Idiopathische Rhinitis

M. Damm

doi:10.1055/s-2005-921113

Laryngo-Rhino-Otologie, Table of Contents

Laryngorhinootologie 2006; 85(5): 361-377
DOI: 10.1055/s-2005-921113

Fortbildung

Idiopathische Rhinitis

Idiopathic RhinitisM. Damm¹

¹ Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde am Klinikum der Universität zu Köln (Direktor: Prof. Dr. med. Dr. h.c. K.-B. Hüttenbrink)

Abstract

Zusammenfassung

Die Idiopathische Rhinitis (IR) ist ein Überbegriff für Rhinitisformen mit unbekanntem Pathomechanismus. Krankheitsbezeichnungen wie vasomotorische Rhinitis oder nicht-infektiöse, nicht-allergische Rhinitis sollen durch IR ersetzt werden. Die heute diskutierten Pathomechanismen lassen sich drei Gruppen von Arbeitshypothesen zuteilen: 1. neurale Dysfunktionen/-regulationen, 2. immunologisch-inflammatorische Störungen oder 3. Schädigungen der Mukosa mit nachfolgender Permeabilitätssteigerung für irritative Substanzen. Die häufig favorisierte neurogene Entzündung besitzt viele Schnittstellen mit immunologischen Mechanismen. Durch die Komplexität der vorgenannten Interaktionen bleiben viele Fragen zur Pathophysiologie unbeantwortet. Die IR ist somit eine Ausschlussdiagnose, wobei eine Vielzahl von Krankheitsbildern abgegrenzt werden müssen - nicht nur die allergische Rhinitis. Bei der nasalen Diagnostik (z. B. Provokationstestungen, Biomarkeranalysen) wurden Fortschritte bei der Standardisierung erzielt. Die Evidenzbasis der Wirksamkeit von medikamentösen Therapieansätzen konnte bei der IR deutlich verbessert werden. Nasale Kortikoide beziehungsweise Antihistaminika können die Hauptsymptomatik der IR oft zuverlässig reduzieren - Indikationen zur operativen Therapie sollten daher zurückhaltend gestellt werden.

Idiopathic Rhinitis

Idiopathic Rhinitis (IR) is a term for a group of nasal diseases of unknown aetiology. Formerly, these diseases were called vasomotor rhinitis, but because there is no indication of a disorder in the vasomotor system, this term has been abandoned. Other terms, like non-infectious non-allergic rhinitis and non-allergic non-infectious perennial rhinitis are purely descriptive. Potential pathomechanisms in IR could be 1) neural dysfunction/dysregulation; 2) immunological inflammatory responses; and 3) changes of the permeability of the mucosa, leading to increase entrance of potential harmful substances. Idiopathic Rhinitis is a diagnosis by exclusion, meaning that a number of more or less defined nasal conditions as a cause of rhinitis have been excluded - not only allergic rhinitis. Although a considerable progress was made in the standardization of provocation tests or biomarkers in nasal secretions, there are today no specific test available to confirm the diagnosis rhinitis in many non allergic conditions.

An evidence-based review of treatment outcomes shows topical sprays of steroids, antihistamines to be of benefit in idiopathic rhinitis. Furthermore, nasal saline solution is effective in many patients with IR. Multiple surgical procedures have been suggested for IR, but should be reserved for patients who fail medical therapy.

Schlüsselwörter

Neurogene Entzündung - Diagnostik - Therapie - nicht-allergisch - allergisch - Neuropeptide - Kortison - Biomarker - Hyperreaktivität - Nase

Key words

Treatment - outcome - non-allergic - allergy - neurogenic inflammation - steroids - antihistamines - endoscopy - hyperreactivity - nose - nasal

Full Text

References

Literatur

1 Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001; 108 S147-S334
2 Bachert C, Ganzer U. Die nasale Hyperreaktivität. Die allergische Rhinitis und ihre Differentialdiagnosen - Konsensusbericht zur Pathophysiologie, Klassifikation, Diagnose und Therapie. Laryngorhinootologie. 1997; 76 65-76
3 Settipane R A, Lieberman P. Update on nonallergic rhinitis. Ann Allergy Asthma Immunol. 2001; 86 494-507
4 Settipane R A. Rhinitis: a dose of epidemiological reality. Allergy Asthma Proc. 2003; 24 147-154
5 Riechelmann H. Bedeutung von Umwelt und Beruf für die Nasenschleimhaut. Laryngorhinootologie. 2000; 79 653-654
6 Johansson S G, Hourihane J O, Bousquet J, Bruijnzeel-Koomen C, Dreborg S, Haahtela T, Kowalski M L, Mygind N, Ring J, Van Cauwenberge P, Hage-Hamsten M, Wuthrich B. A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force. Allergy. 2001; 56 813-824
7 Dykewicz M S, Fineman S, Skoner D P, Nicklas R, Lee R, Blessing-Moore J, Li J T, Bernstein I L, Berger W, Spector S, Schuller D. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol. 1998; 81 478-518
8 Bachert C, Borchard U, Wedi B, Klimek L, Rasp G, Riechelmann H, Schultze-Werninghaus G, Wahn U, Ring J. Allergische Rhinokonjunktivitis - Leitlinie der Deutschen Gesellschaft für Allergologie und klinische Immunologie (DGAI). Allergo J. 2003; 12 182-194
9 Garay R. Mechanisms of vasomotor rhinitis. Allergy. 2004; 59 (Suppl 76) 4-9
10 Widdicombe J G. Autonomic regulation. i-NANC/e-NANC. Am J Respir Crit Care Med. 1998; 158 S171-S175
11 Groneberg D A, Rabe K F, Wagner U, Fischer A. Vasoaktives Intestinales Polypeptid (VIP) im Atemtrakt: Physiologie und Pathophysiologie. Pneumologie. 2004; 58 330-338
12 Knipping S, Riederer A, Berghaus A. Nervale Regulation der respiratorischen Nasenschleimhaut. HNO. 2004; 52 471-487
13 Tai C F, Baraniuk J N. Upper airway neurogenic mechanisms. Curr Opin Allergy Clin Immunol. 2002; 2 11-19
14 Carr M J, Undem B J. Inflammation-induced plasticity of the afferent innervation of the airways. Environ Health Perspect. 2001; 109 (Suppl 4) 567-571
15 Hauser-Kronberger C, Hacker G W, Albegger K, Muss W H, Sundler F, Arimura A, Dietze O. Distribution of two VIP-related peptides, helospectin and pituitary adenylate cyclase activating peptide (PACAP), in the human upper respiratory system. Regul Pept. 1996; 65 203-209
16 Widdicombe J. Upper airway reflexes. Curr Opin Pulm Med. 1998; 4 376-382
17 Fang S Y, Shen C L. Neuropeptide innervation and neuroendocrine cells in allergic rhinitis and chronic hypertrophic rhinitis. Clin Exp Allergy. 1998; 28 228-232
18 Hauser-Kronberger C, Hacker G W, Muss W, Saria A, Albegger K. Autonomic and peptidergic innervation of human nasal mucosa. Acta Otolaryngol. 1993; 113 387-393
19 Albegger K, Hauser-Kronberger C E, Saria A, Graf A H, Bernatzky G, Hacker G W. Regulatory peptides and general neuroendocrine markers in human nasal mucosa, soft palate and larynx. Acta Otolaryngol. 1991; 111 373-378
20 Groneberg D A, Heppt W, Cryer A, Wussow A, Peiser C, Zweng M, Dinh Q T, Witt C, Fischer A. Toxic rhinitis-induced changes of human nasal mucosa innervation. Toxicol Pathol. 2003; 31 326-331
21 Baraniuk J N, Ali M, Yuta A, Fang S Y, Naranch K. Hypertonic saline nasal provocation stimulates nociceptive nerves, substance P release, and glandular mucous exocytosis in normal humans. Am J Respir Crit Care Med. 1999; 160 655-662
22 Baraniuk J N, Ali M, Naranch K. Hypertonic saline nasal provocation and acoustic rhinometry. Clin Exp Allergy. 2002; 32 543-550
23 Fang S Y, Shen C L, Ohyama M. Distribution and quantity of neuroendocrine markers in allergic rhinitis. Acta Otolaryngol. 1998; 118 398-403
24 Heppt W, Peiser C, Cryer A, Dinh Q T, Zweng M, Witt C, Fischer A, Groneberg D A. Innervation of human nasal mucosa in environmentally triggered hyperreflectoric rhinitis. J Occup Environ Med. 2002; 44 924-929
25 Shirasaki H, Kanaizumi E, Watanabe K, Konno N, Sato J, Asakura K, Kataura A, Himi T. Expression of neurokinin a receptor mRNA in human nasal mucosa. Acta Otolaryngol. 2004; Suppl 8 85-89
26 Hauser-Kronberger C, Hacker G W, Franz P, Albegger K, Dietze O. CGRP and substance P in intraepithelial neuronal structures of the human upper respiratory system. Regul Pept. 1997; 72 79-85
27 Riederer A, Knipping S, Fischer A, Unger J. Immunhistochemische Untersuchungen zum Vorkommen von „calcitonin gene-related peptide” (CGRP) in der Nasenschleimhaut des Menschen. HNO. 1995; 43 724-727
28 Baraniuk J N, Kaliner M A. Neuropeptides and nasal secretion. J Allergy Clin Immunol. 1990; 86 620-627
29 Lal D, Corey J P. Vasomotor rhinitis update. Curr Opin Otolaryngol Head Neck Surg. 2004; 12 243-247
30 Knipping S, Riederer A, Agha-Mir-Salim P, Holzhausen H J, Berghaus A. Die klassisch-vegetative, peptiderge und nitrerge Innervation der Drüsen der menschlichen Nasenschleimhaut. Laryngorhinootologie. 2001; 80 697-703
31 Gozes I, Brenneman D E. VIP: molecular biology and neurobiological function. Mol Neurobiol. 1989; 3 201-236
32 Baraniuk J N, Lundgren J D, Okayama M, Mullol J, Merida M, Shelhamer J H, Kaliner M A. Vasoactive intestinal peptide in human nasal mucosa. J Clin Invest. 1990; 86 825-831
33 Baraniuk J N, Castellino S, Lundgren J D, Goff J, Mullol J, Merida M, Shelhamer J H, Kaliner M A. Neuropeptide Y (NPY) in human nasal mucosa. Am J Respir Cell Mol Biol. 1990; 3 165-173
34 Jaradeh S S, Smith T L, Torrico L, Prieto T E, Loehrl T A, Darling R J, Toohill R J. Autonomic nervous system evaluation of patients with vasomotor rhinitis. Laryngoscope. 2000; 110 1828-1831
35 Loehrl T A, Smith T L, Darling R J, Torrico L, Prieto T E, Shaker R, Toohill R J, Jaradeh S S. Autonomic dysfunction, vasomotor rhinitis, and extraesophageal manifestations of gastroesophageal reflux. Otolaryngol Head Neck Surg. 2002; 126 382-387
36 Hess A, Bloch W, Rocker J, Peters S, Stennert E, Addicks K, Michel O. Nachweis von Stickstoffmonoxidsynthasen bei physiologischen und pathophysiologischen Prozessen in der Nasenschleimhaut. HNO. 2000; 48 489-495
37 Giannessi F, Ursino F, Fattori B, Giambelluca M A, Scavuzzo M C, Ceccarelli F, Ruffoli R. Immunohistochemical localization of 3-nitrotyrosine in the nasal respiratory mucosa of patients with vasomotor rhinitis. Acta Otolaryngol. 2005; 125 65-71
38 Giannessi F, Fattori B, Ursino F, Giambelluca M A, Soldani P, Scavuzzo M C, Ruffoli R. Ultrastructural and ultracytochemical study of the human nasal respiratory epithelium in vasomotor rhinitis. Acta Otolaryngol. 2003; 123 943-949
39 Olthoff A, Rohrbach S, Faber M, Gotz W, Laskawi R. Neuronal nitric oxide synthase immunoreactivity in the nasal mucosa of patients with idiopathic and allergic rhinitis. ORL J Otorhinolaryngol Relat Spec. 2002; 64 180-185
40 Powe D G, Hiskisson R S, Carney A S, Jenkins D, Jones N S. Idiopathic and allergic rhinitis show a similar inflammatory response. Clin Otolaryngol. 2000; 25 570-576
41 Powe D G, Huskisson R S, Carney A S, Jenkins D, Jones N S. Evidence for an inflammatory pathophysiology in idiopathic rhinitis. Clin Exp Allergy. 2001; 31 864-872
42 Powe D G, Huskisson R S, Carney A S, Jenkins D, McEuen A R, Walls A F, Jones N S. Mucosal T-cell phenotypes in persistent atopic and nonatopic rhinitis show an association with mast cells. Allergy. 2004; 59 204-212
43 Powe D G, Jagger C, Kleinjan A, Carney A S, Jenkins D, Jones N S. „Entopy”: localized mucosal allergic disease in the absence of systemic responses for atopy. Clin Exp Allergy. 2003; 33 1374-1379
44 Kleinjan A, Vinke J G, Severijnen L W, Fokkens W J. Local production and detection of (specific) IgE in nasal B-cells and plasma cells of allergic rhinitis patients. Eur Respir J. 2000; 15 491-497
45 Pozo D, Delgado M. The many faces of VIP in neuroimmunology: a cytokine rather a neuropeptide?. FASEB J. 2004; 18 1325-1334
46 Vassiliou E, Jiang X, Delgado M, Ganea D. TH2 lymphocytes secrete functional VIP upon antigen stimulation. Arch Physiol Biochem. 2001; 109 365-368
47 Damm M, Jungehulsing M, Eckel H E, Schmidt M, Theissen P. Effects of systemic steroid treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging. Otolaryngol Head Neck Surg. 1999; 120 517-523
48 Fokkens W J. Thoughts on the pathophysiology of nonallergic rhinitis. Curr Allergy Asthma Rep. 2002; 2 203-209
49 International Consensus Report on the diagnosis and management of rhinitis . International Rhinitis Management Working Group. Allergy. 1994; 49 1-34
50 Hansen B, Mygind N. How often do normal persons sneeze and blow the nose?. Rhinology. 2002; 40 10-12
51 Revicki D A, Leidy N K, Brennan-Diemer F, Thompson C, Togias A. Development and preliminary validation of the multiattribute Rhinitis Symptom Utility Index. Qual Life Res. 1998; 7 693-702
52 Damm M, Quante G, Jungehuelsing M, Stennert E. Impact of functional endoscopic sinus surgery on symptoms and quality of life in chronic rhinosinusitis. Laryngoscope. 2002; 112 310-315
53 Damm M, Eckel H E, Streppel M, Jungehulsing M, Stennert E. Abhängigkeit des uni- und bilateralen Riechvermögens von der nasalen Strömung bei Patienten mit chronischer Rhinosinusitis. HNO. 2000; 48 436-443
54 Riechelmann H, Bachert C, Goldschmidt O, Hauswald B, Klimek L, Schlenter W W, Tasman A J, Wagenmann M. Durchführung des nasalen Provokationstests bei Erkrankungen der oberen Atemwege. Positionspapier der Deutschen Gesellschaft für Allergologie und klinische Immunologie (Sektion HNO) gemeinsam mit der Arbeitsgemeinschaft Klinische Immunologie. Laryngorhinootologie. 2003; 82 183-188
55 Goldschmidt O, Mösges R, Klimek L, Hauswald B, Schapowal A. Die Reaktion der Nasenschleimhaut bei gesunden Probanden auf Histaminprovokation. Allergologie. 1998; 21 141-149
56 Litvyakova L I, Baraniuk J N. Nasal provocation testing: a review. Ann Allergy Asthma Immunol. 2001; 86 355-364
57 Van Wijk R G, Mulder P G, Dieges P H. Nasal provocation with histamine in allergic rhinitis patients: clinical significance and reproducibility. Clin Exp Allergy. 1989; 19 293-298
58 Marquez F, Sastre J, Hernandez G, Cenjor C, Sanchez-Hernandez J M, Sanchez J, Gutierrez R, Sanabria J. Nasal hyperreactivity to methacholine measured by acoustic rhinometry in asymptomatic allergic and perennial nonallergic rhinitis. Am J Rhinol. 2000; 14 251-256
59 Braat J P, Mulder P G, Fokkens W J, van Wijk R G, Rijntjes E. Intranasal cold dry air is superior to histamine challenge in determining the presence and degree of nasal hyperreactivity in nonallergic noninfectious perennial rhinitis. Am J Respir Crit Care Med. 1998; 157 1748-1755
60 Van Rijswijk J B, Boeke E L, Keizer J M, Mulder P G, Blom H M, Fokkens W J. Intranasal capsaicin reduces nasal hyperreactivity in idiopathic rhinitis: a double-blind randomized application regimen study. Allergy. 2003; 58 754-761
61 Heppt W. Zytologie der Nasenschleimhaut. Berlin, Heidelberg, New York; Springer 1995
62 Kramer M F, Burow G, Pfrogner E, Rasp G. In vitro diagnosis of chronic nasal inflammation. Clin Exp Allergy. 2004; 34 1086-1092
63 Riechelmann H, Deutschle T, Friemel E, Gross H J, Bachem M. Biological markers in nasal secretions. Eur Respir J. 2003; 21 600-605
64 Shahab R, Phillips D E, Jones A S. Prostaglandins, leukotrienes and perennial rhinitis. J Laryngol Otol. 2004; 118 500-507
65 Iguchi Y, Yao K, Okamoto M. A characteristic protein in nasal discharge differentiating non-allergic chronic rhinosinusitis from allergic rhinitis. Rhinology. 2002; 40 13-17
66 Tosun F, Sezen I, Gerek M, Ozkaptan Y, Yapar M, Caliskaner Z, Akman S. Electrophoretic evaluation of nasal discharge in patients with allergic rhinitis and vasomotor rhinitis. Am J Rhinol. 2002; 16 141-144
67 Long A, McFadden C, De Vine D, Chew P, Kupelnick B, Lau J. Management of allergic and nonallergic rhinitis. Evid Rep Technol Assess (Summ). 2002; 5 1-6
68 Webb D R, Meltzer E O, Finn A F Jr, Rickard K A, Pepsin P J, Westlund R, Cook C K. Intranasal fluticasone propionate is effective for perennial nonallergic rhinitis with or without eosinophilia. Ann Allergy Asthma Immunol. 2002; 88 385-390
69 Banov C H, Lieberman P. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol. 2001; 86 28-35
70 Ciprandi G. Treatment of nonallergic perennial rhinitis. Allergy. 2004; 59 (Suppl 76) 16-22
71 Blom H M, Van Rijswijk J B, Garrelds I M, Mulder P G, Timmermans T, Gerth V W. Intranasal capsaicin is efficacious in non-allergic, non-infectious perennial rhinitis. A placebo-controlled study. Clin Exp Allergy. 1997; 27 796-801
72 Gerth V W, Terreehorst I T, Mulder P G, Garrelds I M, Blom H M, Popering S. Intranasal capsaicin is lacking therapeutic effect in perennial allergic rhinitis to house dust mite. A placebo-controlled study. Clin Exp Allergy. 2000; 30 1792-1798
73 Wolf G, Anderhuber W, Hauser-Kronberger C, Saria A. Die Behandlung der unspezifischen hyperreflektorischen Rhinopathie (vasomotorischen Rhinitis) mit Capsaicin. Laryngorhinootologie. 1995; 74 289-293
74 Riechelmann H, Davris S, Bader D. Behandlung der perennialen nichtallergischen Rhinopathie mit Capsaicin. HNO. 1993; 41 475-479
75 Sanico A M, Philip G, Proud D, Naclerio R M, Togias A. Comparison of nasal mucosal responsiveness to neuronal stimulation in non-allergic and allergic rhinitis: effects of capsaicin nasal challenge. Clin Exp Allergy. 1998; 28 92-100
76 Kim K S, Kim S S, Yoon J H, Han J W. The effect of botulinum toxin type A injection for intrinsic rhinitis. J Laryngol Otol. 1998; 112 248-251
77 Unal M, Sevim S, Dogu O, Vayisoglu Y, Kanik A. Effect of botulinum toxin type A on nasal symptoms in patients with allergic rhinitis: a double-blind, placebo-controlled clinical trial. Acta Otolaryngol. 2003; 123 1060-1063
78 El Guindy A. Endoscopic transseptal vidian neurectomy. Arch Otolaryngol Head Neck Surg. 1994; 120 1347-1351
79 Fernandes C M. Bilateral transnasal vidian neurectomy in the management of chronic rhinitis. J Laryngol Otol. 1994; 108 569-573
80 Prasanna A, Murthy P S. Vasomotor rhinitis and sphenopalatine ganglion block. J Pain Symptom Manage. 1997; 13 332-338
81 Mladina R, Risavi R, Subaric M. CO₂ laser anterior turbinectomy in the treatment of non-allergic vasomotor rhinopathia. A prospective study upon 78 patients. Rhinology. 1991; 29 267-271

Priv.-Doz. Dr. med. Michael Damm

Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde · Klinikum der Universität zu Köln

Kerpener Straße 62 · 50924 Köln

Email: michael.damm@uni-koeln.de