Non Allergic Rhinitis

Diagnosis & Management

Niken L. Poerbonegoro
Allergy-Immunology Division, Department of ENT-HNS
Faculty of Medicine Universitas Indonesia/
Dr. Cipto Mangunkusumo hospital
Jakarta
 Introduction
Rhinitis: inflammation of the nasal lining with symptoms
as anterior/posterior rhinorrhea, sneezing, nasal
blockage and/or itching, occur in 2 or more days and
last for > 1 hour in most days

Prevalence: Allergic rhinitis 15-40%

Infectious rhinitis
Non allergic 25-30%

ENT Department FKUI/RSCM 2014-2015:

Of 282 patients with chronic rhinitis, 101 patients had
negative result in skin prick test (35.8%)
 Chronic symptoms impair quality of life:
Physically, emotion, cognitive impairment, sleep
disturbance due to nasal congestion, headache,
fatigue

untreated
Adults: decreased
Children: loss of school
productivity and work
days
days
 Classification of Rhinitis

Infectious
• Viral
• Bacteria
• Fungus
Allergic Non allergic
• Intermittent • Idiopathic
• persistent • NARES
• Hormonal
• Occupational, etc

rhinitis

Bousquet et all. ARIA 2008 Update. Allergy 2008:63(S86):8-160

Johnson JT, Rosen CA. Bailey’s Head and Neck Surgery Otalaryngology 2014
 Common colds or allergic rhinitis?
Common colds Allergic rhinitis

Watery secretion frequent frequent

Nasal obstruction frequent, severe frequent, severity varies

Sneezing present always

Nasal itch never always
Nasal tenderness present none
Ocular itch seldom or never frequent

Cough frequent frequent

Fever occasionally never
Arthralgia mild none
Fatigue mild Occasionally, mild

Sore throat frequent never

Palatal & throat itch never occasionally
Duration 3-14 days weeks to months

RyanD, Bousquet J, Fokkens W, Wickman M. Primary care : the Cornerstone of diagnosis of AR. Allergy 2008:63;981-989
 Symptoms suggestive Symptoms usually NOT associated
of allergic rhinitis with allergic rhinitis

- unilateral symptoms
2 or more of the following symptoms for > 1 - nasal obstruction without other symptoms
hour on most days : - mucopurulent rhinorrhea
- watery anterior rhinorrhea - posterior rhinorrhea (post nasal drip)
- sneezing, especially paroxysmal - with thick mocous
- nasal obstruction - and / or no anterior rhinorrhea
- nasal pruritis - pain
± conjunctivitis - recurrent epistaxis
- anosmia

Classify and assess severity

(see section 4)

Bousquet et all. ARIA 2008 Update. Allergy 2008:63(S86):8-160

 Non allergic vs Allergic
NAR Difference from AR
Onset Older ages (vs earlier
ages/allergic march)
Structural: deviated septum , turbinate Unilateral symptoms, abnormal
hypertrophy, nasal polyps findings
Drugs: aspirin, NSAIDs, anti hypertension, Symptoms on exposure only
topical decongestant

Culinary: capsaicin

Emotion: anger

Physical exercise, cold-dry air, temperature

changes
Alcohols

Cocain

Irritant: smoke/fume recurrent

RyanD, Bousquet J, Fokkens W, Wickman M. Primary care : the Cornerstone of diagnosis of AR. Allergy 2008:63;981-989
• Occupational: arises
Pregnancy: congestion
in response to
in the last 6 weeks
particular workplace
(w/out infection &
agent
allergic causes),
• NARES vs LAR:
resolved completely 2
eosinophilia
weeks after delivery
syndrome
Non allergic
rhinitis
• Geriatric:
structural, mucosal Idiopathic
& neural changes (NINAR/vasomotor):
in the nose hyperresponsiveness
• Drug to non-specific stimuli
induced/medicame
ntosa
 AR pathophysiology
Early-Phase Response Late-Phase Response
Mast Cell Cellular Infiltration/Inflammation
Histamine Eosinophil
Proteases CysLTs, GM-CSF,
TNF-, IL-1, IL-3,
Allergen PAF, ECP, MBP
Basophil
Chemotactic factors Histamine, CysLTs,
(CysLTs, PAF, IL-5) TNF-, IL-4, IL-5, IL-6
Mast cell CysLTs Monocyte
Prostaglandins CysLTs, TNF-,
Neosynthesis PAF, IL-1, IL-10 Obstruksi
PAF hidung
Bradykinin hiposmia
ILs Lymphocyte Hipereaktivitas
Gatal hidung
TNF- IL-4, IL-13, IL-5,
Bersin GM-CSF IL-3, GM-CSF, IL-6
Rinorea
Obstruksi hidung

Pearlman. J Allergy Clin Immunol 1999;104:S132.

 Neurogenic inflammation

Sarin S, Undem B, Sanico A, Togias A. The Role of the Nervous System in Rhinitis. JACI 2006:118:999-1014
 Diagnosis

Exposure

Anamnesis:
nasal
symptoms
 • Bluish-edematous mucosa/turbinate
• Turbinate hypertrophy
Anterior
rhinoscopy • Watery mucus

• Abnormalities within middle meatus

Naso-
endoscopy
 Diagnostic test
• Serum specific IgE
In vitro
• Allergy skin test
In vivo • Skin prick/puncture test, Multi test
• Intradermal/ SET (skin end point titration)

• eosinophils > 5 cells/view or >20%

Cytology
• Only for research or occupational disease
Nasal provocation • CDA provocation

• Not for diagnosis of allergic/ non allergic

Imaging rhinitis
• Rhinosinusitis, masses
RyanD, Bousquet J, Fokkens W, Wickman M. Allergy 2008:63;981-989
 Management
• Sub-classification
• Aims: symptoms free & improve QOL

Environmental
Pharmacology Surgical
control
• Exposure • Symptomatic • Turbinate
avoidance • Causative reduction
• Self • Neurectomy
protection
• Prevention
 Pharmacology

Topical • H1-histamine receptor blocker

antihistamine • Anti-inflammatory effect

• Drug of choice for chronic rhinitis & nasal

Intranasal obstruction
steroids • Safe for long term use

• Muscarinic receptor blocker

anticholinergic • Effective for refractory rhinorrhea
Saline douching • Isotonic solution

• Severe nasal congestion

Decongestant (temporary relief)

• Cromones
Others
• Desensitization: capsaicin, aspirin
 Right time for referral?

Difficult to diagnose

Nasal obstruction is the only

disturbing symptom: nasal polyps,
deviated septum, hypertrophic
turbinate

Co-morbids: mixed rhinitis,

rhinosinusitis, OME, OSAS

Not responsive to optimal

medications, persistent symptoms
Need for surgery