Traditional triggers such as cat or dog exposure should be absent.
Symptoms and exam 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 postnasal drainage, and retraction of tympanic membranes indicating congestion.
A diagnosis of NAR requires negative specific IgE responses by skin or serologic testing.
Differentiation between the subtypes of non-allergic conditions, vasomotor rhinitis and non-allergic rhinitis with eosinophilia syndrome, is determined by the presence or absence of eosinophilia in the nasal passage.
Algorithm for pharmacotherapy differs dramatically from allergic rhinitis, although some agents overlap.
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, tumor or foreign body.
The non-allergic rhinitis (NAR) conditions are vasomotor rhinitis (VMR) and non-allergic rhinitis with eosinophilia syndrome (NARES). To establish a definitive diagnosis of VMR or NARES, 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 serologic testing are all negative. The presence of eosinophils in the nasal mucosa in NARES distinguishes it from VMR.  
It is a chronic condition that should be distinguished from a common cold, which can manifest with symptoms of NAR but is self-limiting.
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 monograph.
Professor Bernstein would like to gratefully acknowledge Dr Chris Codispoti, a previous contributor to this monograph. CC declares that he has no competing interests.
St. Jude Faculty Director
Pediatric Infectious Diseases Fellowship Program
EEA declares that she has no competing interests.
Istanbul Training and Research Hospital
OY declares that he has no competing interests.
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