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Non-infective Non-allergic Rhintis

Non-infective Non-allergic Rhintis. Dr. Vishal Sharma. 1. Vasomotor rhinitis 2. N on- A llergic R hinitis with E osinophilia S yndrome 3. Occupational Irritant: flour, animal, wood, latex, paint 4. Rhinitis medicamentosa: decongestant nose drops

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Non-infective Non-allergic Rhintis

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  1. Non-infective Non-allergic Rhintis Dr. Vishal Sharma

  2. 1. Vasomotor rhinitis 2. Non-Allergic Rhinitis with Eosinophilia Syndrome 3.Occupational Irritant: flour, animal, wood, latex, paint 4. Rhinitis medicamentosa: decongestant nose drops 5. Drug-induced: propranolol, O.C.P., amytriptilline 6. Endocrine: hypothyroid, pregnancy, menstruation 7. Addiction: alcohol, tobacco 8. Non-airflow: tracheostomy, laryngectomy 9. Miscellaneous: honeymoon / emotional

  3. Autonomic Innervation of Nose • Deep petrosal nerve (Symp) + greater superficial petrosal nerve (Para-symp)  vidian nerve  pterygo-palatine ganglion  nasal glands • Sympathetic stimulation vasoconstriction + ed nasal secretions • Para-sympathetic stimulation vasodilatation + ed nasal secretions

  4. Vasomotor Rhinitis

  5. Pathogenesis • Caused by over activity of para-sympathetic nervous system leading to: • nasal congestion (due to nasal vasodilatation) • nasal block (due to nasal vasodilatation) • watery rhinorrhoea (due to ed nasal secretion)

  6. Trigger Factors 1. emotional stress (hypothalamus controls autonomic nervous system) 2. sudden change in temperature 3. humidity 4. blasts of cold air 5. dust 6. smoking &traffic fumes

  7. Clinical Features Symptoms are perennial • Nasal block (Blockers) • Profuse watery rhinorrhoea (Runners) • Paroxysmal early morning sneezing • Post nasal drip • Turbinates congested & hypertrophied

  8. Diagnostic Nasal Endoscopy

  9. Sequelae & Differential Diagnosis Sequelae  Nasal polyp  Hypertrophic rhinitis  Sinusitis Differential diagnosis • Allergic rhinitis • Non-allergic rhinitis with eosinophilia syndrome • Rhinitis medicamentosa

  10. Treatment of Vasomotor Rhinitis

  11. General Measures  Sleep with head end elevated by 300  Sleep + work in a cool environment (not cold)  Keep body warm Regular exercise program to improve vasomotor tone  Avoidance of trigger factors

  12. Medical Treatment • Ipratropium bromide spray (0.03%) • Intra-turbinal injection of Botulinum toxin • Steroid spray • Topical Cromolyn sodium (prophylaxis only) • Anti-histamines • Nasal decongestant

  13. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical:Azelastine spray (0.1%): 1-2 puff BD

  14. Systemic Antihistamines

  15. Topical Antihistamine spray

  16. Nasal Decongestants Systemic decongestants  Phenylephrine  Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

  17. Anti-cold preparations PsE = Pseudoephedrine; PhE = Phenylephrine

  18. Topical Decongestants • Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) • Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P) • Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) • Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) • Saline 2 %: 3 drops TID • Saline 0.67 %: 2 drops BD (NASIVION-S)

  19. Nasal Decongestants

  20. Ipratropium nasal spray Has anti-cholinergic action

  21. Botulinum Toxin Injection Inhibits release of Acetylcholine   rhinorrhoea

  22. Corticosteroid sprays

  23. Corticosteroid nasal spray

  24. Sodium Cromoglycate

  25. Surgical Treatment • Measures which reduce size of nasal turbinates to relieve nasal obstruction • Sectioning parasympathetic secreto-motor fibers of nose (vidian neurectomy) to relieve excessive rhinorrhoea

  26. Inferior Turbinate Surgeries

  27. Surgeries for mucosal hypertrophy On surface: Electrocautery  Laser vaporization Intramural: Electrocautery (SMD)  Cryotherapy  Radiofrequency ablation Surgeries for bony hypertrophy  Submucous resection of inferior concha Surgeries for mucosal + bony hypertrophy  Partial turbinectomy  Total turbinectomy  Inferior turbinoplasty (neo-turbinate)

  28. Hypertrophied Turbinate

  29. Submucosal diathermy

  30. Radiofrequency ablation

  31. Partial Turbinectomy

  32. Total (Radical) Turbinectomy

  33. Inferior Turbinoplasty

  34. Vidian Neurectomy • Trans-antral approach (Golding Wood) • Trans-septal approach

  35. Rhinitis Medicamentosa

  36. Introduction • Rebound nasal congestion due to use of intranasal decongestants for > 7 days • With prolonged use, tachyphylaxis occurs, resulting in need for more frequent doses & shorter duration of action of these drugs • Nasal medications containing benzalkonium chloride cause more rebound congestion

  37. Offending drugs 1. Oxymetazoline 2. Xylometazoline These drugs contract smooth muscle of venous erectile tissue, present in nasal turbinates, causing mucosal shrinkage & decreasing airway resistance

  38. Pathogenesis

  39. Clinical Features 1. Chronic nasal block requiring increased dose & frequency of topical decongestants 2. Watery rhinorrhoea usually absent, seen only in co-existing allergic or vasomotor rhinitis 3. Nasal mucosa appears hyperemic, granular & boggy in early stages 4. Later, it appears pale & anemic

  40. Treatment • Immediate withdrawal of topical decongestant • Substitute with systemic nasal decongestants • Nasal corticosteroid sprays • Oral corticosteroids (for severe cases only) • Rhinostat system • Patient Education: Avoid topical decongestant use for > 7 days

  41. Treatment For patients unable to stop topical decongestant immediately, stop nose drops in more patent nasal cavity & use it in other cavity for < 7 days Systemic decongestants used to relieve nasal block as pt is weaned off topical decongestants Phenylephrine & pseudoephedrine are used Corticosteroid spray used to  local inflammation

  42. Rhinostat System Consists of 2 bottles.  First contains pt’s nasal decongestant spray, second has saline solution. Two solutions precisely combined for dosage dilution @ 15% / day. Dosage titration allows gradual withdrawal from decongestants while maintaining nasal inspiratory flow. Takes 3-6 weeks days for complete withdrawal.

  43. Rhinostat System

  44. Thank You

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