Non Allergic Rhinitis

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Non Allergic Rhinitis

Literature Reading
Desti Kusmardiani
Supervisor :
Dr. Lina Lasminingrum, dr. M.Kes, Sp.T.H.T.K.L(K).
Department of Otorhinolaryngology Head and Neck Surgery
Medical School of Padjadjaran University
Hasan Sadikin General Hospital
Bandung, 2015
Introduction
Non allergic rhinitis is diseases associated with
symptoms of nasal inflammation in the absence
of identifiable allergic triggers.
Nonallergic rhinitis :
more prevalent after age 20
female predominance
Patients tend to have a heightened sensitivity to
irritants
Symptoms are typically perennial rather than seasonal
And nasal eosinophilia is present in 33% of patients
Nonallergic Rhinitis. Bailey BJ. Head & Neck Surgery Otolaryngology. Fifth Editions. 2014.
CLASSIFICATION
non allergic rhinitis
idiopathic rhinitis (IR),
nonallergic rhinitis with eosinophilia
syndrome (NARES),
autonomic rhinitis,
work-related rhinitis,
drug-induced rhinitis,
hormonal rhinitis,
atrophic rhinitis (AR), and
systemic causes of rhinitis.
CLASSIFICATION
CLASSIFICATION
EPIDEMIOLOGY
NAR presents later in life than allergic
rhinitis, as shown in this graphic, while the
onset of allergic rhinitis usually occurs
before age 20 (and often in childhood)
30
70
After 20 y o
Before 20 y o
Outpatient of Rhinology-Allergy ORL-HNS

Hasan Sadikin Hospital Bandung from JanDec 12 :
207.4
829.6
Non-Allergic
Rhinitis
Allergic Rhinitis
Lieberman PL, Corren J, Feldwe AM. 2013 Chronic nonallergic rhinitis ( UpToDate ).Wolters Kluwer Health.
EPIDEMIOLOGY
EPIDEMIOLOGY
10
EPIDEMIOLOGY
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IDIOPATHIC RHINITIS
60% of non allergic rhinitis
heterogenous disorder that includes
(1) anatomic abnormalities requiring nasal
endoscopy for diagnosis,
(2) incipient, "endogenous" atopy (entopy),
(3) nociceptive nerve dysfunction, and
(4) autonomic dysfunction as found in
chronic fatigue syndrome and other
systemic "functional" syndromes
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PATHOPHYSIOLOGY
Many theories :
a chronic inflammatory state,
an imbalance between sympathetic and
parasympathetic input to the nasal mucosa,
a nonadrenergic noncholinergic mechanism
of stimulating nasal mucosa via peptides
central nervous system sensory
dysregulation, and
nitric oxide synthase induction in vascular
smooth muscle cells causing vasodilation
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PATHOPHYSIOLOGY
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IDIOPATHIC RHINITIS
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IDIOPATHIC RHINITIS
A wide variety of both pharmacologic and
surgical therapies exist for symptomdirected treatment of IR.
THERAPIES:
TOPICAL NASAL STEROID

INTRA NASAL ANTIHISTAMIN
SYSTEMIC ANTIHISTAMIN
NASAL SALINE
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NONALLERGIC RHINITIS WITH

EOSINOPHILIA SYNDROME (NARES)
NARES was first described in 1981 by Jacobs et al.
NARES is a clinical syndrome in which symptoms
such as :
sneezing, pruritus, and profuse watery rhinorrhea seem
decidedly allergic
Nasal smear greater than 20%
NARES are often more severe than in their allergic and

anosmia is present more frequently
Clinical allergy and immunology, Nonallergic rhinitis, Michael A. Kaliner, 2009.
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Pathophysiology
The pathophysiology of NARES is not yet fully elucidated,
but a chronic.
An evaluation of 20 patients with NARES was able to
demonstrate a three-staged process in the evolution of the
disease:
Migration of eosinophils from the vessels into nasal secretions
Retention of eosinophils in the mucosae, which might be linked to
activation of unknown origin
Development of nasal micropolyposis and polyposis
This may occur as a result of the release of toxic substances

such as major basic protein and ECP contained in
eosinophil granules. These toxic proteins may damage nasal
ciliated epithelium and prolong mucociliary clearance
18
A study by Carney et al
19
Medication
Intranasal corticosteroids are the mainstay of treatme
20
WORK-RELATED RHINITIS
(OCCUPATIONAL RHINITIS)
(OR) is nasal irritation and inflammation due to
workplace exposures.
European Academy of Allergy and Clinical
Immunology (EAACI) 2008 "OR is an inflammatory
disease of the nose, which is characterized by
intermittent or persistent symptoms (i.e., nasal
congestion, sneezing, rhinorrhea, itching), and/or
variable nasal airflow limitation and/or
hypersecretion due to causes and conditions
attributable to a particular work environment and
not to stimuli encountered outside the workplace"
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Diagnosis
The diagnosis of OR requires both documentation
of rhinitis and causation by a workplace exposure.
Documentation of rhinitis is accomplished by a
careful medical history, occupational history, and
exam.
Medical history should include preexisting nasal
symptoms, onset of symptoms, exacerbation and
relief of symptoms in and out of the workplace.
severity of symptoms, and impact of symptoms
on work productivity, and the individual's
wellbeing.
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23
Medication
There are three primary tenets to
treatment of the individual with OR :
Limit the impact of disease on the
individual's well-being
Limit untoward effects on work productivity
Prevent additional adverse health sequelae
(e.g., occupational asthma) from continued
occupational exposure.
24
DRUG-INDUCED RHINITIS
Drug-induced rhinitis is divided into three
categories (a) neurogenic, (b) inflammatory, and
(c) idiopathic.
Systemic anti-hypertensive medications are examples of
drugs that cause rhinitis through neurogenic
mechanisms.
such as hypnosedatives (e.g., zolpidem) act centrally

on gamma-aminobutyric (GABA) receptors yet have
effects in the peripheral nasal mucosa idiopathic drug
induced rhinitis.
25
Aspirin and other non-steroidal antiinflammatory drugs (NSAIDs) can exacerbate
26
Rhinitis Medicamentosa
Occurs by a different mechanism than the
drug-induced rhinitis
Overuse of topical nasal vasoconstrictors
induces a rapid tolerance,. or
tachyphylaxis, with a severe rebound
rhinitis
27
Tachiphylaxis
28
Medication
Treatment of rhinitis medicamentosa is directed
at cessation of the offending agent,
Replacement with more therapeutic
pharmacologic options and identifying possible
underlying causes of rhinitis.
Patients should be weaned quickly off these
medications within a matter of days and may be
helped by replacement with nasal saline sprays
and topical nasal steroids.
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HORMONE-INDUCED RHINITIS
Nasal congestion is thought to occur secondary to
elevated estrogen and progesterone levels.
Pregnancy-induced rhinitis occurs in 20% of
pregnancies, frequent onset in second trimester
of pregnancy
30
Pathophysiology
HIGH LEVEL
OF ESTROGEN
ACETYLCHOLINE PRODUCTION
in the parasympathetic ganglia
ACETYL CHOLINESTERASE
ACTIVITY
EDEMA
HYPERSECRETION
VASCULAR ENGORGEMENT
OF NASAL MUCOSA
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Medication
Saline irrigations are very effective for rhinitis of
pregnancy and should be the first-line agent
before trying pharmaceuticals.
Nasal cromolyn sodium is a Category B
medication, which is effective for symptoms of
rhinorrhea, sneezing, and itching.
The first- and second generation oral
antihistamines are listed as Category B except for
fenofexadine and desloratadine, which are
designated as Category C.
Ipratropium bromide is Category B but it is
typically more effective for rhinorrhea and less so
for the primary complaint of congestion.
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33
AUTONOMIC RHINITIS
(VASOMOTOR RHINITIS)
Nonallergic rhinitis (vasomotor rhinitis) is a
condition
that
causes
chronic
sneezing,
congestion or runny nose.
Symptoms may occur in response to physical,
emotional or gustatory stimuli.
While these symptoms are similar to those of
allergic rhinitis (hay fever), nonallergic rhinitis is
different because, unlike an allergy, involve the
immune system.
Provocative stimuli include cold air, certain foods
or beverages
The Journal
of Allergy and Clinical Immunology, 2014
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Medication
Autonomic rhinitis is unique among other causes
of rhinitis in the fact that it responds particularly
well to ipratropium bromide nasal sprays two to
four times daily
Intranasal topical corticosteroids and intranasal
antihistamines have also been found to be
effective agents for autonomic rhinitis.
35
ATROPHIC RHINITIS
AR is a disease of paradoxical nasal congestion
and mucociliary stasis.
Characterized by atrophic mucosa on the septum,
turbinates, or lateral nasal mucosa
Primary atrophic rhinitis occurs among elderly
patients
More prevalent in eastern Europe, Egypt, India,
China
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MEDICATION
The mainstay of treatment for AR is isotonic nasal
saline irrigations of at least 200 mL 2 to 4 times a
day.
Occasionally topical antibiotic solutions in
addition to saline for 2 to 4 weeks are helpful in
eradicating the chronic infection and foulsmelling crusts.
Decongestants and antihistamines should be
avoided as these will exacerbate the dried
mucosa.
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SYSTEMIC CAUSES OF NONALLERGIC

RHINITIS
Systemic diseases may present with clinical
symptoms of chronic rhinitis.
Autoimmune and granulomatous diseases such
as Wegener granulomatosis and sarcoidosis are
the most common considerations.
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GUSTATORY RHINITIS
"Gustatory rhinitis" is the term used to
describe the sudden onset of watery nasal
discharge with eating, especially foods
that are spicy or heated (such as soup).
It usually begins within a few minutes of
ingestion of the implicated food, and is not
associated with pruritus, sneezing, nasal
congestion or facial pain.
It is considered to be a non-immunological
reaction
40
GUSTATORY RHINITIS
Stimulation of trigeminal sensory nerve
endings located at the upper aerodigestive
track
parasympathetic reflex and activation of
cholinergic muscarinic receptors
nasal vasodilation
watery rhinorrhoea
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THERAPY
Avoidance of the implicated foods, is the first
treatment option, but it is rarely sufficient.
The intranasal topical administration of
anticholinergic agents such as atropine,
either prophylactically or therapeutically has
been shown effective.
Surgical therapy in the form of posterior nasal
nerve resection or vidian nerve neurectomy is
not recommended because of its short lasting
result and frequent unpleasant side effects.
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AGING AND RHINITIS

"geriatric rhinitis" or "senile rhinitis
Patients may present with complaints of
thickened nasal secretions and crusting,
excessive postnasal drip and phlegm, nasal
congestion and occasionally decreased sense of
smell and taste.
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PATOPHISIOLOGY
Atropic
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THERAPY
The goals in the treatment of geriatric rhinitis
focus on increasing nasal moisture and
mucociliary clearance.
To this end, saline nasal sprays and irrigations are
the mainstay of treatment.
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HIGHLIGHTS
Nonallergic rhinitis is a common problem, which
is likely underrecognized.
There are no definitive tests for confirmation of
nonallergic rhinitis (or its subcategories).
Diagnosis is arrived upon with a thorough history,
temporal associations to the patient's symptoms,
and exclusion of other potential diagnoses.
Though the terminology may be murky and
categorization may be challenging, in the
practical management of patients with chronic
nonallergic rhinitis the approach to treatment is
similar.
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HIGHLIGHTS
Chronic rhinitis may be alleviated by many
nonpharmacologic.. nonsurgical therapies
including patient education, environmental
control, and nasal saline irrigation.
Topical antihistamines demonstrate both
antihistaminic and anti-inflammatory properties
and are effective, first-line therapies for patients
with idiopathic rhinitis.
Topical nasal corticosteroids are particularly
effective in nonallergic rhinitis patients with
significant nasal eosinophilia.
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THANK YOU

Non Allergic Rhinitis

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Non Allergic Rhinitis

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1

Non Allergic Rhinitis

Outpatient of Rhinology-Allergy ORL-HNS

TOPICAL NASAL STEROID

NONALLERGIC RHINITIS WITH

NARES are often more severe than in their allergic and

This may occur as a result of the release of toxic substances

Clinical allergy and immunology, Nonallergic rhinitis, Michael A. Kaliner, 2009.

Intranasal corticosteroids are the mainstay of treatme

such as hypnosedatives (e.g., zolpidem) act centrally

Aspirin and other non-steroidal antiinflammatory drugs (NSAIDs) can exacerbate

SYSTEMIC CAUSES OF NONALLERGIC

AGING AND RHINITIS

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