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Non-infective
Non-allergic
Rhintis
Dr. Vishal Sharma
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
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
Vasomotor Rhinitis
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)
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
Clinical Features
Symptoms are perennial
•
Nasal block (Blockers)
•
Profuse watery rhinorrhoea (Runners)

Paroxysmal early morning sneezing

Post nasal drip

Turbinates congested & hypertrophied
Diagnostic Nasal Endoscopy
Sequelae & Differential Diagnosis
Sequelae
 Nasal polyp
 Hypertrophic rhinitis
 Sinusitis
Differential diagnosis
• Allergic rhinitis
• Non-allergic rhinitis with eosinophilia syndrome
• Rhinitis medicamentosa
Allergic
N.A.R.E.S.
Vasomotor
Allergen
exposure
Yes
No
No
Nasal itch
+++
+
Minimal
ed sneezing
+++
+
Minimal
Nasal block
++
+++
+
Hyposmia
++
+++
+
Rhinorrhoea
++
++
+++
Allergic
N.A.R.E.S.
Vasomotor
Nasal mucosa
Pale
Congested
Congested
Nasal polyps
++
++
Rare
Absolute
Eosinophil Count
ed
ed
Normal
Nasal smear
eosinophil
ed
ed
Normal
Skin prick test
Positive
Negative
Negative
Treatment
Steroid spray, Anti H1, Ipratropium,
Nasal decongestant
Botulinum
Treatment of
Vasomotor Rhinitis
General Measures
 Sleep with head end elevated by 30
0
 Sleep + work in a cool environment (not cold)
 Keep body warm
 Regular exercise program to improve
vasomotor tone
 Avoidance of trigger factors
Medical Treatment
• Ipratropium bromide spray (0.03%)
• Intra-turbinal injection of Botulinum toxin
• Steroid spray
• Topical Cromolyn sodium (prophylaxis only)
• Anti-histamines
• Nasal decongestant
Drug
Sneeze Rhinorrhoea Nasal Nose ed
block itch smell
Antihistamine
+++
++
+
+++
0
Steroid spray
+++
+++
+++
++
+
Cromoglycate
+
+
+
+
0
Topical nasal
decongestant
0
0
++++
0
0
Ipratropium
0
++
0
0
0
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
Systemic Antihistamines
Topical Antihistamine spray
Nasal Decongestants
Systemic decongestants
 Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline
Anti-cold preparations
Name
Chlorpheniramine
Decongestant
Paracetamol
COLDIN
4 mg
PsE 60 mg
500 mg
SINAREST
4 mg
PsE 60 mg
500 mg
DECOLD
4 mg
PhE 7.5 mg
500 mg
SUPRIN
2 mg
PhE 5 mg
500 mg
PsE = Pseudoephedrine;
PhE = Phenylephrine
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)
Nasal Decongestants
Ipratropium nasal spray
Has anti-cholinergic action
Botulinum Toxin Injection
Inhibits release of Acetylcholine   rhinorrhoea
Corticosteroid sprays
Steroid
Strength Acute attack Maintenance
/ puff
dose
dose
Beclomethasone
50 g
2 puffs BD
1 puff OD
Budesonide
64 g
2 puffs OD-BD
1 puff OD
Fluticasone
50 g
2 puffs OD-BD
1 puff OD
Mometasone
50 g
2 puffs OD-BD
1 puff OD
Corticosteroid nasal spray
Sodium Cromoglycate
Surgical Treatment
1. Measures which reduce size of nasal
turbinates to relieve nasal obstruction
2. Sectioning parasympathetic secreto-motor
fibers of nose (vidian neurectomy) to relieve
excessive rhinorrhoea
Inferior Turbinate
Surgeries
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)
Hypertrophied Turbinate
Submucosal diathermy
Radiofrequency ablation
Partial Turbinectomy
Total (Radical) Turbinectomy
Inferior Turbinoplasty
Vidian Neurectomy
• Trans-antral approach (Golding Wood)
• Trans-septal approach
Rhinitis
Medicamentosa
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
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
Pathogenesis
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
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
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
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.
Rhinostat System
Thank You