Dr. T. Balasubramanian M.S. D.L.O.
Synonyms: Non infective rhinitis, Non allergic
rhinitis, Vasomotor rhinitis, Perenial rhinitis..
Definition:Intrinsic rhinitis is defined as a
non infective and non allergic condition characterised by nasal
block, rhinorrhoea and hyposmia. This is purely a
Intrinsic rhinitis encompasses two separate
disease entities. These entities show 1. inferior turbinate
hypertrophy and 2. nasal polyp formation.
Clinical presentation: 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
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 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
Non eosinophilic group: In these patients
nasal obstruction is very mild, rhinorrhoea is very severe. They
donot have significant mucosal swelling. Inferior turbinate
hypertrophy is not significant. Tendency of nasal
polyp formation is rare in this group.
||Moderate / severe
||Mild / moderate
|Inf turbinate enlargement
|Sinus mucosal thickening
Table showing the differences
between eosninophilic and non eosinophilic types of intrinsic
Aetiology of intrinsic rhinitis:
Theories regarding aetiology of intrinsic rhinitis
1. Autonomic imbalance
2. Airway hyperreactivity
3. Allergic reaction to unidentified
4. Disturbances of Beta receptor
Mechanisms of Beta receptor dysfunction:
1. Down regulation caused by excess endogenous
2. Down regulation and uncoupling of adenylate cyclase
produced by 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
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
The following transmitters are secreted by
parasympathetic nerve endings: Acetyl choline, vaso active
The following transmitters are secreted by sympathetic
nerve endings: adrenaline, noradrenaline, neuropeptide
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 surgical
Medical management of intrinsic rhinitis:
Steroids - Topical e.g. fluticasone, budesonide.
A short course of systemic steriods can be
Alpha receptor agonists - Systemic e.g. pseudoephidrine
Topical e.g. xylometazoline (short course)
Mast cell stabilisers - Topical cromoglycate
Non eosinophlic type :
Anti cholinergic - Topical e.g. ipratropium Hyosine
administered orally or as a patch.
Anti cholinergic / sympathomimetic - Imipramine orally,
||Type of procedure
Excision of vidian nerve
Endoscopic vidian neurectomy
Table showing the surgical
indications for treatment of intrinsic rhinitis
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