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.

Rhinitis%20-%20nonallergic Diagnosis

Diagnosis

  • Nonallergic rhinitis (NAR) is a diagnosis of rhinitis without 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

Classification

Types of Nonallergic Rhinitis
Extrinsic Cause
  • Drug-induced rhinitis
    • May be caused by a variety of medications (eg beta-blockers, ACE inhibitors, beta-blockers, NSAIDs, Aspirin, oral contraceptives, prolonged use of nasal decongestants)
    • Symptoms are nasal blockage, rhinorrhea, crusting, pain & nasal septum perforation
    • 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, acromegaly, 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
  • Idiopathic rhinitis
    • Makes up 50% of patients w/ nonallergic rhinitis
    • Presence of nasal hyperresponsiveness is suggestive of idiopathic etiology
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 within 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 with 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
    • Evaluate nasal obstruction using Nasal Obstruction Symptom Evaluation (NOSE)
    • Postnasal drainage can be assessed using Reflux Symptom Index (RSI) questionnaire
  • Nasal crusting or drying
  • Facial pain
  • Sleep problems/sleep disordered breathing

Physical Examination

Nasal Exam
  • Preferably performed by endoscopy
  • May reveal the following:
    • Erythematous mucosal tissue
    • Swollen nasal turbinates
    • Nasal crease
    • Rhinorrhea
    • 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
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