Definition
A.Nonallergic rhinitis is an inflammation of nasal mucous membranes, usually accompanied by nasal discharge and mucosal edema. Nonallergic rhinitis disorder has no correlation to specific allergen exposures. It is classified in several ways: vasomotor, perennial, atrophic, geriatric, drug-induced, gustatory, or hormonal.
Incidence
A.Chronic or recurrent nasal congestion occurs in about 10% to 40% of the population.
Pathogenesis
A.Vasomotor and perennial nonallergic rhinitis results from hyperreactive nasal mucosa.
B.Atrophic and geriatric rhinitis results from progressive degeneration and atrophy of the mucus membranes and bones of the nose.
C.Overuse of topical nasal decongestants can worsen symptoms and cause severe rebound congestion.
D.Cocaine abuse causes nasal congestion and discharge.
E.Rhinitis in pregnancy results from hormonal increase; congestion abates with delivery.
Predisposing Factors
A.Adulthood.
B.Abrupt changes in temperature, odors, and emotional stress.
C.Other predisposing factors depend on type.
Common Complaints
A.Nasal congestion.
B.Sneezing.
C.Clear rhinorrhea.
D.Coughing.
E.Sore throat.
F.Itchy, puffy eyes.
Subjective Data
A.Ask about onset, duration, and course of symptoms.
B.Inquire about the color and other characteristics of nasal discharge.
C.Ask about other discomforts and exposure to people with similar symptoms.
D.Inquire about seasonal impact on symptoms, effect of weather changes on symptoms, previous treatments, and results.
E.Rule out pregnancy. Ask female patients about birth control method, specifically contraceptives.
F.Ask about use of prescription drugs, over-the-counter (OTC) drugs (especially aspirin), and illicit drugs (cocaine).
G.Review medical history for other respiratory problems, such as asthma, emphysema, or chronic bronchitis.
Physical Examination
A.Check temperature and blood pressure.
B.Inspect:
1.Observe general appearance.
2.Inspect conjunctivae for allergic shiners
(dark circles under eyes), tearing, and eyelid swelling.
3.Examine ears for signs of otitis media (red, bulging, perforated tympanic membrane, and purulent drainage).
4.Examine nose for redness, swelling, polyps (soft, pedunculated, nontender, pale-gray smooth structures), enlarged turbinates, foreign objects, septal deviation, septal perforation (sign of cocaine abuse), ischemia, mucosal injury, atrophy, and cobblestoned
pharyngeal mucosa (sign of allergy).
C.Auscultate: Auscultate heart and lungs.
D.Percuss:
1.Percuss sinus cavities and mastoid process.
2.Percuss chest for consolidation.
E.Palpate:
1.Palpate face for sinus tenderness.
2.Palpate head and neck for enlarged lymph nodes.
Diagnostic Tests
A.Skin testing for allergies may be done.
Differential Diagnoses
A.Nonallergic rhinitis.
B.Allergic rhinitis.
C.Upper respiratory infection (URI).
D.Foreign body.
E.Sinusitis.
F.Otitis media.
G.Deviated septum.
H.Nasal polyps.
I.Endocrine conditions such as hypothyroidism and pregnancy.
J.Drug use: Oral contraceptives, aspirin, alpha-adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), cocaine, and nasal decongestant overuse.
Plan
A.General interventions:
1.Avoid changes in temperature, odors, and emotional stress.
2.Identify triggers for condition and address alleviating triggers.
B.Patient teaching:
1.Teach the patient the significance of individual triggers for nonallergic rhinitis. Encourage use of a journal to learn personal triggers.
2.Avoid triggers such as smoking, smoke-filled rooms, wood-burning stoves/fireplaces, sprays, and perfumes.
3.Other triggers may include weather changes, hormonal changes, and medications.
4.Teach methods of treatment and identify treatments that work best for the patient.
5.Encourage use of neti pot or nasal flush with warm saline water daily to cleanse sinus cavity. Cleansing the sinus cavity daily will help to remove foreign materials inhaled and will also help with tissue edema. Clean pot after each use and allow to air dry.
C.Pharmaceutical therapy:
1.Vasomotor rhinitis: Physiologic saline solution as nasal spray, thorough cleansing of nares, topical ipratropium bromide two inhalations each nostril two to three times daily.
2.Atrophic rhinitis: Guaifenesin 10 mL orally every 4 hours.
3.Physiologic saline nasal spray to nares three times a day.
4.Nasal antihistamines:
a.Azelastine (Astelin). Adults: Two sprays each nostril daily.
b.Olopatadine (Patanase). Adults: Two sprays twice daily.
5.Intranasal corticosteroid sprays (see section Allergic Rhinitis
for additional products): Fluticasone (Flonase). Adults: Two sprays daily or one spray twice daily. Maintenance dosing: One spray in each nostril daily or mometasone (Nasonex). Adults: Two sprays each nostril once
daily.
6.Decongestants: Oral and nasal decongestants are not recommended unless the use of antihistamines and glucocorticoids has failed. Examples may include oral pseudoephedrine or nasal oxymetazoline (Afrin) and phenylephrine (Neo-Synephrine). These should not be used longer than 2 to 3 days at a time for congestion due to the effects of rebound congestion with long-term use.
Follow-Up
A.Have patient return in 2 to 3 weeks, and then for biannual exams and/or as needed.
Consultation/Referral
A.Consult with a physician if symptoms continue despite treatment.
B.If treatment fails, refer the patient to an allergist for testing.
Individual Consideration
A.Pregnancy: Reassure pregnant patients that rhinitis is a common hormonal response. Nonallergic rhinitis is not contagious and cannot cross the placenta.
B.Geriatrics:
1.Obstructive sleep apnea is associated with allergic and nonallergic rhinitis. Obtain a thorough sleep history and look for any signs/symptoms of sleep deprivation and/or decrease cognitive alertness.
2.Chronic rhinitis in elderly needs to be evaluated for nasal polyps. Geriatric patients could be appropriate candidates for endoscopic sinus surgery as well as managed safely with limited prolonged steroid use if closely monitored. Comfort and respiratory benefits play a large role in patient choices for corrective chronic rhinitis surgery. Discuss all of the patient/surrogate’s preferences in a professional shared-decision capacity explaining the importance of surgery/steroid risks as well as quality of life issues.