Nonallergic rhinitis

Last updated: April 19, 2022

Summarytoggle arrow icon

Rhinitis is the irritation and swelling of the mucous membrane of the nose. There are two main types: allergic rhinitis and nonallergic rhinitis. Allergic rhinitis is caused by a type 1 hypersensitivity reaction that leads to inflammation of the nasal mucous membranes on exposure to certain allergens (e.g., dust, animal dander, mold spores, or plant pollen). Nonallergic rhinitis does not always involve an inflammatory process, and it includes infectious rhinitis, atrophic rhinitis, vasomotor rhinitis, drug-induced rhinitis, occupational rhinitis, gustatory rhinitis, hormonal rhinitis, and nonallergic rhinitis with eosinophilia syndrome (NARES). Infectious rhinitis is most often secondary to an upper respiratory tract infection that manifests as rhinosinusitis. Clinical manifestations of rhinitis include nasal congestion, rhinorrhea, and postnasal drip. Atrophic rhinitis can be primary (idiopathic) or secondary (e.g., due to granulomatous diseases). This form of rhinitis commonly manifests with a foul-smelling, crust-filled nasal cavity and anosmia. Patients with NARES might present with nasal polyposis and hyposmia. Initial management of allergic rhinitis involves allergen and irritant avoidance and pharmacotherapy with intranasal corticosteroids or oral or intranasal antihistamines. Nasal lavage and surgical procedures can relieve symptoms in patients with atrophic and vasomotor rhinitis.

Allergic rhinitis is covered in detail separately.

Apart from infectious rhinitis, nonallergic rhinitis includes the following subtypes.

Types of nonallergic rhinitis
Type Description Causes
Nonallergic rhinitis with eosinophilia syndrome (NARES) [2]
  • Unknown
Drug-induced rhinitis
  • Recurrent, nonallergic inflammation of the nasal mucosa associated with certain medications
Rhinitis medicamentosa
  • Rebound nasal congestion that is seen upon discontinuing intranasal sympathomimetics
  • Occurs 5–7 days after use of topical decongestants
  • Classically leads to increasing dose or frequency of decongestants (vicious cycle)
  • Discontinuation of intranasal sympathomimetics (e.g., phenylephrine, oxymetazoline, xylometazoline)
Hormonal rhinitis
Occupational rhinitis
  • Rhinitis as a result of exposure to irritants in a particular work environment
  • Most commonly seen in furriers, followed by bakers, breeders, veterinarians, farmers, cleaners, assemblers of electrical products, and laboratory employees
  • Irritants (e.g., fur, flour, paints, pesticides, dust, talc, detergents, chemicals)
  • Allergenic substances (e.g., rodent allergens, latex, guar gum, psyllium)
Gustatory rhinitis
Atrophic rhinitis
Vasomotor rhinitis
  • A type of nonallergic rhinitis that is caused by an increase in blood flow to the nasal mucosa

Both allergic and nonallergic rhinitis manifest with postnasal drainage and nasal congestion. However, nasal itching and sneezing are only seen in allergic rhinitis.

  • Definition: chronic rhinitis associated with atrophy and sclerosis of the nasal mucosa
  • Etiology
  • Clinical features
    • Merciful anosmia: extremely foul-smelling nasal cavity but the patient is unaware of the foul smell (anosmia)
    • Nasal cavity is spacious, lacks turbinates, and is covered in yellowish-green crusts.
    • Epistaxis
  • Diagnostics
    • No specific diagnostic test is indicated.
    • Rhinoscopy, nasal cultures, and/or CT scans may be performed to evaluate the extent of the disease.
  • Treatment: aims to decrease the size and improve the blood flow of the nasal cavities and to promote regeneration and increase lubrication of the dry nasal mucosa but no form of treatment can completely eliminate the symptoms

Topical sympathomimetic drugs (e.g., xylometazoline) are contraindicated in atrophic rhinitis since they may decrease vascular perfusion of the nasal cavity and worsen symptoms.

Differential diagnosis of nasal congestion

Common differential diagnoses of nasal congestion
Allergic rhinitis Nasal polyps Deviated nasal septum Adenoid hypertrophy Foreign nasal body
Epidemiology
  • 10–30%
  • Usually starts in childhood (before the age of 20 years)
  • More common in those > 40 years old
  • Very common (∼ 80%)
  • Mostly young children (2–6 years)
  • Mostly young children (median age is 3 years)
Causes
  • Trauma (e.g., nasal injury during motor vehicle accidents)
  • Birth trauma (e.g., compression)
  • Congenital disorders (e.g., Marfan syndrome)
  • Insertion of foreign bodies into the nose
Onset
  • Gradual
  • Gradual
  • Gradual
  • Sudden in case of trauma
  • Gradual
  • Sudden
Clinical features
  • Difficulty breathing
  • Snoring or noisy breathing during sleep
  • Headaches or facial pain
  • Mouth breathing
  • Mucopurulent nasal discharge
  • Snoring
  • Impaired hearing
Nasal obstruction
  • Bilateral
  • Bilateral
  • Usually partial and unilateral
  • Unilateral
Olfactory function
  • Normal
  • Frequently impaired
  • Normal
  • Normal
  • Normal

For more info on nasal polyps, deviated nasal septum, and adenoid hypertrophy, see their respective articles.

Foreign nasal body

  • Epidemiology: mostly young children (2–5 years) [5]
  • Etiology: : organic (e.g., food items) or inorganic objects (e.g., pearls; , stones, small toys, button cell batteries) that are inserted into the nose
  • Clinical features
  • Diagnostics
    • Inspection of the nasal cavity with headlight or otoscope
    • Flexible fiberoptic endoscopy: if the foreign body is high up, in the posterior nasal cavity, or not visible with otoscopy
  • Treatment
    • Removal
      • Positive pressure techniques (first line)
      • Forceps
      • If the above fail: removal via endoscopy and anesthesia
    • Instrumentation under direct visualization and examination of the nasal cavity
  • Complications: Paired disc magnets and button cell batteries can lead to tissue necrosis and septal perforation (quick removal is essential).

The differential diagnoses listed here are not exhaustive.

  1. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020; 146 (4): p.721-767. doi: 10.1016/j.jaci.2020.07.007 . | Open in Read by QxMD
  2. Ellis AK, Keith PK. Nonallergic rhinitis with eosinophilia syndrome. Curr Allergy Asthma Rep. 2006; 6 (3): p.215-220. doi: 10.1007/s11882-006-0037-0 . | Open in Read by QxMD
  3. Dutt SN, Kameswaran M. The aetiology and management of atrophic rhinitis. The Journal of Laryngology & Otology. 2005; 119 (11): p.843-852. doi: 10.1258/002221505774783377 . | Open in Read by QxMD
  4. Kaliner MA. Nonallergic Rhinopathy (Formerly Known as Vasomotor Rhinitis). Immunol Allergy Clin North Am. 2011; 31 (3): p.441-455. doi: 10.1016/j.iac.2011.05.007 . | Open in Read by QxMD
  5. François M, Hamrioui R, Narcy P. Nasal foreign bodies in children.. Eur Arch Otorhinolaryngol. 1998; 255 (3): p.132-4. doi: 10.1007/s004050050028 . | Open in Read by QxMD
  6. Dykewicz MS et al. Treatment of seasonal allergic rhinitis. Annals of Allergy, Asthma & Immunology. 2017; 119 (6): p.489-511.e41. doi: 10.1016/j.anai.2017.08.012 . | Open in Read by QxMD
  7. RAPHAEL G et al.. Gustatory rhinitis: A syndrome of food-induced rhinorrhea. J Allergy Clin Immunol. 1989; 83 (1): p.110-115. doi: 10.1016/0091-6749(89)90484-3 . | Open in Read by QxMD
  8. Moscato G et al. Occupational rhinitis. Allergy. 2008; 63 (8): p.969-980. doi: 10.1111/j.1398-9995.2008.01801.x . | Open in Read by QxMD
  9. Varghese M et al.. Drug-induced rhinitis. Clinical & Experimental Allergy. 2010; 40 (3): p.381-384. doi: 10.1111/j.1365-2222.2009.03450.x . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer