Phenotypic classification of rhinitis and basic principles of therapy
It is well known that the nose performs respiratory, protective, resonant and olfactory functions. Free nasal breathing causes positive and negative pressure in the chest and abdominal cavities. When breathing through the mouth, the inspiration becomes less deep, this leads to a decrease in negative pressure in the chest and, as a result, a violation of the hemodynamics of the skull. With inflammation of the nasal mucosa, basic functions are violated and the quality of life is impaired.
Rhinitis (inflammation of the nasal mucosa) is a common pathology in children. According to various sources, in recent years, the frequency of diseases of the nose and paranasal sinuses in children has been 35–37%, of this number 50% of cases become chronic, each year the proportion of such patients increases by 1.5–2.0%.
In recent years, the classification of rhinitis by phenotype has been adopted, proposed by the consensus document on allergic rhinitis – ICAR (2018). The classification is based on the pathophysiological mechanisms of the development of rhinitis of various etiologies. In both adults and children, rhinitis is divided into phenotypes: non-allergic and allergic. Using classification by phenotypes, one can take into account the severity and duration of the disease, as well as the similarity of symptoms, the effectiveness and control of therapy. Consider this classification in more detail.
Rhinitis is divided into allergic (persistent, intermittent), non-allergic (infectious, hormonal, drug, drug, atrophic, etc.).
In the etiology of infectious rhinitis in children, viruses that are tropic to respiratory epithelium and cause acute inflammation of the nasal mucosa are of great importance. These viruses include: adenovirus, rhinovirus (more than 90 serotypes), coronavirus, influenza myxovirus, parainfluenza myxovirus, enterovirus, syncytial respiratory virus. The mucous membrane of the nasal cavity is the first barrier to infection, responding to environmental changes (temperature changes, dryness or humidity, dustiness, irritating odors, etc.). An important role is played by hypothermia of the body, as a result of which protective neuro-reflex mechanisms are disrupted, and this leads to the activation of saprophytic flora in the nasal cavity and the development of a secondary immunodeficiency state and inflammation. Under normal conditions, when microorganisms get on the nasal mucosa, mucus is secreted by the cells of the surface epithelium and is excreted by mucociliary clearance.
In violation of the protective barrier of the nasal mucosa, the virus enters the cell, where the release of nucleic acids occurs. Mature virions ripen in the cell, which exit simultaneously with cell death. In the future, bacterial flora (secondary infection) joins. The integrity of the mucous membrane is violated, it becomes permeable to viruses and constantly vegetative conditionally pathogenic bacterial microflora. It is due to the immaturity of adaptive systems that children, especially young children, are often sick with rhinosinusitis.
The concept of hormonal rhinitis includes conditions such as rhinitis of pregnant women, rhinitis on the background of endocrinological diseases (hypothyroidism and acromegaly), senile (senile) rhinitis, etc.
During pregnancy, hormonal rhinitis is manifested by a number of symptoms: difficulty in nasal breathing, mucous discharge from the nose, sneezing. Most often, rhinitis of pregnant women develops at the end of the first trimester, persists throughout pregnancy and disappears after childbirth for several weeks. Most likely, the pathogenesis is based on an increase in the level of estrogens that inhibit acetylcholinesterase, subsequently increasing the level of acetylcholine in the blood serum and leading to swelling of the nasal mucosa. Also, the inhibitory ability of progesterone affects the tone of the smooth muscles of the vessels, increasing nasal congestion.
Senile (senile) rhinitis is clinically manifested by severe rhinorrhea, it can be considered the result of cholinergic hyperreactivity. The etiology of this condition is not fully understood. Senile rhinitis is probably associated with age-related changes: collagen atrophy and weakening of the cartilage of the nasal septum or vascular insufficiency.
Atrophic rhinitis is characterized by atrophy of the mucous membrane and the nerve endings located in it, is less common in children than in adults. Atrophic rhinitis is divided into 2 types: primary and secondary. The factors affecting its development are diverse: heredity, endocrine imbalance during puberty (more common in the female population), race, nutrient deficiency, infection (Klebsiella ozaenae, diphtheroids, Proteus vulgaris, Escherichia coli, etc.).
Drug rhinitis develops against the background of the uncontrolled use of vasoconstrictor drugs and is more common in school-age children, i.e., in groups of patients where reduced control over medication is possible.