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Non Allergic Rhinitis

Non Allergic Rhinitis
28 Jul, 2017

Non-Allergic Rhinitis


Non Allergic Rhinitis (NAR) is common cause for presentation to otolaryngology clinics. The incidence varies from 26% - 60% and increases with age. It is more common in females than males.

Clinical presentation

NAR generally presents with nasal congestion rhinorrhoea, headache and can be often confused with allergic rhinitis (AR). In fact there is a considerable population presenting to the allergy clinics, which have mixed symptoms of NAR and AR. The most features for diagnosis of condition is the clinical picture of the patient after excluding the criteria pointing towards allergy.


The pathophysiology of the condition can be understood by understanding the normal interplay between the parasympathetic and sympathetic nervous system. The parasympathetic nervous system activation causing glandular hyper secretion . The role of cold air has been also studied in precipitating NAR where in cold air causes hyper osmolality, thereby causing nasal congestion and other symptoms of NAR.


There are various causes of NAR and differentiating the types of NAR can be daunting. NAR can be associated with eosinophilia syndrome, wherein patient can have perennial symptoms of rhinorrhoea, itching, epiphora and sneezing with negative reactions to allergies by skin or by in vitro testing.

NAR can also be associated with normal changes in the body. The symptoms may be aggravated in patients with hypothyroidism and acromegaly. Fluctuating serum hormone levels during menstrual cycle can also lead to the symptoms. Similarly the symptoms may be aggravated during the normal changes that take place during puberty. Pregnancy is also an important condition which can increase the symptoms. This is due to the vascular changes and increased vascular pooling and progesterone induced smooth muscle relaxation. Other common causes associated with NAR are medications such as psychotropic drugs anti-hypertensive, oral contraceptive, hormonal replacement, anti-inflammatory agents etc.

Rhinitis medicamentosa is a unique entity wherein the abuse of nasal decongestant results in rebound congestion of the nose and patient eventually develops a vicious cycle.

Rhinitis is also associated with atrophic changes in the nose which could be associated with infection from bacteria such as klebsiella ozaenae, but more often seen now a days due to aggressive surgery for nasal obstruction, trauma, granulomatous disease and radiation therapy.

NAR can also be irritant induced such as cold air and weather changes, certain foods (gustatory rhinorrhoea), smoking etc. A more complex form of irritant induced rhinitis is the occupational rhinitis caused due to workplace aeroallergens.


Treatment strategy of Non- Allergic rhinitis would broadly include

  1. Avoidance – Information regarding the disease and its pathophysiology is utmost importance in hearting the patient of NAR. Avoidance of inciting agents such as perfumes, smoke and certain food can be accomplished easily. Exercise is important adjunct to therapy, vigorous exercise decreases nasal congestion.
  2. Topical nasal steroids – NAR can be effectively managed by topical steroids. Topical nasal steroids work on nasal mucosa decreasing the edema and inflammation, but to be effective they must come in contact with nasal mucosa. Optimal administration requires propelling the meditation towards the nasal cavity printing away from the septum. They are generally well tolerated and side effects such as dryness, irritation or epistaxis are infrequent.
  3. Antihistamines – Oral antihistamines have a limited role in the management of NAR but may be beneficial in patients having sneezing and itching as component of symptomatology.
  4. Anti-cholinergic – Anticholinergic medications provide relief from the unrelenting rhinorrhoea in NAR. Topical anti-cholinergic agents such as ipratropium bromide can be used with minimal systemic side effects.
  5. Surgery- Nasal polyps, deviated nasal septum and hypertrophic turbinate may completely obstruct a nasal passage and for the topical medications to be effective they must reach the nasal mucosa. Thereby these conditions have to be addressed for the topical medications to act.