SYSTEMIC CAUSES OF NONALLERGIC RHINITIS

Systemic diseases may present with clinical symptoms of chronic rhinitis and must be
considered in the differential of refractory chronic nonallergic rhinitis. Autoimmune and
granulomatous diseases such as Wegener granulomatosis and sarcoidosis are the most
common considerations. Exam findings may be nonspecific but a review of systems may
reveal positive constitutional, pulmonary symptoms, or musculoskeletal symptoms which
should raise one's clinical suspicion for an underlying systemic process. Infectious agents
such as tuberculosis, rhinoscleroma and chronic fungal infections may also incite
granulomatous reactions in the nose and chronic rhinitis. Snuffles" is a term used to describe
the persistent and at times blood-tinged rhinorrhea that is a manifestation of congenital
syphilis. Directed serum studies and intranasal biopsy are indicated to rule out infectious and
autoimmune causes of refractory rhinitis. A chest x-ray is an efficient, low-cost modality that
should also be employed when investigating the potential of coexisting pulmonary disease.

Extraesophageal reflux (EER) is recognized as a common cause of refractory rhinitis in

children (131) and is increasingly recognized as a contributor to chronic rhinosinusitis in
adults (132). EER has also been associated with autonomic rhinitis in adults and may be a
manifestation of generalized autonomic dysfunction (116). Chronic phlegm, excessive throat
dearing, globus, cough, and throat irritation are symptoms that could be equally attributable
to refluxed stomach contents from below or inflammatory mediators in nasal discharge from
above. A history of heartburn, regurgitation, s our brash, or dyspepsia is important to seek
from patients with chronic rhinitis symptoms; however, the absence of these symptoms does
not exclude the diagnosis of EER. Kaufman (133) demonstrated that even trace amounts of
reflux, three times a week, are enough to cause mucosa trauma to the larynx. A specialized
dual pH probe with separate esophageal and nasopharyngeal arms can detect events of add
reflux into the nasopharynx but there is currently no standardized data to delineate what is
normal or what is significant. An empiric trial of antireflux medication may be warranted for
patients with refractory rhinitis symptoms.

Both hematogenous and solid organ malignancies may mimic nonallergic rhinitis symptoms.
Nasal neoplasms should always be investigated with nasal endoscopy and cr scan of the
sinuses. NK/T-cell lymphoma, formerly called lethal midline granuloma, can cause an
aggressive erosion of intranasal structures consistent with AR Chronic lymphocytic leukemia
has also been reported to masquerade as chronic rhinitis ( 134).

Patients with Parkinson Disease demonstrate a fivefold increased incidence of rhinorrhea

against age-matched controls in self-reported studies (135). This appears predominantly
autonomic in description and responds to ipratropium bromide. This may be due to the
sympathetic dysregulation seen in Parkinson Disease. (See Table 30.7 for a listing of
potential systemic and structural causes of chronic rhinitis.) These disease processes are
discussed in more detail in separate chapters.

AGING AND RHINITIS

Rhinitis in children is predominantly infectious and allergic. After age 20, nonallergic rhinitis
is more common. After the sixth and seventh decades of life, changes in the nasal mucosa.

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weakening of the cartilaginous nasal structure, and polypharmacy predispose older adults to a
condition, which some have dubbed "geriatric rhinitis" or "senile rhinitis" (136).

With aging, the nasal mucosa becomes more atrophic with a loss of submucous serous glands
and goblet cells and a decrease in microvascular flow. Laxity in the cartilaginous support of
the nose with age-related loss in collagen may also accentuate symptoms of nasal airflow
obstruction. The aged population is also likely to be on chronic medications such as diuretics,
beta-blockers, anxiolytics, and antivertigo drugs with known side effects of nasal dryness and
congestion.

Patients may present with complaints of thickened nasal secretions and crusting, excessive
postnasal drip and phlegm, excessive throat dearing, nasal congestion, and occasionally
decreased sense of smell and taste. Alternatively elderly patients may report watery
rhinorrhea and exacerbation with meals, temperature changes, or exercise that is more
consistent with autonomic rhinitis. The differential for new-onset geriatric rhinitis includes
allergic rhinitis, vasomotor rhinitis, atrophic rhinitis, chronic sinusitis, EER disease, benign
and malignant nasal masses, and CSF leak. It is paramount to investigate and eliminate more
morbid conditions prior to commencing presumptive therapy.

The goals in the treatment of geriatric rhinitis focus on increasing nasal moisture and
mucociliary clearance. To this end, saline nasal sprays and irrigations are the mainstay of
treatment. Addition of a mucolytic such as guaifenesin can also help to thin nasal secretions.
There is some debate about the role of topical nasal steroids in geriatric rhinitis. Some have
cautioned to use these sparingly as they may exacerbate nasal dryness but in many patients
the combination of saline and a topical nasal steroid is effective. A trial of nasal steroids is
reasonable with dose monitoring for local side effects. Nasal steroids should be used with
caution in patients with narrow angle glaucoma as steroids can raise intraocular pressures. If
treatment with steroids is necessary in a patient with a history of narrowangle glaucoma. the
patient should have frequent intraocular pressure checks by their ophthalmologist.
Ipratropium nasal sprays are very effective for autonomic rhinitis but compliance may be
limited due to the frequency required.

Medications to be avoided in this population include antihistamines and decongestants.

Antihistamines, particularly first-generation antihistamines, can exacerbate mucosal dryness
and compound sedation from other medications. Antihistamines should be limited to
secondgeneration antihistamines when indicated. Topical and systemic nasal decongestants
do not provide long-term solutions for geriatric rhinitis, may exacerbate nasal dryness and
irritation, and may also worsen underlying comorbid conditions such as hypertension and
cardiac disease.