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.
To establish a definitive diagnosis of NAR, all other chronic rhinitis syndromes should be properly considered and excluded. Environmental tobacco smoke, perfumes and fragrances, as well as temperature and barometric changes may aggravate symptoms in NAR, 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.
It is a chronic condition that should be distinguished from a common cold, which can manifest with symptoms of NAR but is self-limiting.
History and exam
Key diagnostic factors
- presence of risk factors
- nasal congestion
- post-nasal drainage
- sore throat
Other diagnostic factors
- ear plugging
- sinus headaches
- postural change triggers
- absence of fever
- purulent discharge
- bilateral symptoms
- sinus pain
- symptom onset age >35
- no seasonal symptoms
- no symptom exacerbation by cats
- exposure to fragrance
- exposure to smoke (e.g., wood, tobacco)
- exposure to hairspray
- exposure to pot pourris
- changes in temperature
- barometric changes
- no family history of allergies
- high oestrogen state
- beta-blocker use
- intranasal drug abuse
1st investigations to order
- allergy prick skin tests
- serological specific IgE testing
Investigations to consider
- nasal eosinophil smear
- sinus computed tomography
- nasal endoscopy
- nasal provocation test
Jonathan A. Bernstein, MD
Professor of Clinical Medicine
Department of Internal Medicine
Division of Immunology/Allergy Section
University of Cincinnati College of Medicine
JAB has acted as a consultant for Inflamax, MEDA, GSK, and ATL, and serves on a medical safety board for HAL Allergy; is a principle investigator or sub-principle investigator for over 30 pharmaceutical companies; has an investigator-initiated research project from Shire; is a protocol chair for a U44 clinical trial funded by NAIAD; is a speaker for AZ, Shire, and CSL Behring; and is an author of a number of references cited in this topic.
Professor Bernstein would like to gratefully acknowledge Dr Chris Codispoti, a previous contributor to this topic.
CC declares that he has no competing interests.
Elisabeth E. Adderson, MD
St. Jude Faculty Director
Pediatric Infectious Diseases Fellowship Program
EEA declares that she has no competing interests.
Ozgur Yigit, MD
Istanbul Training and Research Hospital
OY declares that he has no competing interests.
- Allergic rhinitis (seasonal, perennial, mixed)
- Nasal polyposis
- Deviated septum
- EAACI position paper on non-allergic rhinitis
- BSACI guidelines for the diagnosis and management of allergic and non-allergic rhinitis
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer