Non-Allergic Rhinitis or Vasomotor Rhinitis

by Dr. Christopher Chang, last modified on 5/14/21.

Non-allergic rhinitis is an extremely frustrating sino-nasal disorder that is characterized by all the same symptoms of sinusitis and allergies, but NOT due to sinusitis or allergies. Rather, non-allergic rhinitis is considered to be a nose that is overly-sensitive to air containing particulates whether it be smoke, hairspray, perfume, dust, pollen, etc. Such particulates PHYSICALLY irritates the nasal and sinus lining causing symptoms. This condition is in contrast to allergies where an irritant causes an immunologic reaction causing symptoms or sinusitis which is due to an infection.

To use an analogy... consider the skin. Poison ivy contains a chemical which causes an itchy rash to develop. This reaction is not because of an allergic reaction or infection but rather due to the chemical physically irritating the skin. For patients with non-allergic rhinitis, common air particulates act like poison ivy to the sino-nasal lining.

A typical patient with non-allergic rhinitis suffers symptoms nearly indistinguishable from patients with bad allergies or sinus infections:

Nasal congestion
Sneezing
Post-nasal drainage
Pain/Pressure over the face
Runny nose

Patients often have tried numerous courses of antibiotics, allergy medications, and nasal sprays with nominal or only transient relief.

Subtypes of Non-Allergic Rhinitis

When non-allergic rhinitis is defined as chronic nasal drainage that is not due to infection or allergy, one can come up with 8 different subtypes.

1. Non-allergic rhinopathy (also known as vasomotor rhinitis or idiopathic nonallergic rhinitis). This subtype is what this webpage will mainly focus on.

2. Nonallergic rhinitis with inflammatory cells. The main difference between this subtype and non-allergic rhinopathy is the presence of inflammatory cells on nasal cytology. This condition is also known as local allergic rhinitis. There are other subtypes as well which you can read more about here.

3. Atrophic rhinits is a chronic condition where there is a progressive atrophy of the nasal mucosal lining leading to main complaints of crusting and dryness. I like to use a nasal emollient like ponaris to treat this condition.

4. Senile rhinitis is characterized by watery runny nose in the elderly population.

5. Gustatory rhinitis occurs after eating, especially hot/spicy foods.

6. Drug-induced rhinitis (also known as rhinitis medicamentosa) is basically what I call afrin addiction. Click here for more information.

7. Hormonal-induced rhinitis (also known as rhinitis of pregnancy) occurs secondary to hormone surges that typically occurs during pregnancy. Click here for more information.

8. Cerebral spinal fluid leak. This rare condition is due to a hole in the bone separating the nose from the brain resulting in brain fluid leaking out the nose. Diagnosis is fairly easy by testing the fluid for beta2-transferrin. Treatment is to surgically plug the hole.

Diagnosis of Non-Allergic Rhinitis

Commonly, though not always, many patients with non-allergic rhinitis report that cigarette smoke, hairspray, and perfume trigger symptoms.

However, in the end, studies are needed in order to determine whether allergies and/or chronic sinusitis are truly present or not before pursuing further treatment that may be unhelpful.

Such studies include CT scans of the sinuses to evaluate the presence of a chronic sinus infection as well as allergy testing to determine if allergies are present. If BOTH tests come back normal, one must abandon the diagnosis of chronic sinusitis as well as allergies and consider non-allergic rhinitis as they main culprit.

There are other conditions that may produce similar symptoms due to anatomic factors including a deviated septum, large adenoids, turbinate hypertrophy, as well as nasal polyps, but for the sake of the discussion here and to keep things simple, it will be assumed that all anatomic factors are also normal.

In any case, a normal CT scan and normal allergy testing in a setting of sino-nasal problems is highly suggestive of non-allergic rhinitis and treatment geared towards this diagnosis should be pursued.

Medical Treatment

In order to understand treatment, it is helpful to revisit the poison ivy analogy...

With skin exposure to poison ivy, there's a few things a patient can do to minimize or avoid symptoms altogether:

Wash the skin immediately
Avoid areas with poison ivy
Wear protective clothing
Medications

For patients with non-allergic rhinitis, the treatment is essentially the same:

Avoid environments that trigger symptoms
Use a barrier nasal emollient to prevent the airborne irritants from coming into contact with the nasal lining in the first place. Think of it like chapstick to irritated lips. I typically recommend Ponaris.
Regular saline flushes to keep the nose and sinuses clean. By washing away the airborne irritants out of the nose, you prevent it from causing problems. I usually recommend NeilMed Sinus Rinse to be performed minimum twice a day as well as after exposure to a known environment that causes problems. Please note that saline nasal spray is NOT sufficient as it only humidifies and not washes. Watch video to see how sinus rinses are performed.
The only FDA-approved medication to treat non-allergic rhinitis is the prescription nasal spray Astelin which is an anti-histamine nasal spray. Other similar sprays include Astepro and Patanase, but azelastine active ingredient has been shown to work the best.
If a "runny" nose is a significant symptom, atrovent nasal spray can be used as needed.
Sinus Plumber Nasal Spray which is over-the-counter. This nasal spray contains the ingredient capsaicin which appears to significantly relieve problems related to non-allergic rhinitis.

Video on How to Perform Saline Sinus Flushes

Surgical Treatment

In many individuals with non-allergic rhinitis, the nasal inferior turbinates are quite large. Surgically reducing the large turbinates may provide improvement in symptoms, but not cure. Improvement is typically obtained in about 50% of patients and relief reduction is also around 50%.

Endoscopic vidian nerve and/or posterior nasal nerve resection can be considered the definitive surgical treatment for non-allergic rhinitis [Link #1] [Link #2] [Link #3]. Our office is able to perform an endoscopic technique called RhinAer which can ablate the posterior nasal nerves via radiofrequency ablation. This technique can be performed in the office under local anesthesia only. Read more about RhinAer.

Non-Allergic Rhinitis CAN Turn Into Allergies

Though patients with non-allergic rhinitis may come back negative to allergies on initial testing, over the next 3-5 years, at least a quarter of patients will eventually develop allergies with positive testing. As such, it may be worthwhile to follow these patients and retest every few years to monitor (Research).

This frustrating condition has been portrayed in USA Today as well as Wall Street Journal.

Links

Non-Allergic Rhinitis or Vasomotor Rhinitis

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