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Nonallergic rhinitis: Common problem, chronic … - chronic non allergic rhinitis treatment

Nonallergic rhinitis: Common problem, chronic …-chronic non allergic rhinitis treatment

EDUCATIONAL OBJECTIVE: Readers will distinguish the different forms of rhinitis and their treatments
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 A 55-year-old woman has come to the
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
for controlling symptoms. symptoms.
If symptoms continue, then the first-line treatment for
The patient also has hypertension, hypo-
thyroidism, and hot flashes due to menopause;
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?
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.
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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
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
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-
of patients bance, and cognitive impairment and can be amination. Key questions relate to the triggers
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-
nitis a patient may be experiencing and there-
rhinitis may 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-
form immunoglobulin E (IgE) in the nose, the eti- rhea, rather than sneezing and itching,
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.
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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
Physical findings Vasomotor rhinitis
Some findings on physical examination may Weather-sensitive, temperature-sensitive
help distinguish allergic from nonallergic rhi-
Gustatory rhinitis
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
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
consideration of the several subtypes of Nonallergic rhinitis eosinophilic syndrome
nonallergic rhinitis (Table 1). Immunologic causes
Wegener granulomatosis
Case CONTINUED Sarcoidosis
Relapsing polychondritis
Our patient's symptoms can be caused by many Midline granulomas
different factors. Allergic triggers for rhinitis Churg-Strauss syndrome
include both indoor and outdoor sources. The Amyloidosis Uncontrolled
most common allergens include cat, dog, dust Granulomatous infections
mite, cockroach, mold, and pollen allergens. Occupational rhinitis
rhinitis can
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
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.
and clear rhinorrhea more than sneezing and The diagnosis and management of rhinitis:
an updated practice parameter.
itching. The symptoms can be sporadic, with J Allergy Clin Immunol 2008; 122(suppl 2):S1-S84,
acute onset in relation to identifiable nonal- with permission from Elsevier.
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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How to cope with chronic rhinitis? Treatments Medications. Medications known as antihistamines can help treat the underlying cause of allergic rhinitis. ... Lifestyle changes. The best way to prevent and treat chronic rhinitis is to avoid the environmental allergen or trigger that is causing it. Surgery. ...