REVIEW CME EDUCATIONAL OBJECTIVE: Readers will distinguish the different forms of rhinitis and their treatments CREDIT BRIAN SCHROER, MD LILY C. PIEN, MD Center for Pediatric Allergy, 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 rhinorrhea and na- Nonallergic rhinitis 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 allergies 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 asthma and has had no allergies to drugs, 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 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 79 • NUMBER 4 APRIL 2012 285 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. NONALLERGIC RHINITIS ■ RHINITIS: ALLERGIC OR NONALLERGIC? and nonallergic rhinitis have similar symp- toms, making them difficult to distinguish. While allergic rhinitis 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 sinusitis 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 nasal congestion 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 autonomic nervous system 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 antihistamines have no benefit. 286 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 79 • NUMBER 4 APRIL 2012 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. SCHROER AND PIEN 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. Drug-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. Rhinitis medicamentosa • In allergic rhinitis, the turbinates are often pale, moist, and boggy with a bluish tinge. Infectious rhinitis • Findings such as a deviated nasal septum, Acute upper respiratory tract 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 Sarcoidosis 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