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Chronic Nonallergic Rhinitis
Aka: Chronic Nonallergic Rhinitis, Nonallergic Rhinitis, Non-allergic Rhinitis, Non-Infective Non-allergic Rhinitis, Atrophic Rhinitis, Hormonal Rhinitis, Occupational Rhinitis
- See Also
- Rhinitis
- Rhinitis Causes
- Medication Causes of Rhinitis
- Allergic Rhinitis
- Infectious Rhinitis
- Nonallergic Rhinitis with Eosinophilia
- Nonallergic Rhinopathy (Vasomotor Rhinitis)
- Definitions
- Chronic Nonallergic Rhinitis
- Chronic Rhinitis (>3 months) without allergic or infectious cause
- Epidemiology
- Prevalence: 20-30 Million in U.S.
- Accounts for 23% of Rhinitis cases in U.S.
- More common in women (by factor of 2:1 to 3:1)
- Age >35 years old (contrast with Allergic Rhinitis onset <20 years old)
- Typically no Family History of Allergic Rhinitis, Asthma or Eczema
- Perennial onset (but may also be seasonal)
- Mechanism
- Associated with autonomic and nociceptor nerve dysregulation
- Originally thought to be vascular in origin (hence the original name for a subtype, Vasomotor Rhinitis)
- Initially thought due to increased blood supply to nasal mucosa
- Types: Subtypes
- Nonallergic Rhinopathy (Vasomotor Rhinitis, Idiopathic Nonallergic Rhinitis)
- Nasal symptoms triggered by non-allergic environmental exposures
- Triggers include strong smells, Temperature changes, humidity, barometric pressure
- Nonallergic Rhinitis with Eosinophilia Syndrome
- Inflammatory Rhinitis with nasal secretion Eosinophilia and Mast Cell degranulation, without allergy
- Corticosteroid responsive
- Atrophic Rhinitis
- Nasal mucosa atrophy
- Presents with nasal crusting and drying
- Senile Rhinitis (Geriatric Rhinitis)
- Watery Rhinorrhea with onset at an older age
- Triggers include foods, odors and environmental triggers
- Gustatory Rhinitis
- Rhinorrhea triggered by specific food or liquid intake (e.g. spicy foods, Alcohol)
- Drug-Induced Rhinitis
- See Medication Causes of Rhinitis
- Includes Rhinitis Medicamentosa
- Triggers include antihypertensives, NSAIDs, PDE5 Inhibitors (e.g. Viagra), Cocaine
- Hormonal Rhinitis
- Endogenous female hormone induced nasal congestion and Rhinorrhea (e.g. pregnancy)
- Occupational Rhinitis
- Occupational exposure triggered Rhinitis (worse during work periods, better after a reprieve)
- Triggers include chemical and particle exposures (e.g. Rubber latex, flour)
- Symptoms: Chronic (>3 months)
- Allergic symptoms are typically absent (nasal, ocular or pharyngeal/palatal Pruritus, sneezing, Nasal Polyps)
- Wet or Dry
- Dry: Nasal obstruction, airway resistance and congestion
- Wet: Rhinorrhea predominates
- Mixed (congestion and Rhinorrhea)
- Signs
- Normal nose exam
- Contrast with blue mucosa of Allergic Rhinitis, and the red mucosa of Rhinosinusitis
- Diagnosis
- Normal Allergy Testing (e.g. Antigen-specific serum IgE, RAST testing, skin prick)
- Mixed Rhinitis (allergic and non-allergic causes) occurs in up to one third of patients
- Differential Diagnosis
- See Rhinitis
- See Rhinitis Causes
- See Drug-Induced Rhinitis
- Allergic Rhinitis
- Rhinitis Medicamentosa
- Management: General
- Avoid suspected triggers
- Nasal obstruction or nasal congestion predominant (with or without Rhinorrhea or sneezing)
- Step 1: Choose one of the following
- Intranasal Corticosteroid OR
- Intranasal Antihistamine (Azelastine)
- Step 2: Use both of the following in combination
- Intranasal Corticosteroid AND
- Intranasal Antihistamine (Azelastine)
- Step 3: Continue both agents as above AND add
- Oral Decongestant
- Rhinorrhea predominant
- Step 1: Intranasal Ipratropium (Atrovent) 0.03% two sprays 2-4 times daily
- Step 2: Continue intranasal Ipratropium AND add one of the following
- Intranasal Corticosteroid OR
- Intranasal Antihistamine (e.g. Azelastine)
- Other options that have been used
- Intranasal CromolynSodium (Intal)
- Management: Specific Cohorts
- Pregnancy
- Step 1: Nasal Saline
- Step 2: Intranasal Ipratropium (Atrovent, Pregnancy Category B)
- Older patients (e.g. Geriatric Rhinitis, Gustatory Rhinitis, Vasomotor Rhinitis)
- Intranasal Ipratropium (Atrovent)
- Children
- Age over 2 years
- Congestion: Intranasal Corticosteroid limited to Mometasone furoate (e.g. Nasonex)
- Sneezing: Intranasal CromolynSodium (Intal)
- Age over 6 years
- Rhinorrhea: Intranasal Ipratropium (Atrovent)
- Congestion: Intranasal Corticosteroid
- Sneezing: Intranasal CromolynSodium (Intal)
- References
- Sur (2018) Am Fam Physician 98(3): 171-6 [PubMed]