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Chronic Nonallergic Rhinitis Denise K.C Chronic Nonallergic Rhinitis Denise K.C. Sur, MD, and Monica L. Plesa, MD David Geffen School of Medicine at the University of California, Los Angeles, California Chronic nonallergic rhinitis encompasses a group of rhinitis subtypes without allergic or infectious etiologies. Although chronic nonallergic rhinitis represents about one-fourth of rhinitis cases and impacts 20 to 30 million patients in the United States, its pathophysiology is unclear and diagnostic testing is not available. Characteristics such as no evidence of allergy or defined triggers help define clinical subtypes. There are eight subtypes with overlapping presentations, including nonallergic rhi- nopathy, nonallergic rhinitis with nasal eosinophilia syndrome, atrophic rhinitis, senile or geriatric rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal rhinitis, and occupational rhinitis. Treat- ment is symptom-driven and similar to that of allergic rhinitis. Patients should avoid known triggers when possible. First-line therapies include intranasal corticosteroids, intranasal antihistamines, and intranasal ipratropium. Combination therapy with decongestants and first-generation antihistamines can be considered if monotherapy does not adequately control symptoms. Nasal irrigation and intra- nasal capsaicin may be helpful but need further investigation. (Am Fam Physician. 2018;98(3):171-176. Copyright © 2018 American Academy of Family Physicians.) Chronic nonallergic rhinitis encompasses They can be perennial, persistent, intermittent, a group of rhinitis subtypes without allergic or or seasonal. Clinically, chronic nonallergic rhi- infectious etiologies. Although chronic nonal- nitis is characterized by its nonallergic triggers, lergic rhinitis represents at least 23% of rhinitis including weather changes, tobacco smoke, cases in the United States and impacts an esti- automotive emission fumes, and irritants such mated 20 to 30 million patients, its pathophys- as chemicals with strong odors (e.g., perfumes, iology is unclear.1,2 Chronic nonallergic rhinitis chlorine).6,7 It also represents a group of hetero- was previously referred to as nonallergic vaso- geneous syndromes with common underlying motor or vasomotor rhinitis, but it was renamed clinical characteristics such as nasal congestion because of a lack of evidence showing a vascular and rhinorrhea, but without nasal, pharyngeal, origin. The best current evidence supports noci- or ocular itching; sneezing; pulmonary symp- ceptor and autonomic nerve dysregulation as toms; eczema; or nasal polyps.8,9 In contrast with components in all forms of nonallergic rhinitis.3-5 the blue-hued mucosa associated with allergy and the red mucosa associated with rhinosinus- Clinical Characteristics itis, physical examination of the nasal mucosa is A negative result on allergy testing is one unifying normal with chronic nonallergic rhinitis, except characteristic of the chronic nonallergic rhinitis for the atrophic subtype. subtypes. Beyond that, clinical characteristics Chronic nonallergic rhinitis is more common help define the conditions. First, these conditions in women, with a female-to-male ratio of 2: 1 to are chronic (i.e., lasting at least three months). 3: 1.6,9 In a blinded survey using a validated ques- tionnaire distributed to 100 randomly selected new patients presenting to an allergist’s office for CME This clinical content conforms to AAFP criteria for continuing medical education (CME). chronic rhinitis, those with chronic nonallergic See CME Quiz on page 149. rhinitis were usually older than 35 years and had Author disclosure: No relevant financial no family history of allergies, whereas patients affiliations. with allergic rhinitis often were younger than 20 years and had a family history of allergies.10 Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2018 American Academy of Family Physicians. For the private, noncom- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2018 American Academy of Family Physicians. For the private, noncom- August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 171 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References An intranasal corticosteroid or intranasal anti- B 5, 17, 22, 24 not help distinguish allergic from histamine alone should be the initial treatment nonallergic etiologies or affect man- for nonallergic rhinitis if symptoms are not agement choices. However, iden- rhinorrhea-predominant. tifying eosinophils and mast cells Combination therapy with an intranasal cortico- C 5, 22-24 can help predict response to nasal steroid and intranasal antihistamine is better than corticosteroids. either treatment alone. Intranasal ipratropium should be the initial treatment C 25, 26 ATROPHIC RHINITIS for rhinorrhea in patients with gustatory nonallergic Atrophic rhinitis involves atrophy rhinitis. of the nasal mucosa that can lead to 2 An intranasal corticosteroid plus intranasal ipratro- B 28 nasal crusting and drying. This is a pium is more effective than either treatment alone noninflammatory subtype and is dis- for rhinorrhea. tinguished primarily by its unique physical examination findings. Decongestants may be used in the treatment of C 24 nonallergic rhinitis, but only in the short term because of adverse effects. SENILE RHINITIS Senile or geriatric rhinitis is distin- Nasal irrigation may be used for nonallergic rhinitis. B 29 guished by its late onset, occuring A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality primarily in older patients. It presents patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert as watery rhinorrhea that worsens in opinion, or case series. For information about the SORT evidence rating system, go to https:// www.aafp.org/afpsort. response to patient-identified triggers, including food, odors, or environmen- tal irritants.2 Subtypes GUSTATORY RHINITIS Chronic nonallergic rhinitis is grouped into eight subtypes Gustatory rhinitis represents a nasal response to consuming or clinical entities based on a 2008 consensus panel classifi- specific foods (e.g., spicy foods) or liquids (e.g., alcohol).2,7 It cation (Table 1).2 is distinguished primarily by its trigger and often overlaps with senile rhinitis. NONALLERGIC RHINOPATHY The most common subtype is nonallergic rhinopathy, pre- DRUG-INDUCED RHINITIS viously known as vasomotor rhinitis or idiopathic nonal- Drug-induced rhinitis can occur with use of various medi- lergic rhinitis.6 It is characterized by nasal symptoms that cations and illicit drugs, including antihypertensives, non- are triggered by environmental conditions such as strong steroidal anti-inflammatory drugs, phosphodiesterase-5 smells or changes in temperature, humid- inhibitors, and cocaine. Rhinitis medica- 11 ity, or barometric pressure, typically TABLE 1 mentosa is an example of this subtype in without nasal and palatal itching or bursts which the use of topical decongestants for of sneezing. Subtypes of Chronic longer than three to five days results in a Nonallergic Rhinitis rebound nonallergic vascular congestion. NONALLERGIC RHINITIS WITH NASAL EOSINOPHILIA SYNDROME Atrophic rhinitis HORMONAL RHINITIS Drug-induced rhinitis Nonallergic rhinitis with nasal eosino- Hormonal rhinitis refers to the onset of Gustatory rhinitis philia syndrome is an inflammatory type nasal congestion and rhinorrhea associated Hormonal rhinitis of rhinitis with increased eosinophils in with endogenous female hormones.7 The Nonallergic rhinitis with the secretions and on nasal biopsy, with eosinophilia syndrome response to the hormones of pregnancy is the increased mast cells and evidence of mast Nonallergic rhinopathy most classic and common example. Symp- cell degranulation but without positive Occupational rhinitis toms resolve with the end of pregnancy. 12,13 findings on allergy testing. Clinically, Senile or geriatric rhinitis testing the secretions for eosinophils OCCUPATIONAL RHINITIS is not typically performed because the Information from reference 2. Occupational rhinitis is a result of occupa- presence or absence of eosinophils does tional exposures, ranging from latex and 172 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018 FIGURE 1 Symptoms of chronic nonallergic rhinitis a history of cranial or facial trauma or intranasal surgery Congestion-predominant or Rhinorrhea-predominant presenting with a persistent unilateral clear rhinorrhea that mixed congestion and rhinorrhea is increased with bending over. Intranasal ipratropium Diagnosis Intranasal corticosteroid or intranasal antihistamine Diagnosing chronic nonallergic rhinitis can be challenging Symptoms persist because nasal congestion and rhinorrhea can also occur with allergic rhinitis and chronic rhinosinusitis. Nonaller- Symptoms persist gic rhinitis was previously a diagnosis of exclusion. It was Intranasal ipratropium plus intranasal corticosteroid diagnosed if a patient with suspected allergic rhinitis tested Intranasal corticosteroid or intranasal antihistamine negative for allergies on skin prick testing or antigen-specific
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