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Nonallergic rhinitis

Last updated: March 20, 2025

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Nonallergic rhinitis (NAR) is an acute or chronic rhinitis that is not immune mediated. Common clinical features of NAR are persistent nasal congestion, postnasal drip, rhinorrhea, and intermittent sneezing. There are several types of NAR, including atrophic rhinitis, vasomotor rhinitis, drug-induced rhinitis, and nonallergic rhinitis with eosinophilia syndrome. Diagnosis is usually clinical; allergen testing is not routinely recommended. Management includes avoidance of triggers and topical pharmacological treatment with intranasal antihistamines (INAH) and/or intranasal corticosteroids (INCS). Additional therapies (e.g., intranasal ipratropium, intranasal decongestants) are considered for certain types of NAR. Refractory or severe symptoms require specialist referral for advanced treatments (e.g., oral medications, surgery).

Infectious rhinitis is a type of NAR that often occurs in conjunction with sinusitis (rhinosinusitis); see “Sinusitis” for details. Allergic rhinitis is a distinct entity and is detailed separately.

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See “Management of NAR” for diagnostic and treatment considerations for all types of NAR except atrophic rhinitis and infectious rhinosinusitis, which are detailed separately.

Types of nonallergic rhinitis [1]
Description Causes
Infectious rhinitis
Nonallergic rhinitis with eosinophilia syndrome (NARES) [2]
  • Unknown
Drug-induced rhinitis
  • Recurrent inflammation of the nasal mucosa associated with certain medications
Rhinitis medicamentosa
  • A type of drug-induced rhinitis that manifests as rebound nasal congestion after discontinuing an intranasal decongestant used for > 3–5 days [1][3]
  • Discontinuation of intranasal sympathomimetics, such as:
  • Increased use of intranasal decongestant to manage symptoms, which paradoxically worsens the condition [5]
Hormonal rhinitis
  • Rhinitis associated with hormonal changes
Nonallergic occupational rhinitis
  • Rhinitis as a result of exposure to irritants in a particular work environment
  • Most commonly seen in:
    • Furriers
    • Bakers
    • Breeders
    • Veterinarians
    • Farmers
    • Cleaners
    • Assemblers of electrical products
    • Laboratory employees
  • Irritants such as:
    • Fur
    • Flour
    • Paints
    • Pesticides
    • Dust
    • Talc
    • Detergents
    • Chemicals
Gustatory rhinitis
  • Episodic rhinitis with diffuse watery rhinorrhea caused by consumption of certain foods and beverages
Atrophic rhinitis
Vasomotor rhinitis
  • Rhinitis caused by an increase in blood flow to the nasal mucosa usually in response to triggers
  • Often idiopathic
  • Irritant odors (e.g., cigarette smoke, perfumes) [4]
  • Cold and/or dry air
  • Changes in humidity
  • Exercise
  • Foods (e.g., hot temperature, spicy)
  • Alcohol
Rhinitis in older adults [1][4]
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Clinical featurestoggle arrow icon

Nonallergic and allergic rhinitis often manifest with similar symptoms (e.g., rhinorrhea, sneezing, mouth breathing), but postnasal drip is more common in NAR, and pruritus of the mouth, nose, and ear are more common in allergic rhinitis. [1]

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Vasomotor rhinitis (VMR) [1][3]

Vasomotor rhinitis, often referred to as idiopathic rhinitis; , is a type of NAR that is caused by an increase in blood flow to the nasal mucosa, usually in response to an irritant or stimulant. [1]

Etiology

  • Irritant odors; (e.g., cigarette smoke, perfumes)
  • Cold and/or dry air
  • Changes in humidity, temperature, and air pressures
  • Exercise
  • Foods (e.g., hot temperature, spicy)
  • Alcohol

Pathophysiology [1]

Clinical features

Management

  • Diagnosis is clinical; see “Diagnosis of NAR.”
  • Initial treatment of VMR [1]
    • Avoid triggers, if feasible.
    • Start monotherapy with INAH or INCS.
    • Persistent symptoms: Add or switch to intranasal ipratropium to control anterior rhinorrhea.
  • Severe or refractory symptoms: Endoscopic vidian neurectomy may be considered. [6]
  • See “Treatment of NAR” for details; and dosages.

Vasomotor rhinitis is a diagnosis of exclusion. [1]

Atrophic rhinitis [1][7]

Atrophic rhinitis is a chronic condition in which nasal crusting and dry mucosa are associated with atrophy of the nasal mucosa.

Etiology

Clinical features

Diagnosis

Treatment

Atrophic rhinitis is managed differently from other types of NAR. Refer to an ENT specialist for management.

  • Conservative management options to reduce nasal crusting include:
  • Surgical options to decrease the volume of the nasal cavity: e.g., modified Young procedure, prostheses [7]
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Diagnosistoggle arrow icon

For patients with mucosal edema of the nasal turbinate, consider using an intranasal decongestant before the examination to improve visibility. [1]

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First-line treatment

Further management

Reassess patients 5–7 days after starting monotherapy.

Symptom improvement

  • Triggers are controlled or absent: Stop or taper off treatment.
  • Triggers cannot be controlled: Continue treatment as needed (PRN).

Persistent symptoms

Severe symptoms or symptoms refractory to monotherapy [1]

  • Consider combination intranasal therapy (i.e., INAH + INCS); see “First-line treatment” for dosages. [1]
  • Refer to ENT for oral pharmacotherapy options and/or surgery (e.g., vidian neurectomy for VMR, turbinectomy).

Oral antihistamines and leukotriene-receptor antagonists are not recommended because of insufficient evidence on their efficacy. [1]

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Differential diagnosestoggle arrow icon

In patients with intermittent, clear, watery nasal discharge that worsens with dependent head positioning, evaluate for CSF rhinorrhea, especially if there is a history of recent skull trauma, neurosurgery, or suspected CNS tumor. [1]

Common differential diagnoses of nasal congestion [1]
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
  • Adenoidal inflammation due to viral/bacterial infections or allergens
  • Insertion of foreign bodies into the nose
Onset
  • Gradual
  • Gradual
  • Gradual
  • Sudden in cases 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

The differential diagnoses listed here are not exhaustive.

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