Non-infective Non-allergic Rhintis

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

12. Treatment of Vasomotor Rhinitis

13. 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

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

17. 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

18. Systemic Antihistamines

19. Topical Antihistamine spray

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

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

22. 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)

23. Nasal Decongestants

24. Ipratropium nasal spray Has anti-cholinergic action

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

26. Corticosteroid sprays

27. Corticosteroid nasal spray

28. Sodium Cromoglycate

29. 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

30. Inferior Turbinate Surgeries

31. 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)

32. Hypertrophied Turbinate

33. Submucosal diathermy

34. Radiofrequency ablation

35. Partial Turbinectomy

36. Total (Radical) Turbinectomy

37. Inferior Turbinoplasty

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

39. Rhinitis Medicamentosa

40. 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

41. 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

42. Pathogenesis

44. 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

45. 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

46. 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

47. 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.

48. Rhinostat System

49. Thank You