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Rhinitis%20-%20nonallergic Diagnosis
Etiology of Nonallergic Rhinitis
Neurogenic Rhinitis
Drug-induced or Medication-induced Rhinitis
Eosinophilic or Nonallergic Rhinitis with Eosinophilia Syndrome (NARES)
Drug-induced or Medication-induced Rhinitis
- May be caused by a variety of medications (eg beta-blockers, angiotensin-converting enzyme inhibitors, beta-blockers, Chlorpromazine, nonsteroidal anti-inflammatory drugs, Aspirin, oral contraceptives, prolonged use of nasal decongestants)
- Symptoms are nasal blockage, rhinorrhea, crusting, pain and nasal septum perforation
- 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
- Usually presents with watery rhinorrhea secondary to vagally mediated nasal vasodilatation that occurs within a 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
- Also known as idiopathic rhinitis, noninfectious NAR or nonallergic rhinopathy
- Comprises 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
- Late-onset rhinitis in the elderly (>65 years old)
- Commonly drug-induced but may also be secondary to imbalances in parasympathetic and sympathetic tone
Eosinophilic or Nonallergic Rhinitis with Eosinophilia Syndrome (NARES)
- Eosinophils comprising >20% of cells 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
- Atrophy of the nasal mucosa presenting with nasal congestion with nasal crusting, dryness and fetor
- Usually related to dry climate or mucosal colonization with bacteria but may also occur after irradiation or nasal surgery
- Symptoms are usually triggered by an inhaled irritant (eg wood dust, chemicals, grains)
- Patients report that symptoms are present only when they are in the workplace
- 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
- 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
- Eg Sjogren’s syndrome, rheumatoid arthritis, systemic lupus erythematosus, Churg-Strauss syndrome
- 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, and altered sense of smell, which resolve within 7-10 days
History
Clinical History Features Suggestive of NAR
- Adult onset of 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
