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Nonallergic Rhinitis

2006 Edition, November 15, 2006

Complete Document

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Active, Most Current

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ISBN: 978-0-8493-3991-2
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Product Details:

  • Revision: 2006 Edition, November 15, 2006
  • Published Date: November 15, 2006
  • Status: Active, Most Current
  • Document Language: English
  • Published By: CRC Press (CRC)
  • Page Count: 506
  • ANSI Approved: No
  • DoD Adopted: No

Description / Abstract:


This book is the first iteration stemming from a conversation about the broad differential diagnosis of nonallergic rhinitis (NAR) that began on the long road from Yalta. This conversation has been transformed into an evaluation of rhinopathy that dares not speak its name. This is a topic of significant importance since rhinitis complaints are virtually universal. There is great confusion and misunderstanding about the range of normal nasal sensations and those that indicate inflammatory and noninflammatory nasal disorders. The severity and prevalence of sensations of pruritis, irritation, ‘‘fullness,'' ‘‘congestion,'' limited nasal airflow, anterior and posterior discharge, and facial pain in the general population is poorly understood. Without this information, many patients and physicians may erroneously conclude that an inflammatory rhinitis or rhinosinusitis disease is present when in fact the symptom complex is due to a nonallergic, noninflammatory syndrome. Misdiagnosis, inappropriate medication, and the fact that our pharmacopea for NAR is very limited often leads to ‘‘failure'' of treatment and frustration on the part of the patient and physician.

One factor contributing to this situation is the tendency to have a ‘‘short list'' for rhinitis syndromes. Many current rhinitis paradigms are organized by the split between mechanisms of atopic, allergic rhinitis (AR) and all other mechanisms of nasal discomfort and disease, or NAR. This division is based on the presence or absence of symptoms when exposed to seasonal, perennial or occupational allergens, confirmation of IgE - mediated immediate and/or late phase responses to the appropriate offending allergens, and beneficial responses to antihistamines, nasal steroids and allergen injection therapy. The mechanisms of atopy have been extensively studied, with our level of understanding reaching genomic and molecular complexities. This knowledge can be applied to the approximately 20% of the United States population estimated to have allergic rhinitis syndromes.

This intimate knowledge of atopic syndromes is contrasted by lumping all other syndromes and subjects who are nonresponders to current therapies into the derisive garbage can of NAR. The prevalence of NAR is estimated to be 5% to 7%. However, this may be an underestimate based on the broad set of inflammatory and noninflammatory syndromes in the differential diagnosis, and epidemiological survey tools that group subjects with self-reported rhinitis into either AR or NAR without physician confirmation or evaluation of atopic and other inflammatory mechanisms. Surprisingly little is understood about nonatopic rhinitis in childhood, pregnancy, the aging population, and other influence of irritant exposures on AR complaints. We have included several chapters that offer different strategies for distinguishing allergic from nonallergic syndromes, and that expand on the inflammatory and noninflammatory scope of NAR. However, it is clear that NAR mechanisms and complaints also occur in conjunction with AR. The result is the generalized categorization of ‘‘pure'' AR, ‘‘pure'' NAR, and ‘‘mixed'' AR þ NAR. This is a necessary step forward in our task of distinguishing between individual syndromes, identifying their mechanisms, and developing new treatment options for patients who do not respond to current drugs and avoidance.

Standing back and reviewing our progress while groping our way into the nature of NAR leads to the realization that the job is only beginning, and that our knowledge base is a glass half-filled. This base is the information we ‘‘know''. Our more advanced understanding of AR mechanisms contrasts with the less well-developed and at times contradictory descriptions and mechanistic underpinnings of inflammatory and noninflammatory NAR syndromes. However, the glass half empty should not be viewed with sanguine neglect. This void represents an opportunity to carefully observe and define the subsets of NAR based on coherent pathophysiological mechanisms. Newer studies are already moving to this more rigorous approach. We have included discussion of investigations from other organ systems to provide additional insights. Our hope is that this information will generate new hypotheses that can be tested to confirm the discrete nature of selected NAR syndromes. These studies may investigate the nature of other inflammatory and noninflammatory mechanisms that may be recruited in NAR subtypes and also in AR. We anticipate this multidisciplinary approach will lead to a more logical classification of NAR.

From this perspective, our book represents a stepping stone to cross from established dogmas to future insights. One clinical foot is grounded on established evaluations of syndromes such as nonallergic rhinitis with eosinophila (NARES), drug and hormonal rhinitis, and the ultimate statement of futility and frustration in this field – ‘‘vasomotor rhinitis'' (VMR). Chapters devoted to these topics evaluate the epidemiology, distinguishing clinical features, potential mechanisms and current treatment approaches. They reveal what is known, or often how little is understood about these ‘‘classic'' NAR syndromes. Controversies will be apparent from the parallel discussions of these disorders provided by leading opinion leaders. The discrepancies should spur efforts at more precise synchronization of NAR syndrome definitions. This section of the book was designed to describe the edge of the envelope of our understanding in order to provoke new thoughts, insights, standardized systematic surveys, and analysis of treatment strategies for each niche of NAR.

Recognizing ‘‘what we know'' places us in a position to learn ‘‘what we need to know.'' This phase represents the other foot stepping forward into relatively uncharted waters of occupational, inflammatory, and neurological dysfunction. Advances in understanding disorders of the glottis, esophagus and lung have provided new insights into irritant sensitivity, mucosal hyperresponsiveness, increased neural reflex, and mucosal secretory activities. Newer concepts of nonallergic eosinophilic, arachidonic acid, nociceptive, autonomic and central neural, and other mechanisms may seem misplaced in a book on NAR. However, information learned from studies of cough, vocal cord dysfunction, sleep apnea, virus illness, olfactory, and trigeminal chemosensory systems have important implications that can be applied to understanding nasal, sinus and middle ear disease. We hope these interdisciplinary data will cross-pollinate with the standard, largely static dogmas of NAR to generate fertile hybrid concepts that will invigorate investigations into nasal and related disorders. For example, one long term objective is to stimulate a reassessment of long-held beliefs about "vasomotor rhinitis" and the supposed dichotomy of ‘‘runners'' versus ‘‘blockers'', and replace these concepts with evidence- and mechanism-based clinical diagnoses.