Nonallergic rhinitis

Nonallergic Rhinitis
Amornrat Prasertcharoensuk
MD.

OVERVIEW
Classification
Investigation
Treatment

RHINITIS
Rhinitis is characterized by 1 or more of the
following symptoms: nasal congestion,
rhinorrhea (anterior and posterior), sneezing,
and itching.
Nonallergic rhinitis is characterized by periodic
or perennial symptoms of rhinitis that are not a
result of IgE-dependent events.
Dana V. Wallace, Mark S. Dykewicz, The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008

Nonallergic Rhinitis
NAR is defined as a symptomatic inflammation of the
nasal mucosa with the presence of a minimum of two
nasal symptoms such as nasal obstruction, rhinorrhea,
sneezing, and/or itchy nose, without clinical evidence of
endonasal infection and without systemic signs of
sensitization to inhalant allergens.
Symptoms of NAR may have a wide range of severity
and be either continuously present and/or induced by
exposure to unspecific triggers, also called nasal
hyperresponsiveness.
P. W. Hellings , Non-allergic rhinitis: Position paper of the European Academy of Allergy and Clinical Immunology , Allergy. 2017

The ratio of allergic to pure nonallergic rhinitis 3:1
Data suggest that 44%-87% of patients with rhinitis may have
mixed rhinitis.

Classification of nonallergic rhinitis subtype
 Nonallergic rhinopathy: previously known as vasomotor rhinitis,
irritant-induced rhinitis, and idiopathic rhinitis
 Nonallergic rhinitis with eosinophila
 Drug-induced rhinitis (ie, rhinitis medicamentosa)
 Hormonal-induced rhinitis
 Atrophic rhinitis
 Senile rhinitis
 Gustatory rhinitis (rhinorrhea associated with eating)
 Cerebral spinal fluid leak manifesting as rhinorrhea
Justin Greiwe, MDa,b, Jonathan A. Bernstein, MD , Nonallergic Rhinitis Diagnosis , Immunol Allergy Clin N Am ,2016

Type of Rhinitis

Nonallergic Rhinitis Allergic Rhinitis
Onset of symptoms later in life Usually presents in
childhood
Perennial symptoms in nature
with very little seasonal
variation
Most have seasonal
exacerbation of symptoms
Negative aeroallergen skin
testing
And /or serum igE testing
Positive aeroallergen skin
test and/or serum igE
testing

Nonallergic Rhinitis Allergic Rhinitis
Broad range of irritant triggers Aeroallergen triggers
Symptoms include
- Nasal congestion
- Postnasal drainage
Symptoms include
- Congestion , sneezing , rhinorrhea and
nasal itch
- Ocular conjunctivitis , watering and itch
Nasal mucosa can be normal with
increased clear watery secretions
, may be erythematous or atrophic
Nasal mucosa edematous ,pale
,and boggy
Allergic shiners

Symptoms

Testing for specific IgE antibody
- Skin tests are the preferred test for diagnosis of the
IgE-mediated sensitivity .
- In vitro assays for specific IgE – The precise
sensitivity of specific IgE immunoassays compared
with skin prick/puncture tests is approximately 70%-
75%

Mechanism of Action
 Inflammation (A Th2 cytokine inflammatory pattern is found in AR
patients, as well as in those with occupational allergic rhinitis induced by
high molecular weight (HMW) allergens , LAR )
 Neurogenic Mechanism including rhinitis of the elderly, gustatory
rhinitis, some forms of occupational rhinitis, some forms of drug induced
rhinitis, and IR )

clinical evaluation and nasal cytology
 two groups: patients without inflammation
(symptomatic patients without evidence for nasal cytology with
a cellular inflammatory infiltrate);
 patients with inflammation
(symptomatic patients with evidence for nasal cytology with a
cellular inflammatory infiltrate).
 into 4 subgroups according to the results of the cytological
nasal smear:
• NAR with eosinophils (NARES): eosinophils > 20% of total cells.
• NAR with neutrophils (NARNE): neutrophils > 50% of total cells.
• NAR with mast cells (NARMA): mast cells > 10% of total cells.
• Mixed NAR with eosinophils and mast cells (NARESMA): eosinophils > 20% and
mast cells > 10% of total cells
Eugenio De Corso , Role of inflammation in non-allergic rhinitis ,Rhinology 52: 142-149, 2014

Eugenio De Corso , Role of inflammation in non-allergic rhinitis ,Rhinology 52: 142-149, 2014

Dennis Shusterman , Nonallergic Rhinitis Environmental Determinants , Immunol Allergy Clin N Am 36 (2016) 379–399
NEUROGENIC MECHANISM

Phillip L. Lieberman, Immunol Allergy Clin N Am - (2016)
CAPSAICIN

VASOMOTOR RHINITIS
(idiopathic rhinitis)
Heterogenous group , not immunologic or infection in
origin and is usually not associated with nasal
eosinophilia .
Rhinorrhea – enhanced cholinergic glandular
secretory activity , atropinelike agents effectively
reduce secretions .

Rhinitis from foods and alcohol
After ingestion of foods or alcoholic products .
Gustatory rhinitis is characterized by watery
rhinorrhea after ingestion of hot and spicy food.
induced by a gustatory reflex associated with a
hyperactive, nonadrenergic, noncholinergic, or
peptidergic neural system.
Result of vagally mediated mechanism .
Response to intranasal cholinergic agents

Occupational rhinitis
Response to air-borne substances in the workplace.
Allergic and nonallergic factors
In case of prolonged exposure to occupational
agents, patients may progress to asthma.

Dennis Shusterman , Nonallergic Rhinitis Environmental Determinants , Immunol Allergy Clin N Am 36 (2016) 379–399

NARES
Nasal eosinophil in patients , perennial symptoms
and occasional reduced sense of smell .
Middle ages
NARES may precede the development of nasal
polyposis and aspirin sensitivity .
NARES increased risk for the development of
obstructive sleep apnea.

Hormonal rhinitis
 Pregnancy rhinitis , significant nasal congestion , starts after
second month of pregnancy , and usually disappears within 2
weeks after delivery.
 Menstrual cycle-related rhinitis .
 Estrogens exert a vascular engorgement effect in the nose,
which may lead to nasal obstruction and/or nasal
hypersecretion.
 Beta-estradiol and progesterone increase the expression of
histamine H1-receptors on human nasal epithelial and
microvascular endothelial cells and induce eosinophil
migration and/or degranulation

Drug-induced rhinitis
 ACE inhibitors
 Phosphodiesterase-5-selective inhibitors
 Phentolamine
 Aspirin
 NSAIDS
 α- receptor antagonists
 Rhinitis medicamentosa – syndrome of rebound nasal congestion –
overuse of intranasal α- adrenergic decongestants(oxymetazoline and
phenylephrine) or cocaine . Benzalkonium chloride is vasoconstrictor
spray – develop rebound congestion , tachyphylaxis , reduced
mucociliary clearance .

Atrophic rhinitis
 Empty nose syndrome – absence of identifiable turbinates
on sinus CT
 Secondary atrophic rhinitis result of chronic sinusitis or
excessive surgery to the nasal turbinates .

Senile rhinitis or rhinitis in elderly
 above 65 years of age
 diagnosis of senile rhinitis most often refers to
those patients with late-onset, bilateral watery nasal
secretions without endonasal mucosal and/or anatomic
pathology.
 A neurogenic dysregulation is considered the cause of the
symptoms as ipratropium bromide, that is, an anticholinergic
drug, is effective in reducing the severity and duration of the
rhinorrhea in these patients.

Conditions that mimic rhinitis
Nasal polys
Anatomical abnormalities
Cerebral spinal fluid rhinorrhea ( β-2-transferrin ) giving
rise to (unilateral) watery discharge from the nose. CSF leakage should be
considered in those patients with a relevant history and rhinorrhea not responding
to nasal corticosteroids, ipratropium bromide, or capsaicin nasal treatment
Ciliary dysfunction
Dana V. Wallace, Mark S. DykP. W. Hellings , Non-allergic rhinitis: Position paper of the European Academy of Allergy and Clinical Immunology , Allergy. 2017
ewicz, The diagnosis and management of rhinitis: An updated practice parameter, J Allergy Clin Immunol 2008

LOCAL allergic rhinitis
 Entopy
 Localized nasal allergic response in patients with negative SPT and absence of
detectable specific igE (sIgE) to inhalant allergens in the blood
 diagnosis of LAR can be confirmed by the detection of nasal sIgE, a positive NAPT
response, or both.
 The NAPT is a key tool for the diagnosis although it is time-consuming. NAPT with
multiple aeroallergens (NAPT-M) in one session has proved to be specific, sensitive,
reproducible, and less time-consuming (75% reduction in the number of visits for
diagnosis of NAR, and a 55% for LAR).
 Basophil activation test in peripheral blood is very specific and less time-consuming and
supports the diagnosis of LAR.
 Medical management of LAR is similar to AR, with good response to nasal
corticosteroids.

International Forum of Allergy & Rhinology, Vol. 7, No. 9, September 2017



Heterogenicity

Key findings of this study are that using
allergen sensitization (SPT, serum sIgE) alone can result
in a misdiagnosis occurring in 13.7% of AR patients and
24.7% of NAR

Nasal provocation testing
Clinical Indications for NPT
1. To identify specific allergen in the nasal target organ using allergen preparations.
2. To confirm the role of a special occupational agent
3. To confirm the clinical relevance of a specific allergen in patients with multiple positive
allergy skin tests.
4. To assess the role of allergens implicated by a patient’s history when allergy skin test and/or
RAST are negative or when the reactions of the nasal mucosa to an allergen are more
pronounced than those of skin.
5. To investigate food-induced rhinorrhea.
6. To determine if nasal application of allergen can induce symptoms in the conjunctiva,
middle ear, sinus, and lower respiratory airways.
7. To confirm the allergic nature of asthma, since positive nasal reactions may be obtained
when the corresponding bronchial provocation tests are negative or can not be safely
performed.
8. To confirm nasal reactivity before starting local nasal immunotherapy.
Ludmila I. Litvyakova , Ann Allergy Asthma Immunol 2001;86:355–365

Absolute Contraindications
1. Acute bacterial or viral rhinitis or sinusitis
2. Acute period or exacerbation of allergic disease
(rhinitis, food allergy, drug allergy, insect allergy, urticaria)
3. Previous anaphylactic reaction to an allergen
4. Severe general diseases or acute period of diseases,
especially severe asthma, obstructive bronchial diseases,
cardiopulmonary diseases with restricted lung capacity
5. Pregnancy

Outcome measurement
 True positive response at least two of the following three criteria: 5
sneezes, 50% fall in NPEFR, or rhinorrhea .
 German guidelines, positive test flow reduction <40% and/or more than
three score points: secretion, 0 to 2 points (moderate, 1 point; severe, 2
points); sneezing, 0 to 2 points (0 to 2 sneezes = 0 point; 3 to 5 sneezes
=1 point; >5 sneezes = 2 points); additional symptoms such as tearing,
itching (eyes, throat) =1 point; conjunctivitis, cough, urticaria, and/or
dyspnea = 2 points.
 Positive NPT with a decrease of 20% or more in NEPFR and occurrence
of nasal symptoms such as sneezes, rhinorrhea, nasal blockage and
itching. Changes in
the nasal temperature (using thermography) and the pH of nasal
secretions have also been proposed as endpoints

Nasal Provocation. Unilateral administration of allergen or other materials may lead to local,
ipsilateral responses, and parasympathetic reflex effects

Van Gerven et al.: Cold Dry Air Exposure for NHR DiagnosisLaryngoscope 122: December 2012

Anna Krajewska-Wojtys Jerzy Jarzab, Int Arch Allergy Immunol 2017;173:165–170

Anna Krajewska-Wojtys Jerzy Jarzab, Int Arch Allergy Immunol 2017;173:165–

Fig. 1. Changes in nasal specific IgE (nsIgE)/protein ratios after a nasal provocation test with Dermatophagoides pteronyssinus.
There were no differences in the mean nsIgE values between patients with local allergic rhinitis (LAR) or allergic rhinitis (AR),
but there was a statistically significant difference in comparison to the control group for all time points analyzed
(p < 0.001).

Fig. 2. Changes in nasal specific IgE (nsIgE)/protein ratios after a nasal provocation test with Alternaria.
Changes in the mean nsIgE values between patients with local allergic rhinitis (LAR)/allergic rhinitis (AR)
and controls for all time points analyzed (* p < 0.001–0.013).

Anna Krajewska-Wojtys Jerzy Jarzab, Int Arch Allergy Immunol 2017;173:165–
170

Special diagnostic technique
Fiber optic nasal endoscopy
CT and MRI
Rhinomanometry and acoustic rhinometry
Nasal provocation testing
Nasal cytology
Saccharin test and cilia biopsy
Dana V. Wallace, Mark S. Dykewicz, The diagnosis and management of rhinitis: An
updated practice parameter, J Allergy Clin Immunol 2008

Phillip L. Lieberman, Immunol Allergy Clin N Am - (2016)

Therapeutic strategy of nonallergic rhinitis

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Notes de l'éditeur