Neurogenic Rhinitis: The Missing Piece in Rhinitis

追加: 2026-05-31

[00:00:02]The Rhinology Room, conversations beyond guidelines. [music] Hello, doctor. Hello.

[00:00:12]>> You forget your phone. [laughter] Oh, thank you. Oh, okay.

[00:00:15]>> Very kind of you.

[00:00:15]>> That's my script.

[00:00:17]>> [laughter] >> Welcome [clears throat] to the Rhinology Room. Welcome. Okay. Today we're going to talk about a missing piece in rhinitis, right?

[00:00:25]>> What is What is it?

[00:00:27]What do you think it is?

[00:00:28]>> when the patients come to us Mhm.

[00:00:31]saying that they have blocked nose, >> Mhm. they have runny nose, and you know, one one thing is when we see their noses >> Yeah.

[00:00:40]we notice that it's quite congested nose, and we think that well, it's severely inflamed, but you know, many of them do not have inflammations. Right.

[00:00:53]>> It's a neurogenic pathway, which is the missing piece Yes. to mention. So, I think the neurogenic pathway in the um nose is actually under underestimated the impact that it has on the symptoms of the nose, right? Yeah.

[00:01:11]So, what is it? The neural pathway, why is it so important? One thing is most of the times the patient may say to you >> Yeah. that it's very bad when they exposed to the air con, >> Yeah. when it's raining, the weather change. This is not allergen at all.

[00:01:28]>> Yeah. Or especially when the air quality is quite poor, >> Yeah. and then they show their mobile phone that are showing that the elevated concentration of particulate matters.

[00:01:40]>> Right. And they say that the symptoms are worsening.

[00:01:44]This is not allergen, right?

[00:01:45]>> Right. Yeah. So, you think a lot of people still understand that they have allergic rhinitis when actually they don't have it. It's a totally different entire entity, right? Actually.

[00:01:54]>> actually.

[00:01:55]>> Yeah, it's very common. So, do you experience the same? I experience the same thing. So, I think um most patients are very um they they they just they just think they have allergic rhinitis.

[00:02:06]Yeah, yeah, interesting. Because you say rhinitis. What what is the meaning of rhinitis? True. I think the the term itself is already misleading for this kind of patient because the term rhinitis is actually inflammation, right?

[00:02:18]>> Of the nasal mucosa.

[00:02:20]>> Of the nasal mucosa. But when patients are suffering from non-allergic rhinitis, it's actually not inflammation, right? And also the neurogenic neuritis is not inflammation.

[00:02:29]>> rhinitis?

[00:02:30]>> Yes, yes. So, I think the term itself already misleads a lot of us. Right.

[00:02:35]>> Yeah. Right. Mhm. And uh when the the doctors consider inflammation, they give anti-inflammatory agent, right?

[00:02:43]>> Right. Right. Steroids. Steroids. Mhm.

[00:02:46]Uh-huh.

[00:02:46]And uh the patients are wondering they They don't get better. Right. Right.

[00:02:51]>> Yeah.

[00:02:52]So, I think there's going to be a some patient who get better because sometimes they have actually have non-allergic rhinitis, too. But there'll be a group of patient who doesn't respond to the medication or maybe respond not well enough. And then that like um that um little um remaining symptom that's still bothering them Right. is coming from neurogenic.

[00:03:17]Mhm. Yeah. This is very good point. Mhm.

[00:03:20]One thing is, you know, all patients Yeah.

[00:03:23]>> have nerve. Yes. Yes. Everyone have nerve. They have vessels.

[00:03:27]>> Yeah.

[00:03:28]>> They have glands.

[00:03:29]>> Right. Right? And uh they also have immune, right?

[00:03:33]>> Yeah. Mhm. So, um we should think all together, right?

[00:03:37]>> Yes. Um even the patient who have allergy test positive, Mhm. they also have the nerve, right?

[00:03:43]>> Yes. They they also have parasympathetic, sympathetic, right? And uh one thing is the 1/3 of the patient have mixed allergic rhinitis and Yeah, non-allergic rhinitis.

[00:03:58]So, can I put it this way?

[00:04:00]So, nerve is always there like as a baseline, right? It's It's parasympathetic and sympathetic and sensory nerve.

[00:04:07]>> Yeah.

[00:04:08]And both type of allergic or non-allergic they all have the same neural pathway.

[00:04:14]Yeah. So, I think under the same umbrella of rhinitis, they all have some kind of neurogenic pathway. Either they experience a lot or not a lot or not at all, right? Quite similar to when you look at the nose when the patient have nasal obstruction >> Yeah.

[00:04:31]and [clears throat] you you assess the nasal symptoms >> Yep. you may observe nasal septum deviation but actually for the airway, you should consider inferior turbinate.

[00:04:40]Yeah. You should consider lateral nasal wall all together about the the nasal airway. Yeah, nasal pathway.

[00:04:49]And then when you want to correct the nasal airway or upper airway remodeling Yeah.

[00:04:56]>> you should think about all structures.

[00:04:59]So, when patient have rhinitis congested nose, you should think about allergies, sympathetic, parasympathetic, and sensory nerve and neural markers.

[00:05:10]>> Yeah, true. That's very correct. So, when you So, when we see the endoscope and then we think like it's all it's like no edematous, clear watery discharge, very inflamed.

[00:05:21]Usually we should We always say it's so inflamed. And the word inflamed cells is already like a myth in some case, Yes, really it's a myth. Yeah. So, some people don't have inflammation at all.

[00:05:34]>> You assess the histopathology, there's no inflammatory cell. Yeah. Oh, we have a guest. He wants to come in and get something.

[00:05:41]>> [laughter] >> Hello.

[00:05:45]Um Go get it.

[00:05:46]>> [laughter] >> Okay, where are we?

[00:05:50]They do not respond well to corticosteroids.

[00:05:54]Um but one thing is even the patient who have allergic test positive, they also have nerve. And when the patient have allergy negative >> Mhm. Um you know the doctors start to think that we cannot identify the allergens.

[00:06:09]>> Mhm. But they do not think about the neurogenic part. Yeah. So Yeah, so Actually, there's a receptor. Yeah. That for examples, when we exposed to particulate matters >> Yes. they can trigger Mhm. the trip V1 >> Yes. uh and trip M8 and >> a lot of things and then it can causes vasodilation.

[00:06:40]>> Yeah. It can uh causes rhinorrhea by stimulating the mucosal gland and serous glands.

[00:06:48]>> Yeah.

[00:06:49]I think one thing that the way I want to teach my student is that don't try to um memorize the symptoms. Try to understand the pathophysiology behind it. So just like you said the nerve innovates glands >> Right. and glands secrete secretion >> Yes. causing rhinorrhea. Mhm. And nerve also go to the vessels and also make it vasodilatation. That cause the turbinate to enlarge, right? Right. Yeah.

[00:07:13]>> And some guidelines just mentioned that if the patient have nasal obstruction, you give decongestant.

[00:07:20]>> Yeah. If the patient have rhinorrhea they give antihistamines.

[00:07:25]Uh if it's severely congested, then they give intranasal steroids.

[00:07:29]>> Yeah.

[00:07:30]But uh you know do you never think about the real >> Yeah. Yeah.

[00:07:34]>> It's like you see the tip of the iceberg, but you don't know what's um underneath it. So I think the way we should um really look at a patient is that you see the tip, but you also have to understand what's driving the tip to the top, right?

[00:07:49]>> unseen part. Yeah, I think it should be a reinforced um, all the students or you know, a um, physician to >> Otherwise, you become a symptomatologist, not a rhinologist.

[00:08:01]Okay, symptoma- symptoma- Symptomatologist.

[00:08:04]>> Symptomatologist.

[00:08:06]So, if I'm I'm saying right? Yes.

[00:08:08]Symptomatologist, okay. That's not similar word for me.

[00:08:11]Not us. Okay. In your clinic, when you see a patient who might be suffering from neurogenic pathway, how do you how do you tell them? How do you educate them? Because I think first of all, I think they will not be familiar at all of the word neurogenic pathway or even like what's the matter?

[00:08:29]What's the What? I've never heard of it before. I I've been told my whole life I have allergy, allergic rhinitis, and then one day, boom, you're not allergic rhinitis.

[00:08:38]I think for me, in my experience, it's quite challenging because when I see a lot of patients coming in with the same diagnosis of allergic rhinitis, and then one day I have to break the news that, "Oh, I don't think you have allergic rhinitis. So, I've got to switch your medication." And they were like very alarmed, but like, "No, I've been having this antihistamine my whole life. Like, you're not going to withdraw like my medication." Yeah, I think sometimes it's not easy. So, how should we approach or tell our patients?

[00:09:08]Um, interesting. Um, actually, when I speak to to my patient, I also say about neurogenic pathway, but I agree with you that it's not easy to understand.

[00:09:19]But, we need to explain more. What what is it? And I will say, um, with it's not allergen. Yeah. Uh, particulate matters.

[00:09:31]Uh, okay, uh, one word that is quite simple and easy is irritant. Yeah.

[00:09:37]Right? They understand irritant. Yeah.

[00:09:40]>> Yeah. Mhm. So, irritant is a cause of your um symptoms. Yeah. After you ask your patients what activate the symptoms.

[00:09:50]>> Yeah. So, it's very important to ask what triggers your symptoms. They're like at most important because otherwise you get lost, right?

[00:09:55]>> Right.

[00:09:55]>> So, what do you usually what what do you usually ask your patient?

[00:09:59]>> Especially when the allergy test is positive. But uh they say that they their symptoms are activated by weather, yeah, smoking.

[00:10:09]>> very Tobacco.

[00:10:10]>> Yeah. Yeah, yeah. Um so so uh actually it's not activated by the allergen. And then you say that they are sensitized by the allergen. They're not allergic to that particular allergen, right? I think this patient can be quite challenging, you know why? Because when allergy test is completed, for example, in Thailand like house dust mite is like, you know, like allergy to like almost all allergy patients. But when they say to us, they never mention about having the symptoms indoor. They say it when they go out or when they like, you know, season change, um humidity change, temp change, you know? And they experience this like congestion like um watery rhinorrhea like profuse and then it stop with the when like, you know, like the weather become stable during the day. Yeah. And and then we start thinking, "Oh, but I mean she have like allergy test positive. Like you should have you should get you should give them intranasal corticosteroid.

[00:11:05]>> Yeah. It should be like the, you know, the best medication for them." So, this I think this group of patient kind of tricky because if you really deep dig down like, you know, you going to know that they're not really allergic to the house dust mite. So, I think we have to ask more. Yes.

[00:11:20]>> What are the triggers? And then and then you ask more and more, right? Also the the symptoms. The symptoms tells a lot, yeah. Yeah. Um you know, uh when they They not have itching, Mhm. they did not have sneezing. Yeah. They did not have eye symptoms.

[00:11:36]>> Yeah. Um they did not have any allergic comorbidities.

[00:11:40]>> Yeah. You you should consider they maybe they they are the pathway.

[00:11:44]>> patient with allergic rhinitis doesn't have any kind of itching or sneezing?

[00:11:49]Because I do I do think that patient also have some degree of itching and sneezing as well. Yeah.

[00:11:55]Right. But maybe not prominent one.

[00:11:58]Yeah, but uh you just uh ask everything.

[00:12:01]>> Yeah.

[00:12:01]>> Right? And uh what symptoms are suggesting you to allergy or non-allergy?

[00:12:08]Okay, yeah. And uh the other thing is when you use the nasal speculum using your headlight >> Yeah. um you can see only the inferior turbinate, but you cannot see other structures.

[00:12:20]>> Okay. So you you said that endoscope is very useful in assessing the nasal airway, the nasal mucosa, and it give a lot of information. So in the case of neurogenic rhinitis Mhm. what are you looking for?

[00:12:35]Actually, I'm looking for ex- excluding other diagnosis rather than >> exclusion like the diagnosis of exclusion, right? Okay.

[00:12:44]>> uh when we say exclusions, most people exclude rhinosinusitis when they use nasal endoscopy.

[00:12:52]But the other thing is if you look at the mucosa of the middle turbinate >> Yeah.

[00:12:57]it can suggest you if you observe um you know, edema uh the it general edema of the middle turbinate or polypoid or polyps. Yeah, that suggests allergy. Right. So it's almost like the diagnosis of exclusion.

[00:13:13]But actually I think in some cases of non-allergic rhinitis or like neurogenic rhinitis, I see some mucosa that is not perfectly normal and also have some a bit of polypoid or edematous change.

[00:13:26]Mhm. So I don't think sometime you cannot really differentiate between like, you know, allergy and and an allergy for like 100%. You have to correlate with the clinical always. Do you agree? Yeah. And also like the history of like taking antihistamine and it doesn't work. You still have profuse rhinorrhea. That's a very good clue. Mhm.

[00:13:48]And also some patients already experienced like ipratropium bromide spray.

[00:13:52]>> Yeah. So, I think um if they I mean, what good for them is like just a lot. Yeah.

[00:13:58]Yeah. Mhm.

[00:14:00]And you know, when the patients are suffering from this and then the the doctors bring them to the theater, they try to reduce the size of the inferior turbinate.

[00:14:11]>> Yeah. But then they they most of the time they do not think about neurectomy.

[00:14:16]True. Yeah. So, what which group of patients are good candidates for neurectomy in in your opinion? Um uh severe nasal obstruction and severe rhinorrhea.

[00:14:28]>> Severe rhinorrhea, right. Okay. And in your experience when you do neurectomy, does patient like recover or like, you know, that their response rate of like um decreasing the nasal discharge improve dramatically or is there any circumstance where it does not work perfectly?

[00:14:44]We will keep that to the next episode.

[00:14:46]>> [laughter] >> I want to know now.

[00:14:49]No.

[00:14:51]Just wait. You're so mean, Professor.

[00:14:53]>> us.

[00:14:54]>> [laughter] >> Okay. I think I want to come to the summary and take home message for this episode, right? I think like um when you see rhinitis patient, um we should we shouldn't think just about like allergic rhinitis or non-allergic rhinitis. You should think of the neural pathway as well because there's a many patients who still suffering from this neurogenic rhinitis and we don't really acknowledge that much. So, a lot of patients do suffering from it. So, if you ever encounter patients who have this kind of symptoms and still not been, you know, like they get the medication and still suffering, don't forget that posterior neural nerve is still a missing piece in your treatment.

[00:15:37]See you next episode. Bye.

[00:15:39]>> Bye.