Intrinsic rhinitis is defined as a non infective and non allergic condition characterised by nasal block, rhinorrhoea and hyposmia. This is purely a medical condition. Awareness of this condition will help us to avoid unnecessary surgical procedures on patients suffering from this disorder. Surgery should be reserved only for cases that are intractable to medical management. This article discusses the complete gamut of this disorder.
Rhinitis is inflammation of nasal mucosa characterized by nasal discharge, itching and congestion. It affects 20% of the population1 .
Intrinsic rhinitis is defined as a non infective and non allergic condition characterized by nasal block, rhinorrhoea and hyposmia. This is purely a medical condition.
Intrinsic rhinitis encompasses two separate disease entities 2. These entities show:
1. inferior turbinate hypertrophy
2. nasal polyp formation.
Symptoms of intrinsic rhinitis
|Obstruction||Moderate / severe||Mild|
|Rhinorrhoea||Mild / Moderate||Severe|
|Sneezing / Pruritis||Minimal||Minimal|
|Inferior turbinate enlargement||Marked||Mild|
|Sinus mucosal thickening||Common||Rare|
Rhinitis is generally characterised by 6 main symptoms: They are
3. nasal itching
6. post nasal discharge
Among these main symptoms nasal itching and sneezing are features of allergic rhinitis and hence are not seen in intrinsic rhinitis. All the other symptoms are manifested in intrinsic rhinitis.
Seebohm identified two groups of patients amongst those suffering from perenial rhinitis. One group had eosinophils in their nasal secretions while the other did not have any eosinophils in their nasal secretions. Accordingly he classified intrinsic / perenial rhinitis into eosinophilic and non eosinophilic types.
Eosinophilic group: This group is characterised by marked nasal congestion, profuse rhinorrhoea, hyposmia, inferior turbinate hypertrophy and mucoid nasal secretion. Nasal polyposis frequently occurred in this group of patients.
Non eosinophilic group: In these patients nasal obstruction is very mild, rhinorrhoea is very severe. They do not have significant mucosal swelling. Inferior turbinate hypertrophy is not significant. Tendency of nasal polyp formation is rare in this group.
Aetiology of intrinsic rhinitis:
Theories regarding aetiology of intrinsic rhinitis are:
1. Autonomic imbalance
2. Airway hyperreactivity
3. Allergic reaction to unidentified allergen
4. Disturbances of Beta receptor function
Mechanisms of Beta receptor dysfunction:
1. Down regulation caused by excess endogenous noradrenaline stimualtion.
2. Down regulation and uncoupling of adenylate cyclase producedby the inflammatory mediator induced activation of protein kinase.
3. The action of Beta receptor inhibitory factor presumed to be an anti beta receptor autoantibody.
4. Dysfunction of Beta receptor kinase causing short term desensitisation of beta receptors after exposure to beta agonists.
Role of autonomic nervous system in causing intrinsic rhinitis:
The autonomic nervous system exerts its effects by secreting neurotransmitters ar their nerve endings. The neurotransmitters secreted are adrenaline, noradrenaline, vasoactive intestinal polypeptide, acetylcholine and neuropeptide Y.
The nasal resistance to air flow is controlled by sympathetic system, whereas the nasal glands are innervated by parasympathetic nerves. Increased parasympathetic outflow causes glandular hypersecretion. Vaso active intestinal polypeptide has been known to cause this effect.The vasodilatation caused due to the effects of vaso active intestinal polypeptide is resistant to the effects of atropine.
Majority of patients with intrinsic rhinitis benefit from medical management. Only a few require
Medical management of intrinsic rhinitis:
Topical iso tonic saline spray can be used for both forms of intrinsic rhinitis. Saline spray causes a reduction of post nasal drip, sneezing and nasal congestion 3.
Topical intranasal administration of Capsaicin (derived from pepper). This irritant chemical desensitizes the sensory nerve endings of the nasal mucosa thereby reducing nasal hyperactivity 4.
Steroids – Topical e.g. fluticasone, budesonide. A short course of systemic steriods can be administered.
Alpha receptor agonists – Systemic e.g. pseudoephidrine Topical e.g. xylometazoline (short course)
Mast cell stabilisers – Topical cromoglycate solution.
Non eosinophlic type :
Anti cholinergic – Topical e.g. ipratropium Hyosine administered orally or as a patch.
Anti cholinergic / sympathomimetic – Imipramine orally, chlorpheniramine orally.
Surgical management of Intrinsic rhinitis
Turbinate resectionVidian neurectomy
CryosurgeryLaser surgeryPartial resectionSubmucosal turbinectomyRadical turbinectomyExcision of vidian nerveEndoscopic vidian neurectomy
- Powe DG, Huskinsson RS, Carney AS, et al. Evidence for an inflammatory pathophysiology in idiopathic rhinitis. Clin Exp Allergy 2001;31:864 - 9.
- Settipane RA, Settipane GA. Nonallergic rhinitis. In: Kaliner MA, ed. Current Review of Allergic Diseases. Philadelphia: Current Medicine, 1999.
- Bronsky EA, Druce H, Findlay SR, Hampel FC. A clinical trial of ipratropium bromide nasal spray in patients with perennial nonallergic rhinitis. J Allergy Clin Immunol 1995;95:1117-1122.
- Stjärne P, Lundblad L, Änggard A, et al. Local capsaicin treatment of the nasal mucosa reduces symptoms in patients with nonallergic nasal hyperreactivity. Am J Rhinology 1991;5:145-151.