1. Non-infective Non-allergic Rhintis
Dr. Vishal Sharma

2. 1. Vasomotor rhinitis
2. Non-Allergic Rhinitis with Eosinophilia Syndrome
3. Occupational Irritant: flour, animal, wood, latex, paint
4. Rhinitis medicamentosa: decongestant nose drops
5. Drug-induced: propranolol, O.C.P., amytriptilline
6. Endocrine: hypothyroid, pregnancy, menstruation
7. Addiction: alcohol, tobacco
8. Non-airflow: tracheostomy, laryngectomy
9. Miscellaneous: honeymoon / emotional

3. Autonomic Innervation of Nose
Deep petrosal nerve (Symp) + greater superficial petrosal nerve (Para-symp)  vidian nerve  pterygo-palatine ganglion  nasal glands
Sympathetic stimulation  vasoconstriction +
ed nasal secretions
Para-sympathetic stimulation  vasodilatation +
ed nasal secretions

4. Vasomotor Rhinitis

5. Pathogenesis
Caused by over activity of para-sympathetic nervous system leading to:
nasal congestion (due to nasal vasodilatation)
nasal block (due to nasal vasodilatation)
watery rhinorrhoea (due to ed nasal secretion)

6. Trigger Factors 1. emotional stress (hypothalamus controls
autonomic nervous system)
2. sudden change in temperature
3. humidity
4. blasts of cold air
5. dust
6. smoking & traffic fumes

7. Clinical Features Symptoms are perennial Nasal block (Blockers)
Profuse watery rhinorrhoea (Runners)
Paroxysmal early morning sneezing
Post nasal drip
Turbinates congested & hypertrophied

8. Diagnostic Nasal Endoscopy

9. Sequelae & Differential Diagnosis
 Nasal polyp  Hypertrophic rhinitis  Sinusitis
Differential diagnosis
Allergic rhinitis
Non-allergic rhinitis with eosinophilia syndrome
Rhinitis medicamentosa

10. Allergic
N.A.R.E.S.
Vasomotor
Allergen exposure
Yes No
Nasal itch
+++ +
Minimal
ed sneezing
Nasal block ++
Hyposmia
Rhinorrhoea

11. Absolute Eosinophil Count ed Normal Nasal smear eosinophil
Allergic
N.A.R.E.S.
Vasomotor
Nasal mucosa
Pale
Congested
Nasal polyps ++
Rare
Absolute Eosinophil Count
ed
Normal
Nasal smear eosinophil
Skin prick test
Positive
Negative
Treatment
Steroid spray, Anti H1, Nasal decongestant
Ipratropium, Botulinum

12. Treatment of Vasomotor Rhinitis

13. General Measures  Sleep with head end elevated by 300
 Sleep + work in a cool environment (not cold)
 Keep body warm
 Regular exercise program to improve vasomotor tone
 Avoidance of trigger factors

14. Medical Treatment Ipratropium bromide spray (0.03%)
Intra-turbinal injection of Botulinum toxin
Steroid spray
Topical Cromolyn sodium (prophylaxis only)
Anti-histamines
Nasal decongestant

15. Topical nasal decongestant
Drug
Sneeze
Rhinorrhoea
Nasal block
Nose itch
ed smell
Antihistamine
+++ ++ +
Steroid spray
Cromoglycate
Topical nasal decongestant
++++
Ipratropium

17. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD

18. Systemic Antihistamines

19. Topical Antihistamine spray

20. Nasal Decongestants Systemic decongestants  Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline

21. Anti-cold preparations
Name
Chlorpheniramine
Decongestant
Paracetamol
COLDIN
4 mg
PsE 60 mg
500 mg
SINAREST
DECOLD
PhE 7.5 mg
SUPRIN
2 mg
PhE 5 mg
PsE = Pseudoephedrine; PhE = Phenylephrine

22. Topical Decongestants
Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)
Oxymetazoline %: 2 drops BD (NASIVION-P)
Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)
Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)
Saline 2 %: 3 drops TID
Saline 0.67 %: 2 drops BD (NASIVION-S)

23. Nasal Decongestants

24. Ipratropium nasal spray
Has anti-cholinergic action

25. Botulinum Toxin Injection
Inhibits release of Acetylcholine   rhinorrhoea

26. Corticosteroid sprays
Strength / puff
Acute attack dose
Maintenance dose
Beclomethasone
50 g
2 puffs BD
1 puff OD
Budesonide
64 g
2 puffs OD-BD
Fluticasone
Mometasone

27. Corticosteroid nasal spray

28. Sodium Cromoglycate

29. Surgical Treatment
Measures which reduce size of nasal turbinates to relieve nasal obstruction
Sectioning parasympathetic secreto-motor fibers of nose (vidian neurectomy) to relieve excessive rhinorrhoea

30. Inferior Turbinate Surgeries

31. Surgeries for mucosal hypertrophy
On surface:  Electrocautery  Laser vaporization
Intramural:  Electrocautery (SMD)  Cryotherapy
 Radiofrequency ablation
Surgeries for bony hypertrophy
 Submucous resection of inferior concha
Surgeries for mucosal + bony hypertrophy
 Partial turbinectomy  Total turbinectomy
 Inferior turbinoplasty (neo-turbinate)

32. Hypertrophied Turbinate

33. Submucosal diathermy

34. Radiofrequency ablation

35. Partial Turbinectomy

36. Total (Radical) Turbinectomy

37. Inferior Turbinoplasty

38. Vidian Neurectomy Trans-antral approach (Golding Wood)
Trans-septal approach

39. Rhinitis Medicamentosa

40. Introduction
Rebound nasal congestion due to use of intranasal decongestants for > 7 days
With prolonged use, tachyphylaxis occurs, resulting in need for more frequent doses & shorter duration of action of these drugs
Nasal medications containing benzalkonium chloride cause more rebound congestion

41. Offending drugs 1. Oxymetazoline 2. Xylometazoline
These drugs contract smooth muscle of venous erectile tissue, present in nasal turbinates, causing mucosal shrinkage & decreasing airway resistance

42. Pathogenesis

44. Clinical Features
1. Chronic nasal block requiring increased dose & frequency of topical decongestants
2. Watery rhinorrhoea usually absent, seen only in co-existing allergic or vasomotor rhinitis
3. Nasal mucosa appears hyperemic, granular & boggy in early stages
4. Later, it appears pale & anemic

45. Treatment Immediate withdrawal of topical decongestant
Substitute with systemic nasal decongestants
Nasal corticosteroid sprays
Oral corticosteroids (for severe cases only)
Rhinostat system
Patient Education: Avoid topical decongestant
use for > 7 days

46. Treatment
For patients unable to stop topical decongestant immediately, stop nose drops in more patent nasal cavity & use it in other cavity for < 7 days
Systemic decongestants used to relieve nasal block as pt is weaned off topical decongestants
Phenylephrine & pseudoephedrine are used
Corticosteroid spray used to  local inflammation

47. Rhinostat System
Consists of 2 bottles.  First contains pt’s nasal decongestant spray, second has saline solution. Two solutions precisely combined for dosage 15% / day. Dosage titration allows gradual withdrawal from decongestants while maintaining nasal inspiratory flow.
Takes 3-6 weeks days for complete withdrawal.

48. Rhinostat System

49. Thank You