Rhinitis%20-%20nonallergic Diagnosis

• Atrophy of the nasal mucosa presenting with nasal congestion with nasal crusting, dryness and fetor

• 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

• 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

• 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

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

• 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