Nonallergic rhinitis The pathophysiology of nonallergic rhinitis is complex, with still much to be discovered. It is partly due to an imbalance between parasympathetic and sympathetic inputs on the nasal mucosa. The most critical factor in attaining a proper diagnosis of vaso- motor rhinitis is a comprehensive history and physical (Wheatley & Togias, 2015). Patients with NAR often exhibit a clinical hypersensitivity to odors, which is usually evidenced by the production of rhinitis symptoms. One group of researchers (Wheatley & Togias, 2015) evaluated Noninflammatory rhinitis With noninflammatory rhinitis (defined by biopsies negative for inflammation), it has been hypothesized that the disease results from an abnormality in the autonomic nervous system, including the adrenergic, cholinergic, and nonadrenergic–noncholinergic (NANC) innervation of the nose. Yet, such abnormalities have also
the neurogenic responses to chemical/olfactory stimuli in patients with NAR using functional magnetic resonance imaging (fMRI). Subjects underwent fMRIs during exposure to different types of odors. They exhibited increased blood flow to several odor-sensi - tive brain regions in response to pleasant (vanilla) and unpleasant (hickory smoke) odors. The neurologic responses were associat- ed with the production of symptoms upon exposure to hickory smoke (Wheatley & Togias, 2015).
been demonstrated in some inflammatory cases and, in this con - text, have been proposed to be secondary to a primary inflamma - tory process. Therefore, the pathogenic role of these abnormali- ties is unclear (Small & Kim, 2011)
HISTORY/PHYSICAL EXAM
Allergic rhinitis Allergic rhinitis has a considerable genetic component, and a fam- ily history of atopy makes the diagnosis likely (DeShazo & Kemp, 2022). A history that finds the seasonal versus perennial nature of symptoms, symptoms of exposure to a particular agent (animals, particular plants), current medications, symptoms of exposure to irritants, and symptoms of upper respiratory infection makes aller- gic etiology less likely. Physical findings upon exam include clear Nonallergic rhinitis Nonallergic rhinitis is clinically diagnosed. A full diagnosis involves a complete head and neck examination, as well as diagnostic testing to rule out infectious, allergic, and inflammatory causes. Headache, facial pressure, postnasal drip, coughing, and throat clearing are common allergic and nonallergic rhinitis symptoms. Patients with nonallergic rhinitis are generally categorized into two groups depending on the predominant symptomatology: “Block- ers” with congestion and “runners” with rhinorrhea. Patients with rhinorrhea tend to have an enhanced cholinergic response. Those with nasal obstruction tend to have nociceptive neurons with a heightened response to harmless stimuli. Nonallergic rhinitis is generally perennial. However, seasonal exacerbation of nonaller- gic rhinitis from shifts in barometric pressure, temperature, and
rhinorrhea (clear or colored may exist, though colored rhinorrhea may indicate a comorbid disease process with AR); bluish or pale swelling of the nasal mucosa; ocular findings (watery discharge; swollen conjunctivae, scleral injection); frequent throat clearing; allergic shiners (dark discoloration below the eye); nasal crease; and absence of a foreign body, tumor, or purulence suggesting infection. humidity may get misdiagnosed as allergic rhinitis. Nonallergic rhinitis patients’ environmental triggers may involve strong odors, cold air exposure, alcohol ingestion, and spicy foods. Physical exam often reveals boggy edematous mucosa with clear mucoid secretions. Mucosal injection and lymphoid hyperplasia may be present in the tonsils, adenoids, and lingual tonsils. There are re- ports of an area of blanched mucosa surrounding prominent ves- sels in chemical sensitivities. Examination of the nasal cavity and nasopharynx may help to identify primary or secondary causes of rhinitis. For example, purulent drainage from the middle meatus on nasal endoscopy would indicate an infectious process, ruling out nonallergic rhinitis (Nozad et al., 2010).
ASSESSMENT/DIAGNOSIS
Allergic rhinitis The physical examination of patients with suspected allergic rhi- nitis should include an assessment of outward signs, along with the nose, ears, sinuses, posterior oropharynx (area of the throat at the back of the mouth), chest, and skin. Outward signs suggest- ing allergic rhinitis include persistent mouth breathing, rubbing at the nose or a noticeable transverse nasal crease, frequent sniffling or throat clearing, and allergic shiners due to nasal congestion (Nozad et al., 2010). Examination of the nose typically reveals swelling of the nasal mucosa and pale, thin secretions. An internal endoscopic examination of the nose should also be considered to assess for structural abnormalities and nasal polyps. The ears generally appear normal in patients with allergic rhinitis; however, assessing Eustachian tube dysfunction using a pneumat- ic otoscope should be considered. Valsalva’s maneuver (increas- ing the pressure in the nasal cavity by attempting to blow out the nose while holding it shut) can also be used to assess for fluid behind the eardrum (Nozad et al., 2010). The sinus examination should include palpation of the sinuses for tenderness or tapping of the maxillary teeth with a tongue depressor for evidence of sensitivity. The posterior oropharynx Nonallergic rhinitis The assessment process for nonallergic rhinitis is the same as for allergic rhinitis regarding the body systems. Then it becomes a
should also be examined for signs of postnasal drip (mucous ac- cumulation in the back of the nose and throat), and the chest and skin should be scrutinized for signs of concurrent asthma (e.g., wheezing) or dermatitis, respectively (Nozad et al., 2010).
Evidence-based practice! Healthcare providers should make the clinical diagnosis of allergic rhinitis when patients present with a history and physical examination consistent with an allergic cause and one or more of the following symptoms: ● Nasal congestion. ● Runny or itchy nose. ● Sneezing. By diagnosis based on symptoms, patients can avoid unnecessary treatment or testing, treatment can begin earlier, and patient quality of life can improve sooner (Seidman et al., 2015).
“rule-out” process for nonallergic rhinitis. Nonallergic rhinitis is characterized by the chronic presence of one or more of the fol-
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