Robert H Fletcher, MD, MSc
Phillip L Lieberman, MD
Jonathan Corren, MD
Anna M Feldweg, MD
NONALLERGIC RHINITIS OVERVIEW — Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and post-nasal drip (the sensation that mucus is draining from the sinuses down the back of the throat).
Almost everyone experiences rhinitis at some point during their life. Brief episodes of rhinitis are usually caused by respiratory tract infections with viruses (eg, the common cold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs, some medical conditions, and other unidentifiable factors.
This topic discusses nonallergic rhinitis. A separate topic discusses rhinitis caused by allergies. (See “Patient information: Allergic rhinitis (seasonal allergies)”.)
WHAT IS NONALLERGIC RHINITIS? — Nonallergic rhinitis is the medical term used to describe people who have one or more of the following symptoms without a known cause:
- Runny nose
- Stuffy nose (congestion)
- Postnasal drip (the feeling of fluid in the back of the throat)
Symptoms are usually present year-round, although they may be worsened by certain weather conditions (eg, in the spring or fall). The condition does not usually develop until adulthood.
NONALLERGIC RHINITIS CAUSES — The cause of nonallergic rhinitis is not usually known. However, many triggers of symptoms are known, and include tobacco smoke, traffic fumes, or strong odors and perfumes. People with nonallergic rhinitis are not bothered by pollen or furred animals (the common triggers in allergic rhinitis), although about one-half of people with this condition also have allergic rhinitis. (See “Patient information: Allergic rhinitis (seasonal allergies)”.)
NONALLERGIC RHINITIS TREATMENT — Treatment of nonallergic rhinitis may include trigger avoidance, medications, and/or nasal lavage.
Trigger avoidance — Exposure to tobacco smoke can be reduced if household members stop smoking or smoke only outside of the home. It is also important to avoid smoke exposure in the workplace.
Exposure to pollutants and irritants can be reduced by avoiding wood-burning stoves and fireplaces; properly venting other stoves and heaters; and avoiding cleaning agents and household sprays that trigger symptoms.
Exposure to strong perfumes and scented products may be more difficult. People who are bothered by these items should avoid using them and may need to request that coworkers, family, or friends do the same. Some workplaces have policies regarding the use of strongly scented personal products. Azelastine (Astelin®) can be used when needed to relieve symptoms. (See ‘Nasal antihistamines’ below.)
Nasal irrigation — Simply rinsing the nose with a salt water (saline) solution one or more times a day is helpful for many patients with nonallergic rhinitis, as well as for other rhinitis conditions. Nasal irrigation is particularly useful for symptoms of postnasal drainage. Nasal irrigation can be used before use of nasal medication so that the lining is freshly cleansed when the medication is applied.
The nose can be rinsed with small amounts of saline by using over-the-counter saline nasal sprays, or with larger amounts of saline. The latter technique is called nasal irrigation or nasal lavage. A variety of devices, including bulb syringes, Neti pots, and bottle sprayers, may be used to perform nasal irrigation; instructions for the technique are provided in the table (table 1). At least 200 mL (about 3/4 cup) of fluid is recommended for each nostril. Patients can make their own solution or buy commercially-prepared solutions. All are available without a prescription.
Nasal irrigation with warmed saline can be performed as needed, once per day, or twice daily for increased symptoms. Nasal irrigation carries few risks when performed correctly.
Medications that worsen symptoms — Certain medications can cause or worsen nasal symptoms (especially congestion). These include the following: birth control pills, some drugs for high blood pressure (eg, alpha blockers and beta blockers), antidepressants, medications for erectile dysfunction, and some medications for prostatic enlargement. If rhinitis symptoms are bothersome and one of these medications is used, ask the prescriber if the medication could be aggravating the condition.
Nonallergic rhinitis medications — Daily use of a nasal glucocorticoid and/or an antihistamine nasal spray can be helpful for people with nonallergic rhinitis. These medications may be used alone or in combination.
Nasal antihistamines — A prescription nasal antihistamine spray, such as azelastine (Astelin®), can relieve symptoms of post-nasal drip, congestion, and sneezing. Azelastine starts to work within minutes after use and can be used to treat symptoms after they develop. However, it is most effective when used on a regular basis.
The most common side effect of nasal antihistamines is a bad taste in the mouth immediately after use. This can be minimized by keeping the head tilted forward while spraying, to prevent the medicine from draining down the throat. The usual dose of azelastine is two sprays in each nostril twice per day.
Nasal glucocorticoids — A nasal glucocorticoid, fluticasone (Flonase®), has been shown to be effective for symptoms of nonallergic rhinitis. The dose is one squirt in each nostril twice per day. Other glucocorticoid nasal sprays may also be effective, although these have not been directly studied in people with nonallergic rhinitis.
Some symptom relief may occur on the first day treatment, although the maximal effect may not be noticeable for days to weeks. For this reason, fluticasone is most effective when used regularly. Some people are able to use lower doses when symptoms are less severe. (See ‘How to use a nasal spray’ below.)
Nasal ipratropium — Profuse, watery discharge from the nose (rhinorrhea) can be treated with ipratropium bromide (0.03 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis. (See ‘Gustatory rhinitis’ below.)
How to use a nasal spray — Nasal sprays work best when they are used properly and the medication remains in the nose, rather than draining down the back of the throat. Some people find that holding one nostril closed with a finger improves their ability to draw the spray into the upper nose. Medicine that drains into the throat may be spit out.
The head should be positioned normally or with the chin slightly tucked. The spray should be directed away from the nasal septum (the cartilage that divides the two sides of the nose). The spray is dispensed and then sniffed in slightly to pull it into the higher parts of the nose. Sniffing too hard will result in the medicine draining down the throat, and should be avoided.
Decongestants — Oral decongestant medications (like pseudoephedrine [Sudafed®, Actifed®, Drixoral®]) may help to relieve symptoms of congestion (stuffiness) in some people. However, this treatment is not usually recommended unless nasal antihistamines and nasal glucocorticoids do not improve symptoms.
Several decongestant nasal sprays also are available, including oxymetazoline (Afrin®) and phenylephrine (Neo-synephrine®). Nasal decongestants should not be used for more than two to three days at a time because they may cause a type of rhinitis called rhinitis medicamentosa. (See ‘Rhinitis medicamentosa’ below.)
Oral decongestants elevate blood pressure and may not be appropriate for people with high blood pressure or certain cardiovascular conditions. Men with an enlarged prostate who have difficulty urinating may notice a worsening of this symptom when they take decongestants. (See “Patient information: Benign prostatic hyperplasia (BPH)”.) In addition, oral decongestants can cause nervousness and difficulty sleeping.
How long will I need treatment? — The dose or frequency of medications can be reduced in some patients over time. However, in most patients, symptoms are lifelong and some medication is usually needed on a daily and long-term basis.
OTHER TYPES OF NONALLERGIC RHINITIS
Gustatory rhinitis — Gustatory rhinitis is a type of nonallergic rhinitis that causes a sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Atrophic rhinitis — Atrophic rhinitis is an uncommon type of rhinitis that results from a gradual thinning of the nasal lining and the nasal bones. This condition most commonly occurs in older adults. The symptoms include nasal congestion, crusting of the nasal passages, and a persistent bad smell.
Treatment with a saline spray or lavage often relieves the symptoms of atrophic rhinitis. Occasionally, sinus rinses containing an antibiotic solution are prescribed.
Rhinitis medicamentosa — Rhinitis medicamentosa is a type of rhinitis that develops as a result of overuse of over-the-counter decongestant nasal sprays or from snorting cocaine (this does not happen with use of nasal glucocorticoid sprays). Oral medications can also cause rhinitis medicamentosa. (See ‘Medications that worsen symptoms’ above.)
Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition .
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed every four months on our web site (www.uptodate.com/patients).
Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient Level Information:
Patient information: Allergic rhinitis (seasonal allergies)
Patient information: Benign prostatic hyperplasia (BPH)
Professional Level Information:
Allergen avoidance in the treatment of asthma and allergic rhinitis
An overview of rhinitis
Chronic nonallergic rhinitis
Clinical manifestations and epidemiology of allergic rhinitis (rhinosinusitis)
Diagnosis of allergic rhinitis (rhinosinusitis)
Pathogenesis of allergic rhinitis (rhinosinusitis)
Pharmacotherapy of allergic rhinitis
Recognition and management of allergic disease during pregnancy
Etiologies of nasal symptoms: An overview
The following organizations also provide reliable health information.
- National Library of Medicine
- American Academy of Otolaryngology (Head and Neck Surgery)
- American Academy of Allergy, Asthma, & Immunology
- American Rhinologic Society
- Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998; 81:478.
- van Rijswijk JB, Blom HM, Fokkens WJ. Idiopathic rhinitis, the ongoing quest. Allergy 2005; 60:1471.
- Settipane RA, Lieberman P. Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001; 86:494.
- Berger WE, Schonfeld JE. Nonallergic rhinitis in children. Curr Allergy Asthma Rep 2007; 7:112.