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NONALLERGIC RHINITIS

Arif Dermawan

Department of Otorhinolaryngology Head and Neck Surgery


Medical School of Padjadjaran University
Hasan Sadikin General Hospital
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Bandung

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
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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
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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.

Nasal Anatomy and Physiology


Each nasal cavity is divided into specific regions, which include the nasal
vestibule, nasal septum, lateral nasal wall, and nasopharynx

Adapted from : Vining, E. Rhinitis. In : Bailey, B.J. Head &


Neck Surgery-Otolaryngology. 2nd ed. 1998

Adapted from : Netter7Atlas

The autonomic nervous system supplies both parasympathetic and sympathetic


fibers, which act to regulate the degree of vascular tone, turbinate congestion,
and nasal secretion

Adapted from : Vining, E. Rhinitis. In : Bailey, B.J. Head &


Neck Surgery-Otolaryngology. 2nd ed. 1998

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Adapted from : Netter Atlas

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CLASSIFICATION
Syndromes of known etiology
Infectious
Bacterial
Fungal

immunodeficiencies
immotile cilia syndrome
cystic fibrosis

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 of unknown
Etiology
Vasomotor rhinitis
NARES
Other, undefined sydromes
Atrophic rhinitis
Excessive surgery
ozena

Syndromes related to physical


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

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

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

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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
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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.
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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

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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
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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

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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
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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
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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
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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

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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
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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
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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

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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

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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

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Differential Diagnosis

Differentiating nonallergic from allergic rhinitis

History
Nonallergic
Temporal pattern
of symptoms
Type of symptoms

perenial

congestion
rhinorrhea
posterior drainage
sinus pressure

Spesific tests (for exclusion


of allergic rhinitis)
Allergic
seasonal or
perennial with seasonal
exacerbations
sneezing, pruritus
congestion
rhinorrhea
posterior drainage
sinus pressure

Age of onset

70% >>20 y.o

70%<<20 y.o

Precipitating factors

non specific
irritants

specific antigens +
non speciific irritants

Other atopic disease

not present

frequently present

Family history
of rhinitis

not frequent

frequent

Allergy Skin Testing


Detection of specific
IgE in patients serum

Adapted from Mygind N, et al. Non-allergic


28 Rhinitis.
Allergic and Non-Allergic Rhinitis. 1993.

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
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Differential Diagnosis
Histamine
Leukotrienes
Prostaglandin
Bradykinin
PAF

Mast
cells

Allergen

Immediate rhinitis
Symptoms
itch, sneezing
watery discharge
nasal congestion

IgE
B
lymphocytes
IL-4

T
lymphocytes
(mast cells)

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

Eosinophils

Figure 6.1 Hypothesis on mechanism of allergic rhinis

Chronic ongoing
Rhinitis
nasal blockage
loss of smell
nasal hypereactivity

Adapted from Mechanism and treatment of allergic rhinitis. Scott-Browns


Otolaryngology. Sixth Edition.1997

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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
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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)
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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

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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

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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
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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

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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 :

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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

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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

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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

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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

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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

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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)

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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 .
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WAO

Non-allergic rhinitis
Treatment : surgery
Nasal obstruction
Turbinate
Turbinate resection
Rhinorrhea
Vidian neurectomy

Submucosal diathermy
Cryosurgery
Laser cautery
Partial excision
Submucosal turbinectomy
Total turbinectomy
Excision of vidian nerve
Diathermy
Cryotherapy
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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

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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
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Thank You

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