Perennial Nonallergic Rhinitis

Perennial nonallergic rhinitis (PNAR) is a term used to designate a heterogeneous group of disorders that share clinical features. The pathophysiology is not completely defined, and nasal histology does not correlate with symptoms. PNAR is common, representing 30-60% of subjects referred to an allergy/immunology or otolaryngology clinic for evaluation. PNAR coexists with allergic rhinitis in more than 50% of adults with allergic rhinitis, a condition referred to as mixed rhinitis. Mucosal inflammation is less evident in PNAR than in allergic rhinitis, making the term rhinitis sometimes a misnomer. However, the symptoms are consistent with other inflammatory nasal disease, and inflammation may be present in a subset of PNAR.

The typical presentation of PNAR is complaints of nasal obstruction, with or without rhinorrhea or postnasal drip, exacerbated by physical stimuli such as odor (particularly floral smells), air temperature changes, air movement, body position change, food, beverage (particularly alcoholic drinks such as wine), or exposure to airborne irritants such as cigarette smoke. Paroxysmal sneezing and itching are less common in PNAR than in allergic rhinitis. A variant of PNAR, with copious rhinorrhea associated with eating or preparation for eating, is termed gustatory rhinitis. Exercise often improves the symptoms of PNAR, contrasting with allergic rhinitis.

Non-IgE degranulation of nasal mast cells by physical stimuli such as cold, dry air and hyperosmolar mucosal fluid is not likely a critical part of the pathophysiology of PNAR since the symptoms of itching and sneezing paroxysms and mucosal eosinophilia are typically absent. However, mast cell degranulation has been demonstrated with cold air challenge of the nose in PNAR. Neurogenic mechanisms may play a pathophysiological role in PNAR as some affected subjects hyperrespond with nasal congestion following nasal challenge with cholinergic agents, suggesting a type of nasal hyperreactivity similar to that occurring in the bronchial airway with asthma.

The diagnosis of PNAR is suggested by the symptom history, the nature of provoking stimuli, and absence of a family history of allergy. The nasal mucosa is variable in appearance but generally is congested with normal to erythematous color. The secretions are usually clear and do not contain a significant number of eosinophils or neutrophils. Other causes of nasal symptoms should be excluded because of the lack of a confirmatory diagnostic test for PNAR. The exclusion of perennial allergic rhinitis is particularly important since the symptoms of the two are similar and some subjects have both conditions (Table 6). Sinusitis should also be considered because many symptoms are common to both.

The treatment of PNAR is symptomatic in that the pathophysiology is usually unknown. The physician should focus the therapy on the primary symptom. Decongestants, nasal saline to lavage irritants from the mucosa or dilute secretions, and topical ipratropium bromide 0.03% (Atrovent® Nasal) for rhinorrhea are often helpful. Oral antihistamine therapy offers limited benefits, although the anticholinergic effects of first-generation sedating antihistamines may be helpful for rhinorrhea. Topical antihistamine therapy with azelastine is efficacious and approved for treatment of PNAR, contrasting with the lack of any oral antihistamines being approved. Topical, nasal corticosteroid therapy relieves symptoms of PNAR, probably by reducing glandular secretion and blood flow to the nose, since mucosal inflammation is not consistently present. The response to topical nasal corticosteroids is variable and not as predictable as with allergic rhinitis. Although only select nasal corticosteroids have a US Food and Drug Administration (FDA) indication for nonallergic rhinitis, most likely all work and all are generally used. Nasal corticosteroids with a detectable odor,for example, beclomethasone (Vancenase AQ®) or fluticasone (Flonase®), may aggravate symptoms, suggesting a preference for sprays without smell. Regular aerobic exercise, 20-30 min two to three times a week, may help reduce symptoms, at least temporarily, and is good for general health. Nasal congestion and sinus pressure are often the most bothersome symptoms, so emphasis on avoidance of regular, topical decongestants is important as this may lead to rhinitis medicamentosa. Oral lozenges containing menthol may affect the perception of nasal congestion but have no measurable effect on congestion. Finally, affected subjects need reassurance and sensitive care to reduce "doctor shopping," unnecessary surgery, overuse of antibiotics, and overinterpretation of allergy tests.

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