1. Update on Non Allergic Rhinitis
DILYANA VICHEVA

3. 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

4. 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.

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

6. 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

7. Classification

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

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

11. 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.

12. 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: , 2001

13. 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.

14. 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

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

16. 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

17. 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

18. 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

19. Local inflammatory type
Neurogenic type
Idiopathic type
Drug induced rhinitis

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

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

22. 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 

23. 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

24. 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 

25. 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,
Aging-related rhinitis

26. Treatment

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

28. 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,
Nasal obstruction 

29. 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

31. Enjoy the Rhinologic Leaders from all over the world!