Rhinitis is defined as an inflammation of the nasal mucosa and it is characterised
by nasal obstruction, runny nose (rhinorrhea), sneezing, and (itching) pruritus.
The causes of rhinitis can be broadly categorised into 3 headings:
1. Allergic Rhinitis
- Seasonal – Hay Fever
- Persistent (perennial) eg House dust mite-induced
2. Infectious Rhinitis (eg the common cold). Children,
particularly young children in school or day care centres, may have from eight to
12 colds each year. Viral infections are self-limiting and usually last 7-10 days.
Non-allergic, Non-Infectious eg Vasomotor Rhinitis (or Irritant
"Vaso" means blood vessels and "motor"
refers to the nerves, which innervates nasal tissue and the blood vessels. This
is sometimes referred to as idiopathic non-allergic rhinitis. It is estimated that
up to 10% of the population suffers from non-allergic rhinitis.
Mixed Allergic and Non-allergic Rhinitis probably account for the majority of cases.
This is an important category to recognise, as allergen avoidance measures only,
will give sub-optimal improvements.
Mixed Allergic and Vasomotor probably account for
the majority of cases. This is an important category to recognise, as allergen avoidance
measures only will give sub-optimal improvements.
Features of Vasomotor Rhinitis
Vasomotor Rhinitis is chronic rhinitis that is characterised by intermittent (coming
and going) episodes of sneezing, watery nasal drainage (rhinorrhea), and blood vessel
congestion of the nasal mucus membranes. There appears to be a hypersensitive response
to stimuli such as a dry atmosphere, air pollutants, spicy foods, alcohol, strong
emotions, and some medications.
Indeed any particulate matter
in the air, including pollens, dust, mould, or animal dander can bother people with
VMR, even though they are not actually allergic to these things.
People with VMR are unusually sensitive to irritation and will have significant
nasal symptoms even when exposed to low concentrations of irritants. Thus, vasomotor
rhinitis seems to be an exaggeration of the normal nasal response to irritation,
occurring at levels of exposure, which doesn't bother most people
Subjects with vasomotor rhinitis fall into two general groups:
who have "wet" rhinorrhea, and
subjects with predominant symptoms of nasal congestion
and blockage to airflow, and minimal rhinorrhea. These reactions can be provoked
by non-specific irritant stimuli such as cold dry air, perfumes, paint fumes, and
cigarette smoke. Subjects with predominantly rhinorrhea (sometimes referred to as
cholinergic rhinitis) appear to have enhanced cholinergic glandular secretory activity,
since atropine effectively reduces their secretions.
It is important to understand that VMR is a nonspecific response
to virtually any change or impurity in the air, as opposed to allergic rhinitis
(or hay fever), which involves a response to a specific protein in pollen, dust,
mould, or animal dander.
Key features of VMR
There is usually no history of allergies and an irritant may or may not be identified
by the patient
- There is no infection causing these symptoms.
- Vasomotor Rhinitis can have a variable presentation.
- Most patients seem to be older than the typical patients with hay fever.
Can sometimes present with a seasonal pattern due to changes in temperature and
Patients present with rhinorrhea (thick or scanty), frontal headaches, and congested
turbinates but usually no (itching) pruritus.
Some patients will find that eating (especially, spicy foods) causes more nasal
dripping or congestion.
The autonomic nervous system controls the blood supply into the nasal mucosa and
the secretion of mucus. The diameter of the resistance vessels in the nose is mediated
by the sympathetic nervous system while the parasympathetic nervous system controls
glandular secretion and to a lesser extent, exerts an effect on the capacitance
vessels. Either a hypoactive sympathetic nervous system or a hyperactive parasympathetic
nervous system can engorge these vessels, creating an increased swelling of the
nasal mucosa, and thus congestion. Activation of the parasympathetic nervous system
can also increase mucosal secretions leading to excess runny nose.
Overactive irritant receptors may also play a role in Vasomotor Rhinitis.
Triggers of Vasomotor Rhinitis
Many cases are associated with a specific agent or condition. Examples of such agents/conditions
- Changes in temperature or barometric pressure, turbulent air
- Perfumes, strong cooking odours, smoke
- Inorganic dust (which is separate from house dust mite), air pollution
- Spicy foods, alcohol
- Some medications, like some blood pressure tablets
- Sexual arousal
- Stress (emotional or physical).
Other causes of non-allergic rhinitis are:
Nonallergic rhinitis with eosinophilia syndrome (NARES).
Eosinophilic rhinitis (ie, perennial intrinsic rhinitis) accounts for up to 20%
of rhinitis diagnoses. Some researchers believe that this may be a precursor to
the aspirin triad of intrinsic asthma, nasal polyposis, and aspirin intolerance.
Abnormal prostaglandin metabolism also has been implicated as a cause of NARES.
Elevated eosinophil counts are present in approximately 20% of the general population's
nasal smears. However, not everyone with eosinophilia has symptoms of rhinitis.
A distinguishing feature of NARES is the presence of eosinophils, usually between
10-20%, on nasal smear. Generally, patients with NARES present with nasal congestion,
sneezing, rhinorrhea, nasal pruritus, and hyposmia.
Occupational rhinitis is usually caused by an inhaled
irritant or allergen (eg, laboratory animal antigens, grains, wood dusts, and chemicals).
Frequently patients with occupational rhinitis present with concurrent occupational
Hormonal rhinitis is caused by hormonal imbalances
such as pregnancy, hypothyroid states, puberty, and oral contraceptive use, conjugated
Drug-induced rhinitis is caused by several medications
including angiotensin-converting enzyme inhibitors, reserpine, guanethidine, phentolamine,
methyldopa, beta-blockers, chlorpromazine, gabapentin, penicillamine, aspirin, nonsteroidal
anti-inflammatory drugs, inhaled cocaine, exogenous estrogens, and oral contraceptives.
Rhinitis medicamentosa is considered a drug-induced
rhinitis and results from prolonged use (ie, longer than 5-10 days) of over-the-counter
topical nasal decongestants. Typically, these patients present with extensive nasal
congestion and rhinorrhea, resulting from loss of sympathetic nerve tone, rather
than from the original cause of rhinitis. Normal nasal function should resume within
7-21 days following cessation of decongestants. Symptoms usually improve with nasal
Gustatory rhinitis occurs following consumption of
hot and spicy foods. This is a "wet" (profuse watery) runny nose, secondary
to nasal vasodilatation (dilated blood vessels) and it is due to stimulation of
the vagus nerve, generally occurring within a few hours of eating the food.
Conditions often confused with non-allergic rhinitis include:
- Nasal polyps
- Previous trauma to the nose
- Structural abnormalities eg deviated nasal septum
Diagnosis of VMR
VMR is usually diagnosed by taking a careful history
and performing a thorough exam of the nose and throat.
(skin prick test) should be performed to make sure
there is no allergic basis for some of the symptoms, since this would affect our
In some cases a CT scan of the sinuses may be required to exclude chronic sinusitis
or polyposis. Occasionally, (few usually mild) positive skin prick test reactions
are found in patients with VMR, but it does not fit the history and is therefore
not relevant to the cause of the rhinitis.
Treatment of Vasomotor Rhinitis
Normal saline nasal douches
Antihistamines have a variable response. They seem to help a few patients whose
main symptom is runny nose, and usually when the rhinitis is mixed vasomotor and
Atrovent (Ipratromium bromide) nasal spray is effective in patients who have runny
nose as their main symptom.
Topical steroids help with congestion, runny nose, and sneezing. They suppress the
local inflammatory response caused by vasoactive mediators by inhibiting Phospholipase
A2, reduce the activity of acetylcholine receptors, and decrease basophil, mast
cell, and eosinophil counts. They do not start working immediately, but when they
do, they seem to control all the symptoms. Some adverse effects are mucosal swelling,
mild redness, burning or stinging upon application, drying of the mucosa, nosebleeds,
and nasopharyngeal thrush.
Decongestants, or sympathomimetic agents, are used mostly for congestion.
Pseudoephedrine (Sudafed) tablets. Systemic adverse effects include nervousness,
insomnia, irritability, and difficulty urinating in elderly males. They are contraindicated
in persons with labile or overt hypertension. Decongestants have not been shown
to have an effect on blood pressure in normotensive patients.
- Oxymetazoline (Drixine) nasal sprays
- Xylometazoline (Otrovine) nasal spray
Topically, these drugs can cause Rhinitis Medicamentosa (a rebound congestion which
occurs after taking topical formulations of these drugs for more than five days).
If the rhinitis does not respond to drug therapy, very rarely surgical procedures
can be considered. Some of the procedures that have been performed in the past include:
Cryosurgery affects the mucosa and submucosa, making it a quite successful procedure
for congestion. However, there is sometimes prolonged post-operative nasal congestion
and the possibility of damage to the nasal septum.
Vidian neurectomy disrupts both sympathetic and parasympathetic fibers to the mucosa
and it mainly diminishes rhinorrhea.
If chronic hypertrophic changes appear in the mucosa, a number of surgical procedures
can be tried. These include:
Cauterization can be accomplished via silver nitrate
or electrical current, however it only affects the mucosa.
Cryosurgery is considered superior to cauterization because it also affects the
Submucosal resection of the conchal bone is a difficult procedure with much post-operative
bleeding. Partial or total inferior turbinate resection works well for nasal congestion
but can give post-operative bleeding and crusting.