Nonallergic Rhinopathy: A Comprehensive Review of Classification, Diagnosis, and Treatment.

Chronic nonallergic rhinitis syndromes encompass various conditions, of which vasomotor rhinitis is the most common form, representing approximately 80% of patients, also referred to as nonallergic rhinopathy (NAR), nasal hyperreactivity, neurogenic rhinitis, or idiopathic rhinitis. Expert panels have recommended replacing vasomotor rhinitis terminology because it is more descriptive of this condition that is characterized by symptoms triggered by chemical irritants and weather changes through chemosensors, mechanosensors, thermosensors, and/or osmosensors activated through different transient receptor potential calcium ion channels. Elucidating the specific role of transient receptor potential vanilloid 1, triggered by capsaicin, has been an important advancement in better understanding the pathophysiology of NAR because it has now been shown that downregulation of transient receptor potential vanilloid 1 receptors by several therapeutic compounds provides symptomatic relief for this condition. The classification of NAR is further complicated by its association with allergic rhinitis referred to as mixed rhinitis, which involves both immunoglobulin E-mediated and neurogenic mechanistic pathways. Comorbidities associated with NAR, including rhinosinusitis, headaches, asthma, chronic cough, and sleep disturbances, underscore the need for comprehensive management. Treatment options for NAR include environmental interventions, pharmacotherapy, and in refractory cases, surgical options, emphasizing the need for a tailored approach for each patient. Thus, it is extremely important to accurately diagnose NAR because inappropriate therapies lead to poor clinical outcomes and unnecessary health care and economic burdens for these patients. This review provides a comprehensive overview of NAR subtypes, focusing on classification, diagnosis, and treatment approaches for NAR.

Severity of nasal obstruction can predict the anxiety status of patients with allergic rhinitis but not patients with vasomotor rhinitis.

BACKGROUND: Allergic rhinitis (AR) is a chronic systemic allergic disease with an association reported between allergy and anxiety. The objective of the current study was therefore to investigate and retrospectively evaluate the factors that may possibly induce state and trait anxiety among patients with AR and vasomotor rhinitis (VMR). METHODS: A total of 253 outpatients suffering from AR and 108 suffering from VMR were assessed for nasal symptoms experienced during the 14 days prior to assessment. All patients scored the severity of their symptoms on a visual analogue scale (VAS) and answered the State-Trait Anxiety Inventory (STAI) questionnaire to evaluate their state (STAI-S) and trait (STAI-T) anxiety scores. Pearson's correlation and multiple regression tests were employed to assess correlations between symptom scores and anxiety status scores. RESULTS: The STAI-S/T scores were not significantly different between AR and VMR patients; however, for AR patients, STAI-S and STAI-T were significantly associated with nasal obstruction and the total nasal symptom scores. Multiple regression analysis further demonstrated that only nasal obstruction significantly influenced both STAI-S and STAI-T scores. In contrast, nasal itching and total nasal symptom scores were significantly correlated with the STAI-S and STAI-T scores in VMR patients, whereas continuous sneezing VAS scores were significantly associated with only the STAI-S score. However, multiple regression analysis showed that the associations between any of the 4 nasal symptom scores and STAI-S and STAI-T scores were not significant. CONCLUSION: Nasal obstruction may play a prominent role in mediation of anxiety in patients suffering from AR, but not in patients suffering from VMR.

"Overlapped" rhinitis: a real trap for rhinoallergologists.

Under the broad heading of "vasomotor" rhinitis two big groups can be distinguished: allergic rhinitis (IgE-mediated), and nonallergic rhinitis. Since they are two separate nosological entities, they can co-exist in the same patient, classifying themselves in the group of "overlapped" rhinitis (OR). Although not absolutely rare (indeed it is estimated a 15-20% incidence among all vasomotor rhinopathies), this condition is not investigated and diagnosed, with significant implications in the clinical-diagnostic and therapeutic field.

[Diagnosis and clinical characteristics of patients with non-allergic rhinitis].

OBJECTIVE: To explore a step-by-step exclusive diagnosis and analyze the clinical characters of non-allergic rhinitis (NAR). METHODS: Patients with symptoms (nasal itching, sneezing, rhinorrhea, nasal congestion) were selected to take four-step exclusive diagnosis for NAR and we tried to eliminate the false NAR and retain the true NAR. First step was to exclude the patients who were not suitable for skin prick test (SPT, such as during pregnancy, breastfeeding, asthma, oral antihistamine medication in 7 day, severe skin diseases). The second step was to exclude the patients with positive SPT and the third step was to exclude the patients with 1 level or above of specific sero-immunoglobulin E (sIgE). The fourth step was to exclude the patients with infection rhinitis, clear abnormal nasal structure, drug-induced rhinitis, nasal neoplasm. The remained patients were finally diagnosed as NAR and who were further differential diagnosed as vasomotor rhinitis (VMR) or non-allergic rhinitis with eosinophilia syndrome (NARES) according to the eosinophilia counts in nasal secretion and venous blood. The common characters of patients with NAR were analyzed and their symptoms and quality of life were evaluated by visual analogue scale (VAS) and rhino-conjunctivitis quality of life questionnaire (RQLQ) separately. RESULTS: One thousand four hundred and thirty-seven patients were included after first step exclusion and 735 cases with negative SPT were remained after second step exclusion. Of 735 patients, 302 were tested in vitro for sIgE and 93 cases with 0 level of sIgE and total IgE were remained after third step exclusion. Sixty-two patients were finally diagnosed as NAR after fourth step exclusion. The NAR diagnosis rate was 51.15% (735/1 437) with negative SPT alone and the NAR diagnosis rate was 29.06% (93/302) with combination of negative SPT and sIgE. Of 62 patients with NAR, 47 patients (75.81%) were diagnosed as VMR and 15 cases (24.19%) as NARES. There were 23 males and 39 females in the 62 patients aged 11 - 77 years. The history was 11-47 months. The biggest numbers of patients with VMR or NARES were among 41-50 years. Their onset ages were among 21-30 years in both two groups. VAS scores of nasal congestion in VMR patients were the highest with significant difference among nasal symptoms (F = 3.958 0, P = 0.009 1). VAS scores of sneezing in NARES patients were the highest but without significant difference among nasal symptoms. There were no difference in seven domain scores of RQLQ and the total mean scores between VMR group and NARES group but the nasal symptoms got the highest scores with significant difference among the seven domains in each group (VMR group, F = 9.771 2, P = 0.000 0;NRAES group, F = 3.226 9, P = 0.006 2). CONCLUSIONS: SPT combined with sIgE may exclude much more patients with AR. Females with NAR are much more than males. Patients with NAR aged 21-30 years. The characters of NAR are helpful to improve our knowledge about NAR. VAS and RQLQ may be a suitable tool in assessment of NAR.

Chapter 14: Nonallergic rhinitis.

Rhinitis is characterized by one or more of the following nasal symptoms: congestion, rhinorrhea (anterior and posterior), sneezing, and itching. It is classified as allergic or nonallergic, the latter being a diverse syndrome that is characterized by symptoms of rhinitis that are not the result of IgE-mediated events. Excluding infectious rhinitis and underlying systemic diseases, clinical entities that can be classified among the disorders that make up the nonallergic rhinitis syndromes include gustatory rhinitis, nonallergic rhinitis with eosinophilia syndrome (NARES), atrophic, drug-induced (rhinitis medicamentosa), hormone induced, senile rhinitis (of the elderly), rhinitis associated with chronic rhinosinusitis with or without nasal polyps, and the idiopathic variant formerly known as vasomotor rhinitis but more accurately denoted as nonallergic rhinopathy (NAR). The prevalence of nonallergic rhinitis has been observed to be one-third that of allergic rhinitis, affecting ~7% of the U.S. population or ~22 million people. NAR is the most common of the nonallergic rhinitis subtypes, comprising at least two-thirds of all nonallergic rhinitis sufferers. Although certain precipitants such as perfume, strong odors, changes in temperature or humidity, and exposure to tobacco smoke are frequently identified as symptom triggers, NAR may occur in the absence of defined triggers. The diagnosis of nonallergic rhinitis is purely clinical and relies on a detailed history and physical exam. Skin testing or in vitro testing to seasonal and perennial aeroallergens is required to make the diagnosis of nonallergic rhinitis. Because of the heterogeneous nature of this group of disorders, treatment should be individualized to the patient's underlying pathophysiology and/or symptoms and is often empiric.

When sneezing indicates the cell type.

BACKGROUND: Nasal hyperreactivity is the symptomatic expression of vasomotor rhinitis. This study describes a typical nasal reaction, represented by a "volley of sneezes" found in some patients during nasal endoscopy, and to assess the possible correlation between hyperreactivity and a particular clinical and cytological condition. METHODS: We studied 671 rhinological subjects, 344 male, mean age 35.7 ± 13.76 standard deviation (SD) years. All were submitted to medical histories and clinical and instrumental investigations (skin prick test, nasal endoscopy, and nasal cytology). While performing endoscopy, particular attention was paid to the possible signs of nasal hyperreactivity, in particular "volley of sneezes" both during and immediately after the diagnostic procedure. RESULTS: Out of 671 endoscopies performed, 130 (17.1%) patients presented signs of hyperreactivity during and/or immediately after nasal endoscopy. The ratio of positive vasomotor reaction was 10.6% in the nasal polyposis (NP) group, 19% in the allergic rhinitis (AR) group, 70.6% (p < 0.01) in nonallergic rhinitis with mast cells (NARMA), 76% (p < 0.01) in nonallergic rhinitis with eosinophils and mast cells (NARESMA), and 83% (p < 0.01) in nonallergic rhinitis with eosinophils (NARES). In the AR subjects hyperreactivity was more frequent during the pollen season, compared to the period of absence of pollen (87.5% vs 12%). CONCLUSION: The onset of hyperreactivity (sneezing) can be considered an important "sign" in nasal symptomatology, whose sensitivity and specificity for nonallergic "cellular" rhinitis are 79% and 93%, respectively.

A rhinitis primer for family medicine.

Rhinitis and related problems such as facial pressure and nasal congestion are a very common reason people seek medical care. There are four, often overlapping, syndromes or conditions that account for most of what patients perceive as "nose" problems or rhinitis. These conditions are irritant rhinitis, the anterior nasal valve effect, migraine with vasomotor symptoms, and allergic rhinitis. Virtually all patients with allergic rhinitis have some concomitant irritant or nonallergic rhinitis. Many migraine sufferers with vasomotor nasal symptoms will have their nasal congestion, headaches, and runny noses exacerbated by irritant rhinitis, allergic rhinitis, and/or a preexisting nasal valve effect. Failure to consider all of the causes for the symptoms will result in poor clinical outcomes. The work-up and management of these common conditions is discussed in this article.

Chapter 6: Nonallergic rhinitis.

Nonallergic rhinitis represents a non-IgE-mediated group of disorders that share the symptoms of nasal congestion, rhinorrhea, sneezing, and/or postnasal discharge but not pruritus that characterizes allergic rhinitis. Nonallergic rhinitis may be divided into two broad categories, inflammatory and noninflammatory etiologies. The inflammatory causes include postinfectious (viral and bacterial), rhinitis associated with nasal polyps, and nonallergic rhinitis with eosinophilia, where eosinophils are present in nasal smears but skin testing for aeroallergens is negative. The noninflammatory causes include idiopathic nonallergic rhinitis (formerly referred to as vasomotor rhinitis or colloquially as an "overreactive nose"); rhinitis medicamentosa, which is medication-induced rhinitis; hormone related (pregnancy); systemic disease related (severe hypothyroidism); and structural defect related (deviated septum, head trauma causing cerebrospinal fluid rhinorrhea). The classic symptoms of idiopathic nonallergic rhinitis are nasal congestion, postnasal drip, and sneezing triggered by irritant odors, perfumes, wine, and weather changes. The diagnosis of rhinitis begins with a directed history and physical exam. Examination of the nasal cavity with attention to appearance of the septum and inferior turbinates is recommended. Skin testing for seasonal and perennial aeroallergens is helpful in establishing the presence or absence of IgE antibodies and to help differentiate nonallergic from allergic rhinitis. Topical H(1)-receptor antagonist (antihistamine) nasal sprays, intranasal steroids, intranasal anticholinergics, and oral decongestants are options for pharmacotherapy. It is important to inquire about hypertension, arrhythmias, insomnia, prostate hypertrophy, or glaucoma to prevent undesirable side effects associated with the oral decongestant pseudoephedrine.

A multiallergen and miniscreen can change primary care provider diagnosis and treatment of rhinitis.

BACKGROUND: A number of studies suggested that limited economical airborne allergy screening can successfully predict true respiratory allergy and be of use to primary care providers (PCPs) in improving the accuracy of their differential diagnosis and treatment of allergic rhinitis. More accurate diagnosis would lead to proper use of intranasal corticosteroids, intranasal antihistamines, and oral antihistamines. However, to date, there have been no reports of an actual application of the screens by PCPs. This study was designed to measure the potential impact of providing a limited multiallergen and miniscreen (MAMS) by in vitro allergy testing on PCP diagnosis and treatment of rhinitis, properly differentiating seasonal allergic rhinitis, perennial allergic rhinitis, vasomotor rhinitis, and mixed rhinitis. METHODS: Two hundred adult and adolescent patients who presented to PCPs for rhinitis symptoms were enrolled from July to November of 2007. They signed informed consent and a serum specimen for MAMS was obtained. The PCPs answered a questionnaire concerning their diagnosis and treatment before and after the MAMS results were revealed to the PCP. RESULTS: The PCPs changed or modified the original diagnosis in 139 of 200 patients. Originally, 182 subjects had an allergic rhinitis diagnosis. After the results of the MAMS were known, 113 continued with an allergic rhinitis diagnosis. Vasomotor or nonallergic rhinitis diagnoses increased from 18 to 87 cases. CONCLUSION: Use of MAMS can help PCPs make a more accurate diagnosis and offer better therapy to patients with rhinitis.

Allergic rhinitis and non-allergic rhinitis in children in the tropics: prevalence and risk associations.

BACKGROUND: The age-related comparative prevalence of allergic rhinitis (AR) and non-allergic rhinitis (NAR) in children is poorly defined. We aimed to characterize AR and NAR in children. METHODS: This study enrolled children with chronic rhinitis who presented to a tertiary paediatric center for a diagnostic skin prick test (SPT). Parents completed a medical history questionnaire for their child, including disease activity for asthma and rhinitis. Sociodemographic data was obtained and all participants underwent a common inhalant SPT panel. A positive SPT indicated AR. RESULTS: From March 2001 to March 2009, 6,660 children (64% male) were enrolled (aged 6 months to 19 years, mean 7.82 years). Only 3.7% (249) of the children were <2 years old, and almost 30% of these had AR. Most children with AR (73%) presented after age 6. Males were more likely to have AR (vs. NAR) (OR 1.5; CI 1.39-1.77). Antihistamine and salbutamol use did not differ between children with AR and NAR. Children with AR were more likely to require adjunct therapy with inhaled corticosteroids (51.2% vs. 43.2%, P < 0.001), have drug hypersensitivity (especially antipyretic drugs) (2.5% vs. 1.3%, P = 0.384) or an asthma admission (9.1% vs. 6.0%, P < 0.001). CONCLUSIONS: AR is more common in male children, is relatively rare below the age of 2 years, and accounts for two-thirds of all childhood chronic rhinitis and 73.3% of all chronic rhinitis in school-aged children (≥6 years old). Children with AR have more severe rhinitis symptoms and more often suffer from asthma-related events and admissions.

Nonallergic rhinitis: common problem, chronic symptoms.

Nonallergic rhinitis can significantly affect a patient's quality of life. It is difficult to distinguish from allergic rhinitis, but it has different triggers, and its response to treatment can vary. We review its differential diagnosis, causes, and treatment.

Sphenopalatine artery ligation with nerve resection in patients with vasomotor rhinitis and polyposis: a prospective, randomized, double-blind investigation.

CONCLUSIONS: Sphenopalatine artery ligation relieves symptoms of rhinorrhea, sneezing, and nasal itching in patients with vasomotor rhinitis associated with nasal polyps. OBJECTIVES: Nasal polyps often arise in a setting of vasomotor rhinitis. Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching. Sphenopalatine pedicle resection with autonomic denervation could potentially reduce related symptoms. METHODS: In a prospective, double-blind setting, 60 patients with vasomotor rhinitis and bilateral nasal polyps randomly assigned to functional endoscopic surgery either with (group A) or without (group B) sphenopalatine artery ligation completed a 3-year follow-up. Preoperative and postoperative (at 1 and 3 years) evaluations included symptom score, fiberendoscopy, and active anterior rhinomanometry. RESULTS: In both treatment groups nasal breathing had improved at 1-year and 3-year follow-up (p < 0.001), whereas an improvement in rhinorrhea (p < 0.001) and sneezing and itching (p < 0.01) was attained only in group A. The inter-group comparison showed that a statistically significant improvement in rhinorrhea and nasal itching (p = 0.002) and in sneezing (p < 0.001) was present in group A at both follow-up visits. Rhinomanometry improved in both treatment groups (p < 0.01). Inter-group comparison showed a significant difference only at the 3-year follow-up visit (p < 0.05).

Nonallergic rhinitis.

This article reviews a uniform way to describe nonallergic rhinitis in its various forms. The insights into its pathophysiology are briefly reviewed. A classification scheme for the different forms is provided. This is followed by descriptions of the diagnosis, evaluation, and management of nonallergic rhinitis.

Olopatadine 0.6% nasal spray protects from vasomotor challenge in patients with severe vasomotor rhinitis.

BACKGROUND: Vasomotor rhinitis (VMR) is a hypersensitivity syndrome with heightened reactivity to environmental triggers. METHODS: Twenty-two patients with severe VMR were treated nasally with either normal saline or 0.6% olopatadine and challenged nasally with a hyperosmolar mannitol solution. RESULTS: Treatment with 0.6% olopatadine resulted in an improvement in instantaneous nasal symptom scores at 5 and 30 minutes (p < 0.01) compared with baseline and at 30 minutes after hyperosmolar challenge compared with saline-pretreated individuals (p < 0.01). There was also an improvement in nasal peak inspiratory flow rate at 30 minutes after hyperosmolar challenge compared with saline-pretreated individuals (p < 0.01). CONCLUSION: In this patient population 0.6% olopatadine appears to be efficacious in symptom reduction in VMR and protects from hyperosmolar challenge.

Nonallergic rhinopathy (formerly known as vasomotor rhinitis).

This review focuses on the poorly understood condition of nonallergic rhinopathy (NAR) at a clinical level, with an eye on current optimal treatment. NAR is the new designation for the conditions formerly referred to as vasomotor rhinitis or nonallergic idiopathic rhinitis. The clinical characteristics and differential diagnosis are provided in detail in this review, and the disease should now be characterized sufficiently for clinical studies.

Overview of the treatment of allergic rhinitis and nonallergic rhinopathy.

Allergic rhinitis (AR) and nonallergic rhinopathy (NAR) represent common nasal conditions affecting millions of individuals across the world. Although patients present with similar symptomatology, those with NAR are frequently affected only after childhood and present with a lack of other comorbid atopic disorders such as asthma, atopic dermatitis, and food allergies. Patients with pure NAR usually have no identifiable specific allergen sensitivity, whereas those with mixed (allergic and nonallergic) rhinitis are sensitized to aeroallergens in a manner that does not fully explain the duration or extent of their symptoms. This review presents the diverse options of currently available pharmacologic agents for the treatment of AR and NAR, including intranasal corticosteroids, H(1)-antihistamines, decongestants, cromolyn sodium, antileukotrienes, anticholinergics, capsaicin, anti-IgE, and intranasal saline, in addition to subcutaneous immunotherapy. Furthermore, treatment algorithms for AR and NAR are presented with a stepped-up, stepped-down scheme to aid the clinician in choosing appropriate therapy.

Vasomotor rhinitis.

Vasomotor rhinitis is a common disorder that is seen routinely in allergy practice. It affects millions of Americans and results in significant morbidity. The pathophysiology of this complex heterogeneous disorder is unknown, but we are making advances in this regard. Symptoms and signs can closely resemble those of allergic rhinitis and can be difficult to differentiate from those resulting from allergy. A careful history, physical examination, and diagnostic testing help clinicians arrive at a definitive diagnosis, but treatment can be challenging. Therapy should be based on the presenting symptoms of vasomotor rhinitis. Combination therapy with topical corticosteroids and azelastine is useful. However, in patients whose predominant symptom is rhinorrhea, use of atopical anticholinergic agents can be quite useful. Up-to-date pathogenesis, epidemiology, diagnosis, and treatment approaches are discussed in this review.