Treatment Guideline Chart
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

Etiology of Nonallergic Rhinitis

Atrophic Rhinitis
  • Atrophy of the nasal mucosa presenting with nasal congestion with nasal crusting, dryness and fetor
Extrinsic Cause
  • Drug-induced rhinitis or medication-induced rhinitis
    • May be caused by a variety of medications [eg beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), Aspirin, oral contraceptives, prolonged use of nasal decongestants]
    • Symptoms are nasal blockage, rhinorrhea, crusting, pain and nasal septum perforation
    • Rhinitis medicamentosa or rebound rhinitis
      • Results from prolonged use (>5-10 days) of intranasal decongestants
      • Nasal congestion and 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 with watery rhinorrhea secondary to vagally mediated nasal vasodilatation that occurs within few minutes or hours of oral ingestion
    • Common triggers are hot and spicy foods
    • Alcohol-induced rhinitis
      • Most common symptoms are nasal congestion and rhinorrhea
      • Elevation of systemic cysteinyl leukotrienes after alcoholic beverages consumption may be a contributing factor
  • Hormonal rhinitis
    • Symptoms appear when hormonal imbalances occur (eg hypothyroidism, acromegaly, pregnancy, puberty, menstruation, oral contraceptive use)
    • Nasal vascular engorgement is induced by hormones thus producing rhinitis symptoms
    • Usual symptoms are nasal congestion and 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
  • Eosinophilic or Nonallergic Rhinitis with Eosinophilia Syndrome (NARES)
    • Eosinophils comprising 10-20% of cells are seen on nasal smear
    • Lacks other allergic evidence by skin-prick testing or specific IgE blood tests
    • Usual symptoms are nasal obstruction, sneezing, rhinorrhea, nasal pruritus and hyposmia
    • May lead to nasal polyposis, asthma and Aspirin sensitivity
  • Granulomatous diseases
    • Eg Granulomatosis with polyangiitis (Wegener’s), Sarcoidosis
      • Presents with inflammatory rhinitis with negative skin prick test
      • Nasal mucosa appears to be red or granulomatous, sometimes with crusting and bleeding, nasal perforation or collapsed nasal bridge
  • Systemic diseases
    • Eg Sjogren’s syndrome, rheumatoid arthritis, systemic lupus erythematosus (SLE), Churg-Strauss syndrome

Infectious Rhinitis/Rhinosinisitis

  • Usually caused by a viral or bacterial upper respiratory infection
    • If bacterial infection is suspected: Please see Rhinosinusitis - Acute, Bacterial disease management chart for further information
  • More severe disease are caused by fungal infections in an immunocompromised patient
  • Symptoms include clear to mucopurulent nasal discharge, facial pain and pressure, postnasal drainage with cough, altered sense of smell, which resolve within 7-10 days
Neurogenic Cause
  • Vasomotor rhinitis
    • Also known as idiopathic rhinitis, noninfectious NAR or nonallergic rhinopathy 
    • Makes up 50% of patients with NAR 
    • General category for all remaining types of NAR
    • Usually due to parasympathomimetic activity which results in vasodilation and edema of the nasal vessels
      • Presence of nasal hyperresponsiveness is suggestive of idiopathic etiology
    • Symptoms may worsen with exposure to cold air, stress, inhaled irritants or strong odors


  • A detailed clinical history and physical exam should be obtained to rule out other nasal conditions which can cause similar symptoms

Features in the Clinical History that 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 and changes in weather conditions
  • Overuse of topical decongestants
  • Prominent symptoms of postnasal drainage and nasal obstruction
    • Evaluate nasal obstruction using Nasal Obstruction Symptom Evaluation (NOSE)
    • Postnasal drainage can be assessed using Reflux Symptom Index (RSI) questionnaire
  • Facial pain
  • Sleep problems/sleep disordered breathing

Physical Examination

Nasal Exam
  • Preferably performed by nasal 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 with a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation, turbinate hypertrophy)
    • Surgical treatment may be required
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