CLINICAL SCIENCE SESSION (CSS)

* Kepaniteraan Klinik Senior / G1A220085 / September 2021

** Pembimbing / dr. Lusiana Herawati Yamin, Sp.THT-KL

Rhinitis Nonalergi Kronik

Oleh :
Dilla Juwita Sari, S.Ked*
G1A220085

Pembimbing :

dr. Lusiana Herawati Yamin, Sp.THT-KL**

KEPANITERAAN KLINIK SENIOR

BAGIAN THT RSUD RADEN MATTAHER PROVINSI

JAMBI FAKULTAS KEDOKTERAN DAN ILMU

KESEHATAN UNIVERSITAS JAMBI

2021
 HALAMAN PENGESAHAN

CASE SCIENCE SESSION (CSS)

Rhinitis Nonalergi Kronik

Disusun Oleh:

Dilla Juwita Sari,

S.Ked
G1A220085

Sebagai salah satu tugas Bagian Ilmu Penyakit

THT RSUD Raden Mattaher Jambi
Program Studi Profesi Dokter Universitas Jambi

Jambi, September 2021

Pembimbing,

dr. Lusiana Herawati Yamin, Sp.THT-KL

ii
 KATA PENGANTAR

Puji dan syukur penulis panjatkan kepada Tuhan Yang Maha Esa atas berkat dan
karunia-Nya, penulis dapat menyelesaikan Case Science Session (CSS) ini dengan judul
“Rhinitis Nonalergi Kronik”. Laporan ini merupakan bagian dari tugas Kepaniteraan
Klinik Senior di Bagian Ilmu Penyakit THT RSUD Raden Mattaher Jambi.
Terselesaikannya laporan ini tidak lepas dari bantuan, bimbingan dan dorongan dari
berbagai pihak, oleh karena itu penulis menyampaikan ucapan terima kasih kepada dr.
Lusiana Herawati Yamin, Sp.THT-KL selaku pembimbing yang telah memberikan arahan
sehingga Case Science Session (CSS) ini dapat terselesaikan dengan baik dan kepada semua
pihak yang telah membantu dalam penyelesaian laporan ini.
Penulis menyadari bahwa laporan ini masih banyak kekurangannya, untuk itu saran
dan kritik yang bersifat membangun sangat diharapkan oleh penulis. Semoga kiranya Case
Science Session (CSS) ini dapat bermanfaat bagi kita khususnya dan bagi dunia kesehatan
pada umumnya.

Jambi, September 2021

Penulis

iii
 Chronic Nonallergic Rhinitis
Denise K.C. Sur, MD, and Monica L. Plesa, MD
David Geffen School of Medicine at the University of California, Los Angeles, California

Chronic nonallergic rhinitis encompasses a group of rhinitis subtypes without

allergic or infectious etiologies. Although chronic nonallergic rhinitis represents
about one-fourth of rhinitis cases and impacts 20 to 30 million patients in the United
States, its pathophysiology is unclear and diagnostic testing is not available.
Characteristics such as no evidence of allergy or defined triggers help define clinical
subtypes. There are eight subtypes with overlapping presentations, including
nonallergic rhi- nopathy, nonallergic rhinitis with nasal eosinophilia syndrome,
atrophic rhinitis, senile or geriatric rhinitis, gustatory rhinitis, drug-induced rhinitis,
hormonal rhinitis, and occupational rhinitis. Treat- ment is symptom-driven and
similar to that of allergic rhinitis. Patients should avoid known triggers when
possible. First-line therapies include intranasal corticosteroids, intranasal
antihistamines, and intranasal ipratropium. Combination therapy with decongestants
and first-generation antihistamines can be considered if monotherapy does not
adequately control symptoms. Nasal irrigation and intra- nasal capsaicin may be
helpful but need further investigation. (Am Fam Physician. 2018;98(3):171-176.
Copyright © 2018 American Academy of Family Physicians.)

Chronic nonallergic rhinitis encompasses They can be perennial, persistent, intermittent,

a group of rhinitis subtypes without allergic or
infectious etiologies. Although chronic nonal-
lergic rhinitis represents at least 23% of rhinitis
cases in the United States and impacts an esti-
mated 20 to 30 million patients, its pathophys-
iology is unclear.1,2 Chronic nonallergic rhinitis
was previously referred to as nonallergic vaso-
motor or vasomotor rhinitis, but it was renamed
because of a lack of evidence showing a vascular
origin. The best current evidence supports noci-
ceptor and autonomic nerve dysregulation as
components in all forms of nonallergic rhinitis.3-5
Clinical Characteristics
A negative result on allergy testing is one
unifying characteristic of the chronic nonallergic
rhinitis subtypes. Beyond that, clinical
characteristics help define the conditions. First,
these conditions are chronic (i.e., lasting at
least three months).
CME This clinical content conforms to AAFP criteria for
Author disclosure: No relevant financial affiliations.
or seasonal. Clinically, chronic nonallergic rhi-
nitis is characterized by its nonallergic triggers,
including weather changes, tobacco smoke,
automotive emission fumes, and irritants such
as chemicals with strong odors (e.g., perfumes,
chlorine).6,7 It also represents a group of hetero-
geneous syndromes with common underlying
clinical characteristics such as nasal congestion
and rhinorrhea, but without nasal, pharyngeal,
or ocular itching; sneezing; pulmonary symp-
toms; eczema; or nasal polyps.8,9 In contrast with
the blue-hued mucosa associated with allergy
and the red mucosa associated with rhinosinus-
itis, physical examination of the nasal mucosa is
normal with chronic nonallergic rhinitis, except
for the atrophic subtype.
Chronic nonallergic rhinitis is more common
in women, with a female-to-male ratio of 2:1 to
3:1.6,9 In a blinded survey using a validated ques-
tionnaire distributed to 100 randomly selected
new patients presenting to an allergist’s office
continuing medical education
for chronic rhinitis, (CME).
thoseSee CME
withQuizchronic
on page 149.
nonallergic rhinitis were usually older than 35
years and had no family history of allergies,
whereas patients with allergic rhinitis often were
younger than 20 years and had a family history
of allergies.10

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August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician
one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
 SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References
An intranasal corticosteroid or intranasal anti- B 5, 17, 22, 24 not help distinguish allergic from
histamine alone should be the initial treatment for nonallergic etiologies or affect man-
nonallergic rhinitis if symptoms are not rhinorrhea-
agement choices. However, iden-
predominant.
tifying eosinophils and mast cells
Combination therapy with an intranasal cortico- steroid C 5, 22-24 can help predict response to nasal
and intranasal antihistamine is better than either corticosteroids.
treatment alone.

Intranasal ipratropium should be the initial treatment for C 25, 26 ATROPHIC RHINITIS
rhinorrhea in patients with gustatory nonallergic rhinitis. Atrophic rhinitis involves atrophy
of the nasal mucosa that can lead to
An intranasal corticosteroid plus intranasal ipratro- pium B 28 nasal crusting and drying.2 This is a
is more effective than either treatment alone for noninflammatory subtype and is dis-
rhinorrhea. tinguished primarily by its unique
Decongestants may be used in the treatment of C 24 physical examination findings.
nonallergic rhinitis, but only in the short term because of
adverse effects. SENILE RHINITIS
Nasal irrigation may be used for nonallergic rhinitis. B 29 Senile or geriatric rhinitis is distin-
guished by its late onset, occuring
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For
primarily in older patients. It presents
information about the SORT evidence rating system, go to https:// as watery rhinorrhea that worsens in
www.aafp.org/afpsort. response to patient-identified triggers,
including food, odors, or environmen-
tal irritants.2

Subtypes GUSTATORY RHINITIS

Chronic nonallergic rhinitis is grouped into eight subtypes Gustatory rhinitis represents a nasal response to consuming
or clinical entities based on a 2008 consensus panel specific foods (e.g., spicy foods) or liquids (e.g., alcohol).2,7 It
classifi- cation (Table 1).2 is distinguished primarily by its trigger and often overlaps
with senile rhinitis.
NONALLERGIC RHINOPATHY
The most common subtype is nonallergic rhinopathy, pre- DRUG-INDUCED RHINITIS
viously known as vasomotor rhinitis or idiopathic nonal- Drug-induced rhinitis can occur with use of various medi-
lergic rhinitis. It is characterized by nasal symptoms that
6 cations and illicit drugs, including antihypertensives, non-
are triggered by environmental conditions such as strong steroidal anti-inflammatory drugs, phosphodiesterase-5
smells or changes in temperature, humid- inhibitors, and cocaine. Rhinitis medica-
ity, or barometric pressure, typically
11 mentosa is an example of this subtype in
TABLE 1 which the use of topical decongestants for
without nasal and palatal itching or bursts
of sneezing. longer than three to five days results in a
Subtypes of Chronic rebound nonallergic vascular congestion.
Nonallergic Rhinitis
NONALLERGIC RHINITIS WITH NASAL
EOSINOPHILIA SYNDROME Atrophic rhinitis HORMONAL RHINITIS
Nonallergic rhinitis with nasal eosino- Drug-induced rhinitis Hormonal rhinitis refers to the onset of
philia syndrome is an inflammatory type Gustatory rhinitis nasal congestion and rhinorrhea associated
of rhinitis with increased eosinophils in Hormonal rhinitis with endogenous female hormones.7 The
the secretions and on nasal biopsy, with Nonallergic rhinitis with response to the hormones of pregnancy is
increased mast cells and evidence of mast eosinophilia syndrome the most classic and common example.
cell degranulation but without positive Nonallergic rhinopathy Symp- toms resolve with the end of
findings on allergy testing.12,13 Clinically, Occupational rhinitis pregnancy.
Senile or geriatric rhinitis
testing the secretions for eosinophils
is not typically performed because the Information from reference 2.
OCCUPATIONAL RHINITIS
presence or absence of eosinophils does Occupational rhinitis is a result of occupa-
tional exposures, ranging from latex and

172 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018
 FIGURE 1

Symptoms of chronic nonallergic rhinitis

a history of cranial or facial trauma or intranasal surgery

Congestion-predominant
presenting with a persistent unilateral clear rhinorrhea that
orRhinorrhea-predominant mixed congestion and rhinorrhea
is increased with bending over.
Intranasal ipratropium
Intranasal corticosteroid or intranasal antihistamine Diagnosis
Symptoms persist
Diagnosing chronic nonallergic rhinitis can be challenging
Symptoms persist because nasal congestion and rhinorrhea can also occur
Intranasal ipratropium plus with allergic rhinitis and chronic rhinosinusitis. Nonaller-
intranasal corticosteroid Intranasal corticosteroidor intranasal antihistamine
plus intranasal antihistamine gic rhinitis was previously a diagnosis of exclusion. It was
diagnosed if a patient with suspected allergic rhinitis tested
negative for allergies on skin prick testing or antigen-
specific immunoglobulin E testing (formerly called
radioallergosor- bent testing), or if a patient had mild to no
nasal eosino- philia on nasal cytology. However, it is now
Symptoms persist
recognized that patients who experience characteristic nasal
symptoms in response to defined triggers have a nonallergic
Intranasal corticosteroid plus intranasal antihistamine plus oral decongestant component either as the sole diagnosis or as part of a mixed
All treatment involves avoiding known triggers. Consider allergy testing if symptoms persist despite therapy.
rhinitis (i.e., in patients with positive allergy test
findings).1,2,6,14 Studies suggest that as many as 34% of
rithm for the treatment of nonallergic rhinitis.
patients with chronic rhinitis may have mixed rhinitis.15
Finally, imaging may be useful in distinguishing infection
or anatomic abnormalities.

Management
flour to chemicals and particles. Symptoms typically Treatment is symptom-driven, and patients should be
worsen throughout the workweek and improve with time advised to avoid any identifiable triggers when possible
off. Deter- mining and avoiding the trigger are key to (Figure 1). Because allergic rhinitis and nonallergic rhinitis
treatment. are both initially treated with intranasal corticosteroids, it
may not be necessary to distinguish between the two diag-
OTHER noses before initiating treatment in most patients. However,
Cerebrospinal fluid leak or rhinorrhea is included in some correctly identifying and treating chronic nonallergic rhi-
lists of subtypes and should be considered in patients with nitis can decrease the use of nonsedating antihistamines
in patients who will have
poor response to treatment.
TABLE 2 Tables 2 and 3 summarize
treatments for rhinitis.16
Treatments for Nonallergic Rhinitis Based on Symptoms
INTRANASAL
Symptoms CORTICOSTEROIDS
Intranasal corticosteroids
Treatment Nasal congestion Postnasal drip Rhinorrhea Sneezing are first-line therapy for
Intranasal corticosteroids ✓ ✓ ✓ ✓ nonallergic rhinitis. An
integrated analysis of data
Intranasal antihistamines ✓ ✓ ✓ ✓ from three double-blind,
Combination intranasal corti- ✓ ✓ ✓ ✓ placebo-controlled stud-
costeroid and antihistamine ies of 983 patients demon-
strated a decrease in nasal
Intranasal anticholinergics ✓
obstruction, postnasal drip,
Decongestants ✓ and rhinorrhea with intra-
nasal fluticasone propionate
Adapted with permission from Sur DK, Plesa ML. Treatment of allergic rhinitis. Am Fam Physician. 2015; 92(11):987.
(Flonase) at doses of 200 or
400 mcg when compared

August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 173
 CHRONIC NONALLERGIC

TABLE 3

Summary of Treatments for Nonallergic Rhinitis

Pregnancy Minimum Mechanism and
Treatment category age onset of action Adverse effects

Intranasal corticostero ids

Beclomethasone C 4 years Inhibits the influx of inflamma- tory Bitter aftertaste, burning, stinging, epi-
cells; onset of action is less than 30 staxis, headache, nasal dryness, throat
Fluticasone propio- nate C 4 years minutes irritation; potential risk of systemic
(Flonase) absorption

Intranasal antihistamines
Azelastine 0.1% C 5 years Anti-inflammatory effects, onset Bitter aftertaste, epistaxis, headache,
of action is 15 to 30 minutes nasal irritation, sedation

Combination intranasal corticosteroid and intranasal antihistamine

Azelastine/fluticasoneC propionate (Dymista)12 years See separate treatments See separate treatments

Intranasal anticholiner gics

Ipratropium B 5 years Blocks acetylcholine receptors; onset Epistaxis, headache, nasal dryness
of action is 15 minutes

Oral decongestants
Phenylephrine C 4 years Vasoconstriction; onset of Arrhythmias, hypertension, insomnia,
Pseudoephedrine C 4 years action is 15 to 30 minutes nervousness

Intranasal decongestants
Oxymetazoline (Afrin)C PhenylephrineC 6 yearsVasoconstriction; onset of 2 yearsaction is within 10 minutes
Rhinitis medicamentosa with long- term use

Adapted with permission from Sur DK, Plesa ML. Treatment of allergic rhinitis. Am Fam Physician. 2015;92(11):988-989.

with placebo, although there was no difference in symptom
reduction between the two dosages.17 However, one study
did not demonstrate a symptomatic benefit for nonallergic
rhinitis, except for a reduction in sneezing, with 200 mcg of
fluticasone propionate once or twice daily.18
Subgroups of patients with nonallergic rhinitis may not
respond to intranasal corticosteroids, such as those with
symptoms triggered predominantly by weather and tem-
perature changes.5 Currently, fluticasone propionate and
beclomethasone are the only intranasal corticosteroids
approved by the U.S. Food and Drug Administration (FDA)
for the treatment of nonallergic rhinitis, although studies
suggest other intranasal corticosteroids, including flunisol-
ide, are effective for perennial rhinitis.19
ANTIHISTAMINES
Intranasal antihistamines are effective for nonallergic rhi-
nitis, likely because of their actions as anti-inflammatory
and neuroinflammatory blockers.20 Azelastine and olopa-
tadine (Patanol) are available in the United States, but only
azelastine is FDA approved for the treatment of chronic
nonallergic rhinitis. Azelastine is the best studied of the two
drugs, and randomized, double-blind, placebo-controlled
trials have demonstrated its effectiveness, with significant
improvement in nasal congestion, rhinorrhea, postnasal
drip, and sneezing. Bitter aftertaste was the most common
adverse effect of azelastine.20 A 14-day, multicenter,
randomized, par- allel study comparing azelastine 0.1% with
olopatadine found no statistically significant difference
between the two drugs in improving congestion, rhinorrhea,
postnasal drip, and sneezing, and there was no difference in
adverse effects.21
Oral antihistamines are not as well studied and have not
been shown to be as effective for symptoms of nonaller-
gic rhinitis compared with allergic rhinitis. One placebo-
controlled study comparing flunisolide with a combination
of flunisolide and loratadine (Claritin) found that the com-
bination is superior to flunisolide alone in reducing
sneezing and rhinorrhea in patients who have nonallergic
rhinitis with nasal eosinophilia syndrome.22 First-generation
oral anti- histamines are likely more effective than second-
generation
174 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018
 CHRONIC
CHRONIC NONALLERGIC
NONALLERGIC RHINITIS
antihistamines, but this must be weighed against their more
clinically significant anticholinergic adverse effects, includ-
ing sedation, urinary retention, and dry mouth.
COMBINATION THERAPY
Although there is more evidence for using intranasal cor-
ticosteroids combined with intranasal antihistamines to
treat allergic rhinitis, this combination is also beneficial
in patients with nonallergic rhinitis whose symptoms are
not adequately controlled with either therapy alone. Intra-
nasal corticosteroids and intranasal antihistamines can be
administered as individual nasal sprays or as a combination
nasal spray (azelastine/fluticasone propionate [Dymista])
twice daily. A post hoc analysis of a one-year, random-
ized, open-label, active-controlled, parallel study in 612
patients with perennial allergic rhinitis or nonallergic rhi-
nitis showed the combination of fluticasone propionate and
azelastine is effective in the treatment of both conditions. 23
The combination may be considered if monotherapy does
not adequately control symptoms.1,5,6,24
INTRANASAL ANTICHOLINERGICS
Intranasal ipratropium has been proven effective in decreas-
ing rhinorrhea and is a reasonable monotherapy for patients
who have rhinorrhea as a predominant symptom, particu-
larly those with gustatory nonallergic rhinitis or weather-
induced nonallergic rhinitis, such as skiers and joggers. 25-27
Although intranasal ipratropium is available in 0.03% and
0.06% concentrations, only 0.03% is FDA approved for the
treatment of nonallergic rhinitis. Intranasal ipratropium
is typically administered as one or two sprays two or three
times per day, although it can be used as needed or one
hour before exposures that cause rhinorrhea. A double-
blind, multicenter, randomized, active- and placebo-
controlled, parallel study of more than 500 patients
comparing beclo- methasone alone, ipratropium alone, and
the two therapies combined showed that combination
therapy had a superior effect on rhinorrhea compared with
either therapy alone. Beclomethasone alone controlled
sneezing and congestion more effectively than ipratropium
alone.28
DECONGESTANTS
Decongestants effectively manage congestion regard-
less of etiology. However, they have not been studied in
the treatment of nonallergic rhinitis. Oral decongestants
(pseudoephedrine and phenylephrine) have been proven
effective for congestion related to allergic rhinitis, but their
adverse effect profiles must be weighed against their ben-
efits. Intranasal decongestants (oxymetazoline [Afrin] and
phenylephrine) are more potent and rapid acting. They
should be considered for short-term use only to avoid
August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp
rhinitis medicamentosa or rebound congestion with con-
tinued nasal decongestant use.24
OTHER THERAPIES
Nasal irrigation with saline or hypertonic saline may be
helpful in the treatment of nonallergic rhinitis. A Cochrane
review concluded that daily large-volume (more than
150 mL) hypertonic saline irrigations may be more effec-
tive than placebo.29 In addition to nasal irrigation, intrana-
sal capsaicin may be beneficial, but adverse effects such as
irritation, burning, sneezing, and coughing limit its use.30,31
Further investigation is needed for irrigation and intranasal
capsaicin in the treatment of nonallergic rhinitis. Surgery
is an option for select patients whose symptoms are not
adequately controlled with traditional therapies and may
be most effective in patients with significant obstructive
symptoms.1,2,5,6,24
This article updates previous articles on this topic by Wheeler and
Wheeler,32 and Quillen and Feller.33
Data Sources: Searches were performed in PubMed, the Cochrane
database, and Essential Evidence Plus. Key words included nonallergic
rhinitis, vasomotor rhinitis, and non-allergic rhinitis. Search dates:
December 12, 2016, to January 30, 2017.
The Authors
DENISE K.C. SUR, MD, is a clinical professor and vice chair in the Department of
MONICA L. PLESA, MD, is an assistant clinical professor in the Department of Fam
Address correspondence to Denise K.C. Sur, MD, UCLA Medi- cal Center, Sa
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Volume 98, Number 3 ◆ August 1, 2018
 CHRONIC NONALLERGIC

RINITIS NONALERGI KRONIS

Denise KC Sur, MD, dan Monica L. Plesa, MD

Sekolah Kedokteran David Geffen di Universitas California, Los Angeles, California

Rinitis nonalergi kronis mencakup sekelompok subtipe rinitis yang tidak

RINITIS NONALERGI
disebabkan oleh adanya KRONIS
pemicu mencakup
alergi atausekelompok subtipe
infeksi. Rinitis rinitis yang
nonalergi
kronis
tidak mewakili
disebabkan sekitar
oleh adanya seperempat kasusatau
pemicu alergi rinitis dan berdampak
infeksi. pada 20kronis
Rinitis nonalergi
hingga 30 juta pasien di Amerika Serikat dengan patofisiologi yang pasti
mewakili setidaknya 23% kasus rinitis di Amerika Serikat dan berdampak pada
belum diketahui dan uji diagnostik tidak tersedia. Karakteristik seperti,
sekitar 20 hingga
tidak 30 juta
ada bukti pasien,alergi
pemicu namunatau
patofisiologi
lainnya yang yangpasti belum diketahui.
ditentukan akan
1,2

membantu
Rinitis nonalergimenentukan subtipe disebut
kronis sebelumnya klinis. sebagai
Ada delapan subtipe dengan
rinitis vasomotor atau rinitis
presentasi klinis yang tumpang tindih, diantaranya rinopati nonalergi,
vasomotor nonalergi, tetapi diganti namanya karena kurangnya bukti yang
rinitis nonalergi dengan sindrom eosinofilia nasal, rinitis atrofi, rinitis
menunjukkan
senilis atauvascular origin. gustatory,
geriatri, riinitis Saat ini, riinitis
beberapayanghipotesis telah
diinduksi obat,dikemukakan
riinitis
hormonal,
untuk dan riinitis
menerangkan occupational. Pengobatan
keterlibatannya dalam semua rinitissubtipe
nonalergi diberikan
rinitis nonalergi
berdasarkan gejala. Pasien harus menghindari pemicu yang diketahui bila
diantaranya disregulasi nosiseptor dan saraf otonom. 3-5
memungkinkan. Terapi lini pertama diantaranya kortikosteroid intranasal,
antihistamin intranasal, dan ipratropium intranasal. Terapi kombinasi
dengan dekongestan dan antihistamin 1
generasi pertama dapat
dipertimbangkan jika monoterapi tidak cukup mengontrol gejala. Irigasi
hidung dan capsaicin intranasal dapat membantu namun perlu penelitian
lebih lanjut. ( Am Fam Physician. 2018;98(3):171-176. Hak Cipta © 2018
American Academy of Family Physicians.)
 2

KARAKTERISTIK KLINIS
Rinitis nonalergi kronis memiliki karakteristik salah satunya adalah hasil
negatif pada tes alergi. Kemudian, karakteristik klinis juga membantu menentukan
kondisi seperti kondisi kronis (yaitu, berlangsung setidaknya tiga bulan), bisa
perennial/sepanjang tahun, persisten/menetap, intermiten/kadang-kadang, atau
seasonal/musiman. Secara klinis, rhinitis nonalergi kronis ditandai oleh pemicu
nonalerginya, termasuk perubahan cuaca, asap tembakau, asap emisi otomotif, dan
iritan seperti bahan kimia dengan bau yang kuat (misalnya, parfum, klorin). 6,7 Rinitis
nonalergi kronis juga mewakili sekelompok sindrom heterogen dengan karakteristik
klinis umum yang mendasari seperti hidung tersumbat dan rhinore, tetapi tanpa gatal
hidung, faring, atau mata; bersin; gejala paru; eksim; atau polip hidung.8,9 Pada
kasus alergi mukosa hidung bewarna kebiruan, rinosinusitis mukosa hidung bewarna
merah/hiperemis, sedangkan pada rinitis nonalergi kronis (kecuali untuk subtipe
atrofi) mukosa hidung normal bwarna merah muda.
Rinitis nonalergi kronis lebih sering terjadi pada wanita, dengan rasio wanita-
pria 2:1 hingga 3:1.6,9 Dalam survei menggunakan kuesioner tervalidasi yang
didistribusikan ke 100 pasien baru yang dipilih secara acak yang datang ke
departemen ahli alergi untuk rinitis kronis, pasien yang menderita rinitis nonalergi
kronis biasanya berusia lebih dari 35 tahun dan tidak memiliki riwayat alergi dalam
keluarga, sedangkan pasien dengan rinitis alergi sering lebih muda dari 20 tahun
dan memiliki riwayat alergi dalam keluarga.10
 3

REKOMENDASI UTAMA
Rekomendasi Klinis Evidence rating Referensi

Kortikosteroid intranasal atau

antihistamin intranasal saja harus
B 5,17,22,24
menjadi pengobatan awal untuk rinitis
nonalergi jika gejalanya tidak
dominan rinorea.
Terapi kombinasi dengan kortikosteroid
intranasal dan antihistamin intranasal C 5,22,24
lebih baik dari pada monoterapi.
Ipratropium intranasal harus menjadi
C 25,26
pengobatan awal untuk rinore pada pasien
dengan rinitis gustatory.

Kortikosteroid intranasal ditambah

ipratropium intranasal lebih efektif B 28
untuk rinorea dari pada hanya
menggunakan salah satu.
Dekongestan dapat digunakan dalam
pengobatan rinitis nonalergi, tetapi C 24
hanya dalam jangka pendek karena efek
sampingnya.
Irigasi hidung dapat dilakukan pada B 29
rinitis nonalergi.

A = bukti berorientasi pasien yang konsisten dan berkualitas baik; B = bukti

berorientasi pasien yang tidak konsisten atau berkualitas terbatas; C = konsensus,
bukti berorientasi penyakit, praktik biasa, pendapat pakar, kasus
 4

SUBTIPE / ENTITAS KLINIS BERDASARKAN KLASIFIKASI

KONSENSUS

Rinitis nonalergi kronis dikelompokkan menjadi delapan subtipe atau entitas

klinis berdasarkan klasifikasi konsensus 2008 (Tabel1).2

TABEL 1

SUBTIPE RINITIS KRONIK NONALERGI

Rinitis Atrofi
Rinitis yang diinduksi obat
Rinitis Gustatory
Rinitis Hormonal
Rinitis Nonalergi dengn Sindrom Eosinofilia Nasal
Rinopati Nonalergi
Rinitis Occupational
Rinitis Sinile/ Geriatri
Informasi dari referensi 2

Rinopati Nonalergi
Rinopati nonalergi merupakan subtipe yang paling umum, sebelumnya dikenal
sebagai rinitis vasomotor atau rinitis nonalergi idiopatik. 6 Hal ini ditandai dengan
gejala yang dipicu oleh kondisi lingkungan seperti bau kuat/menyengat atau
perubahan suhu, kelembaban, atau tekanan udara, 11 biasanya tanpa gatal pada hidung
dan palatal atau bersin.
 5

Rinitis Nonalergi dengan Sindrom Eosinofilia Nasal

Rinitis nonalergi dengan sindrom eosinofilia nasal adalah jenis rinitis subtipe
inflamasi, dimana terjadi peningkatan eosinofil dan peningkatan sel mast dengan
degranulasi sel mast pada pemeriksaan darah tepi dan sitologi hidung, tanpa temuan
positif pada tes alergi.12,13 Secara klinis, hitung eosinofil dalam darah tepi biasanya
tidak dilakukan karena ada atau tidak adanya eosinofil tidak membantu membedakan
alergi atau nonalergi dan juga tidak mempengaruhi pilihan terapi. Namun,
mengidentifikasi eosinofil dan sel mast dapat membantu memprediksi respons
terhadap kortikosteroid nasal.

Rinitis Atrofi
Rinitis atrofi adalah jenis rinitis subtipe noninflamasi yang ditandai adanya
atrofi progresif mukosa dan tulang konka. Secara klinis, mukosa hidung
menghasilkan sekret yang kental dan cepat mengering sehingga terbentuk krusta yang
berbau busuk.2 Ini adalah subtipe noninflamasi dan dibedakan terutama oleh temuan
pemeriksaan fisiknya yang unik.

Rinitis Senile
Rinitis senile/geriatri dibedakan oleh onsetnya yang lambat, terutama terjadi
pada pasien yang lebih tua. Gejala muncul sebagai rinore yang memberat, hal ini
sebagai respons terhadap pemicu yang diidentifikasi pasien diantaranya makanan,
bau, atau iritasi lingkungan.

Rinits Gustatory
Rinitis gustatory merupakan respon hidung terhadap pemicu seperti
mengkonsumsi makanan tertentu (misalnya, makanan pedas) atau cairan (misalnya,
alkohol).2,7 Rinitis gustatory dibedakan terutama oleh pemicunya dan sering tumpang
tindih dengan rinitis senilis.
 6

Rinitis yang diinduksi obat

Rinitis yang diinduksi obat dapat terjadi akibat penggunaan berbagai obat-
obatan dan obat-obatan terlarang diantaranya obat antihipertensi, obat antiinflamasi
nonsteroid, fosfodiesterase inhibitor, dan kokain. Rinitis medikamentosa adalah
contoh dari subtipe ini di mana penggunaan dekongestan topikal selama lebih dari
tiga sampai lima hari menghasilkan rebound congestion.

Rinitis Hormonal
Rinitis hormonal mengacu pada timbulnya hidung tersumbat dan rinorea yang
berhubungan dengan hormon endogen pada wanita.7 Respon terhadap hormon
kehamilan adalah contoh yang paling klasik dan umum. Gejala hilang pada akhir
kehamilan.

Rinitis Occupational
Rinitis occupational adalah rinitis yang timbul akibat dari pajanan kerja,
mulai dari lateks, bahan kimia dan partikel. Gejala biasanya memburuk sepanjang
minggu saat bekerja dan membaik pada waktu istirahat. Kunci pengobatan adalah
menentukan dan menghindari pemicu.

Lainnya
Kebocoran cairan serebrospinal atau rinorea termasuk dalam beberapa daftar
subtipe dan harus dipertimbangkan pada pasien dengan riwayat trauma kepala atau
wajah atau operasi intranasal yang disertai dengan rinorea jernih unilateral persisten
yang meningkat dengan membungkuk.

DIAGNOSIS
Mendiagnosis rinitis nonalergi kronis dapat menjadi tantangan karena hidung
tersumbat dan rinorea juga dapat terjadi pada rinitis alergi dan rinosinusitis kronis.
Rinitis nonalergi sebelumnya merupakan diagnosis eksklusi, didiagnosis dengan
rinitis nonalergi jika pasien dengan dugaan rinitis alergi pada tes alergi skinprick test
 7

atau tes imunoglobulin E spesifik antigen (sebelumnya disebut tes

radioallergosorbent) hasilnya negatif, peningkatan eosinofil ringan hingga tidak ada
peningkatan eosinofil dalam darah tepi atau sitologi nasal. Namun, saat ini diketahui
bahwa pasien yang mengalami gejala nasal yang khas sebagai respons terhadap
pemicu yang diketahui memiliki komponen nonalergi, maka akan didiagnosis baik
sebagai diagnosis tunggal atau sebagai bagian dari rinitis campuran (yaitu, pada
pasien dengan temuan tes alergi positif). 1,2,6,14
Studi menunjukkan bahwa sebanyak
34% pasien dengan rinitis kronis mungkin menderita rinitis campuran. 15
Oleh karena
itu, pencitraan mungkin berguna dalam membedakan infeksi atau kelainan anatomi.

PENATALAKSANAAN
Penatalaksanaan diberikan berdasarkan pada gejala dan pasien harus diedukasi
untuk menghindari pemicu yang dapat diidentifikasi jika memungkinkan (Gambar 1).
Karena rinitis alergi dan rinitis nonalergi terapi lini pertamanya kortikosteroid
intranasal, sehingga sebelum memulai pengobatan pada sebagian besar pasien tidak
perlu membedakan diagnosis antara keduanya. Namun, apabila pengidentifikasian
dan pengobatan rinitis dilakukan dengan benar, dapat mengurangi penggunaan
antihistamin nonsedasi pada pasien yang akan memiliki respon yang buruk terhadap
terapi. Pada Tabel 2 dan 3 merupaka ringkaskan tatalaksana untuk rinitis.
 8

TABEL 2
TATALAKSANA RHINITIS NONALERGI BERDASARKAN GEJALA
Gejala
Terapi Kongesti Postnasal
Rinorea Bersin
nasal drip
Kortikosteroid intranasal V v v v
Antihistamin intranasal V v v v
Kombinasi kortkostreroid
V v v v
intranasal dan
antihistamin
Antikolinergik intranasal v
Dekongestan V
Adapted with permission from Sur DK, Plesa ML. Treatment of allergic rhinitis. Am
Fam Physician. 2015; 92(11): 987.
 9

TABEL 3
Ringkasan Tatalaksana untuk Rhinitis Non-Alergi
Kategori Usia Mekanisme dan
Terapi Efek Samping
Kehamilan Minimum Onset Kerja
Kortikosteroid Intranasal
Beclomethason C 4 tahun Rasa pahit, rasa
Menghambat inlamasi terbakar, epistaksis,
sel; onset kerja <30 sakit kepala, hidung
Fluticasone propionate
C 4 tahun menit kering, iritasi
(Flonase)
tenggorokan, resiko
absorbsi sistemik
Antihistmin Intranasal
Rasa pahit,
Efek antiinflamasi,
Azelastine 0,1% C 5 tahun epistaksis, sakit
onset kerja 15-30
kepala, iritasi
menit
nasal, sedasi
Kombinasi Kortikosteroid Intranasal dan Antihistamin
Lihat secara terpisah
Lihat secara terpisah
Azelastine/fluticasone masing-masing
C 12 tahun masing-masing efek
propionate (Dymista) mekanisme dan onset
samping obat
kerja obat
Intranasal Antikolinergik
Blokade reseptor Epistaksis, sakit
Ipratropium B 5 tahun
acetylcholine kepala, hidung kering
Dekongestan Oral
Phenylephrine C 4 tahun Vasokonstriksi, onset Aritmia, hipertensi,
Pseudoephedrine C 4 tahun kerja 15-30 menit insomnia, gugup
Dekongestan Intranasal
Oxymetazoline C 6 tahun Rhinitis
Vasokonstriksi, onset medikamentosa
Phenylephrine C 2 tahun kerja 10 menit dengan pengunaan
jangka panjang
 1

Kortikosteroid Intranasal
Kortikosteroid intranasal adalah terapi lini pertama untuk rinitis nonalergi. Pada
Studi double blind dengan analisis data terintegrasi terkontrol plasebo, dari 983
pasien menunjukkan penurunan obstruksi nasal, postnasal drip, dan rinore dengan
fluticasone propionate (flonase) intranasal pada dosis 200 atau 400 mcg bila
dibandingkan dengan plasebo, meskipun tidak ada perbedaan dalam pengurangan
gejala antara kedua dosis.17 Namun, dalam penelitian lain tidak menunjukkan manfaat
simtomatik untuk rinitis nonalergi, kecuali untuk pengurangan bersin dengan 200
mcg fluticason propionat sekali atau dua kali sehari. 18
Pasien dengan rinitis nonalergi
mungkin tidak berespons terhadap kortikosteroid intranasal, seperti pada pasien yang
gejalanya dipicu terutama oleh perubahan cuaca dan suhu.5 Saat ini, fluticasone
propionate dan beclomethasone adalah satu-satunya kortikosteroid intranasal yang
disetujui oleh Food and Drug Administration (FDA) Amerika Serikat untuk terapi
rinitis nonalergi, meskipun penelitian menunjukkan kortikosteroid intranasal lainnya,
termasuk flunisoide, efektif untuk rinitis perennial/sepanjang tahun. 19

Antihistamin
Antihistamin intranasal efektif untuk rinitis nonalergi, karena aksinya sebagai
antiinflamasi dan neuroinflamasi blokcers.20 Di Amerika Serikat, tersedia azelastine
dan olopatadine (Patanol), tetapi hanya azelastine yang disetujui FDA untuk
pengobatan rinitis nonalergi kronis. Setelah dilakukan uji coba terkontrol plasebo
azelastine telah menunjukkan efektivitasnya, dengan perbaikan yang signifikan
hidung tersumbat, rinorea, postnasal drip, dan bersin. Efek samping yang paling
umum dari azelastine adalah sisa rasa pahit.20 Pada studi paralel yang dilakukan
selama 14 hari untuk membandingkan azelastine 0,1% dengan olopatadine,
didapatkan hasil yaitu tidak ada perbedaan yang signifikan secara statistik antara
kedua obat dalam meningkatkan kongesti nasal, rinorea, postnasal drip, bersin, dan
tidak ada perbedaan dalam efek samping.21 Antihistamin oral belum terbukti efektif
untuk gejala rinitis nonalergi dibandingkan dengan rinitis alergi. Pada studi terkontrol
 1

plasebo membandingkan flunisolide dengan kombinasi flunisolide dan loratadine

(Claritin) menemukan bahwa kombinasi lebih unggul dari pada flunisolide saja dalam
mengurangi bersin dan rinore pada pasien yang memiliki rinitis nonalergi dengan
sindrom eosinofilia nasal.22 Antihistamin oral generasi pertama kemungkinan lebih
efektif dari pada antihistamin generasi kedua, tetapi ini harus dipertimbangkan
terhadap efek samping antikolinergik yang lebih signifikan secara klinis, termasuk
sedasi, retensi urin, dan mulut kering.

Terapi Kombinasi
Penggunaan kortikosteroid intranasal yang dikombinasikan dengan
antihistamin intranasal efektif untuk mengobati rinitis alergi, kombinasi ini juga
bermanfaat pada pasien dengan rinitis nonalergi yang gejalanya tidak cukup
terkontrol dengan salah satu terapi saja. Kortikosteroid intranasal dan antihistamin
intranasal dapat diberikan sebagai semprotan hidung/nasal spray atau sebagai
kombinasi semprotan hidung/nasal spray (azelastine/ fluticasone propionate
(Dymista]) dua kali sehari. Pada studi paralel dengan analisis post hoc terkontrol
aktif, pada 612 pasien dengan rinitis alergi perennial/sepanjang tahun atau rinitis
nonalergi menunjukkan kombinasi fluticason propionat dan azelastine efektif dalam
pengobatan kedua kondisi ini. 23
Kombinasi dapat dipertimbangkan jika monoterapi
tidak cukup untuk mengontrol gejala. 1,5,6,24

Antikolinergik Intranasal
Ipratropium intranasal telah terbukti efektif dalam mengurangi rinore dan
merupakan monoterapi yang baik untuk pasien yang memiliki rinore sebagai gejala
utama, terutama mereka dengan rhinitis nonalergi gustatory atau rinitis nonalergi
yang disebabkan oleh cuaca, seperti pemain ski dan jogging.25-27 Ipratropium
intranasal tersedia dalam 0,03% dan konsentrasi 0,06%, tetapi hanya ipratropium
intranasal 0,03% yang disetujui FDA untuk pengobatan rinitis nonalergi. Ipratropium
intranasal biasanya diberikan sebanyak satu atau dua semprotan untuk dua atau tiga
 1

kali sehari, meskipun dapat digunakan sesuai kebutuhan atau satu jam sebelum
paparan yang menyebabkan rinorea. Pada studi paralel double-blind, multicenter
terkontrol plasebo, lebih dari 500 pasien membandingkan beclomethasone saja,
ipratropium saja, dan dua terapi gabungan menunjukkan bahwa terapi kombinasi
memiliki efek superior pada rhinorrhea dibandingkan monoterapi. Beclomethasone
mengendalikan bersin dan kongesti lebih efektif daripada ipratropium saja. 28

Dekongestan
Dekongestan efektif mengelola kongesti nasal terlepas dari etiologinya.
Dekongestan oral (pseudoefedrin dan fenilefrin) telah terbukti efektif untuk kongesti
yang berhubungan dengan rinitis alergi, tetapi profil efek sampingnya harus
dipertimbangkan terhadap manfaatnya. Dekongestan intranasal (oxymetazoline
[Afrin] dan phenylephrine) lebih poten dan bekerja cepat. Namun, harus
dipertimbangkan untuk penggunaan jangka pendek hanya untuk menghindari rinitis
medikamentosa atau rebound congestion dengan penggunaan dekongestan nasal yang
berkelanjutan. 24

Terapi Lainnya
Irigasi hidung dengan saline atau saline hipertonik dapat membantu dalam
pengobatan rinitis nonalergi. Sebuah penelitian oleh Cochrane menyimpulkan bahwa
volume besar harian (lebih dari 150 mL) irigasi salin hipertonik mungkin lebih efektif
dari pada plasebo.29 Selain irigasi hidung, capsaicin intranasal mungkin bermanfaat,
tetapi efek samping seperti iritasi, rasa terbakar, bersin, dan batuk membatasi
penggunaannya. 30,31
Penyelidikan lebih lanjut diperlukan untuk irigasi dan capsaicin intranasal
dalam pengobatan rinitis nonalergi. Pembedahan adalah pilihan untuk pasien tertentu
yang gejalanya tidak cukup terkontrol dengan terapi tradisional dan mungkin paling
efektif pada pasien dengan obstruktif yang menunjukkan gejala signifikan. 1,2,5,6,24
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