Nonallergic rhinitis
Nonallergic rhinitis is inflammation of the inner part of the nose that is not caused by an allergy. Nonallergic rhinitis involves symptoms including chronic sneezing or having a congested, drippy nose without an identified allergic reaction. Other common terms for nonallergic rhinitis are vasomotor rhinitis and perennial rhinitis. The prevalence of nonallergic rhinitis in otolaryngology is 40%. Allergic rhinitis is more common than nonallergic rhinitis; however, both conditions have similar presentation, manifestation and treatment. Nasal itching and paroxysmal sneezing are usually associated with nonallergic rhinitis in comparison to allergic rhinitis. Presentation. Paroxysmal sneezing in morning, especially in morning  while getting out of bed. Excessive rhinorrhea - watering discharge from the nose when patient bends forward. Nasal obstruction - bilateral nasal stuffiness alternates from one site to other; this is more marked at night, when the dependent side of nose is often blocked. Postnasal drip. Complications. Nonallergic rhinitis cases may subsequently develop polyps, turbinate hypertrophy and sinusitis. Pathophysiology. Nasal mucosa has a rich blood supply and has venous sinusoids or "lakes" surrounded by smooth muscle fibers. These smooth muscle fibers act as sphincters and control the filling and emptying of sinusoids. Sympathetic stimulation causes vasoconstriction and shrinkage of mucosa, which leads  to decongestion of the nose. Parasympathetic stimulation causes not only excessive secretion from the nasal gland but also vasodilatation and engorgement, which lead to rhinorrhoea and congestion of the nose. The autonomic nervous system, which supplies the nasal mucosa, is under the control of the hypothalamus. Diagnosis. Nose examination: The mucosa is usually boggy and edematous with clear mucoid secretions. The turbinates are congested and hypertrophic. Pharynx examination: Mucosal injection and lymphoid hyperplasia involving tonsils, adenoids and base of tongue may be seen. Investigations. Absolute eosinophil count, nasal smear, skin and in vitro allergy tests to rule out allergic rhinitis , acoustic rhinometry for measuring nasal patency, smell testing, CT scan in cases of sinus disease and MRI in case of mass lesions. Treatment. Medical. The avoidance of inciting factors such as sudden changes in temperature, humidity, or blasts of air or dust is helpful. Intranasal application of antihistamines, corticosteroids, or anticholinergics may also be used for vasomotor rhinitis. Intranasal cromolyn sodium may be used in patients older than two years. A Cochrane review concluded that it is unclear whether intranasal corticosteroids, when compared with a placebo, reduce patient‐reported disease severity in people with nonallergic/vasomotor rhinitis due to the low  certainty of the evidence available from clinical trials. However, intranasal corticosteroids probably increase risk of nosebleeds. Astelin (azelastine) "is indicated for symptomatic treatment of vasomotor rhinitis including rhinorrhea, nasal congestion, and post nasal drip in adults and children 12 years of age and older." Surgical. Reduction of hypertrophied turbinates, correction of nasal septum deviation, removal of polyps, sectioning of the parasympathetic secretomotor fiber to nose (vidian neurectomy) for controlling refractory excessive rhinorrhea.