Update on Non Allergic Rhinitis DILYANA VICHEVA The

Update on Non Allergic Rhinitis DILYANA VICHEVA

The Journal of Asthma Research. Vol. 14. No. 1. October, 1976 The Diagnostic Dilemma of Allergic and Non-Allergic Rhinitis Vincent Fontana

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.

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

Classification Mechanisms and mediators of nasal symptoms in non-allergic rhinitis Salib, Harries, Nair, Howarthz Clinical and Experimental Allergy, 38, 393– 404, 2008

Classification

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

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

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.

Pathophysiology • 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 and Aspirin reaction Sittipane et al. Update on Nonallergic rhinitis. Ann Allergy Asthma Immunol 86: 494 -508, 2001

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 Ig. E in the secretion.

�Elimination of irritant factors �Antihistamines �Nasal or oral decongestants �Local Steroids �Metabolic & Endocrine systems �Sedatives �Imidazoline preparations (Potential for habituation) Vasomotor Rhinitis Conservative Treatment

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

� Greenish–yellow or brownish-black crusts � Wide nasal cavity � Atrophic mucosa & dry � Subepithelial layer fibrosis � Anosmia & social problem � Nasal obstruction � Mucosal changes Atrophic Rhinitis

�Unknown but is multifactorial �Bacterial infection: Klebsiella ozaene, Staphylococcus aureus, Escherichia colli, Proteus mirabilis �Secondary Atrophic Rhinitis �Empty Nose Syndrome Atrophic Rhinitis

�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

Local inflammatory type Neurogenic type Idiopathic type Drug induced rhinitis

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

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

• 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

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

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

• 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 8 th edition, 2013, 664 -685. Aging-related rhinitis

Treatment

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

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 8 th edition, 2013, 664 -685. Nasal obstruction

• • • 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