Non-allergic rhinitis

Traditional triggers such as cat or dog exposure should be absent.

Symptoms and examination findings can overlap between perennial allergic rhinitis and non-allergic rhinitis (NAR), with nasal turbinates swollen and beefy red, scant mucus, cobblestoning of posterior pharynx from chronic post-nasal drainage, and retraction of tympanic membranes indicating congestion.

A diagnosis of NAR requires negative specific IgE responses by skin or serological testing.

Differentiation between non-allergic rhinitis with eosinophilia syndrome and other sub-types of NAR is determined by the presence or absence of eosinophilia in the nasal passage.

Treatment is based on symptoms, and all patients should be counselled on avoidance of triggers. Symptom control in NAR requires a balance between the control of excess secretions and over-suppression. First-line treatments include intranasal corticosteroids, intranasal antihistamines, and intranasal ipratropium.

Structural problems or other complicating conditions should be ruled out with imaging if initial therapeutic trials fail to relieve symptoms. Possibilities include osteomeatal complex obstruction that occurs as a result of chronic inflammation or recurrent infections, severe nasal septal deviation and nasal polyposis, or, less commonly, tumour or foreign body.

Non-allergic rhinitis (NAR) refers to a group of chronic rhinitis sub-types that are not caused by allergy or infection. At least eight sub-types have been proposed, including vasomotor rhinitis (VMR [also known as 'autonomic rhinitis', 'non-allergic rhinopathy', and 'idiopathic non-allergic rhinitis']), non-allergic rhinitis with eosinophilia syndrome (NARES), atrophic rhinitis, senile rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal rhinitis, and occupational rhinitis. VMR is the most common sub-type.[1]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 Jun 15;2(6):119-20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650969 http://www.ncbi.nlm.nih.gov/pubmed/24229320?tool=bestpractice.com

To establish a definitive diagnosis of NAR, all other chronic rhinitis syndromes should be properly considered and excluded.[2]Nassef M, Shapiro G, Casale TB. Identifying and managing rhinitis and its subtypes: allergic and non-allergic components - a consensus report and materials from the Respiratory Allergic Disease Foundation. Curr Med Res Opin. 2006 Dec;22(12):2541-8. http://www.ncbi.nlm.nih.gov/pubmed/17265594?tool=bestpractice.com [3]Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 1998 Nov;81(5 Pt 2):478-518. http://www.ncbi.nlm.nih.gov/pubmed/9860027?tool=bestpractice.com Environmental tobacco smoke, perfumes and fragrances, as well as temperature and barometric changes may aggravate symptoms in NAR,[2]Nassef M, Shapiro G, Casale TB. Identifying and managing rhinitis and its subtypes: allergic and non-allergic components - a consensus report and materials from the Respiratory Allergic Disease Foundation. Curr Med Res Opin. 2006 Dec;22(12):2541-8. http://www.ncbi.nlm.nih.gov/pubmed/17265594?tool=bestpractice.com [3]Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 1998 Nov;81(5 Pt 2):478-518. http://www.ncbi.nlm.nih.gov/pubmed/9860027?tool=bestpractice.com but specific IgE responses by skin or serological testing are all negative. The presence of eosinophils in the nasal mucosa in NARES distinguishes it from other sub-types of NAR.[2]Nassef M, Shapiro G, Casale TB. Identifying and managing rhinitis and its subtypes: allergic and non-allergic components - a consensus report and materials from the Respiratory Allergic Disease Foundation. Curr Med Res Opin. 2006 Dec;22(12):2541-8. http://www.ncbi.nlm.nih.gov/pubmed/17265594?tool=bestpractice.com [3]Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 1998 Nov;81(5 Pt 2):478-518. http://www.ncbi.nlm.nih.gov/pubmed/9860027?tool=bestpractice.com

It is a chronic condition that should be distinguished from a common cold, which can manifest with symptoms of NAR but is self-limiting.