Chronic Nonallergic Rhinitis

Aka: Chronic Nonallergic Rhinitis, Autonomic Rhinitis, Nonallergic Rhinitis, Non-allergic Rhinitis, Non-Infective Non-allergic Rhinitis, Atrophic Rhinitis, Hormonal Rhinitis, Occupational Rhinitis

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II. Definitions

  1. Chronic Nonallergic Rhinitis
    1. Chronic Rhinitis (>3 months) without allergic or infectious cause

III. Epidemiology

  1. Prevalence: 20-30 Million in U.S.
  2. Accounts for 23% of Rhinitis cases in U.S.
  3. More common in women (by factor of 2:1 to 3:1)
  4. Age >35 years old (contrast with Allergic Rhinitis onset <20 years old)
  5. Typically no Family History of Allergic Rhinitis, Asthma or Eczema
  6. Perennial onset (but may also be seasonal)

IV. Mechanism

  1. Associated with autonomic and Nociceptor nerve dysregulation
  2. Originally thought to be vascular in origin (hence the original name for a subtype, Vasomotor Rhinitis)
    1. Initially thought due to increased blood supply to nasal mucosa

V. Types: Subtypes

  1. Nonallergic Rhinopathy (Vasomotor Rhinitis, Idiopathic Nonallergic Rhinitis)
    1. Nasal symptoms triggered by non-allergic environmental exposures
    2. Triggers include strong smells, Temperature changes, humidity, barometric pressure
  2. Nonallergic Rhinitis with Eosinophilia Syndrome
    1. Inflammatory Rhinitis with nasal secretion Eosinophilia and Mast Cell degranulation, without allergy
    2. Corticosteroid responsive
  3. Atrophic Rhinitis
    1. Nasal mucosa atrophy
    2. Presents with nasal crusting and drying
  4. Senile Rhinitis (Geriatric Rhinitis)
    1. Watery Rhinorrhea with onset at an older age
    2. Triggers include foods, odors and environmental triggers
  5. Gustatory Rhinitis
    1. Rhinorrhea triggered by specific food or liquid intake (e.g. spicy foods, Alcohol)
  6. Drug-Induced Rhinitis
    1. See Medication Causes of Rhinitis
    2. Includes Rhinitis Medicamentosa
    3. Triggers include Antihypertensives, NSAIDs, PDE5 Inhibitors (e.g. Viagra), Cocaine
  7. Hormonal Rhinitis
    1. Endogenous female Hormone induced nasal congestion and Rhinorrhea (e.g. pregnancy)
  8. Occupational Rhinitis
    1. Occupational exposure triggered Rhinitis (worse during work periods, better after a reprieve)
    2. Triggers include chemical and particle exposures (e.g. Rubber latex, flour)

VI. Symptoms: Chronic (>3 months)

  1. Allergic symptoms are typically absent (nasal, ocular or pharyngeal/palatal Pruritus, sneezing, Nasal Polyps)
  2. Wet or Dry
    1. Dry: Nasal obstruction, airway resistance and congestion
    2. Wet: Rhinorrhea predominates
    3. Mixed (congestion and Rhinorrhea)

VII. Signs

  1. Normal nose exam
    1. Contrast with blue mucosa of Allergic Rhinitis, and the red mucosa of Rhinosinusitis

VIII. Diagnosis

  1. Normal Allergy Testing (e.g. Antigen-specific serum IgE, RAST testing, skin prick)
  2. Mixed Rhinitis (allergic and non-allergic causes) occurs in up to one third of patients

IX. Differential Diagnosis

  1. See Rhinitis
  2. See Rhinitis Causes
  3. See Drug-Induced Rhinitis
  4. Allergic Rhinitis
  5. Rhinitis Medicamentosa

X. Management: General

  1. Avoid suspected triggers
  2. Nasal obstruction or nasal congestion predominant (with or without Rhinorrhea or sneezing)
    1. Step 1: Choose one of the following
      1. Intranasal Corticosteroid OR
      2. Intranasal Antihistamine (Azelastine)
    2. Step 2: Use both of the following in combination
      1. Intranasal Corticosteroid AND
      2. Intranasal Antihistamine (Azelastine)
    3. Step 3: Continue both agents as above AND add
      1. Oral Decongestant
  3. Rhinorrhea predominant
    1. Step 1: Intranasal Ipratropium (Atrovent) 0.03% two sprays 2-4 times daily
    2. Step 2: Continue intranasal Ipratropium AND add one of the following
      1. Intranasal Corticosteroid OR
      2. Intranasal Antihistamine (e.g. Azelastine)
    3. Other options that have been used
      1. Intranasal CromolynSodium (Intal)

XI. Management: Specific Cohorts

  1. Pregnancy
    1. Step 1: Nasal Saline
    2. Step 2: Intranasal Ipratropium (Atrovent, Pregnancy Category B)
  2. Older patients (e.g. Geriatric Rhinitis, Gustatory Rhinitis, Vasomotor Rhinitis)
    1. Intranasal Ipratropium (Atrovent)
  3. Children
    1. Age over 2 years
      1. Congestion: Intranasal Corticosteroid limited to Mometasone furoate (e.g. Nasonex)
      2. Sneezing: Intranasal CromolynSodium (Intal)
    2. Age over 6 years
      1. Rhinorrhea: Intranasal Ipratropium (Atrovent)
      2. Congestion: Intranasal Corticosteroid
      3. Sneezing: Intranasal CromolynSodium (Intal)

XII. References

  1. Sur (2018) Am Fam Physician 98(3): 171-6 [PubMed]

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