Non-allergic rhinitis

Nonallergic RhinitisNonallergic RhinitisWat Mitthamsiri, MD.Allergy and Clinical Immunology Unit, Department of MedicineKing Chulalongkorn Memorial Hospital

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

Epidemiology

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

• 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

Epidemiology

R A Sittipane, Demographics and Epidemiology of Allergic and Nonallergic Rhinitis. Allergy and Asthma Proc 22:185–189, 2001

•Mixed rhinitis = the definite presence of allergic rhinitis in an individual who also experiences chronic rhinitis symptoms, which are not entirely explained by skin test reactivity

Epidemiology

R A Sittipane, Demographics and Epidemiology of Allergic and Nonallergic Rhinitis. Allergy and Asthma Proc 22:185–189, 2001D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.

• 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)

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

Epidemiology: Thailand, adult

C Bunnag, et al., Epidemiology of rhinitis in Thais, Asia Pac J Allergy Immunol. 2000;18:1-7.

• A questionnaire survey• Performed on 3,124 subjects living in

Bangkok and its vicinity in 2000• Cumulative prevalence of chronic rhinitis

was 13.15% (95% CI =13.13-13.17)– N = 383

• Allergic rhinitis = 152• Nonallergic rhinitis = 231

Epidemiology: Thailand, children

P Vichyanond, et al., Clinical characteristics of children with non-allergic rhinitis vs with allergic rhinitis, Asian Pac J Allergy Immunol 2010;28:270-4

• A retrospective, descriptive study• 302 children (ages </=14 years) with

chronic rhinitis• Evaluated at the Siriraj Hospital in 2006• Use of SPT to classified into 2 groups; AR

and NAR• Medical records were reviewed

Epidemiology: Thailand

VASOMOTOR RHINITISVASOMOTOR RHINITIS(IDIOPATHIC RHINITIS)(IDIOPATHIC RHINITIS)

Definition and prevalence

D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.

• 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

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

Etiology

R A Sittipane, Demographics and Epidemiology of Allergic and Nonallergic Rhinitis. Allergy and Asthma Proc 22:185–189, 2001J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.

• 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

R A Sittipane, et al., Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 86:494–508, 2001J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.

• 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• Autonomic dysfunction

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

Pathophysiology

Symptoms

R A Sittipane, Demographics and Epidemiology of Allergic and Nonallergic Rhinitis. Allergy and Asthma Proc 22:185–189, 2001R A Sittipane, et al., Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 86:494–508, 2001J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.

• 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

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

• 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

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 NONALLERGIC RHINITIS WITH EOSINOPHILS SYNDROMEEOSINOPHILS SYNDROME(NARES)(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

D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.

• 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

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

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., Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 86:494–508, 2001

Delayed mucociliary clearanceIncreased propensity toward infection

Recurrent infections Predisposing nasal polyps development

Nasal polypsAssociated with nasal Eo

Nasal Eo may be a precursor for nasal polyps or aspirin intolerance

Nasal polyps + Aspirin reactionAspirin 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

D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84. 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

• 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

Investigation

D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84. 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

• 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• But will have nasal eosinophilia

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 RHINITIS WITH OTHER CELL INFILTRATIONINFILTRATION

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 RHINITISATROPHIC 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

D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.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

• 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 MEDICATION-RELATED RHINITISRHINITIS

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

• 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.gifM. Varghese ,et al., Drug-induced rhinitis, Clinical & Experimental Allergy, 2010;40, 381–384

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

Neurogenic type

Idiopathic type

HORMONAL RHINITISHORMONAL RHINITIS

Hormonal rhinitis

D V Wallace, et al., The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008;122:S1-84.J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.

• 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 RHINITISAGING-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 RHINITIS FROM OTHER SYSTEMIC DISEASESSYSTEMIC DISEASES

Diseases related to rhinitis

R A Sittipane, et al., Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 86:494–508, 2001J. Corren, et al., Allergic and Nonallergic Rhinitis, Middleton’s Allergy 8th edition, 2013, 664-685.

• 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

TREATMENTTREATMENT

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 MESSAGETAKE HOME MESSAGE

Algorithm of rhinitis diagnosis

GK. Scadding, Non-allergic rhinitis: diagnosis and management, Curr Opin Allergy Clin Immunol, 2001;1:15-20

Algorithm of nonallergic rhinitis Rx

AN. Greiner, Overview of the Treatment of Allergic Rhinitis and Nonallergic Rhinopathy, Proc Am Thorac Soc , 2011;8.,121–131.

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