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

Neurogenic Rhinitis

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
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 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
Vasomotor Rhinitis
  • 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
Senile Rhinitis
  • Late-onset rhinitis in the elderly (>65 years old)
  • Commonly drug-induced but may also be secondary to imbalances in parasympathetic and sympathetic tone
Inflammatory Rhinitis

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
Atrophic Rhinitis
  • 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
Occupational Rhinitis
  • 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
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
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, Churg-Strauss syndrome
Infectious Rhinitis/Rhinosinusitis
  • 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


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
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