-allergic rhinitis' is commonly applied to a diagnosis of any nasal condition in which the symptoms are identical to those seen in Allergic rhinitis but an allergic aetiology has been excluded.

RHINITIS Other forms: Allergic Infective Idiopathic NARES Occupational Drug induced Hormonal Irritans Gustatory Emotional Atrophic Allergic Seasonal Perennial Infective Acute Chronic - Specific - Nonspecific

Mechanisms and mediators of nasal symptoms in non-allergic rhinitis Classification Mechanisms and mediators of nasal symptoms in non-allergic rhinitis Salib, Harries, Nair, Howarthz Clinical and Experimental Allergy, 38, 393–404, 2008

Classification

Signs and Symptoms of Non-allergic rhinitis Stuffy nose Runny nose Sneezing Nasal pain Mucus in the throat (Postnasal drip) Cough

The exact cause of Non-allergic rhinitis is unknown! Weather changes Environmental or occupational irritants Infections Medications Foods and beverages Hormonal changes

How is Non-allergic rhinitis diagnosed? Eosinophilic or Non-allergic rhinitis with eosinophilia syndrome (NARES) Skin test is negative, but nasal smears show eosinophilia. Perennial symptoms with paroxysmal episodes. About 50% have bronchial hyperreactivity.

Pathophysiology Delayed muco-ciliary clearance Recurrent infection Eosinophilia may contribute to nasal mucosal dysfunction May be due to realize of toxic substances contained in eosinophil granules Delayed muco-ciliary clearance Recurrent infection Nasal polyps Nasal polyps and Aspirin reaction Sittipane et al.Update on Nonallergic rhinitis.Ann Allergy Asthma Immunol 86:494-508, 2001

How is Non-allergic rhinitis diagnosed? Vasomotor Rhinitis More common in middle age with clear rhinorrhoea especially in the morning, sneezing, nasal obstruction. Negative allergen tests, no elevated IgE in the secretion.

Vasomotor Rhinitis Conservative Treatment Elimination of irritant factors Antihistamines Nasal or oral decongestants Local Steroids Metabolic & Endocrine systems Sedatives Imidazoline preparations (Potential for habituation) Vasomotor Rhinitis Conservative Treatment

Vasomotor Rhinitis Surgical Treatment Turbinate surgery Correction of anatomical deformity Parasympathetic nasal fibers divisions (Vidian neurectomy) Vasomotor Rhinitis Surgical Treatment

Atrophic Rhinitis Greenish–yellow or brownish-black crusts Wide nasal cavity Atrophic mucosa & dry Subepithelial layer fibrosis Anosmia & social problem Nasal obstruction Mucosal changes Atrophic Rhinitis

Unknown but is multifactorial Secondary Atrophic Rhinitis Bacterial infection: Klebsiella ozaene, Staphylococcus aureus, Escherichia colli, Proteus mirabilis Secondary Atrophic Rhinitis Empty Nose Syndrome Atrophic Rhinitis

Various eponyms Drug induced rhinitis Rhinitis medicamentosa Rhinitis of pregnancy Honeymoon rhinitis Emotional rhinitis Rhinitis due to hypothyroidism Gustatory rhinitis Non-air flow rhinitis Primary mucus defect & ciliary diskinesia Immunodeficiency Granulomatous disease Malignancy Structural abnormalities Various eponyms

Local inflammatory type Neurogenic type Idiopathic type Drug induced rhinitis

Rhinitis medicamentosa Treatment Withdrawal of nasal drops Short course systemic steroids In case of turbinate hypertrophy- surgical reduction Rhinitis medicamentosa

Rhinitis of pregnancy Local measures Cryosurgery Nasal mucosa - oedematous & blocks airway Secondary infection – rhinosinusitis Care in prescribing drugs Local measures Cryosurgery Rhinitis of pregnancy

Follows sexual excitement leading to nasal stuffiness Emotional rhinitis Psychological states like tension, hostility, humiliation, resentment & grief Proper counselling for psychological adjustment Imipramine - has both antidepressant & anticholinergic action Honeymoon rhinitis 

Cholinergic response to stimulation of sensory receptors on palate Spicy & pungent food Rhinorrhoes, nasal stuffiness, lacrimation, sweating & flushing of face RELIEVED by Ipratopium bromide (anticholinergic) nasal spray taken few mins before meals Gustatory rhinitis

Post of laryngectomy & tracheostomy Nose not used for air flow - swollen turbinates due to loss of vasomotor control Similar changes in nasopharyngeal obstruction due to choanal atresia or adenoidal hyperplasia Non-air flow rhinitis 

Aging-related rhinitis Important changes in nasal physiology in aging Decrease in total body water content Decrease in nasal blood flow Degeneration of mucous glands Collagen fibers in cartilage and elastic fibers in the dermis become progressively atrophic Retraction of the nasal columella Downward rotation of the nasal tip J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685. Aging-related rhinitis

Treatment

Treatment Saline nasal sprays Antihistamine nasal sprays Corticosteroid nasal sprays Anti-drip anticholinergic nasal sprays Oral decongestants Combination nasal antihistamine and nasal glucocorticoid  Treatment

Nasal obstruction Intranasal steroid or Intranasal azelastine Nasal cytology: – Eo predominance (i.e., NARES) → Prefer INS – Absence of Eo → Prefer Azelastine If either agent alone is not completely effective → Try adding the other drug J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685. Nasal obstruction 

Can Nasal Mucosa return to a normal functioning state ??? Endoscopic vidian nerve section and/or electrocoagulation of the anterior ethmoidal nerve Sphenopalatine ganglion block  A variety of surgical procedures available Can Nasal Mucosa return to a normal functioning state ??? R A Sittipane, et al., Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 86:494–508, 2001 Surgical treatment

Enjoy the Rhinologic Leaders from all over the world!