antihistamine, chronic rhinitis, drug therapy, nose drops abuse, vasomotor rhinitis
A Al-Shehri. Medical Treatment Of Chronic Rhinitis. The Internet Journal of Otorhinolaryngology. 2002 Volume 2 Number 1.
In most cases chronic rhinitis can be a symptom of nasal sinus affection, allergic, immunologic or systemic disease as well as a result of toxic effects. Others are adenoids, septum deviation, foreign bodies and abuse of nasal drops. Besides of non-specific treatment pharmacological therapy aims at the treatment of the underlying disease. Possible complications of the chronic rhinitis are the atrophic rhinitis, sinusitis, chronic bronchitis as well as foetor and disturbance of olfactory perception. Therefore there is need for a causal therapy to avoid exacerbation. This essay gives a survey of the pharmacological possibilities in the treatment of the chronic rhinitis.
The chronic rhinitis is a specific or non-specific disease of the nasal mucosa including the nasal sinus. The diagnosis is made if symptoms last more than 10 days. As a rule, the clinical appearance of the chronic rhinitis is not specific, but shows symptoms of bacterial, viral or fungal infection of the nasal sinus, symptoms of allergic or immunologic or systemic diseases. Disturbances of the hormonal status, e.g. in pregnancy or because of the intake of contraceptive agents, adenoids, hyperplasia of the nasal conchae, nasal polyps, tumors, septumdeviation and other malformations of the nose, foreign bodies and abuse of nose drops can lead to a chronic rhinitis as well. Chemical and physical toxic agents or extrem dry air because of defects of air conditioner or the use of too many personal computers in one room are further reasons.  In some cases the chronic rhinitis is a symptom of the sick building syndrome. 
Possible complications of the chronic rhinitis are the atrophic rhinitis, sinusitis, chronic bronchitis as well as foetor and disturbance of olfactory perception. Therefore there is need for a causal therapy to avoid exacerbation. This essay gives a survey of the pharmacological possibilities in the treatment of the chronic rhinitis.
Basic diagnostic steps should include general and specific, especially allergological history of actual and past illness, clinical examination of the ear, nose and throat and the anterior and posterior rhinoscopy as well. Important complementary tests are skin tests to identify IgE-mediated allergic diseases [5,16], laboratory tests, nasal, konjunctival and oral provocation tests including investigations of occupational environment with trials concerning deficiency and exposition of irritative agents.
Functional diagnostic measures of the nose as well as bacterial, fungal, radiologic, endoscopic (e.g. contact endoscopy of the nasal mucosa ), sonographic investigations of the nasal sinus and the pharynx and larynx and additional laboratory tests are additional diagnostic tools that lead to a correct diagnosis. In case of negative results further gynecological, endocrinological, toxic, internal and occupational studies are necessary.
General Pharmacological Treatment Of The Chronic Rhinitis
There are contraindications for phytopharmacological rhinologica containing eucalyptus, spruce or pine oil - e.g. Pumilen®-N - in the treatment of infants or in case of asthma bronchiale and pertussis as well as the local application of peppermint and thymian oil to the nasal mucosa of younger children.
Supporting drugs are homeopathic complex preparations as e.g. Traumeel® tablets or drops, Euphorbium comp. drops® and spray as well. Other proved methods are the nasal irrigation, aerosol therapy with solution of Emser Salz or panthenol. For optimal resorption at the nasal mucosa the particles should achieve a size of at least 10 µm, as smaller particles precipitate in the lower airways and thus have no sufficient effect. With inhalation therapy high drug concentrations on the mucosa can be achieved.  There is evidence that there is not only a secretolytic effect, these methods may also reduce the concentration of inflammatory mediators as e.g. histamine and leucotriens. 
Under constitutional aspects homeopathic drugs as Euphorbium D3, D4, Galphimia D4, D6, D12, Kalium bichromicum D3-6, Luffa D3-12, Calcium carbonicum, Hepar sulfuris, Sulfur, Sulfur jodatum, Natrium muriaticum, Graphites, Pulsatilla, Silicea, Sticta pulmonaria are used. 
In a general practice an unguent containing Belladona planta tota 1% + Unguentum apis Weleda® aa 25,0, locally applied as a thin film to the paranasal skin several times per day, often shows surprising effects, provided that the rhinitis is due to a chronic or recurrent sinusitis (personal information of the general practitioner).
Most of the antihistamines have contraindications, e.g. disturbed micturition with residual urine in case for e.g. prostata hyperplasia, angle-closure glaucoma, disturbance of the liver function (e.g. Terfenadin), combination with macrolid antibiotics (e.g. Terfenadin, Astemizol) and restriction concerning the age of the patient (e.g. Cetirizin, Loratadin: >2 years, Azelastin-HCL: >6 years) as well as the application during pregnancy and lactation period.
The most frequent side effects are those of the vegetative nervous system as headache, nausea, queasiness, dryness of the mouth, gastrointestinal effects, disturbance of micturition, visual disorders and skin reactions. There has to be special attention to side effects on the central nervous system like excitation or sedation, as reactivity and concentration may be significantly reduced. Those patients, who drive a car or who are working on rotating machines or in special dangerous areas, should not take these substances. Antihistamines of the new generation have an effect of 24 hours and clearly show less side effects on the central nervous system. Nevertheless individual adverse reactions are possible, so that the first medication intake should e.g. be at a weekend.
Pharmacotherapy Of Specific Diseases
The pharmacotherapy of the allergic rhinitis consists in local and oral application of antihistamines, e.g. DNCG spray, Lisino® 10 mg/die, and in the application of topic corticoids, e.g. Topinasal®, Beconase®, Flutide®. Alternatively there is a treatment with Luffa D3-12 4 weeks before and during the whole pollen season.
The medical treatment of the NH concerns the basic illness. NH caused by endocrinologic illness cannot be treated by the ENT. Topical corticoids have a broad effect and may be successful.
The reflectoric NH can also be treated with oral antihistamines, dinatriumcromoglycin acid or capsaicin. Treatment of essential NH or NH of unknown origin contains dinatriumcromoglycin acid, topic corticoids and antihistamines. 
The medical treatment of ozaena is: physical treatment with inhalation and lavage, secretolysis e.g. with Tacholiquin, application of nose salves (Nisita®, Bepanthen® = panthenol, Siozwo®) and a specific antibiotic therapy appropriate to the results of smear tests. There may be a therapeutic trial with hydergin or reserpin in the dosage of 2x0,25 mg/die p.o. for 4 days, followed by 4x0,25 mg/die for 2-3 months. There is a lifelong need for intensive care of the mucosa.
The medical treatment concerns concomitant symptoms. As a short-term treatment nose drops, e.g. Nasivin® or Otriven® 0,5 %, are indicated. Acetylcystein in a dosage corresponding to the age of the patient as well as inhalation of Emser Salz and a solution of panthenol promote secretolysis and calm down the irritated mucosa. Immunostimulating drugs are e.g. Lymphozil K®, Esberitox®, Tonsilgon®, that as a side effect may reduce the swelling of the mucosa.
Sinusitis maxillaris and frontalis, immune deficiency diseases, mucoviscidosis, tuberculosis, nasal polyps, tumors as well as endocrinologic diseases can cause a chronic rhinitis. In all these cases the chronic rhinitis will only be treated, unless the treatment of the original illness is not successful.
It is important to know the exact origin of the chronic rhinitis before starting therapy. Beside general measures as secretolysis and inhalation, that calm down the irritated nasal mucosa, the treatment of the basic illness is essential.
Especially the elderly often show symptoms of a chronic rhinitis.  The physiological process of aging leads to atrophic nasal mucosa combined with recession of the collagen fibers and loss of elastic fibers in the skin, resulting in the change of the outer form of the nose und a higher nasal air resistance. Dry mucosa and a higher viscosity of the mucos promote a chronic rhinitis. Some medical drugs can lead to chronic rhinitis, especially in the elderly, e.g. antihypertensive agents or estrogene. In case of the need of antihistamines, those of the first generation should be applied with caution because of their effects on the central nervous system. They should not be combined with other central sedative agents as barbiturates or benzodiazepine.  Prolongation of the QT-interval was seen especially in antihistamines of the second generation as Terfenadin and Astemizol. There are some cases of cardiac side effects, so that these substances should not be applied in patients with arrhythmia, heart insufficiency and coronary disease as well as those with disturbed liver function. Because of the retardation of elimination in the elderly patient antihistamines should principally - even in healthy ones - be given in the lowest dosage.  A good alternative is the regulary application of topical cromoglycine acied, a drug with nearly no side effects.
As a rule it is better to prevent allergic rhinitis than to treat it. Beside medical treatment we can do also hyposensitization of patients and instruct the patient to avoid exposure to allergens like pollen. Nevertheless a medical treatment often has to be done at least for a limited time - as to take care of the occupational and social capacity of the patient, especially at the times of high pollen exposition the allergic rhinitis leads to a severe impairment of the general condition. Nasal application of cromoglycine acid as well as topic nasal corticoids and ipratropiumbromid have only few side effects with a therapeutical effect of long duration.
Because of the rebound effect sympathomimetics should be restricted to short-term application. A nose drop dependency, caused by long-term application, is difficult to treat.
As the chronic rhinitis is a strainful disease compromising social life, there is a great patient's desire of change. Therapy should aim at an intensive treatment and a flexible handling of the therapy concerning changing symptoms of the disease.
Dr. A. Wegener, Buschweg 39a, D-53229 Bonn, Germany e-mail: email@example.com