Chronic Nonallergic Rhinitis

 

Am Fam Physician. 2018 Aug 1;98(3):171-176.

Author disclosure: No relevant financial affiliations.

Chronic nonallergic rhinitis encompasses a group of rhinitis subtypes without allergic or infectious etiologies. Although chronic nonallergic rhinitis represents about one-fourth of rhinitis cases and impacts 20 to 30 million patients in the United States, its pathophysiology is unclear and diagnostic testing is not available. Characteristics such as no evidence of allergy or defined triggers help define clinical subtypes. There are eight subtypes with overlapping presentations, including nonallergic rhinopathy, nonallergic rhinitis with nasal eosinophilia syndrome, atrophic rhinitis, senile or geriatric rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal rhinitis, and occupational rhinitis. Treatment is symptom-driven and similar to that of allergic rhinitis. Patients should avoid known triggers when possible. First-line therapies include intranasal corticosteroids, intranasal antihistamines, and intranasal ipratropium. Combination therapy with decongestants and first-generation antihistamines can be considered if monotherapy does not adequately control symptoms. Nasal irrigation and intranasal capsaicin may be helpful but need further investigation.

Chronic nonallergic rhinitis encompasses a group of rhinitis subtypes without allergic or infectious etiologies. Although chronic nonallergic rhinitis represents at least 23% of rhinitis cases in the United States and impacts an estimated 20 to 30 million patients, its pathophysiology is unclear.1,2 Chronic nonallergic rhinitis was previously referred to as nonallergic vasomotor or vasomotor rhinitis, but it was renamed because of a lack of evidence showing a vascular origin. The best current evidence supports nociceptor and autonomic nerve dysregulation as components in all forms of nonallergic rhinitis.35

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

An intranasal corticosteroid or intranasal antihistamine alone should be the initial treatment for nonallergic rhinitis if symptoms are not rhinorrhea-predominant.

B

5, 17, 22, 24

Combination therapy with an intranasal corticosteroid and intranasal antihistamine is better than either treatment alone.

C

5, 2224

Intranasal ipratropium should be the initial treatment for rhinorrhea in patients with gustatory nonallergic rhinitis.

C

25, 26

An intranasal corticosteroid plus intranasal ipratropium is more effective than either treatment alone for rhinorrhea.

B

28

Decongestants may be used in the treatment of nonallergic rhinitis, but only in the short term because of adverse effects.

C

24

Nasal irrigation may be used for nonallergic rhinitis.

B

29


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

An intranasal corticosteroid or intranasal antihistamine alone should be the initial treatment for nonallergic rhinitis if symptoms are not rhinorrhea-predominant.

B

5, 17, 22, 24

Combination therapy with an intranasal corticosteroid and intranasal antihistamine is better than either treatment alone.

C

5, 2224

Intranasal ipratropium should be the initial treatment for rhinorrhea in patients with gustatory nonallergic rhinitis.

C

25, 26

An intranasal corticosteroid plus intranasal ipratropium is more effective than either treatment alone for rhinorrhea.

B

28

Decongestants may be used in the treatment of nonallergic rhinitis, but only in the short term because of adverse effects.

C

24

Nasal irrigation may be used for nonallergic rhinitis.

B

29


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Clinical Characteristics

A negative result on allergy testing is one unifying characteristic of the chronic nonallergic rhinitis subtypes. Beyond that, clinical characteristics help define the conditions. First, these conditions are chronic (i.e., lasting at least three months). They can be perennial, persistent, intermittent, or seasonal. Clinically, chronic nonallergic rhinitis is characterized by its nonallergic triggers, including weather changes, tobacco smoke, automotive emission fumes, and irritants such as chemicals with strong odors (e.g., perfumes, chlorine).6,7 It also represents a group of heterogeneous syndromes with common underlying clinical characteristics such as nasal congestion

The Authors

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DENISE K.C. SUR, MD, is a clinical professor and vice chair in the Department of Family Medicine at the David Geffen School of Medicine at the University of California, Los Angeles....

MONICA L. PLESA, MD, is an assistant clinical professor in the Department of Family Medicine at the David Geffen School of Medicine at the University of California, Los Angeles.

Address correspondence to Denise K.C. Sur, MD, UCLA Medical Center, Santa Monica, 1920 Colorado Ave., Santa Monica, CA 90404 (e-mail: dsur@mednet.ucla.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Scarupa MD, Kaliner MA. Nonallergic rhinitis, with a focus on vasomotor rhinitis: clinical importance, differential diagnosis, and effective treatment recommendations. World Allergy Organ J. 2009;2(3):20–25....

2. Kaliner MA, Baraniuk JN, Benninger M, et al. Consensus definition of nonallergic rhinopathy, previously referred to as vasomotor rhinitis, nonallergic rhinitis, and/or idiopathic rhinitis. World Allergy Organ J. 2009;2(6):119–120.

3. Baraniuk JN. Pathogenic mechanisms of idiopathic nonallergic rhinitis. World Allergy Organ J. 2009;2(6):106–114.

4. Baraniuk JN, Merck SJ. Neuroregulation of human nasal mucosa. Ann N Y Acad Sci. 2009;1170:604–609.

5. Lieberman PL, Smith P. Nonallergic rhinitis: treatment. Immunol Allergy Clin North Am. 2016;36(2):305–319.

6. Kaliner MA. Nonallergic rhinopathy (formerly known as vasomotor rhinitis). Immunol Allergy Clin North Am. 2011;31(3):441–455.

7. Schroer B, Pien LC. Nonallergic rhinitis: common problem, chronic symptoms. Cleve Clin J Med. 2012;79(4):285–293.

8. Erwin EA, Faust RA, Platts-Mills TA, Borish L. Epidemiological analysis of chronic rhinitis in pediatric patients. Am J Rhinol Allergy. 2011;25(5):327–332.

9. Mølgaard E, Thomsen SF, Lund T, Pedersen L, Nolte H, Backer V. Differences between allergic and nonallergic rhinitis in a large sample of adolescents and adults. Allergy. 2007;62(9):1033–1037.

10. Bernstein JA, Brandt D, Ratner P, Wheeler W. Assessment of a rhinitis questionnaire in a seasonal allergic rhinitis population. Ann Allergy Asthma Immunol. 2008;100(5):512–513.

11. Hoshino T, Hoshino A, Nishino J. Relationship between environment factors and the number of outpatient visits at a clinic for nonallergic rhinitis in Japan, extracted from electronic medical records. Eur J Med Res. 2015;20:60.

12. Powe DG, Huskisson RS, Carney AS, Jenkins D, Jones NS. Evidence for an inflammatory pathophysiology in idiopathic rhinitis. Clin Exp Allergy. 2001;31(6):864–872.

13. Berger G, Goldberg A, Ophir D. The inferior turbinate mast cell population of patients with perennial allergic and nonallergic rhinitis. Am J Rhinol. 1997;11(1):63–66.

14. Kaliner MA, Baraniuk JN, Benninger MS, et al. Consensus description of inclusion and exclusion criteria for clinical studies of nonallergic rhinopathy (NAR), previously referred to as vasomotor rhinitis (VMR), non-allergic rhinitis, and/or idiopathic rhinitis. World Allergy Organ J. 2009;2(8):180–184.

15. Settipane RA, Settipane GA. Nonallergic rhinitis. In: Kaliner MA, ed. Current Review of Rhinitis. Philadelphia, Pa.: Current Medicine; 2002:53–65.

16. Sur DK, Plesa ML. Treatment of allergic rhinitis. Am Fam Physician. 2015;92(11):985–992.

17. Webb DR, Meltzer EO, Finn AF Jr, et al. Intranasal fluticasone propionate is effective for perennial nonallergic rhinitis with or without eosinophilia. Ann Allergy Asthma Immunol. 2002;88(4):385–390.

18. Blom HM, Godthelp T, Fokkens WJ, KleinJan A, Mulder PG, Rijntjes E. The effect of nasal steroid aqueous spray on nasal complaint scores and cellular infiltrates in the nasal mucosa of patients with nonallergic, noninfectious perennial rhinitis. J Allergy Clin Immunol. 1997;100(6 pt 1):739–747.

19. Varricchio A, Capasso M, De Lucia A, et al. Intranasal flunisolide treatment in patients with non-allergic rhinitis. Int J Immunopathol Pharmacol. 2011;24(2):401–409.

20. Banov CH, Lieberman P; Vasomotor Rhinitis Study Groups. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. Ann Allergy Asthma Immunol. 2001;86(1):28–35.

21. Lieberman P, Meltzer EO, LaForce CF, Darter AL, Tort MJ. Two-week comparison study of olopatadine hydrochloride nasal spray 0.6% versus azelastine hydrochloride nasal spray 0.1% in patients with vasomotor rhinitis. Allergy Asthma Proc. 2011;32(2):151–158.

22. Purello-D'Ambrosio F, Isola S, Ricciardi L, Gangemi S, Barresi L, Bagnato GF. A controlled study on the effectiveness of loratadine in combination with flunisolide in the treatment of nonallergic rhinitis with eosinophilia (NARES). Clin Exp Allergy. 1999;29(8):1143–1147.

23. Price D, Shah S, Bhatia S, et al. A new therapy (MP29-02) is effective for the long-term treatment of chronic rhinitis. J Investig Allergol Clin Immunol. 2013;23(7):495–503.

24. Tran NP, Vickery J, Blaiss MS. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res. 2011;3(3):148–156.

25. Raphael G, Raphael MH, Kaliner M. Gustatory rhinitis: a syndrome of food-induced rhinorrhea. J Allergy Clin Immunol. 1989;83(1):110–115.

26. Georgalas C, Jovancevic L. Gustatory rhinitis. Curr Opin Otolaryngol Head Neck Surg. 2012;20(1):9–14.

27. Silvers WS. The skier's nose: a model of cold-induced rhinorrhea. Ann Allergy. 1991;67(1):32–36.

28. Dockhorn R, Aaronson D, Bronsky E, et al. Ipratropium bromide nasal spray 0.03% and beclomethasone nasal spray alone and in combination for the treatment of rhinorrhea in perennial rhinitis. Ann Allergy Asthma Immunol. 1999;82(4):349–359.

29. Chong LY, Head K, Hopkins C, et al. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016;(4):CD011995.

30. Blom HM, Van Rijswijk JB, Garrelds IM, Mulder PG, Timmermans T, Gerth van Wijk R. Intranasal capsaicin is efficacious in nonallergic, noninfectious perennial rhinitis. A placebo-controlled study. Clin Exp Allergy. 1997;27(7):796–801.

31. Gevorgyan A, Segboer C, Gorissen R, van Drunen CM, Fokkens W. Capsaicin for non-allergic rhinitis. Cochrane Database Syst Rev. 2015;(7):CD010591.

32. Wheeler PW, Wheeler SF. Vasomotor rhinitis. Am Fam Physician. 2005;72(6):1057–1062.

33. Quillen DM, Feller DB. Diagnosing rhinitis: allergic vs. nonallergic. Am Fam Physician. 2006;73(9):1583–1590.

 

 

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