Nonallergic rhinitis

Nonallergic rhinitis is inflammation of the inner part of the nose that is not caused by an allergy. Nonallergic rhinitis involves symptoms including chronic sneezing or having a congested, drippy nose without an identified allergic reaction.^[1] Other common terms for nonallergic rhinitis are vasomotor rhinitis^[2][3] and perennial rhinitis. The prevalence of nonallergic rhinitis in otolaryngology is 40%. Allergic rhinitis is more common than nonallergic rhinitis; however, both conditions have similar presentation, manifestation and treatment. Nasal itching and paroxysmal sneezing are usually associated with nonallergic rhinitis in comparison to allergic rhinitis.^[4][5]

Pathophysiology

Nasal mucosa has rich blood supply and has venous sinusoids or "lakes" surrounded by smooth muscle fibers. These smooth muscle fibers act as sphincters and control the filling and emptying of sinusoids. Sympathetic stimulation causes vasoconstriction and shrinkage of mucosa, which leads to decongestion of nose. Parasympathetic stimulation causes not only excessive secretion from the nasal gland but also vasodilatation and engorgement, which lead to rhinorrhoea and congestion of nose. The autonomic nervous system, which supplies the nasal mucosa, is under the control of the hypothalamus. Therefore, emotions play significant role in nonallergic rhinitis.^[6]

Classification

TYPE	CLASSIFICATION	DEFINITION	SPECIFIC PRESENTATION
Drug Induced	NSAIDS AND ASA, ACEI and Beta Blockers	Intense eosinophilic inflammation with an overproduction of cysteinyl leukotrienes and other prostanoids	profuse rhinorrhea, red eyes, periorbital edema, asthma attacks
Hormonal	Pregnancy	Nasal congestion present during pregnancy without other cause, disappears after two weeks of delivery	Rhinorrhea and nasal congestion
Idiopathic		Unknown cause	Vasomotor Rhinitis and nonallergic rhinitis with eosinophilia
Occupational	Caused by work	Inflammatory disease of the nose causing intermittent and persistent symptoms arising out of causes and conditions attributable to a particular work environment; can be elicited by single or multiple exposures. Corrosive rhinitis is the most severe form	frequently associated with concurrent asthma, nonallergic form is without latency. Nasal challenge test confirms the diagnosis

^[7]

Other forms of nonallergic rhinitis

• Rhinitis medicamentosa - topical decongestant nasal drops are notorious for causing rebound phenomenon. Their excessive use causes rhinitis if treated by withdrawal of nasal drops, short course of systemic steroid therapy and in some cases, surgical reduction of turbinates, if they have become hypertrophy.
• Rhinitis of pregnancy - pregnant women may develop persistent rhinitis due to hormonal changes. Nasal mucous become edematous and block the airway. Some may develop secondary infection and even sinusitis in such cases. Care should be taken while prescribing drugs. Generally, local measures such as limited use of nasal drops, topical steroids and limited surgery (cryosurgery) to turbinates are sufficient to relate the symptoms. Safety of developing fetus is not established for newer antihistamines and they should be avoided.
• Honeymoon rhinitis - this usually follows sexual excitement, leading to nasal stuffiness.
• Gustatory rhinitis - spicy and pungent food may in some people produce rhinorrhea, nasal stuffiness, lacrimation, sweating and flushing of face. It can be relieved by ipratropium bromide nasal spray (an anticholinergic), a few minutes before meal.
• Non-air flow rhinitis - it is seen in patients of laryngectomy, tracheostomy and choanal atresia. Nose is not used for air flow and the turbinates become swollen due to loss of vasomotor control. In choanal atresia there is an additional factor of infection due to stagnation of discharge in the nasal cavity which should otherwise drain freely into nasopharynx.

Clinical features

Paroxysmal sneezing in morning, especially in morning while getting out of the bed. Excessive rhinorrhea - watering discharge from the nose when patient bends forward. Nasal obstruction - bilateral nasal stuffiness alternates from one site to other; this is more marked at night, when the dependent side of nose is often blocked. Postnasal drip.^[8]

Examination

Nose: The mucosa is usually boggy and edematous with clear mucoid secretions. The turbinates are congested and hypertrophic.

Pharynx: Mucosal injection and lymphoid hyperplasia involving tonsils, adenoids and base of tongue may be seen.

Complications

Nonallergic rhinitis cases may subsequently develop polyps, turbinate hypertrophy and sinusitis.

Diagnosis

Nose: The mucosa is usually boggy and edematous with clear mucoid secretions. The turbinates are congested and hypertrophic.

Pharynx: Mucosal injection and lymphoid hyperplasia involving tonsils, adenoids and base of tongue may be seen.^[9]

Investigations

Absolute eosinophil count, nasal smear, skin and in vitro allergy tests to rule out allergic rhinitis, acoustic rhinometry for measuring nasal patency, smell testing, CT scan in cases of sinus disease and MRI in case of mass lesions.^[9]

Treatment

Medical

The avoidance of inciting factors such as sudden changes in temperature, humidity, or blasts of air or dust is helpful.

Intranasal application of antihistamines,^[7] corticosteroids, or anticholinergics may also be used for vasomotor rhinitis. Intranasal cromolyn sodium may be used in patients older than two years.^[10]

Astelin (Azelastine) "is indicated for symptomatic treatment of vasomotor rhinitis including rhinorrhea, nasal congestion, and post nasal drip in adults and children 12 years of age and older."^[11][12]

Surgical

Reduction of hypertrophied turbinates, correction of nasal septum deviation, removal of polyps, sectioning of the parasympathetic secretomotor fiber to nose (vidian neurectomy) for controlling refractory excessive rhinorrhea.^[9]

References

1. "Nonallergic rhinitis: Definition". Mayo Clinic. Mayo Clinic. Retrieved 2015-10-15.
2. Vasomotor rhinitis Am Fam Physician. 2005 Sep 15;72(6):1057-62.
3. "Vasomotor rhinitis ''Medline Plus". Nlm.nih.gov. Retrieved 2014-04-23.
4. "Vasomotor rhinitis Medline Plus". Nlm.nih.gov. Retrieved 2014-04-23.
5. "Characteristics of Human Turbinate-Derived Mesenchymal Stem Cells Are Not Affected by Allergic Condition of Donor". PLOS ONE. 10: e0138041. doi:10.1371/journal.pone.0138041.
6. "Up-date on neuro-immune mechanisms involved in allergic and non-allergic rhinitis". Rhinology. 50: 227–35. Sep 2012. doi:10.4193/Rhino11.152. PMID 22888478.
7. Brown, KR; Bernstein, JA (June 2015). "Clinically relevant outcome measures of novel pharmacotherapy for nonallergic rhinitis.". Current opinion in allergy and clinical immunology. 15 (3): 204–12. doi:10.1097/aci.0000000000000166. PMID 25899692.
8. "Nonallergic rhinitis Symptoms - Mayo Clinic". mayoclinic.org. Retrieved 2015-10-11.
9. diseases of ear, nose and throat, mohan bansal. nonallergic rhinitis. jaypee brothers. pp. 330–332. ISBN 9789350259436.
10. Vasomotor Rhinitis Am Fam Physician. 2005 Sep 15;72(6):1057-1062.
11. Product Information: Astelin, azelastine. Wallace Laboratories, Cranbury, NJ. (PI Revised 08/2000) PI Reviewed 01/2001
12. Vasomotor rhinitis: clinical efficacy of azelastine nasal spray in comparison with placebo.