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Non-Allergic Rhinitis with Osteopathic Treatment … - chronic non allergic rhinitis treatment


Non-Allergic Rhinitis with Osteopathic Treatment …-chronic non allergic rhinitis treatment

16 Osteopathic Family Physician (2020) 16 - 20 Osteopathic Family Physician | Volume 12, No. 2 | March/April, 2020
Review ARTICLE
Non-Allergic Rhinitis with Osteopathic Treatment Techniques
Omar Bukhari, DO PGY21; Grant Phillips, MD1; Kathleen Sweeney, DO1
1UPMC Altoona - Altoona Family Physicians, Altoona, PA
KEYWORDS: ABSTRACT: Rhinitis is generally classified as allergic or non-allergic and is differentiated from
Non-Allergic Rhinitis
conditions that mimic symptoms of rhinitis. This article reviews the non-allergic forms of rhinitis
highlighting signs, symptoms and diagnosis. An in-depth overview of osteopathic treatment
Osteopathic Manipulative options for the head and neck are outlined to assist osteopathic family physicians
Medicine in providing symptom relief to their non-allergic rhinitis patients.
INTRODUCTION DIFFERENTIAL DIAGNOSIS
Non-allergic rhinitis (NAR) is a heterogeneous condition rather Infectious rhinitis is an acute process generally secondary to
than a specific disease. It is characterized by periodic or perennial viral infections or secondary bacterial infection. Symptoms
symptoms of rhinitis that are not a result of IgE-dependent events include nasal congestion, mucopurulent nasal discharge, pain
or infectious in origin. These include non-allergic rhinopathy, and pressure, headache, olfactory disturbance, postnasal
infectious rhinitis, and rhinitis caused by foods or alcohol.1 NAR drainage, and cough. Viral infections account for as many as
disproportionately affects women; who tend to suffer from 98% of acute infectious rhinitis and the majority of rhinitis
recurring headaches and recurrent sinusitis as well.2 NAR affects symptoms in children.6 Conditions associated with NAR include
about 7% of the U.S. population.3 acute and chronic sinusitis, headaches, asthma, chronic cough,
The extensive mucosal area of the nose provides a surface for conjunctivitis, otitis media with or without effusion, nasal polyps,
warming and humidification of inspired air and removal of air hearing impairment, obstructive sleep apnea, and other sleep
pollutants. Physical and chemical stimuli can elicit specific nasal disturbances.
sensations, including olfaction, warming or cooling, irritation and Allergic rhinitis is an IgE-mediated inflammatory process of the
nasal pruritus. These stimuli can trigger nasal secretion or and nasal mucosa prompted by environmental allergens that are
obstruction. often seasonal.7 These patients tend to have more sneezing and
NAR is defined by symptoms where there is some combination of itchy eyes compared to patients with NAR, and asthma is more
sneezing, rhinorrhea, nasal congestion, and postnasal drainage common.2
in the absence of a specific etiology. Non-allergic rhinopathy
replaced the term vasomotor rhinitis (VMR) since the term SIGNS AND SYMPTOMS AND DIAGNOSIS
VMR implies the involvement of nasal vascular and glandular
abnormalities contributing to inflammation and current data The diagnosis of NAR is made on clinical grounds and starts with
suggest that NAR is due to neurosensory abnormalities with a careful history and physical. Some authors suggest skin testing
minimal inflammation. NAR is a heterogeneous disorder that or in vitro testing for seasonal and perennial aeroallergens to
includes anatomic abnormalities, endogenous atopy, nociceptive rule out an allergic component.8 Start by identifying the pattern,
nerve dysfunction and autonomic dysfunction4 and is probably seasonality, related symptoms response to medications and
due to neurosensory abnormalities not inflammation.5 NAR an environmental history. Primary symptoms of NAR are nasal
should be differentiated from other causes of rhinitis that include congestion and rhinorrhea. Secondary symptoms might include
infectious and allergic subtypes, among other causes. throat clearing, cough, ear pressure or popping, sneezing, reduced
ability to smell and to detect odors (hyposmia) and facial pressure
or headache. Symptoms may be continuous or intermittent and
may be influenced by one or more precipitating factors.9
CORRESPONDENCE: Physical examination for NAR is more variable than in allergic
Omar Bukhari, DO PGY2 | bukharimo2@upmc.edu rhinitis and therefore is of limited value in differentiating rhinitis
subtypes. The nasal mucosa is normal or erythematous, often
with evidence of prominent postnasal drip with cobblestoning or
Copyright? 2020 by the American College of Osteopathic Family may appear red and beefy with scant mucus.10 Note that if the
Physicians. All rights reserved. Print ISSN: 1877-573X
10.33181/12023
Bukhari, Phillips, Sweeney Non-Allergic Rhinitis with Osteopathic Treatment Techniques 17
patient is asymptomatic, the physical exam may be normal. Short- the scope of this review. The approach described below includes
and long-term complications decreased quality of life and include easily mastered OMT techniques that provide symptom relief and
chronic cough, poor cognitive functioning, daytime fatigue, often can be taught in the office to the patient or family member
reduced productivity, and absenteeism. to utilize at home.
The clinician's approach could include releasing the thoracic inlet,
TREATMENT hyoid, cricoid and thyroid cartilage release, cervical chain drainage
Treatment is symptomatic. First-line treatment should include techniques, submandibular release, mandibular drainage/
avoidance of triggers when practicable. There is evidence that Galbreath technique, auricular drainage technique, alternating
topical saline is beneficial in the treatment of the symptoms when nasal pressure, trigeminal nerve decongestion and effleurage
used alone or as an adjunctive treatment.6 Other treatments include of the maxilla and frontal sinuses. Correction of cervical somatic
intranasal steroids, intranasal antihistamines, a combination of both dysfunction and treatment of parasympathetic and sympathetic
and oral decongestants. Oral second-generation antihistamines influences can also be addressed. This suggested order allows
are minimally effective. Though first-generation oral antihistamines for optimal lymphatic flow, but a busy family physician most
may haves some benefit due to anticholinergic activity, use of commonly will adapt and utilize the techniques they feel are most
these medications may impair cognitive function and in worst-case efficacious and that can be performed in the constraints of the
scenarios lead to an increase in motor vehicle crashes.11 standard office visit.
Intranasal ipratropium bromide is helpful when rhinorrhea is Release of Thoracic Inlet
the predominant symptom. It is more effective when used in The physician decompresses the thoracic inlet by correcting the
combination with an intranasal cortico?steroid than either drug asymmetry of the soft tissues and fascia. This is done by screening
alone. The main side effect is dryness of the nasal mucosa.6 the thoracic inlet in all three planes of motion which are bounded by
the first rib, first thoracic vertebra, and the clavicles. The physician
OSTEOPATHIC TECHNIQUES FOR THE palpates the soft tissues and boney landmarks to ascertain the
freedom and restrictions. The physician then applies an indirect
HEAD AND NECK or direct force to normalize motion and symmetry. This lymphatic
Restrictions in cranial movement can lead to altered subtle mobility technique allows for freer movement of lymphatic drainage from
of the parietal and temporal bones interfering with the proper the head and regions that are subsequently treated. Treatment
articulation of the cranial bones and the primary respiratory of restrictions of the first rib may also be considered.
mechanism. Restriction in the sphenoid and occiput relationship
can lead to different movements of the frontal, parietal, temporal FIGURE 1:
bones, which can influence patients' ear, nose and throat complaints. Release of the thoracic inlet
If the physician is familiar with basic cranial osteopathic manipulative
technique (OMT) the CV4 compression technique and frontal sinus
lift can be utilized to normalize cranial motion. Most Osteopathic
physicians that practice in-depth cranial OMT take courses beyond
what is the standard curriculum in medical school that are not in
TABLE 1:
Treatment summary
TREATMENT LEVEL OF EVIDENCE REFERENCES
Avoidance of Level C 6
known triggers
Nasal saline Level A 6 Hyoid, Cricoid and Thyroid Cartilage Release
Oral antihistamines Level C 12 The physician gently articulates the cartilage of the hyoid bone,
Intranasal Level A 12,13
cricoid cartilage and thyroid cartilage while stabilizing the head
corticosteroids gently with the opposite hand at the forehead or occiput.
Intranasal
antihistamines Level A 6 Cervical Chain Drainage
Intranasal The physician downwardly displaces the sternocleidomastoid
anticholinergics Level A 6 muscle and uses a "milking" motion along the span of the muscle
from a caudad to cephalad direction to facilitate cervical lymphatic
Oral decongestants Level A 6 drainage.
18 Osteopathic Family Physician | Volume 12, No. 2 | March/April, 2020
Submandibular Release FIGURE 4:
The physician uses the tips of the fingers to assess the ease of Teaching patient auricular drainage
motion and symmetry of the submandibular fascia.
FIGURE 2:
Submandibular release
Alternation Nasal Pressure
The physician or patient presses in a diagonal fashion downward
on the ethmoid sinus in a rhythmic pattern to facilitate lymphatic
Mandibular Drainage/Galbreath maneuver drainage through the sinus.
The physician places one hand to stabilize the head and then uses Trigeminal Nerve Decompression at the supra,
the fingers and hypothenar eminence to gently ease the mandible infra and mental foramina
forward and toward the midline in a slow and rhythmic motion. The physician or patient uses the pads of the fingers to apply
This technique can help relieve the dysfunction of the eustachian gently rotary pressure to decompress the trigeminal nerve at the
tubes and is helpful for lymphatic congestion in the ear, nose, areas of exit of the branches of cranial nerve V in the V1, V2 and
throat and submandibular region. Care must be taken in patients V3 distribution. These foramina are easily palpated and can be
with temporomandibular pain and dysfunction to not stress the shown to the patient or family member for home treatment.
joint or cartilage. FIGURE 5:
FIGURE 3: Trigeminal nerve decompression
Mandibular drainage/Galbreath maneuver
Auricular Drainage
The outer ear is stabilized and secured between the third and
fourth digits of the physician's dominant hand while the other
hand stabilizes the head. The hand applied to the external ear
then makes gentle circles in clockwise direction ending with a
gentle tug on the tragus. This technique can be taught to patients
and family members.

Is there a cure for rhinitis medicamentosa? Chronic ethmoiditis[15] Atrophic rhinitis[15] Septal perforation Chronic rhinosinusitis Turbinate hyperplasia