Signs and Symptoms

Often, VMR is associated with nasal obstruction and thickened postnasal drip. In addition, it can present with copious, watery anterior rhinorrhea, often triggered by changes in temperature, alcohol use, or exposure to odors and aromas. Other common symptoms of NAR include sneezing, congestion, and itching, which can be triggered by inhaled agents, cigarette smoke, foods, chemicals, and medications. All can have an irritant effect on the nasal mucosa.

Differential Diagnosis

NAR is diagnosed after AR has been excluded. Stimulation of the nasal mucosa by endogenous and exogenous agents causes symptoms that characterize rhinitis. In addition, NAR can be exacerbated by hormonal influences such as those experienced during pregnancy, endocrine disturbances such as hypothyroidism, and autonomic dysfunction.

Occupational Rhinitis

Occupational (irritative-toxic) rhinitis is caused by inhalant irritants or toxic agents including chemicals, solvents, and cigarette smoke. Cigarette smoking is the most common cause, and occupational exposure the next leading cause, of this subtype. Cessation and adequate protection from these stimuli result in control of symptoms.

Hormonal Rhinitis

The most commonly reported hormonal rhinitis is rhinitis of pregnancy, seen in 22% of nonsmoking women and in 69% of smokers. Rhinitis of pregnancy is most common during the later stages of pregnancy. Rhinitis of pregnancy resolves within 2 to 4 weeks of delivery.

Drug-Induced Rhinitis

Many common medications have physiologic side effects on the nose, resulting in nasal congestion. These medications include angiotensin-converting enzyme (ACE) inhibitors, β-blockers, oral contraceptives, antipsychotics, and recently, phosphodiesterase type-5 inhibitors. Some patients may have a non-IgE-mediated sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin.

Rhinitis medicamentosa is most commonly associated with prolonged use of topical vasoconstrictive nasal sprays such as oxymetazoline. Prolonged use of these medications results in tachyphylaxis, and cessation of use is associated with rebound nasal congestion, which can be severe and refractory to treatment.

Gustatory Rhinitis

Gustatory rhinitis is characterized by watery, often profuse rhinorrhea that develops with ingestion of food. Anticipation of eating or even the smell of food may precipitate clear nasal drainage. The response is mediated by aberrant parasympathetic stimulation of nasal secretomotor fibers on stimulation of salivary secretomotor activity.

Nonallergic Rhinitis with Eosinophilia

Nonallergic rhinitis with eosinophilia (NARES) was originally described as a constellation of perennial sneezing attacks, profuse watery rhinorrhea, and nasal pruritus, as well as nasal congestion in patients who showed a lack of evidence for allergy on skin testing or in vitro testing for specific IgE and who had greater than 20% eosinophils on nasal smears.

Vasomotor Rhinitis

VMR is the most common form of chronic NAR. VMR is a diagnosis of exclusion. VMR is widespread, especially in the elderly, and may be frustrating to treat.

Chemical Sensitivity

A particularly severe form of sensitivity to certain chemical substances is seen on occasion. History generally describes an exposure to a strong or caustic substance with onset of severe or disabling rhinitis symptoms on repeat exposure to even mild or normal chemicals, such as perfumes or cleaning agents. This is poorly understood and has been considered a “multiple chemical sensitivity syndrome.” Strict avoidance, if possible, may be effective, although better treatment options remain to be determined.