rhinitis%20-%20nonallergic
RHINITIS - NONALLERGIC
Nonallergic rhinitis is the inflammation of the nasal lining membranes without any immunoglobulin E mediation, as documented by allergen skin testing.
Major signs and symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Symptoms can reverse spontaneously with or without treatment.

Diagnosis

  • Nonallergic rhinitis (NAR) is a diagnosis of rhinitis w/o any immunoglobulin E (IgE) mediation, as documented by allergen skin testing or radioallergosorbent testing (RAST)
  • A detailed clinical history & physical exam should be obtained to rule out other nasal conditions which can cause similar symptoms
  • The diagnosis is based mostly by exclusion

Classification

Types of Nonallergic Rhinitis
Extrinsic Cause
  • Drug-Induced Rhinitis
    • May be caused by a variety of medications (eg beta-blockers, ACE inhibitors, NSAIDs, Aspirin, oral contraceptives)
    • Rhinitis medicamentosa
      • Results from prolonged use (>5-10 days) of intranasal decongestants
      • Nasal congestion & rhinorrhea result from loss of adrenergic tone rather than the original cause of rhinitis
      • Nasal function normalizes in 7-21 days after discontinuation of decongestants
  • Gustatory Rhinitis
    • Usually presents w/ watery rhinorrhea secondary to vagally mediated nasal vasodilatation that occurs w/in few hours of oral ingestion
    • Common triggers are hot & spicy foods
  • Hormonal Rhinitis
    • Symptoms appear when hormonal imbalances occur (eg hypothyroidism, pregnancy, puberty, menstruation, oral contraceptive use)
    • Usual symptoms are nasal congestion & rhinorrhea
  • Occupational Rhinitis
    • Symptoms are usually triggered by an inhaled irritant (eg wood dusts, chemicals, grains)
    • Patients report that symptoms are present only when they are in the workplace
Inflammatory Rhinitis
  • Granulomatous diseases
    • Eg Wegener’s, Sarcoidosis
      • Presents w/ inflammatory rhinitis w/ negative skin prick test
      • Nasal mucosa appears to be red or granulomatous, sometimes w/ crusting & bleeding, nasal perforation or collapsed nasal bridge
  • Systemic diseases
    • Eg Sjogren’s syndrome, rheumatoid arthritis, systemic lupus erythematosus (SLE), Churg-Strauss syndrome
  • Nonallergic Rhinitis w/ Eosinophilia Syndrome (NARES)
    • Eosinophils comprising 10-20% of cells are seen on nasal smear
    • Usual symptoms are nasal obstruction, sneezing, rhinorrhea, nasal pruritus & hyposmia
    • May lead to nasal polyposis, asthma & Aspirin sensitivity

Infectious Rhinitis

  • Usually caused by a viral or bacterial upper respiratory infection
  • See Rhinosinusitis - Acute Bacterial Disease Management Chart if bacterial infection is suspected
  • Symptoms include clear to mucopurulent nasal discharge, facial pain & pressure, postnasal drainage w/ cough, altered sense of smell, which resolve w/in 7-10 days
Neurogenic
  • Vasomotor Rhinitis
    • General category for all remaining types of nonallergic rhinitis
    • Usually due to parasympathomimetic activity which results in vasodilation & edema of the nasal vessels
    • Symptoms may worsen w/ exposure to cold air, stress, inhaled irritants or strong odors

History

The following features in the clinical history are suggestive of nonallergic rhinitis:

  • Adult onset of symptoms w/ symptoms occurring throughout the year
  • Previous negative allergy testing
  • Sensitivity to smoke, perfume, environmental irritants & changes in weather conditions
  • Overuse of topical decongestants
  • Prominent symptoms of postnasal drainage & nasal obstruction
  • Nasal crusting or drying
  • Facial pain

Physical Examination

Nasal Exam
  • Preferably performed by endoscopy
  • May reveal the following:
    • Erythematous mucosal tissue
    • Swollen nasal turbinates
    • Nasal crease
    • Rhinorrhea w/ clear, cloudy or colored discharge
    • Mouth breathing
  • Patient should be referred to a specialist if findings are more consistent w/ a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation, turbinate hypertrophy)
    • Surgical treatment may be required
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Respirology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Jairia Dela Cruz, 02 Mar 2017
The placement of personalized inhaler technique reminder labels on dry-powder asthma inhalers may improve the retention of inhaler technique skills after training and potentially extend the benefit of the training onto asthma outcomes, according to a study.
Audrey Abella, 08 Feb 2018
Better clinical efficacy was observed among cancer patients with postoperative hospital-acquired pneumonia (HAP) who received prolonged infusion of the mixed preparation of the broad-spectrum β-lactamase inhibitor tazobactam and β-lactam antibiotic piperacillin (TZP) compared with those who received the traditional regimen, according to a study.

Stephen Padilla, 02 Mar 2017
Use of vitamin D supplementation prevents acute respiratory tract infection, with individuals who are very deficient in vitamin D and those not receiving additional bolus doses benefitting the most, a recent study has found.
18 Feb 2018
Plasma brain natriuretic peptide (BNP) threshold of 340 pg/mL appears to strongly predict survival up to 5 years in patients with pulmonary arterial hypertension, a study suggests.