Babak Saedi Assistant Professor Of Tehran University Imam Khomainey hospital

Introduction  nearly 2.5 percent of the $47 billion annual direct cost for respiratory treatment in the United States.  50% are diagnosed with a form of NAR, and the rest are diagnosed with allergic rhinitis (AR).

Introduction  Rhinitis, in which the classification by etiology may be allergic or nonallergic, is a disorder characterized by inflammation of the mucous membranes lining the nasal passages.  In many instances, AR and NAR are often indistinguishable and coexist.

Non allergic rhinitis  Nonallergic rhinitis is characterized by sporadic or persistent perennial nasal symptoms that do not result from IgE mediated immunopathologic events.  The symptoms can be similar to allergic rhinitis, but with a less prominent nasal itch and conjunctival irritation.

 The incidence increase by age

Review article \\  No studies were found that specifically sought to differentiate between allergic and nonallergic rhinitis on the basis of clinical symptoms, signs on physical examination, or the presence or absence of co morbid conditions.

 No diagnostic test has been specifically developed to diagnose nonallergic rhinitis  Given the absence of studies to differentiate nonallergic rhinitis, diagnostic testing rather than symptoms or signs is necessary to differentiate isolated vasomotor or nonallergic rhinitis from allergic rhinitis.

 patient will complain of rhinorrhea, nasal congestion, and sneezing despite a negative allergic history, skin testing, and nasal cytology.

CLASSES OF RHINITIS  Nonallergic rhinitis with eosinophilia  Hormone-related disorders  Hypothyroidism  Acromegaly  Puberty  Pregnancy  Postmenopausal  Irritant  Temperature  Barometric changes  Gustatory  Chemical exposure  Animal proteins  Wheat  Latex  Perfumes  Exhaust fumes  Pesticides  Cleaning agents  Room deodorizers  Floral fragrances  Cosmetics  Irritant  Air pollution  Ozone  Tobacco smoke  Paint fumes  Atrophic rhinitis  Cocaine abuse  Surgery  Aging  Associated systemic disorders  Idiopathic or vasomotor

MEDICATIONS CONTRIBUTING TO RHINITIS  Cocaine  Topical nasal decongestants  AIpha-adrenoceptor antagonists  Reserpine  Hydralazine  Angiotensin-converting enzyme inhibitors  Beta-blockers  Methyldopa  Guanethidine  Phentolamine  Oral contraceptives  Nonsteroidal antiinflammatory medications  Aspirin  Psychotropic agents  Thioridazine  Chlordiazepoxide  Chlorpromazine  Amitriptyline  Perphenazine  Alprazolam

Diagnosis in NAR  Diagnosis of NAR is based on thorough history, complete head and neck examination, and diagnostic tests  Examination includes nasal endoscopy.  Nasal cytology(lack of inflammation→NAR)

treatment  Environmental control  Physical treatment

treatment  Antihistamines : symptomatic relief  a nasal topical product –azelastine (an H1 antihistamine) – for the treatment of vasomotor rhinitis. Intranasal corticosteroids : recommended for long- term therapy in nonallergic rhinitis  Sympathomimetics : symptomatic  Anticholinergic: ipratropium in reducing nose blowing and rhinorrhea  Cromoglycate: improvement in symptoms

COMMONLY PRESCRIBED ANTIHISTAMINES  First generation  Diphenhydramine  Clemastine  Chlorpheniramine  Second generation  Acrivastine  Loratadine  Third generation  Fexofenadine  Cetirizine  Topical  Azelastine

Topical steroid  Beclomethasone→ Narrow margin of safety  Budesonide  Fluticasone→ NARES  Mometasone

Surgical treatment  Anatomical correction  FESS  Vidin neurectomy