Rhinogenous neuroses in adolescents and adults

Management Strategies for Rhinogenic Neuroses

The management of conditions historically termed rhinogenic neuroses involves a multifaceted approach, focusing on treating identifiable nasal pathology, addressing psychological components, and managing systemic symptoms.

 

Addressing Nasal Pathology

A cornerstone of management is the thorough evaluation and treatment of any underlying nasal or paranasal sinus disease. This includes:

• Surgical removal of nasal polyps, foreign bodies.
• Correction of significant septal deviations, spurs, or ridges.
• Reduction of turbinate hyperplasia.
• Treatment of chronic rhinosinusitis.

The rationale is that by eliminating potential sources of chronic irritation or nerve impingement within the nose, reflex symptoms in other organs might be alleviated.

 

Psychological and Supportive Care

As mentioned, psychotherapy is extremely important, especially when anxiety, panic, or fear (e.g., fear of suffocation during an asthma attack) are prominent. Cognitive-behavioral therapy (CBT) and relaxation techniques can be beneficial. Educating the patient about their condition and reassuring them about the nature of their symptoms can reduce anxiety and improve coping mechanisms.

 

Symptomatic and Adjunctive Treatments (Historical and Modern)

In addition to measures for general body "hardening" or strengthening (e.g., hydrotherapy, air baths – historical concepts), specific treatments were used:

• Iodine Preparations (Historical): Iodine preparations (e.g., 2-3 g of potassium iodide during an attack) were previously used, with alternative agents employed if intolerance occurred with prolonged use.
• Antispasmodics: Sprays and powders containing antispasmodic agents often brought relief for asthma-like symptoms.
• Atropine Injections (Historical): Subcutaneous injections of atropine (0.0005-0.001 ml, likely referring to a 1mg/ml solution, so 0.5-1 microgram) were used to stop acute attacks, presumably due to its anticholinergic effects. Modern asthma management uses inhaled bronchodilators and corticosteroids.
• Breathing Aids: Various breathing apparatuses designed to act on respiratory muscles and facilitate exhalation by squeezing air out of the lungs were used. Similar effects could be achieved by manual chest compressions (as in artificial respiration).
• Distraction Therapies: Hot foot baths and mustard plasters were sometimes found effective during an acute attack, likely acting as counter-irritants or through reflex mechanisms.

 

Surgical Interventions for Reflex Phenomena (Historical Context)

For "nasal" asthma (rhinogenic neurosis), a specific surgical procedure involving bilateral resection of the anterior ethmoidal nerve was historically proposed. An incision was made from the middle of the eyebrow to its inner end and downward to the inner corner of the eye. The soft tissues, along with the periosteum, were retracted into the orbit until, at a depth of 2-2.5 cm from the wound edge, the neurovascular bundle (containing the anterior ethmoidal nerve and vessels) emerging from the orbital fatty tissue became noticeable. The nerve and blood vessels were then ligated at their exit point. This is a highly invasive procedure with significant risks and is not standard practice today for asthma, which is now understood as a primary airway inflammatory disease.

 

Specific Reflex Relationships and Controversies

Several specific reflex connections between the nose and other body systems have been historically debated, and their clinical significance remains controversial or has been reinterpreted in modern medicine.

 

Nose and Genital Apparatus (Dysmenorrhea)

The reflex relationship between the nose and the female reproductive system in rhinogenic neuroses has not been fully elucidated. However, historical suggestions posited that pain in the sacrum during dysmenorrhea (painful menstruation), as well as labor pains, could often depend on functional or organic changes within the nose. It was believed that these pains could be eliminated by topical application of cocaine (anesthetic and vasoconstrictor) or by cauterization of specific "genital points" or "reflexogenic zones" on the inferior turbinate. While the precise mechanisms and efficacy of such treatments are questionable by modern standards, and the direct causal link uncertain, it was considered appropriate in the past to attempt such harmless measures if they provided relief, regardless of whether the effect was truly reflex-mediated or due to suggestion (placebo effect).

 

Nose and Epilepsy

The relationship between nasal changes and epilepsy remains an open question in the context of rhinogenic neuroses. Historically, attempts to provoke an epileptic seizure by irritating reflex points in the nose were unsuccessful. On the other hand, some experts reported that after eliminating nasal anomalies (e.g., removal of foreign bodies, polyps, reduction of turbinate hyperplasia, correction of septal protrusions), epileptic seizures sometimes temporarily ceased. Based on such observations, the existence of "epilepsy of reflex nasal origin" was postulated. Regardless of certainty about influencing epilepsy this way, a thorough examination of the nose and treatment of any detected pathological changes was considered necessary in epileptic patients. Some authors even observed cessation of epileptic seizures in children after adenoidectomy (removal of pharyngeal tonsils); such observations exist in historical practice.

 

Nose and Cardiac Symptoms

Cardiac disorders such as a feeling of constriction in the chest, increased palpitations (tachycardia), or pain in the heart region (angina-like pain) can occasionally appear in individuals with increased nervous system excitability (neurotic predisposition) under the influence of irritation of the nasal mucosa. In such patients, the approach involved attempting to eliminate the neuropathic predisposition through general systemic treatment and surgically addressing any painful or significantly pathological changes within the nose.

 

Nose and Visual Disturbances/Orbital Pain

Visual impairments due to nasal diseases often arise as a direct result of the inflammatory or infectious process spreading to the conjunctiva of the eye and the lacrimal apparatus (e.g., dacryocystitis). However, sometimes symptoms like photophobia (light sensitivity), amblyopia (reduced vision without apparent organic lesion), asthenopia (eye strain), and blepharospasm (eyelid twitching) were thought to develop reflexively from nasal irritation. Neuralgic pains in the eye socket (orbit) and forehead along the distribution of the trigeminal nerve can also be of rhinogenic origin (e.g., from contact points or sinus inflammation). In these cases as well, careful treatment of any identified changes within the nose was reported to provide a beneficial effect.

 

Differential Diagnosis of Symptoms Attributed to Rhinogenic Neuroses

When evaluating symptoms historically attributed to rhinogenic neuroses, it's crucial to conduct a thorough differential diagnosis to rule out primary organ-specific diseases or other underlying conditions:

Symptom/Condition Historically Attributed to Nasal Reflex	Modern Differential Diagnoses to Consider
"Nasal" Asthma / Bronchospasm	Allergic asthma, non-allergic asthma, GERD with aspiration, vocal cord dysfunction, chronic bronchitis, COPD, anxiety/panic disorder with hyperventilation. Coexisting rhinitis/sinusitis as a trigger for true asthma.
Dysmenorrhea / Sacral Pain	Primary dysmenorrhea, endometriosis, pelvic inflammatory disease, uterine fibroids, ovarian cysts, musculoskeletal issues (e.g., sacroiliitis), psychosomatic pain.
Epileptic Seizures	Primary epilepsy syndromes, secondary epilepsy (due to brain tumor, stroke, trauma, infection), psychogenic non-epileptic seizures (PNES), syncope, metabolic disturbances.
Cardiac Symptoms (Palpitations, Chest Discomfort)	Arrhythmias (e.g., SVT, atrial fibrillation), ischemic heart disease, valvular heart disease, panic disorder, anxiety, GERD, costochondritis.
Visual Disturbances (Photophobia, Amblyopia, Asthenopia) / Orbital Pain	Refractive errors, dry eye syndrome, uveitis, migraine with aura, optic neuritis, sinusitis with orbital involvement, orbital tumors, trigeminal neuralgia, tension headaches.

 

Conclusion and Modern Approach

While the historical concept of "rhinogenic neuroses" encompassing a wide range of reflex phenomena has evolved, the interplay between nasal health and overall well-being remains an important clinical consideration. Modern medicine focuses on:

1. Accurate Diagnosis: Identifying and treating specific nasal and sinus pathologies (e.g., chronic rhinosinusitis, allergic rhinitis, structural abnormalities) based on current diagnostic standards.
2. Understanding Comorbidities: Recognizing that nasal/sinus conditions can coexist with and potentially exacerbate other systemic diseases (e.g., asthma, certain types of headache). The "united airway" concept highlights the connection between upper and lower airway inflammation.
3. Holistic Patient Care: Addressing psychological factors, anxiety, and somatization when present, often through a multidisciplinary approach involving ENT specialists, allergists, pulmonologists, neurologists, and mental health professionals.
4. Evidence-Based Treatments: Employing treatments with proven efficacy for both the nasal condition and any associated systemic symptoms, rather than relying on historical interventions with limited scientific support.

While direct, far-reaching reflex neuroses are less emphasized, the impact of chronic nasal symptoms on quality of life, sleep, and psychological state is well-recognized and actively managed.

 

When to Consult an ENT Specialist and Other Professionals

Patients experiencing persistent or unexplained symptoms possibly related to nasal issues should consult relevant specialists:

• ENT Specialist: For evaluation of any underlying nasal or sinus pathology (polyps, sinusitis, septal deviation, etc.) if nasal symptoms are prominent or if a nasal trigger for other symptoms is suspected.
• Allergist/Immunologist: If allergies are suspected as contributing to nasal symptoms or asthma.
• Pulmonologist: For primary management of asthma or other lung conditions.
• Neurologist: For evaluation of epilepsy, severe headaches, or other neurological symptoms.
• Cardiologist: For cardiac symptoms.
• Gynecologist: For dysmenorrhea or other pelvic issues.
• Psychiatrist/Psychologist: If anxiety, panic disorder, or significant psychological distress is present or suspected to be contributing to symptoms.

A multidisciplinary approach is often best for complex cases where symptoms may involve multiple systems or have a significant psychosomatic component.