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Vasomotor Rhinitis

Rhinitides Vasomotor

Vasomotor rhinitis is a chronic inflammatory disease of the inner lining in the nose.


Presentation

Patients with non-allergic rhinitis may present with the following features:

Itching of the eyes, nose and throat are rarely seen in non-allergic rhinitis and if present, they point towards a diagnosis of allergic rhinitis.

Patients with vasomotor rhinitis classically present with watery rhinorrhea and sneezing. The mucous membrane becomes edematous and the color may vary from a bright red to purple. Vasomotor rhinitis is characterized by several periods of exacerbation and remission. Unlike bacterial and certain viral causes of rhinitis, cases with vasomotor rhinitis do not develop purulent exudate. The absence of distinguished allergens differentiates vasomotor rhinitis from the allergic rhinitis.

The symptoms of vasomotor rhinitis may be aggravated by cigarette smoke, perfumes, paint fumes, spicy foods, emotional stress, alcohol, bright lights, temperature, and barometric pressure changes [7]. It is unusual to be diagnosed with vasomotor rhinitis prior to adulthood. Patients with vasomotor rhinitis may have symptoms all year, which can be influenced and/or worsened by changes in weather. Generally, symptoms develop not until adulthood.

Sneezing
  • Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching.[ncbi.nlm.nih.gov]
  • The rate of patient satisfaction was 90% for the relief of nasal obstruction and sneezing, and 80% for nasal discharge.[ncbi.nlm.nih.gov]
  • Only those cases were selected who had sneezing as the presenting symptom, while 17 per cent of these patients also suffered from asthma.[ncbi.nlm.nih.gov]
  • There was a significant reduction in nasal hypersecretion during ipratropium treatment, but no effect on nasal blockage, sneezing or tickling.[ncbi.nlm.nih.gov]
  • The speediest effect was registered for sneezing, followed by nasal catarrh, nasal itching, and blocking. No changes in the levels of cortisol occurred during the treatment.[ncbi.nlm.nih.gov]
Nasal Congestion
  • Vasomotor rhinitis is a condition of chronic nasal congestion which is noninfectious and nonallergic. Its cause is thought to be an imbalance of autonomic control to the nasal mucosa.[ncbi.nlm.nih.gov]
  • It has been suggested that there may be an imbalance of the sympathetic and parasympathetic nervous systems, with parasympathetic hyper-activity and sympathetic hypo-activity resulting in nasal congestion and rhinorrhoea.[ncbi.nlm.nih.gov]
  • The classic symptoms are clear rhinorrhea and nasal congestion, commonly brought on by exercise, stress, heat, cold, and environmental irritants.[ncbi.nlm.nih.gov]
  • In the OLO and AZE groups, reflective scores for individual nasal symptoms (nasal congestion, rhinorrhea, postnasal drip, and sneezing) and total nasal VMR symptom scores decreased significantly from baseline to day 14 (p 0.05).[ncbi.nlm.nih.gov]
  • Vasomotor rhinitis (VMR) is a condition in which the blood vessels lining the nose swell leading to nasal congestion, and in which the mucus glands in the nose become overactive leading to excessive drainage.[allergypartners.com]
Rhinorrhea
  • Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching.[ncbi.nlm.nih.gov]
  • The classic symptoms are clear rhinorrhea and nasal congestion, commonly brought on by exercise, stress, heat, cold, and environmental irritants.[ncbi.nlm.nih.gov]
  • Vasomotor rhinitis is a nonallergic, noninfectious cause of nasal obstruction and rhinorrhea. The etiology is believed to be an imbalance of the autonomic neural supply to the nasal mucosa with resultant vasodilation and hypersecretion.[ncbi.nlm.nih.gov]
  • Characterized by a combination of symptoms that includes nasal obstruction and rhinorrhea, vasomotor rhinitis is a diagnosis of exclusion reached after taking a careful history, performing a physical examination, and, in select cases, testing the patient[ncbi.nlm.nih.gov]
  • Gustatory rhinitis - spicy and pungent food may in some people produce rhinorrhea, nasal stuffiness, lacrimation, sweating and flushing of face.[en.wikipedia.org]
Nasal Discharge
  • The rate of patient satisfaction was 90% for the relief of nasal obstruction and sneezing, and 80% for nasal discharge.[ncbi.nlm.nih.gov]
  • These findings indicate that electrophoretic analysis of nasal discharge can be used for the diagnosis of allergic rhinitis and vasomotor rhinitis.[ncbi.nlm.nih.gov]
  • Criteria for selection of patients were (1) clear watery nasal discharge more than 1 hour each day, (2) absent or mild nasal obstruction, (3) no known allergic cause, and (4) no satisfactory response to previous alternative medications.[ncbi.nlm.nih.gov]
  • The symptoms of patients (nasal obstruction, sneezing, nasal discharge, and nasal itching) were scored from 1 to 5, with 1 as less severe and 5 as most severe.[ncbi.nlm.nih.gov]
  • The active drug clearly reduced nasal discharge. Nasal methacholine testing showed reduction of nasal secretion after the active treatment period. The majority of the patients preferred the active drug to the placebo.[ncbi.nlm.nih.gov]
Common Cold
  • Vasomotor rhinitis, also called non-allergic rhinitis , is a condition that's used to describe a runny nose and/or congestion that doesn't go away and is not caused by allergies or infections such as the common cold.[ent.about.com]
  • Acute rhinitis is the medical term for the common cold . Chronic rhinitis may result in permanent thickening of the nasal mucosa.[medical-dictionary.thefreedictionary.com]
  • cold] 2016 2017 2018 2019 Billable/Specific Code Applicable To Acute rhinitis Coryza (acute) Infective nasopharyngitis NOS Infective rhinitis Nasal catarrh, acute Nasopharyngitis NOS Type 1 Excludes acute pharyngitis ( J02.- ) acute sore throat NOS ([icd10data.com]
  • About rhinitis - causes and symptoms There are different types of rhinitis, the most common is the acute rhinitis, which usually occurs as part of a common cold.[nasic.eu]
Neglect
  • Neglect the treatment of vasomotor rhinitis is not: at the first sign of a physician must be consulted. How to treat nasal asthma arthritis? Treatment of vasomotor rhinitis is complex.[medicalcentr.com]

Workup

There are no specific diagnostic tests available for vasomotor rhinitis. Also, there are no established criteria for a minimum level of diagnostic workup necessary for diagnosing vasomotor rhinitis [8]. Diagnosis is mostly based on clinical clues, such as clear discharge which differs from the purulent discharge seen in infective rhinitis.

Certain tests that may be of value such as CT scan and allergy testing, that if are reported as normal in a patient with symptoms of rhinitis and/or sinusitis, is highly suggestive of non-allergic rhinitis.

Treatment

The standard first line medical treatment for vasomotor rhinitis is topical anti-histamines. There is no single agent that is effective in all cases for the control of symptoms. According to existing evidence base, a step-wise application of multiple agents should be advised for achieving symptom control.

In cases where the standard therapy fails, the other options that may be considered include oral decongestants, topical decongestants, and local silver nitrate application by an expert such as an otolaryngologist [9]. However, there is no strong evidence that demonstrates clear benefit from these treatment options. Patients with severe symptoms that cannot be controlled by medical therapy options and are causing significant impairment of routine activity may be considered for sphenopalatine block [10].

Submucosal injection of botulinum toxin type A is a novel treatment option for severe vasomotor rhinitis that is presently being studied in dog models [11] [12].

The standard treatment options for vasomotor rhinitis are as follows:

  • Humidified air through a vaporizer or a central heating system.
  • Sympathomimetic amines such as pseudoephedrine 30 mg orally as needed, may cause nervousness and tachycardia; recommended only as short course.
  • Topical vasoconstrictors
  • Topical corticosteroids such as mometasone, twice daily

A step-wise application of various treatment options should be employed based upon the symptoms of the patient. If the predominant symptom is rhinorrhea, the first line of treatment is with a topical anti-cholinergic agent [8] [13]. Topical corticosteroids may be used as a first line in cases presenting with nasal congestion as a primary concern [8]. Topical anti-histamine is the best initial therapy for patients with nasal congestion, rhinorrhea, sneezing and post-nasal drip [8] [14] [15]. If the response is inadequate to the first line agents, the medications may be changed or added as necessary.

Exercise may be a useful adjunct as it reduces airway resistance and enhances natural decongestion of the nasal cavity through I-adrenergic mediated mechanisms [7]. However, the decongestion mediated by exercise is for only a short period of time, but can be repeated given the several benefits from it.

In the pediatric age group, it is preferable to consider a trial of non-pharmacological and preventive measures prior to the initiation of any medications for the treatment of vasomotor rhinitis. During pregnancy, the symptoms of vasomotor rhinitis may be treated with intranasal saline instillation [3].

If the drug therapy fails to suppress the symptoms of rhinitis, surgery may be considered in very rare circumstances. The procedures that can be performed include the following:

  • Disruption of parasympathetic and sympathetic innervation of the nasal mucosa by vidian neurectomy for reducing rhinorrhea.
  • Cryosurgery may be considered for patients with a primary complaint of nasal congestion. 

In cases presenting with chronic rhinitis, where the nasal mucosa has underwent chronic hypertrophic changes, the following procedures may be considered:

  • Submucosal resection of the conchal bone (partial or total inferior turbinate resection) 
  • Cauterization of the nasal mucosa, achieved by either electrical cauterization or application of silver nitrate.
  • Cryosurgery: It affects the nasal mucosa and submucosa hence is thought to be superior as compared to cauterization.

In the treatment of vasomotor rhinitis, endoscopic sinus surgery is preferred over the open procedure (Transantral approach) owing to lower morbidity, better tolerability, and safety. It was observed that the symptoms of vasomotor rhinitis such as nasal congestion and rhinorrhea remained suppressed for several years after the procedure.

Prognosis

There is no cure available for non-allergic rhinitis; however, the symptoms can be controlled using prescription or over-the-counter medications. The prognosis of patients diagnosed with vasomotor rhinitis depends upon the severity of symptoms. The correction of the underlying condition, for instance a deviated nasal septum, remains the mainstay for permanent control of symptoms and improvement in prognosis.

In patients with vasomotor rhinitis, persistent symptoms for a period of weeks may lead to several complications. These may include chronic sinusitis, otitis media, and development of nasal polyps.

Etiology

The etiology of vasomotor rhinitis has not been fully understood, however there has been some association made with an imbalance in sympathetic and parasympathetic nervous systems, where the parasympathetic effects predominate and thus leading to symptomatic disease. The symptoms associated with vasomotor rhinitis are known to exacerbate in a dry atmosphere. Various environmental antigens may also act as triggers for inducing symptoms of vasomotor rhinitis like air pollution, pollen, perfume, and dust. In addition, several other triggers may also induce vasomotor rhinitis. These include the following:

  • Physical stress
  • Emotional stress
  • Antidepressant medications
  • Alcohol
  • Hot and spicy food
  • Hormonal changes
  • Infection
  • Chemical odors
  • Bright lights
  • Change in the barometric pressure
  • Pregnancy (vasomotor rhinitis may develop due to increase in blood volume and vasodilation under the influence of elevated estrogen and progesterone levels [3])

It is interesting to note that individuals with non-allergic rhinitis remain asymptomatic when exposed to allergens that trigger allergic rhinitis, such as animal dander and pollen, unless they have co-existing allergic rhinitis.

Epidemiology

Data obtained from the National Rhinitis Classification Task Force shows that almost 17 million people in the United States have non-allergic rhinitis. Non-allergic rhinitis is found in all age groups; however, it is more frequently diagnosed in adults. A study conducted in Norway reported that almost 25% of the total population suffered from the condition and close to half presented to the hospital seeking treatment for the same. Non-allergic rhinitis is rarely diagnosed in pediatric age group. The incidence has been increasing in the elderly population [4].

Sex distribution
Age distribution

Pathophysiology

Nonallergic rhinitis is a distinct disease classification, separate from allergic rhinitis, which is characterized by an IgE-mediated response. The diagnosis of non-allergic rhinitis encompasses several individual classifications, including NARES, as well as vasomotor, occupational, hormonal, infectious, drug-induced, and gustatory conditions.

The mucus secretion and blood flow in the mucosal lining of the nasal cavity is controlled by the autonomic nervous system. The sympathetic nervous system controls the diameter of nasal resistance vessels. The glandular secretions and the capacitance vessels in the nasal mucosa are primarily influenced by the parasympathetic system. Increased parasympathetic activity or hypoactivity of the sympathetic system leads to engorgement of these vessels. This in-turn causes swelling of the nasal mucosa that presents as nasal congestion. Parasympathetic system overactivity also causes increased secretions from the nasal mucosa thus causing rhinorrhea. Hyperactive allergen receptors may also contribute to the pathophysiology of vasomotor rhinitis.

Cases diagnosed with vasomotor rhinitis are sub-divided as:

  • "Runners" that predominantly have rhinorrhea, loosely referred to as "wet" rhinorrhea, believed to be secondary to an elevated cholinergic activity [5].
  • "Dry" patients, that predominantly have airflow resistance and nasal obstruction with insignificant rhinorrhea, believed to be caused by hypersensitive nociceptive neurons to basically unoffending stimuli [5].

Autonomic stimulation by activities such as sexual intercourse and emotional exacerbation may also affect the vasomotor control in the nasal mucosa. Data from a small scale study revealed that individuals with vasomotor rhinitis also have a significant autonomic dysfunction (p<.005). Factors that possibly contributed to this conclusion were extraesophageal effects of gastroesophageal reflux disease and history of trauma to the nose [6].

Prevention

All patients that have been diagnosed with vasomotor rhinitis should be advised to avoid all known allergens and environmental agents that may trigger exacerbation of symptoms, such as cigarette smoke, perfumes, auto emission fumes, light stimuli, hot or spicy foods, or changes in temperature.

Summary

The inflammation of mucosal lining in the nasal cavity is called as rhinitis. The inflamed mucosa may lead to different irritable symptoms such as nasal congestion, rhinorrhea, sneezing, pruritus, and post-nasal drip. Chronic non-allergic rhinitis is a diagnosis of exclusion. This is considered as a syndrome rather than a specific disease. Since there is no clear definition of the pathology that causes chronic non-allergic rhinitis, it therefore has been referred by several terms. The terms are as follows:

  • Intrinsic rhinitis
  • Idiopathic rhinitis
  • Vasomotor rhinitis
  • Non-allergic non-infectious rhinitis

Patients with vasomotor rhinitis present with complaint of intermittent watery nasal discharge and/or congestion of the nasal cavity. Vasomotor rhinitis occurs due to an exaggerated inflammatory response to non-specific antigens, for instance, exposure to cold dry air and air pollution [1] [2]. The inflammation leads to engorgement of mucosal vessels in the nasal cavity that in-turn lead to sneezing spells and rhinorrhea. Vasomotor rhinitis is considered as a subtype of non-allergic rhinitis.

Patient Information

The inflammation of the nasal passage is referred to as rhinitis. One of the several kinds of rhinitis is vasomotor rhinitis. You may experience symptoms such as stuffiness of the nose, runny nose and sneezing. You may also notice the mucosa or the insides of your nose change color anywhere from shades of red to purple. The exact cause of vasomotor rhinitis is not known, however, several irritants are known to exacerbate the symptoms. These may include pollen, dust, spicy food, pollution, perfumes, emotional stress, physical stress, and hormonal changes. The symptoms may also be exacerbated by certain prescription medications such as anti-depressants.

There is no cure for the condition. There are no specific tests that could be run to diagnose vasomotor rhinitis. The treatment is always aimed at relieving the symptoms of the patient. The most commonly prescribed initial treatment for most patients is topical anti-histamines. However, the initial treatment may vary according to the symptoms that you are experiencing.

References

Article

  1. Mikaelian AJ. Vasomotor rhinitis. Ear Nose Throat J 1989; 68:207.
  2. Kaliner MA. The treatment of vasomotor nonallergic rhinitis. Clin Allergy Immunol 2007; 19:351.
  3. Lekas MD. Rhinitis during pregnancy and rhinitis medicamentosa. Otolaryngol Head Neck Surg. 1992; 107(6 pt 2):845–9.
  4. Pinto JM, Jeswani S; Rhinitis in the geriatric population. Allergy Asthma Clin Immunol. 2010 May 13; 6(1):10.
  5. Dykewicz MS, Fineman S, Skoner DP, Nicklas R, Lee R, Blessing-Moore J, et al. Diagnosis, and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma, and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol. 1998; 81(5 pt 2):478–518.
  6. Jaradeh SS, Smith TL, Torrico L, Prieto TE, Loehrl TA, Darling RJ, et al. Autonomic nervous system evaluation of patients with vasomotor rhinitis. Laryngoscope. 2000; 110:1828–31.
  7. Druce HM. Allergic and nonallergic rhinitis. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF, Busse WW, eds. Allergy principles and practice. 5th ed. St. Louis: Mosby, 1998:1005–16.
  8. Management of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. AHRQ Publication No. 02-E024, May 2002. Rockville, Md.: Agency for Healthcare Research and Quality, 2002. Accessed online August 5, 2005, at: http://www.ahrq.gov/clinic/rhininv.htm.
  9. Bhargava KB, Abhyankar US, Shah TM. Treatment of allergic and vasomotor rhinitis by the local application of silver nitrate. J Laryngol Otol. 1980; 94:1025–36.
  10. Prasanna A, Murthy PS. Vasomotor rhinitis, and sphenopalantine ganglion block. J Pain Symptom Manage. 1997; 13:332–8.
  11. Shaari CM, Sanders I, Wu BL, Biller HF. Rhinorrhea is decreased in dogs after nasal application of botulinum toxin. Otolaryngol Head Neck Surg. 1995; 112:566–71.
  12. Bushara KO. Botulinum toxin and rhinorrhea [Letter]. Otolaryngol Head Neck Surg. 1996; 114:507.
  13. Dolovich J, Kennedy L, Vickerson F, Kazim F. Control of the hypersecretion of vasomotor rhinitis by topical ipratropium bromide. J Allergy Clin Immunol. 1987; 80(3 pt 1):274–8.
  14. Banov CH, Lieberman P, for the Vasomotor Rhinitis Study Groups. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol. 2001; 86:28–35.
  15. Gehanno P, Deschamps E, Garay E, Baehre M, Garay RP. Vasomotor rhinitis: clinical efficacy of azelastine nasal spray in comparison with placebo. ORL J Otorhinolaryngol Relat Spec. 2001; 63:76–81.

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Last updated: 2018-06-22 06:01