Overlap in Common Nonallergic Rhinitis Causes of Rhinitis ... - PDF of  · PDF...

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    Nonallergic RhinitisEvaluation and Treatment

    Charity C. Fox, M.D.Clinical Assistant Professor

    Allergy and ImmunologyDepartment of Internal Medicine

    The Ohio State University Medical Center

    A Diagnosis of Exclusion Candidates have

    Negative allergy skin tests or RAST testsNo infectious process

    No definitive diagnostic test Diagnosis based primarily on clinical

    features and associated conditions

    Nonallergic Rhinitis

    Overlap in Common Causes of Rhinitis

    AllergicRhinitis

    NonAllergicRhinitis

    Infection(Sinusitis)

    Three major types of chronic rhinitis

    Nonallergic Rhinitis Little prevalence data for nonallergic

    rhinitis syndromes

    52% of patients seen in an allergy clinic were found to have nonallergic rhinitis

    Female>male in a few studies looking at epidemiology

    Mullarkey et al J Allergy Clin Immunol 65: 122, 1980.Sibbald et all. Thorax 6:895, 1991.

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    Overlap in Non-Infectious Causes of Rhinitis

    Lieberman et al All Asthma Proc 24:95,2003

    AllergicRhinitis

    NonAllergicRhinitis

    Pure Allergic43%

    Mixed34%

    Pure Nonallergic

    23%

    CombinedNonallergic

    57%

    RhinitisNonallergicAllergic

    Sneezing Sneezing

    Itch Itch

    Posterior Rhinorrhea

    Eye symptoms Eye symptomsPressurePressure

    Headache Headache

    Posterior RhinorrheaCongestion Congestion

    Mechanistic Classificationof Rhinitis

    Inflammatory(Leukocytes)

    Non Inflammatory (No Leukocytes)

    Eosinophil Neutrophil Mixed EpithelialDysplasia

    Neural Hormonal Structural

    Allergy

    NARES

    CESS

    Polyps

    NSAIDSensitivity

    Allergic FungalSinusitis

    BacterialSinusitis

    CiliaryDysfunction

    ImmuneDeficiency

    Dentogenic

    Foreign Body

    Viral

    Vasculitis

    Glandular Sinusitis

    Atrophic

    Sjogrens

    Oxidants

    Mucosaldisruption

    Nociceptive

    Parasympathetic

    Sympathetic

    Olfactory

    Thyroid

    Pregnancy

    Anatomic/Trauma

    Tumors

    Occupational Meltzer et al. J AllergyClin Immunol114:S155, 2004.

    Mechanistic Classification: Nonallergic Noninfectious Rhinitis

    InflammatoryEosinophils NARES/BENARES Polyps NSAID sensitivity

    Neutrophils or Mixed Vasculitis/Autoimmune

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    Mechanistic Classification: Nonallergic Noninfectious Rhinitis Non-Inflammatory

    Drug InducedEpithelial dysfunctionOccupational/IrritantHormonalStructuralIdiopathic/Neural/Vasomotor

    Perennial symptoms similar to allergic rhinitis

    Sneezing, rhinorrhea, nasal itch, congestion, anosmia

    Eosinophilia on nasal smears Negative allergy skin tests or RAST

    tests Associated with asthma, aspirin

    intolerance and nasal polyps

    Nonallergic Rhinitis with Eosinophilia Syndrome

    (NARES)

    Good response to intranasal corticosteroids. Budesonide, beclomethasone and fluticasonehave indications for nonallergic rhinitis.

    Oral antihistamines some efficacy in only a few studies.

    Subtypes of the condition with blood eosinophilia(BENARES)

    Patients sometimes describe antigen triggers

    Nonallergic Rhinitis with Eosinophilia Syndrome

    (NARES)

    Purello-DAmbrosio et al. Clin Exp Allergy 29:1143, 1999.

    Positive nasal allergen challenges in patients with

    persistent nonallergic rhinitisEvidence for localized allergic response

    Rondon et al. J Allergy Clin Immunol 119:899,2007.

    54% of persistent nonallergicrhinitispatients (PNAR) showed positive nasal allergen provocation tests (NAPT) to D. pteronyssinus (DP) dust mite

    22% had nasal specific IgE to DP mite in the face of negative skin tests and serum specific IgE to DP

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    Nasal Polyps

    Photo courtesy of David M. Powell M.D.

    David M Powell MD

    Benign polypoidmasses arising from inflamed nasal mucosa.

    Contain eosinophils,Lymphocytes, plasma cells and mucin with few nerves.

    Nasal PolypsAssociated with Aspirin intolerance Sampters syndrome

    aspirin intolerance,asthma, nasal polyps, sinusitis.

    Cystic Fibrosis Churg-Strauss syndrome Chronic sinusitis Ciliary dyskinesia Young syndrome Allergic fungal sinusitis

    David M Powell MD

    Pathophysiology unknown Recurrent infections contribute Increased histamine, leukotrienes and

    serotonin Not IgE-mediated Respond to corticosteroids Possible role for leukotriene inhibitors

    Nasal Polyps

    Systemic Autoimmunity/Vasculitis

    Churg-Strauss syndrome Systemic lupus granulomatosis Wegeners granulomatosis

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    Systemic Autoimmunity/Vasculitis Sarcoidosis

    Treat underlying conditionTopical corticosteroids

    Sjogrens syndromeTreatment of xerostomia with nasal saline sprays, moisturizing nasal gels, sialogogues

    Non-Steroidal Anti-Inflammatory Drugs(NSAID Rhinitis, ASA Triad)

    AntihypertensivesACE Inhibitors

    Hydralazine

    Beta-blockers

    Drug Induced Nonallergic Rhinitis

    Rhinitis MedicamentosaTopical decongestants

    Oral Contraceptives/Hormone Replacement Therapy

    Psychotropic agents

    Drug Induced Nonallergic Rhinitis

    Epithelial DysfunctionAtrophic Rhinitis1) Epistaxis, nasal crusting, stuffiness,

    halitosis1) Excessive surgical removal of nasal

    mucosa1) Treatment with nasal saline rinses and

    moisturizing agents2) Klebsiella infection in elderly

    1) Treatment with antibiotics

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    Epithelial Dysfunction2) Profuse rhinorrhea in elderly

    1) Possible parasympathetic overactivity

    1) Treatment with intranasal ipratropium bromide

    Many causative agents in the workplace or home

    Can be inflammatory or non-inflammatory

    Immunologic responses

    Comparable to agents of occupational lung disease

    Occupational/Irritant

    Corrosive effects with epithelial injury

    Irritant Rhinitis

    Smoke, paint, air pollution, dust

    Physical Stimuli

    Cold dry air, bright lights

    Occupational/Irritant

    Hormone Induced Nonallergic Rhinitis

    Rhinitis of Pregnancy

    Hormone replacement therapy and oral contraceptive associated rhinitis

    Hypothyroidism

    Acromegaly

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    Structural Rhinitis Septal deviation or other obstructing

    abnormality can aggravate rhinitis

    Tumors

    Cerebral Spinal fluid leak

    Associated with trauma or surgery

    CSF contains glucose and 2-transferrin

    Is the new vasomotor rhinitis

    Corresponds to neural or reflexrhinitis

    After having excluded all known causes of chronic rhinitis

    Nasal hyperreactivity key feature

    Idiopathic Rhinitis

    Exclusion criteriaPositive allergy testSmokingNasal polypsAnatomical abnormalityInfectionPregnancy, lactation, hormone replacementMedications affecting nasal functionBeneficial effect of nasal corticosteroid (NARES)

    Idiopathic Rhinitis

    Rijswijk et al. Allergy 60:1471, 2005.

    Selection criterionNasal hyperreactivity

    To nonspecific stimuli

    Smoke, spices, strong odors, and other irritants

    Idiopathic Rhinitis

    Rijswijk et al. Allergy 60:1471, 2005.

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    Importance of neurologic vascular control Hyperactive parasympathetic system

    Hypoactive sympathetic system

    Overactivity of C-fibers of the nonadrenergic noncholinergic system

    Enhanced release of substance p and other neuropeptides

    Idiopathic Rhinitis

    Efficacy of topical antihistamine in idiopathic

    rhinitisAzelastineeffective for thetreatment ofIdiopathic(vasomotor)rhinitis in twoDBPC trials.

    From Gehanno et al. ORL J Otorhinolaryngol Relat Spec 63:76, 2001.

    Summary: Treatment of Nonallergic Rhinitis

    Inflammatory Non Inflammatory

    PruritisSneezingCongestionRhinorrheaCongestion

    Eliminate triggers and treat identifiable causes

    azelastine

    Consider ipratropium or cromoglycate

    nasal corticosteroid

    Nasal corticosteroid

    AddAntihistamine

    Oral or Azelastine

    (Leukotrieneinhibitors Proposed)

    Rhinorrhea

    Ipratropium

    (EspGustatory Or Atrophic

    Rhinitis)

    Azelastine

    With or without nasal saline rinses

    Allergic Rhinitis:Initial Diagnosis and

    TreatmentDavid W. Hauswirth, M.D.

    Clinical Assistant ProfessorAllergy and Immunology,

    Internal Medicine and PediatricsThe Ohio State University Medical Center

    Nationwide Childrens Hospital

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    Sneezing Runny Nose Nasal Congestion Facial Pressure Headache Facial Pain Ear Pressure/fullness Eyes water or itch

    Chief Complaint

    Decreased Smell Decreased Taste Bad Breath Cough Sore Throat Throat Clearing Throat Drainage Sinus Infections

    Chief Complaint

    Adolescents and AdultsAllergic RhinitisNon-Allergic Rhinitis/Vasomotor RhinitisInfection (viral URI or sinusitis)Obstructing polyps, septaldeviation

    Age Matters

    ChildrenInfection Allergic Rhinitis (generally >2 y/o)Non-Allergic Rhinitis/Vasomotor Rhinitis

    Irritant (esp. tobacco smoke)Obstruction (Adenoid hypertrophy, foreign body)

    Age Matters

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    Exam Pearls Edema and venous sinusoid congestion

    leads to swollen pale or blue turbinates

    Clear middle ear fluid is common with significant congestion

    The eyes are important (redness, swelling, shiners, Dennies lines)

    Other sign of atopy--asthma, eczema

    Testing should be to relevant local antigens

    Pollen seasons and indoor allergen patterns help interpret history

    Spring-Trees; Summer-Grass; Fall-Weeds

    Skin Testing

    History dictates what antigens are to be tested

    Interpreted only in the context