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Home , Nonallergic rhinitis

REVIEW CME EDUCATIONAL OBJECTIVE: Readers will distinguish the different forms of and their treatments CREDIT BRIAN SCHROER, MD LILY C. PIEN, MD Center for Pediatric , and Department of Department of Pulmonary, Allergy, and Critical Pulmonary, Allergy, and Critical Care Medicine, Care Medicine, and Center for Medical Education Cleveland Clinic Research and Development (CMERAD), Education Institute, Cleveland Clinic

Nonallergic rhinitis: Common problem, chronic symptoms

■■ ABSTRACT 55-year-old woman has come to the A clinic because of clear and na- can significantly affect a patient’s sal congestion, which occur year-round but are quality of life. It is difficult to distinguish from allergic worse in the winter. She reports that at times rhinitis, but it has different triggers, and its response to her nose runs continuously. Nasal symptoms treatment can vary. We review its differential diagnosis, have been present for 4 to 5 years but are wors- causes, and treatment. ening. The clear discharge is not associated with sneezing or itching. Though she lives ■■ KEY POINTS with a cat, her symptoms are not exacerbated by close contact with it. When evaluating a patient with rhinitis, a key question is One year ago, an allergist performed skin whether it is allergic or nonallergic. testing but found no evidence of as a cause of her rhinitis. A short course of intrana- Identifying triggers that should be avoided is important sal steroids did not seem to improve her nasal symptoms. for controlling symptoms. The patient also has hypertension, hypo- thyroidism, and hot flashes due to menopause; If symptoms continue, then the first-line treatment for these conditions are well controlled with lisin- nonallergic rhinitis is intranasal steroids. opril (Zestril), levothyroxine (Synthroid), and estrogen replacement. She has no history of Failure of intranasal steroids to control symptoms should and has had no allergies to , in- prompt a consideration of the many potential causes cluding nonsteroidal anti-inflammatory drugs of rhinitis, and further evaluation and treatment can be (NSAIDs.) How should this patient be evaluated and tailored accordingly. treated?

■■ COMMON, OFTEN OVERLOOKED

Many patients suffer from rhinitis, but this problem can be overshadowed by other chron- ic diseases seen in a medical clinic, especially during a brief office visit. When a patient pres- ents with rhinitis, a key question is whether it is allergic or nonallergic. This review will discuss the different forms of nonallergic rhinitis and their causes, and give recommendations about therapy. doi:10.3949/ccjm.79a11099

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■■ Rhinitis: allergic or nonallergic? and nonallergic rhinitis have similar symp- toms, making them difficult to distinguish. While affects 30 and 60 mil- However, their mechanisms and treatment lion Americans annually, or between 10% to differ. By categorizing a patient’s type of rhi- 30% of US adults,1 how many have nonaller- nitis, the physician can make specific recom- gic rhinitis has been difficult to determine. mendations for avoidance and can initiate In a study in allergy clinics, 23% of pa- treatment with the most appropriate therapy. tients with rhinitis had the nonallergic form, Misclassification can lead to treatment failure, 43% had the allergic form, and 34% had both multiple visits, poor adherence, and frustra- forms (mixed rhinitis).2 Other studies have tion for patients with uncontrolled symptoms. suggested that up to 52% of patients present- Patients for whom an allergic cause cannot ing to allergy clinics with rhinitis have nonal- be found by allergy skin testing or serum spe- lergic rhinitis.3 cific IgE immunoassay (Immunocap/RAST) Over time, patients may not stay in the for environmental aeroallergens are classified same category. One study found that 24% of as having nonallergic rhinitis. patients originally diagnosed with nonallergic rhinitis developed positive allergy tests when ■■ CLUES POINTING TO NONALLERGIC retested 3 or more years after their initial eval- VS ALLERGIC RHINITIS uation.4 Regardless of the type, untreated or uncon- Nonallergic rhinitis encompasses a range of trolled symptoms of rhinitis can significantly syndromes with overlapping symptoms. While affect the quality of life. tools such as the Rhinitis Diagnostic Work- All forms of rhinitis are characterized by sheet are available to help differentiate aller- one or more of the following symptoms: na- gic from nonallergic rhinitis, debate continues sal congestion, clear rhinorrhea, sneezing, and about whether it is necessary to characterize itching. These symptoms can be episodic or different forms of rhinitis before initiating chronic and can range from mild to debilitat- treatment.8 One-fourth ing. In addition, rhinitis can lead to systemic The diagnosis of nonallergic rhinitis de- to one-half symptoms of fatigue, headache, sleep distur- pends on a thorough history and physical ex- bance, and cognitive impairment and can be amination. Key questions relate to the triggers of patients associated with respiratory symptoms such as that bring on the rhinitis, which will assist the with chronic and asthma.1 clinician in determining which subtype of rhi- rhinitis may nitis a patient may be experiencing and there- Mechanisms are mostly unknown fore how to manage it. Clues: have the While allergic rhinitis leads to symptoms • Patients with nonallergic rhinitis more nonallergic when airborne allergens bind with specific often report and rhinor- immunoglobulin E (IgE) in the nose, the eti- rhea, rather than sneezing and itching, form ology of most forms of nonallergic rhinitis is which are predominant symptoms of aller- unknown. However, several mechanisms have gic rhinitis. been proposed. These include entopy (local • Patients with nonallergic rhinitis tend to nasal IgE synthesis with negative skin tests),5 develop symptoms at a later age. nocioceptive dysfunction (hyperactive senso- • Common triggers of nonallergic rhinitis ry receptors),6 and are changes in weather and temperature, abnormalities (hypoactive or hyperactive dys- food, perfumes, odors, smoke, and fumes. function of sympathetic or parasympathetic Animal exposure does not lead to symp- nerves in the nose).7 toms. • Patients with nonallergic rhinitis have few Does this patient have an allergic cause complaints of concomitant symptoms of of rhinitis? allergic conjunctivitis (itching, watering, When considering a patient with rhinitis, the redness, and swelling). most important question is, “Does this patient • Many patients with nonallergic rhinitis have an allergic cause of rhinitis?” Allergic find that have no benefit.

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Also, they do not have other atopic diseas- TABLE 1 es such as eczema or food allergies and have no family history of atopy. Types of nonallergic rhinitis

■ Vasomotor rhinitis ■ Physical findings Irritant-sensitive Weather-sensitive, temperature-sensitive Some findings on physical examination may Gustatory rhinitis help distinguish allergic from nonallergic rhi- nitis. -induced rhinitis • Patients with long-standing allergic rhinitis Aspirin, nonsteroidal anti-inflammatory drugs may have an “allergic crease,” ie, a horizon- Alpha receptor agonists and antagonists tal wrinkle near the tip of the nose caused Vasodilators by frequent upward wiping. Another sign Antihypertensive drugs, other cardiovascular drugs may be a gothic arch, which is a narrowing Oral contraceptives of the hard palate occurring as a child. • In allergic rhinitis, the turbinates are often pale, moist, and boggy with a bluish tinge. Infectious rhinitis • Findings such as a deviated , Acute upper infection discolored nasal discharge, atrophic na- Chronic rhinosinusitis sal mucosa, or nasal polyps should prompt Nonallergic rhinitis eosinophilic syndrome consideration of the several subtypes of nonallergic rhinitis (Table 1). Immunologic causes Wegener granulomatosis ■■ Case CONTINUED Relapsing polychondritis Our patient’s symptoms can be caused by many Midline granulomas Churg-Strauss syndrome different factors. Allergic triggers for rhinitis Amyloidosis Uncontrolled include both indoor and outdoor sources. The Granulomatous infections most common allergens include cat, dog, dust rhinitis can mite, cockroach, mold, and pollen allergens. Occupational rhinitis significantly The absence of acute sneezing and itching Hormonal rhinitis when around her cat and her recent negative Pregnancy affect skin-prick tests confirm that the rhinitis symp- Menstruation a patient’s toms are not allergic. Hypothyroidism In this patient, who has symptoms through- quality of life out the year but no allergic triggers, consider- Structural ation of the different subtypes of nonallergic Polyps rhinitis may help guide further therapy. Deviated septum Adenoidal hypertrophy ■ Tumors ■ SUBTYPES OF NONALLERGIC RHINITIS Cerebrospinal fluid leak Vasomotor rhinitis Atrophic rhinitis Vasomotor rhinitis is thought to be caused by Infectious a variety of neural and vascular triggers, often Secondary without an inflammatory cause. These triggers lead to symptoms involving nasal congestion Adapted from Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: and clear rhinorrhea more than sneezing and an updated practice parameter. J Allergy Clin Immunol 2008; 122(suppl 2):S1–S84, itching. The symptoms can be sporadic, with with permission from Elsevier. acute onset in relation to identifiable nonal- http://www.jacionline.org lergic triggers, or chronic, with no clear trigger. Gustatory rhinitis, for example, is a form of vasomotor rhinitis in which clear rhinor-

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rhea occurs suddenly while eating or while terase-5 inhibitors such as (Viagra), drinking alcohol. It may be prevented by using can lead to acute rhinitis symptoms (“anniver- nasal ipratropium (Atrovent) before meals. sary rhinitis”). Irritant-sensitive vasomotor rhinitis. In Unknown mechanisms. Many other medi- some patients, acute vasomotor rhinitis symp- cations can lead to rhinitis by unknown mech- toms are brought on by strong odors, cigarette anisms, usually with normal findings on physi- smoke, air pollution, or perfume. When asked, cal examination. These include beta-blockers, most patients easily identify which of these ir- angiotensin-converting enzyme inhibitors, ritant triggers cause symptoms. calcium channel blockers, exogenous estro- Weather- or temperature-sensitive vaso- gens, oral contraceptives, antipsychotics, and motor rhinitis. In other patients, a change in gabapentin (Neurontin). temperature, humidity, or barometric pressure Correlating the initiation of a drug with or exposure to cold or dry air can cause na- the onset of rhinitis can help identify offend- sal symptoms.9 These triggers are often hard ing medications. Stopping the suspected med- to identify. Weather- or temperature-sensitive ication, if feasible, is the first-line treatment. vasomotor rhinitis is often mistaken for sea- Rhinitis medicamentosa, typically caused sonal allergic rhinitis because weather chang- by overuse of over-the-counter topical nasal de- es occur in close relation to the peak allergy congestants, is also classified under drug-induced seasons in the spring and fall. However, this rhinitis. Patients may not think of nasal decon- subtype does not respond as well to intranasal gestants as medications, and the physician may steroids.9 need to ask specifically about their use. Other nonallergic triggers of vasomotor On examination, the nasal mucosa appears rhinitis may include exercise, emotion, and beefy red without mucous. Once a diagnosis is (honeymoon rhinitis).10 made, the physician should identify and treat Some triggers, such as tobacco smoke and the original etiology of the nasal congestion perfume, are easy to avoid. Other triggers, that led the patient to self-treat. such as weather changes, are unavoidable. Patients with rhinitis medicamentosa of- In nonallergic If avoidance measures fail or are inadequate, ten have difficulty discontinuing use of topical rhinitis, there is medications (described below) can be used for decongestants. They should be educated that prophylaxis and symptomatic treatment. the withdrawal symptoms can be severe and more nasal that more than one attempt at quitting may congestion Drug-induced rhinitis be needed. To break the cycle of rebound con- Drugs of various classes are known to cause ei- gestion, topical intranasal steroids should be and rhinorrhea; ther acute or chronic rhinitis. Drug-induced used, though 5 to 7 days of oral steroids may in allergic rhinitis has been divided into different types be necessary.1 11 rhinitis, more based on the mechanism involved. Cocaine is a potent vasoconstrictor. Its il- The local inflammatory type occurs in licit use should be suspected, especially if the sneezing and aspirin-exacerbated , which patient presents with symptoms of chronic ir- itching is characterized by nasal polyposis with chron- ritation such as frequent , crusting, ic rhinosinusitis, hyposmia, and moderate to and scabbing.12 severe persistent asthma. Aspirin and other NSAIDs induce an acute local , Infectious rhinitis leading to severe rhinitis and asthma symp- One of the most common causes of acute rhi- toms. Avoiding all NSAID products is rec- nitis is upper respiratory infection. ommended; aspirin desensitization may lead Acute viral upper respiratory infection of- to improvement in rhinosinusitis and asthma ten presents with thick nasal discharge, sneez- control. ing, and nasal obstruction that usually clears The neurogenic type of drug-induced rhi- in 7 to 10 days but can last up to 3 weeks. nitis can occur with sympatholytic drugs such Acute bacterial sinusitis can follow, typically as alpha receptor agonists (eg, clonidine [Cat- in fewer than 2% of patients, with symptoms apres]) and antagonists (eg, prazosin [Mini- of persistent nasal congestion, discolored mu- press]).11 Vasodilators, including phosphodies- cus, facial pain, cough, and sometimes fever.

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Chronic rhinosinusitis is a syndrome with A lack of a response to intranasal steroids sinus mucosal inflammation with multiple or oral antibiotics should lead to consideration causes. It is clinically defined as persistent na- of these conditions, and treatment should be sal and sinus symptoms lasting longer than 12 tailored to the specific disease. weeks and confirmed with computed tomog- raphy (CT).13 The CT findings of chronic rhi- Occupational rhinitis nosinusitis include thickening of the lining of Occupational exposure to chemicals, biologic the sinus cavities or complete opacification of aerosols, flour, and latex can lead to rhinitis, the pneumatized sinuses. typically through an inflammatory mecha- Major symptoms to consider for diagno- nism. Many patients present with associated sis include facial pain, congestion, obstruc- occupational asthma. The symptoms improve tion, purulent discharge on examination, and when the patient is away from work and wors- changes in olfaction. Minor symptoms are en throughout the work week. cough, fatigue, headache, halitosis, fever, ear Avoiding the triggering agent is necessary symptoms, and dental pain. to treat these symptoms. Treatment may involve 3 or more weeks of an oral antibiotic and a short course of an Hormonal rhinitis oral steroid, a daily nasal steroid spray, or both Hormonal rhinitis, ie, rhinitis related to meta- oral and nasal steroids. Most patients can be bolic and endocrine conditions, is most com- managed in the primary care setting, but they monly associated with high estrogen states. can be referred to an ear, nose, and throat spe- Nasal congestion has been reported with preg- cialist, an allergist, or an immunologist if their nancy, menses, menarche, and the use of oral symptoms do not respond to initial therapy. contraceptives.15 The mechanism for conges- tion in these conditions still needs clarifica- Nonallergic rhinitis eosinophilic syndrome tion. Patients with nonallergic rhinitis eosinophilic When considering drug therapy, only in- syndrome (NARES) are typically middle-aged tranasal budesonide (Rhinocort) has a preg- and have perennial symptoms of sneezing, nancy category B rating. Weather- or itching, and rhinorrhea with intermittent ex- While hypothyroidism and acromegaly temperature- acerbations. They occasionally have associ- have been mentioned in reviews of nonal- ated hyposmia (impaired sense of smell).1 The lergic rhinitis, evidence that these disorders sensitive diagnosis is made when account cause nonallergic rhinitis is not strong.16,17 vasomotor for more than 5% of cells on a nasal smear and rhinitis allergy testing is negative. Structurally related rhinitis Patients may develop nasal polyposis and Anatomic abnormalities that can cause per- is frequently aspirin sensitivity.1 Entopy has been described sistent nasal congestion include nasal septal mistaken for in some.14 deviation, turbinate hypertrophy, enlarged ad- Because of the eosinophilic inflammation, enoids, tumors, and foreign bodies. These can seasonal this form of nonallergic rhinitis responds well be visualized by simple anterior nasal exami- allergic rhinitis to intranasal steroids. nation, nasal endoscopy, or radiologic studies. If structural causes lead to impaired quality of Immunologic causes life or chronic rhinosinusitis, then consider Systemic diseases can affect the nose and referral to a specialist for possible surgical cause variable nasal symptoms that can be treatment. mistaken for rhinitis. Wegener granuloma- Clear spontaneous rhinorrhea, with or tosis, sarcoidosis, relapsing polychondritis, without trauma, can be caused by cerebro- midline granulomas, Churg-Strauss syndrome, spinal fluid leaking into the nasal cavity.18 and amyloidosis can all affect the structures A salty, metallic taste in the mouth can be in the nose even before manifesting systemic a clue that the fluid is cerebrospinal fluid. A symptoms. Granulomatous infections in the definitive diagnosis of cerebrospinal fluid leak nose may lead to crusting, bleeding, and nasal is made by finding beta-2-transferrin in nasal obstruction.1 secretions.

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Our guidelines for treating nonallergic rhinitis History and physical examination consistent with nonallergic rhinitis

Initiate intranasal steroid spray Follow up in 2–4 weeks

Medication effective No improvement

Continue therapy Address adherence and spray technique Consider triggers Consider adjunctive medications and avoidance Consider accuracy of initial diagnosis

Symptoms of congestion Symptoms of rhinorrhea or weather- and rhinorrhea or temperature-sensitive vasomotor rhinitis

Intranasal antihistamines Topical ipratropium (Atrovent) or intranasal antihistamines

If no response, consider: Different diagnosis Specialty consultation Imaging FIGURE 1 Suspect cocaine Atrophic rhinitis rhinorrhea when he is away on business trips. abuse if the Atrophic rhinitis is categorized as primary or She notes that her symptoms are often worse secondary. on airplanes (dry air with an acute change in patient Primary (idiopathic) atrophic rhinitis barometric pressure), with weather changes, presents is characterized by atrophy of the nasal mu- and in cold, dry environments. Symptoms are with frequent cosa and mucosal colonization with Klebsi- not induced by eating. ella ozaenae associated with a foul-smelling We note that she started taking lisinopril nosebleeds, nasal discharge.19,20 This disorder has been 2 years ago and conjugated equine estrogens 8 crusting, and primarily reported in young people who pres- years ago. Review of systems reveals no history ent with nasal obstruction, dryness, crusting, of facial or head trauma, polyps, or hyposmia. scabbing and epistaxis. They are from areas with warm The rhinitis and congestion are bilateral, climates, such as the Middle East, Southeast and she denies headaches, acid reflux, and Asia, India, Africa, and the Mediterranean. conjunctivitis. She has a mild throat-clearing Secondary atrophic rhinitis can be a com- cough that she attributes to postnasal drip. plication of nasal or sinus surgery, trauma, gran- On physical examination, her blood pres- ulomatous disease, or exposure to radiation.21 sure is 118/76 mm Hg and her pulse is 64. Her This disorder is typically diagnosed with nasal turbinates are congested with clear rhinor- endoscopy and treated with daily saline rinses rhea. The rest of the examination is normal. with or without topical antibiotics.21 ■■ AVOID TRIGGERS, ■■ Case continued PRETREAT BEFORE EXPOSURE

Questioned further, our patient says her symp- While treatment for nonallergic rhinitis varies toms are worse when her husband smokes, but according to the cause, there are some general that she continues to have congestion and guidelines for therapy (FIGURE 1).

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TABLE 2 Medications recommended for treating nonallergic rhinitis

Medication official indication for nonal- Dosing Regimen x Appro imate Cost Class lergic rhinitis; Benefits Intranasal Beclomethasone and flutica- Two sprays in each nostril Generic: $60a Beclomethasone (Beconase AQ, sone diproprionate have US once daily Name brand: $86–$145a Vancenase) Food and Drug Adminstra- Budesonide (Rhinocort AQ) tion (FDA) indication Stop if there is nasal Ciclesonide (Omnaris) bleeding and consult with Fluticasone (Flonase, Benefits: relief of nasal physician Veramyst, generic) congestion, rhinorrhea, Mometasone (Nasonex) sneezing, and itching Triamcinolone (Nasacort) Intranasal antihistamines Only Astelin has FDA indica- Two sprays in each nostril Astelin: $120a

Azelastine (Astelin, Astepro) tion twice a day as needed a Olopatadine (Patanase) Astepro: $108 Benefits: improvement of Patanase: $135a rhinorrhea, nasal conges- tion, sneezing and itching. Intranasal Has FDA indication Two sprays each nostril Generic: $38 0.03% two to three times a day (Atrovent 0.03%) Benefits: decreases rhinor- Name brand 0.03%: rhea $101 Oral decongestants No indication Not recommended for Sudafed 60 mg, 100 (eg, Sudafed) regular use tablets: $10.13 Phenylephrine Benefits: May be helpful for acute rhinorrhea and congestion

aMost intranasal corticosteroids contain 120 sprays per bottle, which is 60 doses; Astelin and Astepro have 200 sprays, and Patanase has 200.

People with known environmental, non- pionate (Beconase AQ) are approved by the immunologic, and irritant triggers should be US Food and Drug Administration (FDA) reminded to avoid these exposures if pos- for treating nonallergic rhinitis. Intrana- sible. sal mometasone (Nasonex) is approved for If triggers are unavoidable, patients can treating nasal polyps. pretreat themselves with topical nasal sprays Nasal steroid sprays are most effective if before exposure. For example, if symptoms the dominant nasal symptom is congestion, occur while on airplanes, then intranasal ste- but they have also shown benefit for rhinor- roids or sprays should be used rhea, sneezing, and itching. before getting on the plane. Side effects of nasal steroid sprays include nasal irritation (dryness, burning, and sting- Many drugs available ing) and epistaxis, the latter occurring in 5% Fortunately, many effective drugs are available to 10% of patients.23 to treat nonallergic rhinitis. These have few Intranasal antihistamines include az- adverse effects or drug interactions. elastine (Astelin, Astepro) and olopatadine Intranasal steroid sprays are consid- (Patanase). They are particularly useful for ered first-line therapy, as there are studies treating sneezing, congestion, and rhinor- demonstrating effectiveness in nonallergic rhea.24 Astelin is the only intranasal antihis- rhinitis.22 Intranasal fluticasone propio- tamine with FDA approval for nonallergic nate (Flonase) and beclomethasone dipro- rhinitis.

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Side effects of this drug class include bit- benefits of saline irrigation are clearance of ter taste (with Astelin), sweet taste (with As- nasal secretions, improvement of nasociliary tepro), headache, and somnolence. function, and removal of irritants and pollen Oral antihistamines such as loratadine from the nose. (Claritin), cetirizine (Zyrtec), and fexofena- dine (Allegra) are now available over the A strategy counter, and many patients try them before Initial therapy (TABLE 2) should be based on seeking medical care. These drugs may be help- the presentation. If the patient has a limited ful for those bothered by sneezing. However, response to the therapy at follow-up in 2 to no study has demonstrated their effectiveness 4 weeks, the physician should consider using for nonallergic rhinitis.25 First-generation an- adjunctive medications, address patient ad- tihistamines may help with rhinorrhea via herence and technique, and reassess the ac- their anticholinergic effects. curacy of the initial diagnosis. At this point, Ipratropium, an antimuscarinic agent, one can consider referral to a specialist such decreases secretions by inhibiting the nasal as an allergist or otolaryngologist, especially if parasympathetic mucous glands. Intranasal ip- there are comorbid conditions such as asthma ratropium 0.03% (Atrovent 0.03%) should be or polyps. considered first-line if the dominant symptom Imaging the sinuses with CT, which has re- is rhinorrhea. Higher-dose ipratropium 0.06% placed standard nasal radiography, may help if is approved for rhinorrhea related to the com- one is concerned about chronic rhinosinusitis, mon cold or allergic rhinitis. Because it is used nasal polyps, or other anatomic condition that topically, little is absorbed. Its major side ef- could contribute to persistent symptoms. Cost fect is nasal dryness. and radiation exposure should enter into the Decongestants, either oral or topical, can decision to obtain this study because a diagno- relieve the symptoms of congestion and rhi- sis based on the patient’s report of symptoms norrhea in nonallergic rhinitis. They should may be equally accurate.29,30 only be used short-term, as there is little evi- Sexual arousal dence to support their chronic use. ■■ CASE CONTINUED can lead to Phenylpropanolamine, a decongestant previously found in over-the-counter cough Our patient has a number of potential causes ‘honeymoon medicines, was withdrawn from the market of her symptoms. Exposure to second-hand rhinitis,’ and in 2000 owing to concern that the drug, es- tobacco smoke at home and to the air in air- erectile pecially when used for weight suppression, planes could be acute triggers. Weather and was linked to hemorrhagic stroke in young temperature changes could explain her chron- dysfunction women.26,27 Other oral decongestants, ie, ic symptoms in the spring and fall. Use of an drugs can pseudoephedrine and phenylephrine, are angiotensin-converting enzyme inhibitor (in still available, but there are no definitive her case, lisinopril) and estrogen replacement lead to guidelines for their use. Their side effects in- therapy may contribute to perennial symp- ‘anniversary clude tachycardia, increase in blood pressure, toms, but the onset of her nonallergic rhinitis and insomnia. does not correlate with the use of these drugs. rhinitis’ Nasal saline irrigation has been used for There are no symptoms to suggest chronic centuries to treat rhinitis and sinusitis, despite rhinosinusitis or anatomic causes of her symp- limited evidence of benefit. A Cochrane re- toms. view concluded that saline irrigation was well This case is typical of vasomotor rhinitis tolerated, had minor side effects, and could of the weather- or temperature-sensitive type. provide some relief of rhinosinusitis symptoms This diagnosis may explain her lack of im- either as the sole therapeutic measure or as provement with intranasal steroids, though adjunctive treatment.28 Hypertonic saline so- adherence and spray technique should be as- lutions, while possibly more effective than iso- sessed. At this point, we would recommend try- tonic saline in improving mucociliary clear- ing topical antihistamines daily when chronic ance, are not as well tolerated since they can symptoms are present or as needed for acute cause nasal burning and irritation. Presumed symptoms. ■

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