Nonallergic Rhinitis: Febryanti P Sari, DR, SP.T.H.T.K.L

Nonallergic Rhinitis
Febryanti P Sari, dr, Sp.T.H.T.K.L.

Department of Ear, Nose,Throat, Head and Neck Surgery
Waled Hospital
Rhinitis classifications
(based on major
etiologic factor)
Nonallergicnoninfecti
Infectious rhinitis Allergic rhinitis Mixed rhinitis
ous rhinitis (NANIR)
2
3
Infectious Rhinitis
› Acute and self-limiting disease caused by a
virus, usually known as common cold.
› May have a prolonged disease course with
bacterial infection, especially in patients
with a septal perforation, nose picking,
and/or corpus alienum.
› Clinical landmarks: Discolored secretions
and/or crust formation
4
Allergic Rhinitis
› Most prevalent noncommunicable disease
› Symptomatic inflammation of the nose induced by
allergen inhalation by sensitized individuals.
› Diagnosis is based on the correspondence
between:
› History of induction of symptoms by allergen
contact and
› Positive results of skin prick test (SPT) or
allergen-specific IgE in the blood.
5
Mixed rhinitis
› Have more than one known/unknown
etiologic factor
› Example: patients with an isolated
positive SPT for pollen suffering all
year long despite absence of
eosinophilia in secretions.
6
Outline
• Definition and classification
• Epidemiology
• Specific types of nonallergic rhinitis
– Vasomotor rhinitis
– NARES
– Rhinitis with other cell infiltration
– Atrophic rhinitis
– Medication-related rhinitis
– Hormonal rhinitis
– Aging-related rhinitis
– Rhinitis from other systemic diseases
• Treatment
Definition
• Nonallergic rhinitis
• = Periodic or perennial symptoms of

rhinitis that are not a result of IgE-
dependent events
D .V. Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol
2008;122:S1-84.
Classification
DV Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.
Classification
DV Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.
Classification
J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.
Classification
R A Settipane, et al., Update on nonallergic rhinitis, Ann Allergy Asthma Immunol 2001;86:494–508.
Classification
R. J. Salib, et al., Mechanisms and mediators of nasal symptoms in non-allergic rhinitis, Clinical and Experimental Allergy, 2008; 38,
393–404
Classification
Classification
Epidemiology
• Prevalence about 7% of U.S.

population (About 22 million people)
• Combination of both nonallergic and
allergic rhinitis, “mixed rhinitis”:
– 44–87% of patients with allergic rhinitis
– More common than either pure allergic
rhinitis or nonallergic rhinitis
• Risk factors for nonallergic rhinitis:
female sex and age of 40 years
D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.
R A Sittipane, et al., Nonallergic Rhinitis, Am J Rhinol Allergy 27, S48–S51, 2013
Epidemiology
• A report has observed that

– 70% of patients diagnosed with nonallergic
nasal disease developed their condition in
adult life (age, >20 years)
– 70% of patients diagnosed with allergic
rhinitis developed their condition in
childhood (age, <20 years)
R A Sittipane, Demographics and Epidemiology of Allergic and Nonallergic Rhinitis. Allergy and Asthma Proc 22:185–189, 2001
Epidemiology
R A Sittipane, et al., Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 86:494–508, 2001
Epidemiology
• Nonallergic rhinitis: more likely to

experience perennial rather
than seasonal symptoms
• Frequencies of negative skin
testing:
– 50% in patients with perennial
rhinitis
– 32% in patients with combined
perennial/seasonal rhinitis
– 22% in patients with purely seasonal
allergic rhinitis
Epidemiology: Subclassification
• 61% Vasomotor rhinitis

• 33% Nonallergic rhinitis with
eosinophils syndrome (NARES)
• 16% Sinusitis
• 12% Elevated IgE
• 4% Blood eosinophilia nonallergic
rhinitis syndrome (BENARS)
• 2% Hypothyroidism
VASOMOTOR RHINITIS
(IDIOPATHIC RHINITIS)
Definition and prevalence
• Definition
– “Heterogeneous group of patients with chronic
nasal symptoms that are not immunologic or
infectious in origin and are usually not
associated with nasal eosinophilia”
• Dx by exclusion
• Prevalence: At least 2/3 of all nonallergic

rhinitis sufferers
Etiology
• Likely to result from many different

etiologies
– Cold air
– Exercise
– Pungent odors
– Tobacco smoke
– Alcohol
– Specific physiologic states
Etiology
• Likely to result from many different

etiologies
– Change in temperature, humidity, and
barometric pressure
– Certain precipitants such as perfume or
strong odors are frequently identified
– May occur in the absence of defined
triggers

Etiology

Pathophysiology
• Nasal mucosa often does not show any

evidence of inflammation
– No significant difference in number of mast cells
to allergic patients
• No hyperresponsiveness to histamine
• But rather increased reactivity to cold dry air
• Some reported hypersensitivity to
metacholine, capsaicin
Pathophysiology
• Symptoms and hyperresponsiveness to

cold dry air decrease after capsaicin
Rx
– Sensory neural dysregulation that capsaicin-
sensitive nerves may be important?
• May involve incipient, local atopy

(entopy)
• Dysfunction of nociceptive nerve sensor
and ion channel proteins
Pathophysiology
• Autonomic imbalance?
– Parasympathetic dominance?
• Theoretically can produce excessive rhinorrhea
– A few studies found abnormal responses to
autonomic tests
• Some patients show increased parasympathetic
activity
• Some show more generalized autonomic
dysfunction including both the sympathetic and
parasympathetic nervous systems
Symptoms
• Variable
• Mainly
– Nasal obstruction (Most common)
– Increased secretion (watery rhinorrhea)
• Sneezing and pruritus and conjunctival
symptoms are less common
• Worsen acutely in response to nonspecific
provocateurs (as already mentioned)
Symptoms
• Patterns of symptom occurrence may be:

– Perennial
– Persistent
– Intermittent
– Seasonal

Exercise-induced rhinitis
• Clinical findings
– Most common: Clear, watery rhinorrhea
– Acute nasal congestion
– Itching
– Sneezing
• Up to 20% of elite runners and
swimmers experience symptoms during
routine workouts
Cold air-induced rhinitis
• Watery discharge
• Congestion
• Burning of the nasal mucosa
• Develop within minutes of exposure to
cold air
• Stop soon after the end of exposure
• Common in areas with low outdoor
relative humidity
Gustatory rhinitis
• Watery rhinorrhea
– Mostly bilateral
– Begins soon after beginning to eat
• Virtually all foods have been reported
to cause symptoms
– Hot and spicy foods: most commonly
– Beer and wine may produce nasal
congestion by direct nasal vasodilation
and may exacerbate most forms of rhinitis
J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685. R
A Sittipane, et al., Nonallergic Rhinitis, Am J Rhinol Allergy 27, S48–S51, 2013
Gustatory rhinitis
• Some patient may acquire specific IgE

to select foods
– > Consequently development of acute
food-induced rhinitis
• Patients who experience recurrent

nasal symptoms after eating virtually
any food are rarely found to have
an atopic etiology
Pathophysiology
• Proposed mechanism:
– Vagally mediated mechanisms
– Nasal vasodilation
– Food allergy
– Other undefined mechanisms
– Food allergy is a rare cause of rhinitis
without associated GI, dermatologic, or
systemic manifestations
Investigation for VMR
• Negative responses on skin or blood

tests for specific IgE
• May exhibit a small number of positive
reactions that do not correlate with
the clinical symptoms
• Nasal tissue cytologic analysis will not
demonstrate eosinophils or other
inflammatory cells
NONALLERGIC RHINITIS WITH
EOSINOPHILS SYNDROME
(NARES)
Prevalence
• About 1/3 of cases of nonallergic rhinitis

• Mostly found in middle-aged patients
• Extremely infrequently in childhood
• <2% of children with nasal eosinophilia
• Prevalence general population: Unknown
Symptoms
• Usually more intense nasal symptoms

than vasomotor or allergic rhinitis
• Symptoms
– Perennial nasal symptoms and signs
– Congestion
– Clear discharge being most prominent
– Sneezing
– Pruritus
– Anosmia
D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-
84.
Pathophysiology
• Not clearly understood

• Eosinophilia may contribute to nasal
mucosal dysfunction
• May be due to release of toxic substances
contained in eosinophil granules
– Major basic protein
– Eosinophil cationic protein
– Result: May damage nasal ciliated epithelium
and prolong mucociliary clearance
Pathophysiology
Delayed mucociliary clearance

Increased propensity toward infection
Recurrent infections
Predisposing nasal polyps development
Nasal polyps
Associated with nasal Eo
Nasal Eo may be a precursor for nasal polyps or aspirin intolerance
Nasal polyps + Aspirin reaction

Aspirin reaction is not the etiology of the eosinophilic rhinosinusitis
But mainly a marker of a severe form of NARES that is often associated with
asthma, sinusitis, and nasal polyps.
Pathophysiology
• Nasal eosinophilia in patients with

nonallergic rhinitis
– Generally regarded as a good prognostic
indicator for response to treatment with
topical steroid therapy
• If eosinophilic infiltration is massive (e.g.,
in aspirin sensitivity syndrome)
– Use of oral glucocorticoid may be required to
control symptoms
Investigation
• Nasal smears:
– If 10% of cells are Eo = Elevated Eo
– But in NARES, usually large numbers of Eo
(5–20%) found
– No systemic allergy as assessed by allergy
skin or blood testing
Nasal smears
• Both nostrils should be sampled

• Samples collection
– Blowing mucus into transparent wrap
– Cytology brush
– Probe
– Ultrasonic nebulization of hypertonic saline
• Transfer samples to slides, fixed, and
then treated with Hansel stain
• Nasal biopsy is more accurate
D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol
2008;122:S1-84.
Investigation
• Local allergic rhinitis?

– IgE is present in the nasal mucosa but absent
from other body tissues
– Nasal allergen challenge results in clinical
symptoms
Investigation
• In patients with Hx very suggestive of

allergy
– 4.7%
• Have negative prick tests
• But a positive nasal challenge
• And a positive nasal smear for Eo
• And may have nasal specific IgE
– 6%
• Have negative prick skin test and nasal
challenge
D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol
2008;122:S1-84.
•
Other rhinitis with high nasal Eo
• BENARS = blood eosinophilia nonallergic

rhinitis syndrome
– A subtype of NARES
– Associated with elevated blood eosinophils
• Phaeohyphomycosis of maxillo-ethmoid
sinus
• Churg-Strauss syndrome
RHINITIS WITH OTHER CELL
INFILTRATION
Nasal mastocytosis
• = Basophilic/metachromatic nasal disease

• A histologic diagnosis
• Unknown etiology
• Hallmark: Mast cell infiltration (frequently
>2,000/mm3) without nasal eosinophilia
• Nasal symptoms:
– More likely to be secretion/rhinorrhea and
congestion/blockage
– Without significant sneezing/pruritus
Nasal mastocytosis
• PE: Pale nasal mucosa

• This condition are not predisposed to
develop aspirin sensitivity, nasal polyps,
asthma, or sinusitis.
• Treatment: Inflammatory condition
– Topical anti-inflammatories
– Intranasal cromolyn
– Intranasal/oral corticosteroids
ATROPHIC RHINITIS
Primary atrophic rhinitis
• Epidemiology
– Most prevalent:
• Developing countries
• In subtropical and temperate climate zones
• With prolonged warm seasons
– Typically afflicts middle-aged adults
• More common in women
– Not seen in children
Primary atrophic rhinitis
• Atrophy of glandular cells

• No known specific cause
– But many patients are found to have chronic
bacterial infection of the nose and sinuses
– Bacterial infection is thought to be primarily or
secondarily involved
• Klebsiella ozaenae
• Staphylococcus aureus,
• Proteus mirabilis
• Escherichia coli
Secondary atrophic rhinitis
• More prevalent in developed countries

• Less severe and less progressive
• Most commonly occurs in older patients
• Causes:
– Multiple nasal sinus surgeries
– Trauma
– Irradiation
– Granulomatous diseases
Syptoms
• Crusting
• Purulent discharge
• Nasal obstruction
• Halitosis (foul odor or fetor emanating
from the patient’s nose)
• Recurrent epistaxis
Empty nose syndrome
• Usually follows aggressive resection of

inferior +/- middle turbinates
• Manifestation:
– Symptoms of severe nasal obstruction
– Inability to sense airflow through the nose
– Profound sense of dyspnea
– But
• No objective findings of pulmonary disease
• Complete patency of the nasal airways
Signs of atrophic rhinitis
• Nasal mucosa:
– Ulceration
– Covered by thick yellow/brown/green crusts
– Possible evidence of bleeding
• Nasal cavities:
– May be enlarged
– Bowing of the lateral nasal wall
• Advanced cases:
– Saddle nose deformity
– Nasal septal perforation
Signs of atrophic rhinitis
Image from http://www.drtbalu.com/images/ar.jpg

MEDICATION-RELATED
RHINITIS
Topical α-adrenergic decongestant
• Nasal sprays
– Oxymetazoline
– Phenylephrine
• Repetitive use
– More than a few days
• Rebound nasal congestion
• Most likely due to downregulation of α-agonist
receptors (tachyphylaxis)
– Long-term use (several months)
• Rhinitis medicamentosa
Rhinitis medicamentosa
• Causes
– Topical decongestant drugs
– Cocaine
– Benzalkonium chloride in vasoconstrictor
spray products
• When used >30 days
• May augment local pathologic effects.
M. Varghese ,et al., Drug-induced rhinitis, Clinical & Experimental Allergy, 2010;40, 381–384
• Manifestations:
– Severe nasal congestion without other
significant symptoms
– Rarely, septal perforation
– Cocaine causes significantly more crusting,
bleeding, and septal perforation
• Physical examination
– Erythematous (beefy red), swollen, granular
mucosa
– Minimal discharge
– Areas of punctate bleeding because of tissue
friability
Other drugs
Other drugs
• Mechanism?
– Induce changes in nasal function by causing
inflammation, through neurogenic effects
– Unknown mechanisms
• Evidence is anecdotal and not supported
by rigorous investigation
Other drugs
• Apart from rhinitis medicamentosa,

drug-induced rhinitis may be further
classified into:
– Local inflammatory type
– Neurogenic type
– Idiopathic (unknown) type
• In these mechanism, nasal mucous
membrane is often normal (different
from rhinitis medicamentosa)
Local inflammatory type
• Main drugs: ASA and NSAIDs

– Including
• ASA exacerbated asthma (AEA)
• “Triad” of nasal polyposis, asthma and aspirin
or other NSAIDs sensitivity
• Principle mechanism : Inhibition of
cyclooxygenase-1 (COX-1)
Image from http://journals.prous.com/journals/dot/19983411/html/dt340957/images/Bha2.gif



Neurogenic type
Sympathetic
Parasympathetic
Sensory
fibres
Neurogenic type
Sympathetic
Adrenergic
sympathetic neuron
fibres contain
- Norepinephrine
- Neuropeptide-Y
(NPY)
Neurogenic type
▼Sympathetic
↓
-Down regulation of
the sympathetic
nervous system
↓
-Blunting effects of
norepinephrine and
NPY
Pathophysiology
R. J. Salib, et al., Mechanisms and mediators of nasal symptoms in non-allergic rhinitis, Clinical and Experimental Allergy, 2008; 38,
393–404
Neurogenic type
Neurogenic type
Idiopathic type
HORMONAL RHINITIS
Hormonal rhinitis
• Most frequently encountered hormonal

state associated with rhinitis: Pregnancy
• Most common causes of nasal symptoms
requiring treatment during pregnancy:
– Rhinitis of pregnancy
– Allergic rhinitis
– Rhinitis medicamentosa
– Sinusitis
Rhinitis of pregnancy
• Incidence: 20% to 30% of pregnant

women
• Definition:
– New-onset nasal symptoms (usually
congestion and/or rhinorrhea)
– Absence of other known cause
– Lasts >/= 6 weeks
– Peaking in the last 6 weeks of
pregnancy
– Resolves within 2 weeks after
delivery
• Pathophysiology: unknown
– Condition has been attributed to changes in
estrogen or progesterone, or both
– Little evidence has emerged to support this
assertion
• Preexisting chronic rhinitis can worsen,
improve, or remain unchanged during
pregnancy
Possible pathophysiology
• Massive expansion of blood volume

– Increase in nasal vascular pooling
• Progesterone-induced, vascular smooth
muscle relaxation
• Pregnancy-associated hormones may
have a direct effect on the nasal mucosa
– Increased nasal mucous gland hyperactivity
– Increased nasal secretion/rhinorrhea
• More bacterial rhinosinusitis
• Uncontrolled rhinitis during pregnancy

– Severe snoring
– Increased risk of
• Gestational hypertension
• Preeclampsia
• Intrauterine growth retardation
Other hormonal rhinitis
• Little knownledge about relationship

between the menstrual cycle or use of
exogenous ovarian hormones (i.e., oral
contraceptives, hormone replacement
therapy) and rhinitis
• One clinical trial showed that hormone
replacement therapy had no effect on
quality of life, nasal airway resistance, or
nasal mucociliary clearance
Other hormonal rhinitis
• Growth hormone?
– Acromegaly can contribute to rhinitis
symptoms
• Hypothyroidism?
– Evidence linking to rhinitis is limited and may
merely represent the concomitant occurrence
of two common disorders
AGING-RELATED RHINITIS
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
Previously non-rhinitis person
• Result…
• Nasal mucosal dryness
• Increased nasal airway resistance
Established allergic rhinitis person
• Aging causes:
– Gradual diminution in clinical symptoms
– Skin tests and in vitro tests for allergy
decrease in magnitude
• But quality of life related to allergic rhinitis
remains significantly impaired in patients
older than 65 years
RHINITIS FROM OTHER
SYSTEMIC DISEASES
Diseases related to rhinitis
• Granulomatous diseases
– Granulomatosis with polyangiitis
– Sarcoidosis
– Midline granuloma
– Wegener granulomatosis
• Cystic fibrosis
• Ciliary dyskinesia syndromes
• Immunodeficiencies
• Autoimmune/vasculitis
– Churg-Strauss syndrome
– Systemic lupus erythematosus
– Relapsing polychondritis
– Sjogren syndrome
• Rhinitis sicca

TREATMENT
Treatment of vasomotor rhinitis
• Avoidance of factors that may be

contributing
– Cigarette smoke
– Other environmental triggers
• Pharmacologic Rx
– Intranasal antihistamines: 1st line
treatment
– Intranasal corticosteroids: useful in treatment
of some forms of nonallergic rhinitis
Persistent rhinorrhea
• Nasal irrigation with saline

– May be very helpful any of the forms of
nonallergic rhinitis
– Extremely important in the management of
nasal crusting, as seen in atrophic rhinitis
– May have no effect on nasal congestion
Intermittent watery rhinorrhea
• May caused by
– Irritant
– Cold air exposure
– Exercise
– Food
• Ipratroprium bromide used before
symptoms occur can be very effective
– Used with caution in patients with preexisting
glaucoma or prostatic hypertrophy
Nasal congestion
• Intranasal steroid or intranasal azelastine

– 1st line pharmacologic Rx
– Used on an intermittent or as-needed basis
• Nasal cytology: helpful in guiding therapy
– 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
Nasal congestion
• Intranasal corticosteroids (INS)

– In recommended doses: Generally not
associated with clinically significant systemic
side effects: (In both children and adults)
• Hypothalamic-pituitary-adrenal (HPA) axis
• Ocular pressure or cataract formation
• Bone density
• Growth suppression has been reported only with
long-term use of beclomethasone dipropionate
that exceeded recommended doses or
administration to toddlers
Nasal congestion
• Intranasal corticosteroids (INS)

– Local side effects: Rare and can be avoided
with proper administration technique
• Nasal irritation
• Bleeding
• Nasal septal perforation
Intranasal cortocosteroids
Nasal congestion
• Intranasal decongestants
– Phenylephrine
– Imidazoline derivatives (oxymetazoline and
xylometazoline)
– No effect on Ag-provoked nasal response
– No effect on itching, sneezing, or nasal
secretion
– Not recommended for continuous use
• Due to induction of rhinitis medicamentosa
Nasal congestion
• Intranasal decongestants
– Side effects
• Local stinging or burning
• Sneezing
• Dryness of the nose and throat
– Efficacy and safety of intermittent use of this

drug have not been formally studied
Nasal congestion
• Oral decongestants
– Pseudoephedrine (restricted prescription)
– Phenylephrine (less effective)
– Effective at relieving nasal congestion
– Side effects:
• Insomnia
• Loss of appetite
• Irritability
• Palpitations
• Elevated BP
Nasal congestion
• Oral decongestants side effect

– Elevated BP
• Very rare in normotensive patients
• Occasionally in controlled HT patients
• But changes in BP still should be followed
• Concomitant use of caffeine and stimulants may
be associated with an increase in adverse events
Nasal congestion
• Oral decongestants
– Used with caution in:
• Cerebrovascular
• Cardiovascular disease
• Hyperthyroidism
• Closed-angle glaucoma
• Bladder neck obstruction
Nasal congestion
• Oral decongestants…in children

– Usually very well tolerated in children >6
years of age
– Use in infants and young children has been
associated with…
• Agitated psychosis
• Ataxia
• Hallucinations
• Even death
– ADR can occur even in recommended
dose
Pharmacological Rx summary
Other pharmacological Rx
• Topical use of capsaicin intranasally

– Desensitize sensory neural fibers in the nose
– Reducing nasal hyperreactivity
– Beneficial effects are delayed
– 63% reduction of nasal congestion
– 69% reduction of nasal discharge
– After 1 month of therapy
• Topical application of 15% to 20% silver
nitrate might also be effective
Rhinitis medicamentosa Rx
• Withdrawal from topical decongestant

• Treatment of underlying rhinitis disorder
• Use of topical/systemic glucocorticoid:
– INS bilaterally + discontinueation of
decongestant in one nostril and, 1 week later,
in the remaining nostril
– 1-week tapering course of oral glucocorticoid,
with discontinuation of the decongestant on
days 2 or 3
Medication-related rhinitis
• Change in therapy should be considered
• If a particular medication is necessary and

irreplaceable?
– Topical therapy
• In order to avoid drug interactions and/or additional
systemic adverse effects
Surgical Rx
• Endoscopic vidian nerve section and/or

electrocoagulation of the anterior
ethmoidal nerve
– Parasympathetic supply to the nasal mucosa
is divided, resulting in reduced nasal secretion
– Recurrence of symptoms due to re-innervation
can occur
– But enough long-term benefits
Surgical Rx
• Sphenopalatine ganglion block

– Reported to relieve symptoms
– Number of blocks required for complete relief
range from 2 to 4
• Turbinectomy
– In cases of predominant congestion
– A variety of surgical procedures available
– Can nasal mucosa return to a normal
functioning state after radical turbinectomy?
Surgical Rx of atrophic rhinitis
• To reduce the nasal cavity size

• Providing tissue augmentation
• Means to help restore nasal anatomy
toward the premorbid state

TAKE HOME MESSAGE
Algorithm of rhinitis diagnosis
GK. Scadding, Non-allergic rhinitis: diagnosis and management, Curr Opin Allergy Clin Immunol, 2001;1:15-20
nal s
AN. Greiner, Overview of the Treatment of Allergic Rhinitis and Nonallergic Rhinopathy, Proc Am Thorac Soc , 2011;8.,121–131.
THANK YOU

Nonallergic Rhinitis: Febryanti P Sari, DR, SP.T.H.T.K.L

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Nonallergic Rhinitis

Febryanti P Sari, dr, Sp.T.H.T.K.L.

• = Periodic or perennial symptoms of

• Prevalence about 7% of U.S.

• A report has observed that

• Nonallergic rhinitis: more likely to

• 61% Vasomotor rhinitis

• Prevalence: At least 2/3 of all nonallergic

• Likely to result from many different

• Likely to result from many different

R A Sittipane, et al., Nonallergic Rhinitis, Am J Rhinol Allergy 27, S48–S51, 2013

R A Sittipane, et al., Nonallergic Rhinitis, Am J Rhinol Allergy 27, S48–S51, 2013

• Nasal mucosa often does not show any

• Symptoms and hyperresponsiveness to

• May involve incipient, local atopy

• Patterns of symptom occurrence may be:

R A Sittipane, et al., Nonallergic Rhinitis, Am J Rhinol Allergy 27, S48–S51, 2013

• Some patient may acquire specific IgE

• Patients who experience recurrent

• Negative responses on skin or blood

• About 1/3 of cases of nonallergic rhinitis

• Usually more intense nasal symptoms

• Not clearly understood

Delayed mucociliary clearance

Nasal polyps + Aspirin reaction

• Nasal eosinophilia in patients with

• Both nostrils should be sampled

• Local allergic rhinitis?

• In patients with Hx very suggestive of

• BENARS = blood eosinophilia nonallergic

• = Basophilic/metachromatic nasal disease

• PE: Pale nasal mucosa

• Atrophy of glandular cells

• More prevalent in developed countries

• Usually follows aggressive resection of

Image from http://www.drtbalu.com/images/ar.jpg

• Apart from rhinitis medicamentosa,

• Main drugs: ASA and NSAIDs

Image from http://journals.prous.com/journals/dot/19983411/html/dt340957/images/Bha2.gif

Image from http://journals.prous.com/journals/dot/19983411/html/dt340957/images/Bha2.gif

Image from http://journals.prous.com/journals/dot/19983411/html/dt340957/images/Bha2.gif

• Most frequently encountered hormonal

• Incidence: 20% to 30% of pregnant

• Massive expansion of blood volume

• Uncontrolled rhinitis during pregnancy

• Little knownledge about relationship

• Important changes in nasal physiology in

R A Sittipane, et al., Nonallergic Rhinitis, Am J Rhinol Allergy 27, S48–S51, 2013

• Avoidance of factors that may be

• Nasal irrigation with saline

• Intranasal steroid or intranasal azelastine

• Intranasal corticosteroids (INS)

• Intranasal corticosteroids (INS)

– Efficacy and safety of intermittent use of this

• Oral decongestants side effect

• Oral decongestants…in children

• Topical use of capsaicin intranasally

• Withdrawal from topical decongestant

• Change in therapy should be considered

• If a particular medication is necessary and

• Endoscopic vidian nerve section and/or

• Sphenopalatine ganglion block

• To reduce the nasal cavity size