Overlap in Common Nonallergic Rhinitis Causes of Rhinitis Three major Evaluation and Treatment Allergic types of Rhinitis Charity C. Fox, M.D. chronic rhinitis Clinical Assistant Professor Allergy and Immunology Non Allergic Infection Department of Internal Medicine Rhinitis (Sinusitis) The Ohio State University Medical Center Nonallergic Rhinitis Nonallergic Rhinitis • A Diagnosis of Exclusion • Little prevalence data for nonallergic • Candidates have rhinitis syndromes 9 Negative allergy skin tests or RAST tests • 52% of patients seen in an allergy clinic were found to have nonallergic rhinitis 9 No infectious process • No definitive diagnostic test • Female>male in a few studies looking at epidemiology • Diagnosis based primarily on clinical features and associated conditions Mullarkey et al J Allergy Clin Immunol 65: 122, 1980. Sibbald et all. Thorax 6:895, 1991. 1 Overlap in Non-Infectious Mechanistic Classification of Rhinitis Causes of Rhinitis Inflammatory Non Inflammatory Pure Allergic (Leukocytes) (No Leukocytes) Allergic 43% Eosinophil Neutrophil Mixed Epithelial Neural Hormonal Structural Mixed Rhinitis Dysplasia 34% Allergy Bacterial Viral Atrophic Nociceptive Thyroid Tumors Combined Sinusitis NARES Para Nonallergic Vasculitis Sjogrens Pregnancy Non Ciliary sympathetic 57% CESS Allergic Dysfunction Anatomic/ Polyps Oxidants Sympathetic Rhinitis Immune Glandular Trauma Deficiency Sinusitis Mucosal Olfactory Pure NSAID Dentogenic disruption Nonallergic Sensitivity 23% Allergic Foreign Occupational Meltzer et al. J Allergy Fungal Body Clin Immunol Lieberman et al All Asthma Proc 24:95,2003 Sinusitis 114:S155, 2004. Mechanistic Classification: Rhinitis Nonallergic Noninfectious Rhinitis Allergic Nonallergic Sneezing Sneezing • Inflammatory Itch Itch 9 Eosinophils • NARES/BENARES Eye symptoms Eye symptoms Pressure Pressure • Polyps Headache Headache • NSAID sensitivity 9 Neutrophils or Mixed Posterior Rhinorrhea Posterior Rhinorrhea • Vasculitis/Autoimmune Congestion Congestion 2 Mechanistic Classification: Nonallergic Rhinitis with Nonallergic Noninfectious Rhinitis Eosinophilia Syndrome (NARES) • Non-Inflammatory 9 Drug Induced • Good response to intranasal corticosteroids. Budesonide, beclomethasone and fluticasone 9 Epithelial dysfunction have indications for nonallergic rhinitis. 9 Occupational/Irritant • Oral antihistamines some efficacy in only a few studies. 9 Hormonal • Subtypes of the condition with blood eosinophilia 9 Structural (BENARES) 9 Idiopathic/Neural/Vasomotor • Patients sometimes describe antigen triggers Purello-D’Ambrosio et al. Clin Exp Allergy 29:1143, 1999. Nonallergic Rhinitis with Positive nasal allergen Eosinophilia Syndrome challenges in patients with (NARES) persistent nonallergic rhinitis • Perennial symptoms similar to allergic Evidence for localized allergic response rhinitis 54% of persistent nonallergic 9 Sneezing, rhinorrhea, nasal itch, rhinitis patients (PNAR) showed congestion, anosmia positive nasal allergen provocation tests (NAPT) to • Eosinophilia on nasal smears D. pteronyssinus (DP) dust mite • Negative allergy skin tests or RAST 22% had nasal specific IgE to tests DP mite in the face of negative skin tests and serum • Associated with asthma, aspirin specific IgE to DP intolerance and nasal polyps Rondon et al. J Allergy Clin Immunol 119:899,2007. 3 Nasal Polyps Nasal Polyps • Pathophysiology unknown Benign polypoid masses • Recurrent infections contribute arising from inflamed nasal mucosa. • Increased histamine, leukotrienes and serotonin Contain eosinophils, Lymphocytes, plasma cells • Not IgE-mediated and mucin with few • Respond to corticosteroids © David M Powell MD nerves. • Possible role for leukotriene inhibitors Photo courtesy of David M. Powell M.D. Systemic Nasal Polyps Autoimmunity/Vasculitis Associated with • Aspirin intolerance • Sampter’s syndrome • Churg-Strauss syndrome 9 aspirin intolerance,asthma, nasal polyps, sinusitis. • Cystic Fibrosis • Systemic lupus granulomatosis © David M Powell MD • Churg-Strauss syndrome • Wegener’s granulomatosis • Chronic sinusitis • Ciliary dyskinesia • Young syndrome • Allergic fungal sinusitis 4 Systemic Drug Induced Autoimmunity/Vasculitis Nonallergic Rhinitis • Sarcoidosis • Rhinitis Medicamentosa 9Treat underlying condition 9 Topical decongestants 9Topical corticosteroids • Oral Contraceptives/Hormone • Sjogren’s syndrome Replacement Therapy 9Treatment of xerostomia with nasal • Psychotropic agents saline sprays, moisturizing nasal gels, sialogogues Drug Induced Epithelial Dysfunction Nonallergic Rhinitis Atrophic Rhinitis • Non-Steroidal Anti-Inflammatory Drugs 1) Epistaxis, nasal crusting, stuffiness, 9 (NSAID Rhinitis, ASA Triad) halitosis • Antihypertensives 1) Excessive surgical removal of nasal mucosa 9 ACE Inhibitors 1) Treatment with nasal saline rinses and 9 Hydralazine moisturizing agents 9 Beta-blockers 2) Klebsiella infection in elderly 1) Treatment with antibiotics 5 Epithelial Dysfunction Occupational/Irritant 2) Profuse rhinorrhea in elderly 9 Corrosive effects with epithelial injury 9 Irritant Rhinitis 1) Possible parasympathetic overactivity • Smoke, paint, air pollution, dust 9 Physical Stimuli 1) Treatment with intranasal ipratropium bromide • Cold dry air, bright lights Hormone Induced Occupational/Irritant Nonallergic Rhinitis • Many causative agents in the workplace or home • Rhinitis of Pregnancy • Can be inflammatory or non- • Hormone replacement therapy and inflammatory oral contraceptive associated rhinitis 9 Immunologic responses • Hypothyroidism • Comparable to agents of occupational lung disease • Acromegaly 6 Structural Rhinitis Idiopathic Rhinitis • Exclusion criteria • Septal deviation or other obstructing abnormality can aggravate rhinitis 9 Positive allergy test 9 Smoking • Tumors 9 Nasal polyps 9 Anatomical abnormality • Cerebral Spinal fluid leak 9 Infection 9 Associated with trauma or surgery 9 Pregnancy, lactation, hormone replacement 9 Medications affecting nasal function 9 CSF contains glucose and β -transferrin 2 9 Beneficial effect of nasal corticosteroid (NARES) Rijswijk et al. Allergy 60:1471, 2005. Idiopathic Rhinitis Idiopathic Rhinitis • Is the new vasomotor rhinitis • Selection criterion • Corresponds to “neural” or “reflex” 9 Nasal hyperreactivity rhinitis • To nonspecific stimuli • “After having excluded all known causes of chronic rhinitis……” –Smoke, spices, strong odors, and other irritants • Nasal hyperreactivity key feature Rijswijk et al. Allergy 60:1471, 2005. 7 Summary: Treatment of Idiopathic Rhinitis Nonallergic Rhinitis Inflammatory Non Inflammatory Importance of neurologic vascular control Eliminate triggers and treat identifiable causes • Hyperactive parasympathetic system Rhinorrhea Nasal corticosteroid Pruritis Sneezing • Hypoactive sympathetic system Congestion Add Rhinorrhea Antihistamine Ipratropium Azelastine • Overactivity of C-fibers of the Oral or Congestion nonadrenergic noncholinergic system Azelastine (Esp Gustatory Or Atrophic 9 Enhanced release of substance p and (Leukotriene Rhinitis) nasal corticosteroid azelastine inhibitors other neuropeptides Proposed) With or without nasal saline rinses Consider ipratropium or cromoglycate Efficacy of topical antihistamine in idiopathic Allergic Rhinitis: rhinitis Initial Diagnosis and Azelastine Treatment effective for the David W. Hauswirth, M.D. treatment of Clinical Assistant Professor Idiopathic Allergy and Immunology, (vasomotor) Internal Medicine and Pediatrics rhinitis in two The Ohio State University Medical Center DBPC trials. Nationwide Children’s Hospital From Gehanno et al. ORL J Otorhinolaryngol Relat Spec 63:76, 2001. 8 Chief Complaint Age Matters • Sneezing • Runny Nose • Adolescents and Adults • Nasal Congestion 9Allergic Rhinitis • Facial Pressure 9Non-Allergic Rhinitis/Vasomotor Rhinitis • Headache • Facial Pain 9Infection (viral URI or sinusitis) • Ear Pressure/fullness 9Obstructing polyps, septal deviation • Eyes water or itch Chief Complaint Age Matters • Decreased Smell • Children • Decreased Taste 9Infection • Bad Breath 9Allergic Rhinitis (generally >2 y/o) • Cough 9Non-Allergic Rhinitis/Vasomotor • Sore Throat Rhinitis • Throat Clearing –Irritant (esp. tobacco smoke) • Throat Drainage 9Obstruction (Adenoid hypertrophy, • Sinus Infections foreign body) 9 Exam Pearls Skin Testing • Edema and venous sinusoid congestion leads to swollen pale or blue turbinates • History dictates what antigens are to be tested • Clear middle ear fluid is common with significant congestion • Interpreted only in the context of • The eyes are important (redness, the clinical history swelling, shiners, Dennie’s lines) • Other sign of atopy--asthma, eczema Skin Testing Population Data • Testing should be to relevant local antigens • Pollen seasons and indoor allergen patterns help interpret history –Spring-Trees; Summer-Grass; Fall-Weeds J Allergy Clin Immunol 2005;116:377-83. 10 Test Performance- RAST Testing Cat Allergy • A number describing the amount of allergen specific IgE 93.6 (+4.3) 90.1 (+5.3) 87.1 (+6.0) • Should be interpreted in context of total IgE, symptoms • No defined level for each antigen 87.2(+6.9) 91.1 (+5.9) 86.4 (+7.1) to predict clinical symptoms J Allergy Clin Immunol 1999;103:773-9. RAST Testing ARIA Classification • Can be used to qualify a patient Intermittent Persistent Less that 4 days/week OR More than 4 days/week AND for anti-IgE therapy less than 4 weeks/year more than 4 weeks/year • Not all antigens have defined cutoff values Mild Moderate-Severe No Sleep Disturbance