This document discusses intrinsic rhinitis, including vasomotor rhinitis and its causes, symptoms, and treatments. It notes that vasomotor rhinitis is caused by overactivity of the parasympathetic nervous system in the nose, leading to nasal congestion and watery rhinorrhea. Treatments include nasal decongestants, antihistamines, steroid nasal sprays, and surgical procedures like turbinate reduction or vidian neurectomy. The document also discusses rhinitis medicamentosa, or rebound nasal congestion caused by overuse of topical decongestants, and its pathophysiology and treatments involving withdrawal of decongestants and use of steroids.

1. Intrinsic Rhinitis
(Non-allergic Non-infective rhinitis,
Vasomotor rhinitis)
Prof. (Dr.) Krishna Koirala
18-07-2023

2. Spectrum of Disease
• Vasomotor rhinitis
• Non-Allergic Rhinitis with Eosinophilia Syndrome (NAREs)
• Occupational rhinitis: flour, animal, wood, latex, paint
• Rhinitis medicamentosa: Prolonged use of decongestant
nasal drops
• Drug-induced: propranolol, O.C.P., antidepressants
• Endocrine: hypothyroid, pregnancy, menstruation
• Miscellaneous: honeymoon / emotional/ non airflow /
addiction

3. Autonomic nerve supply of nose

4. • Deep petrosal nerve (sympathetic) + Greater Superficial
petrosal nerve (Parasympathetic) Vidian nerve (Nerve of
Pterygoid canal) Pterygopalatine ganglion  Nasal
glands
Parasympathetic
stimulation 
Vasodilatation,
Increased nasal
secretions
Sympathetic
stimulation
Vasoconstriction ,
Decreased nasal
secretions

5. Vasomotor Rhinitis

6. • Pathogenesis:
– Overactivity of Parasympathetic nervous system of nose
• Nasal congestion (due to nasal vasodilatation)
• Nasal block (due to nasal vasodilatation)
• Watery rhinorrhoea (due to ed nasal glandular
secretions)
• Trigger Factors:
– Emotional stress, sudden change in temperature, humidity ,
blasts of cold air, dust, smoking & traffic fumes

7. Clinical Features
• Symptoms - perennial
– Nasal block (blockers)
– Profuse watery rhinorrhoea (runners)
– Paroxysmal early morning sneezing
– Postnasal drip
• Signs
– Turbinates congested & hypertrophied
• Sequelae
• Nasal polyp, hypertrophic rhinitis, sinusitis

8. ALLERGIC INTRINSIC
Allergen exposure Yes No
Nasal itching +++ Minimal
Sneezing +++ +
Rhinorrhoea ++ +++
Nasal obstruction ++ +
Hyposmia ++ +

9. ALLERGIC INTRINSIC
Nasal mucosa Pale Congested
Nasal polyps ++ Rare
Absolute Eosinophil
Count
ed Normal
Nasal smear
eosinophil
ed Normal
Skin prick test Positive Negative
Treatment Steroid spray, Anti H1,
Nasal decongestant
Ipratropium,
Botulinum

10. Treatment of
Vasomotor Rhinitis

11. 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

12. Medical Treatment
• Antihistamines:
– Systemic: Cetirizine, fexofenadine, loratadine, levocetrizine,
ebastine
– Topical: Azelastine spray
• Nasal Decongestants
– Systemic: Phenylephrine, pseudoephedrine
– Topical : Xylometazoline, oxymetazoline, saline
• Topical and systemic steroids

13. Drug Sneeze Rhinorrhoea Nasal
block
ed smell
Antihistamine +++ ++ + 0
Steroid spray +++ +++ +++ +
Cromoglycate + + + 0
Topical nasal
decongestant
0 0 ++++ 0
Ipratropium 0 ++ 0 0

14. Steroid sprays Strength /
puff
Acute attack
dose
Maintenance
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

15. Surgical Treatment
1. To reduce size of nasal turbinates thus to
relieve nasal obstruction
2. Sectioning parasympathetic secretomotor
fibers of nose (Vidian neurectomy) to relieve
excessive rhinorrhea

16. Surgeries to reduce the size of turbinate
• For mucosal hypertrophy
– On surface: Electrocautery , Laser
– Submucosal: Electrocautery (Submucosal diathermy),
cryotherapy, radiofrequency ablation
• For bony hypertrophy
– Submucous resection of inferior concha
• For mucosal + bony hypertrophy
– Partial / total turbinectomy

18. • Trans - septal approach
• Trans - antral approach (Golding Wood)

19. Rhinitis Medicamentosa
(Rebound Nasal Congestion)
• Inflammation of the nasal mucosa leading to rebound
nasal congestion caused by the overuse of topical nasal
decongestants (>10-14 days)
• Subset of drug-induced rhinitis
• Prolonged use tachyphylaxis  more frequent dose
• Nasal medications containing benzalkonium chloride
(antimicrobial preservative) cause more rebound
congestion by inducing mucosal swelling

20. Physiology of Nasal Congestion
• The nasal mucosal vascular system
– Resistance vessels (arterioles) which are predominantly
regulated by alpha-2 adrenoreceptors
– Capacitance vessels (venous plexus) regulated by both
alpha-1 and alpha-2 adrenoreceptors
• Stimulation of these receptors leads to the decongestant effect
(vasoconstriction of the large venous sinusoids and collecting veins)
decreased blood flow decreased nasal edema and rhinorrhea
• Parasympathetic nervous system stimulation contributes to nasal
congestion

21. Types of intranasal decongestants
(adrenoreceptor activity)
• Beta-phenylethylamine derivatives (primarily
alpha-1 agonists)
– Ephedrine, Phenylephrine
• Imidazoline derivatives (primarily alpha-2 agonists)
– Oxymetazoline ,Xylometazoline
• Imidazolines produce the effect mainly via alpha-2
adrenoreceptors (more effective due to their
vasoconstrictive effect to both capacitance and
resistance vessels in the nasal mucosa)

22. Offending drugs : Oxymetazoline , Xylometazoline
• Oxymetazoline is an adrenergic α1- and α2-agonist and
a direct-acting sympathomimetic drug
• It causes vasoconstriction of dilated arterioles and
reduces blood flow by stimulating adrenergic receptors
• Contracts smooth muscle of venous erectile tissue
present in nasal turbinates  mucosal shrinkage and
decrease airway resistance

23. Pathophysiology
• Chronic vasoconstriction leads to ischemia of the nasal
mucosa leading to interstitial edema
• Fatigue of the constrictor mechanisms occurs resulting in
reactive hyperemia and congestion leading to reduced
sensitivity to endogenous catecholamines  the
adrenoreceptors become refractory to nasal
decongestants, necessitating higher dosage of medication
(tachyphylaxis)
• Alteration in vasomotor tone results in increased vascular
permeability and edema
• The beta-adrenoreceptor activity may outlast the alpha
effects leading to rebound vasodilatation

24. Pathogenesis

25. Clinical Features
• Chronic nasal block requiring increased dose &
frequency of topical decongestants after its
prolonged use
• Nasal mucosa appears hyperemic, granular &
boggy in early stages and pale & anemic in later
stages

26. Treatment
• Immediate withdrawal of topical decongestant -
Substitute with systemic nasal decongestants
• Nasal corticosteroid sprays & oral corticosteroids
• Rhinostat system: Decreasing concentration of
decongestants
• Patient Education:
– Avoid topical decongestant use for > 10 days