2007 Annual Evidence Update on Rhinitis: Non-allergic Rhinitis

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Guideline summary - non-allergic rhinitis

Knowledge week contents

 

 

 

 

Contributing Author: Glenis Scadding

Non-allergic rhinitis has a variety of causes and is a risk factor for the development of asthma. Some forms are inflammatory, are associated with increased nasal eosinophils and respond to topical nasal corticosteroids. Non-allergic rhinitis with eosinophilia syndrome (NARES) may progress to nasal polyposis, asthma and aspirin sensitivity. Inflammatory rhinitis with negative skin prick tests can also be a manifestation of systemic disorders such as Wegener’s, Churg-Strauss and sarcoidoisis. In these conditions the nasal mucosa has a granulomatous, reddened appearance, often with crusting and bleeding, sometimes together with nasal septal perforation and collapse of the nasal bridge. Rhinitis may accompany other systemic disorders such as Sjogren’s syndrome, rheumatoid arthritis and SLE.
Non-inflammatory causes include neurogenic forms such as autonomic (vasomotor) rhinitis which is triggered by chemical or physical stimuli. The major symptom is profuse, clear rhinorrhoea , especially in the morning, often with some nasal congestion. Parasympathetic dominance of the nasal vasculature, replacing the usual sympathetic tone, may be the cause. Ipratropium bromide spray reduces rhinorrhoea and may be curative if used regularly three times daily for several months. Several other neurogenic and emotional rhinitides probably exist but are as yet incompletely understood. Capsaicin, the extract from chilli peppers which destroys c-fibres, can be used (together with local anaesthetic) to reduce rhinitis symptoms in some non- allergic rhinitis patients when no other cause has been found (idiopathic rhinitis).

Drugs can induce rhinitis. Those which reduce sympathetic tone, e.g. beta blockers and other anti-hypertensive medications, result in a degree of nasal obstruction. Conversely alpha agonists increase nasal patency and are used as decongestants. Overuse of these in topical sprays or drops results in rhinitis medicamentosa in which the nose is blocked by an oedematous swollen mucosa which exhibits tachyphylaxis to applied alpha stimuli but also to those emanating naturally from the brain stem. Cocaine can result in reduction of septal blood flow sufficient to cause perforation.
Aspirin and other Cyclo-oxygenase 1 inhibitors induce rhinitis symptoms in susceptible patients, often those with nasal polyps and asthma. The mechanism probably relates to increased leukotriene production and marked leukotriene sensitivity plus decreased protection from prostaglandin E2. Avoidance of all Cox 1 inhibitors is necessary, Cox 2 inhibitors and low doses of paracetamol are usually tolerated. Topical corticosteroids are helpful and sometimes anti-leukotrienes.
Other drugs affecting the nose are the oestrogenic molecules used in the oral contraceptive and hormone replacement therapy and chlorpromazine, all of which tend to reduce nasal patency.

Hormonal changes involving oestrogen e.g. pregnancy and puberty can also cause nasal symptoms. Hypothyroidism is another cause of nasal obstruction and hyposmia. Acromegaly can involve similar symptoms. Treatment is of the cause.

Food allergy is rarely a cause of rhinitis unless associated with other allergic symptoms. However food intolerance to alcohol, spices, pepper, sulphites in some individuals, especially those with aspirin sensitivity, give rise to rhinitic symptoms and sometimes asthma. Gustatory rhinitis in which eating any food results in rhinorrhoea is probably a neurogenic problem.

Atrophic rhinitis is a condition in which the widely patent nose is dry, crusted and foul- smelling. It can follow over- enthusiastic nasal surgery, radiation or trauma and Klebsiella ozaenae is a frequent co-pathogen. Moisturising the nose with saline then glucose and glycerine drops may help and benefits from prolonged courses of ciprofloxacin have been noted.

Immune deficiency affecting innate (mucus, cilia) or acquired immunity (immunoglobulins) frequently present with upper respiratory tract symptoms, often rhinitis or rhinosinusitis. (see below)

Malignancies can affect the nose and sinuses but are fortunately rare. Lymphoma, melanomas and squamous carcinomas tend to present with pain and blood stained discharge. Such symptoms, especially if unilateral, should prompt immediate ENT referral.

Nasal structural abnormalities such as deviation of the nasal septum are, unless very severe, only associated with symptoms if rhinitis is additionally present. It is sensible to look for and treat this before considering septal surgery.

Type

Suggested triggers/cause

Signs/symptoms

1.INFLAMMATORY:

 

 

1.1 Eosinophilic or NARES (non-allergic rhinitis with eosinophilia syndrome)

50% develop aspirin sensitive disease with asthma and nasal polyposis later in life [1]

Skin tests negative but nasal smears show eosinophilia. Perennial symptoms with paroxysmal episodes. About 50% have bronchial hyper-reactivity [1]

1.2 Systemic/

Inflammatory

Sjogren, SLE, rheumatoid arthritis,  Churg-Strauss [2]

Nasal blockage Polyps, sinusitis, asthma, eosinophilia

1.3.Granulomatous

Sarcoidosis  Wegener’s disease [3]

External nasal swelling or collapse, sinusitis, swelling, crusting, bleeding, septal perforation

2. EXTRINSIC CAUSE:

 

 

2.1. Drugs

a-adrenergic blockers, ACE inhibitors, chlorpromazine  Cocaine    Nasal decongestants (with prolonged use)  Aspirin/NSAIDs

Nasal blockage,   Rhinorrhoea, crusting, pain and nasal septum perforation reduced olfaction [4] Rhinitis medicamentosa with  chronic nasal blockage [5] Acute rhinitis symptoms +/- asthma

2.2.Hormonal

Pregnancy [6], puberty, HRT, contraceptive pill [7;8]. Possibly hypothyroidism, acromegaly [9;10]

All can cause nasal blockage and/or rhinorrhoea

2.3.Food

Alcohol, spicy foods, pepper, sulphites

Rhinorrhoea, facial flushing Gustatory rhinorrhoea

2.4 Atrophic

Klebsiella Ozonae [11] or secondary to trauma,  surgery, radiation

Foul-smelling odour, crusting, hyposmia, nasal blockage [12]

3. IMMUNE DEFICIENCY:

 

 

3.1 Primary mucus defect

Cystic fibrosis

Children with polyps must be screened for cystic fibrosis [13]

3.2 Primary ciliary dyskinesias

Kartagener and Young syndromes

Rhinosinusitis, bronchiectasis and reduced fertility.

3.3 Immunodeficiency

Antibody deficiency

Chronic infective sinusitis

4. NEUROGENIC

 

 

 

4.1 Autonomic (vasomotor)

Triggered by physical/chemical agents

More common in middle age with clear rhinorrhoea especially in the morning. Less favourable course than allergic. Possibly caused by  parasympathetic hyperactivity [14]

4.2 Idiopathic    

Unknown cause - Diagnosis of  exclusion

May respond to topical capsaicin [15-17]

5. STRUCTURAL ABNORMALITIES

Nasal septal deviation

Unilateral nasal obstruction unlikely to present unless additional cause, e.g. rhinitis

6. MALIGNANCY

Lymphoma, melanoma, squamous cell carcinoma

Bloody, purulent discharge, pain and nasal blockage - symptoms may be unilateral

References

1. Leone C, Teodoro C, Pelucchi A, Mastropasqua B, Cavigioli G, Marazzini L, Foresi A. Bronchial responsiveness and airway inflammation in patients with nonallergic rhinitis with eosinophilia syndrome. J Allergy Clin Immunol 1997;100:775-80. [Link to abstract]

2. Cottin V, Cordier JF. Churg-Strauss syndrome. Rev Pneumol Clin 2003; 59:17-24. [Link to abstract]

3. Rasmussen N. Management of the ear, nose, and throat manifestations of Wegener granulomatosis: an otorhinolaryngologist's perspective. Curr Opin Rheumatol 2001; 13:3-11. [Link to abstract]

4. Yewell J, Haydon R, Archer S, Manaligod JM. Complications of intranasal prescription narcotic abuse. Ann Otol Rhinol Laryngol 2002; 111:174-7. [Link to abstract]

5. Scadding GK. Rhinitis medicamentosa. Clin Exp Allergy 1995; 25:391-4. No abstract available.

6. Gani F, Braida A, Lombardi C, Del GA, Senna GE, Passalacqua G. Rhinitis in pregnancy. Allerg Immunol (Paris) 2003; 35:306-13. [Link to abstract] 

7. Hamano N, Terada N, Maesako K, Numata T, Konno A. Effect of sex hormones on eosinophilic inflammation in nasal mucosa. Allergy Asthma Proc 1998; 19:263-9. [Link to abstract]

8. Philpott CM, El-Alami M, Murty GE. The effect of the steroid sex hormones on the nasal airway during the normal menstrual cycle. Clin Otolaryngol Allied Sci 2004; 29:138-42. [Link to abstract]

9. Scadding GK. Non-allergic rhinitis: diagnosis and management. Curr Opin Allergy Clin Immunol 2001; 1:15-20. [Link to abstract]

10. Bachert C. Persistent rhinitis - allergic or nonallergic? Allergy 2004; 59 Suppl 76:11-5. [link to abstract]

11. Ferguson JL, McCaffrey TV, Kern EB, Martin WJ. Effect of Klebsiella ozaenae on ciliary activity in vitro: implications in the pathogenesis of atrophic rhinitis. Otolaryngol Head Neck Surg 1990; 102:207-11. [Link to abstract]

12. Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol 2001; 15:355-61. [Link to abstract] 

13. Krzeski A, Kapiszewska-Dzedzej D, Gorski NP, Jakubczyk I. Cystic fibrosis in rhinologic practice. Am J Rhinol 2002; 16:155-60.
14. Garay R. Mechanisms of vasomotor rhinitis. Allergy 2004; 59 Suppl 76:4-9. [Link to abstract]

15. van Rijswijk JB, Boeke EL, Keizer JM, Mulder PG, Blom HM, Fokkens WJ. Intranasal capsaicin reduces nasal hyperreactivity in idiopathic rhinitis: a double-blind randomized application regimen study. Allergy 2003;58:754-61. [Link to full text]

16. van Rijswijk JB, Gerth van WR. Capsaicin treatment of idiopathic rhinitis: the new panacea? Curr Allergy Asthma Rep 2006; 6:132-7. [Link to abstract]

17. Blom HM, van Rijswijk JB, Garrelds IM, Mulder PG, Timmermans T, Gerth van WR. Intranasal capsaicin is efficacious in non-allergic, non-infectious perennial rhinitis. A placebo-controlled study. Clin Exp Allergy 1997; 27:796-801. [Link to abstract]