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 non-allergic rhinitis with eosinophilia syndrome and other subtypes 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 counseled 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, tumor or foreign body.
Non-allergic rhinitis (NAR) refers to a group of chronic rhinitis subtypes that are not caused by allergy or infection. At least eight subtypes 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 subtype.
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 serologic testing are all negative. The presence of eosinophils in the nasal mucosa in NARES distinguishes it from other subtypes 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
- nasal congestion
- postnasal 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 potpourris
- changes in temperature
- barometric changes
- no family history of allergies
- high estrogen state
- beta-blocker use
- intranasal drug abuse
1st investigations to order
- allergy prick skin tests
- serologic 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
- BSACI guidelines for the diagnosis and management of allergic and non-allergic rhinitis
- EAACI position paper on non-allergic rhinitis
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