Allergic and Nonallergic Rhinitis

Rhinitis is described as inflammation and irritation of the mucous membrane lining the nose. This condition can be caused by bacteria, allergens, pollen, air pollutants, certain foods and beverages, smoke, hormonal changes or viruses. Allergic rhinitis, which is the most common form, affects approximately 30 million people in the United States each year including children.  While not life-threatening, it does contribute to missed days at work and school, decreased productivity, overall quality of life and sleep disorders.  

At Mount Sinai, the rhinologists in the Department of Otolaryngology – Head and Neck Surgery have vast expertise treating this condition, not only with the various over-the-counter (OTC) and prescription medications, minimally invasive surgery but also with novel techniques and procedures targeting the cause of many of the symptoms. Working together with you, we can customize a treatment plan, based on your medical history and address any anatomical issues with minimal impact on your lifestyle to improve your overall quality of life.  

Types of Rhinitis

As noted, there are two main distinctions of rhinitis.  Differentiating them revolves around the presence of allergic causes. Please see below for further classification. 

Allergic rhinitis: triggered by a sensitivity to inhaled environmental allergens such as pollen and dust.  The body mounts a response to certain exposures that induces symptoms (i.e. nasal obstruction, swelling, nasal drainage, etc.).  Symptoms can present seasonally or perennial, persistent or intermittent, and exposure induced. 

Nonallergic rhinitis: causes and triggers are varied as noted below. Symptoms and trigger are extremely important in the diagnosis and proper treatment. Symptoms can be persistent or intermittent.

• Granulomatous rhinitis: relatively uncommon, this type is characterized by granuloma formation in the nasal lining. Tuberculosis and syphilis all produce this form of rhinitis.
• Medicamentosa: this is a drug-induced form of nonallergic rhinitis caused by the use of certain oral or topical medications. The biggest offender is habitual afrin use for longer than 5 days.  When stopping these medications there is an overt rebound congestion.    
• Non-allergic rhinitis with eosinophilia: thought to be in patients that have no evidence of allergy sensitivities on skin and blood work, this type could possibly generate local reaction at the nasal level.   
• Occupational: induced by environmental or work environments, this category is typically triggered by dust, factory byproducts, and chemicals.
• Sicca: dryness of the mucous membrane is the primary indication of this category. 
• Hormone Induced: pregnancy, oral contraceptive use, and hypothyroidism can trigger this category, which typically occurs at first trimester of pregnancy and resolves after delivery of child. 
• Gustatory:  this may be brought on by spicy, hot food or liquid intake.
• Atrophic: this is considered to be secondary change of the normal sinus mucosa to more squamous and is characterized by loss of mucosal glands and sensory nerves.  Some forms include “empty nose syndrome,” chronic infection, nutritional deficiency, or irritant exposures.

Risk Factors of Rhinitis

• Being female versus male
• Genetics
• Exposure to pollutants or occupational irritants
• Stress
• Other medical conditions such as hypothyroidism

Diagnosis of Rhinitis

For allergic rhinitis, allergy testing may involve skin or blood tests.

• Skin testing: involves several pricks with tiny amounts of common airborne allergens (mold, pollen, dust, dander, etc.) placed over the test site. If you are allergic to a specific allergen, a raised bump will appear at the test site.  
• Blood testing: can measure antibodies to allergens in your bloodstream called immunoglobulin E (IgE) antibodies. The lab will then reveal if there is evidence of specific allergen sensitivities.

For nonallergic rhinitis, allergy testing as noted above is often performed to rule out any sensitivities. It is important to provide your physician with symptoms, triggers, timing, a full list of current medications (both OTC and prescription)- so that a proper diagnosis can be made. Interestingly, there is no definitive test or exam for diagnosing nonallergic rhinitis. Your physician may order blood work or a CT scan to rule out any other diseases (sinusitis or cerebrospinal brain fluid leak). Your provider may also use a small camera to look into the nasal cavity, back of the nose to determine any other warning signs. The test is painless and can provide a volume of information. 

Symptoms of Rhinitis

• Runny nose or postnasal drip
• Nasal congestion/ obstruction
• Sneezing
• Cough
• Decreased smell
• Ear fullness
• Throat clearing
• Cough
• Eye or nasal itching

Treatment Options

Non-pharmacologic treatments

• Avoidance of triggers: the first line in the treatment armamentarium and often overlooked!  This can be an efficient and effective method to reduce symptoms.
• Environmental controls: removal of pets (pet free rooms/sanctuary), bed covers, HEPA filters, and laundering sheet in hot water.

Over-the-counter treatments

• Nasal rinses/Netipot: the physical act of lavage with large volume (240ml) of saline or frequent nasal sprays will help with reducing the amount of allergens in the nose. It is critically important to use twice a day to keep allergen levels acceptably low and prevent symptoms.
• Decongestants: can help with symptomatic treatment of nasal obstruction and congestion.  It is important to limit the use of spray decongestants (Afrin) to less than 3 days.
• Nasal corticosteroids: this is the gold standard for non-allergic and allergic rhinitis; they are effective in treating most rhinitis cases, reducing inflammation and nasal symptoms (congestion, itching, nasal drip, sneezing).
• Oral antihistamines/allergy medications: if more systemic symptoms, such as eye or throat itching are present, this treatment may be recommended.

Prescription treatments

• Antihistamine nasal sprays: if symptoms are limited to nasal, this is often a recommended treatment.  Can help to reduce nasal drip, congestion and sneezing.
• Anticholinergic nasal spray: helps reduce mucus production by acting on receptors responsible for nasal drip. This treatment is often selected if the predominate symptom is nasal drainage. 
• Immunotherapy: this treatment is often selected if sensitivity is noted on allergy testing. The treatment can be provided with subcutaneous shots or sublingual drops. 

Surgical treatments

• There is no surgical treatment specifically for allergic or nonallergic rhinitis.  Surgical treatment revolves around ameliorating symptoms, such as nasal drip and nasal congestion/obstruction.
• Addressing anatomical abnormalities (deviated septum, inferior turbinate enlargement, and nasal valve collapse) can help with obstruction. Deviated septums can be addressed with a septoplasty, enlarged inferior turbinate can be reduced with in-office/OR treatments and nasal valve collapse can be addressed with bolstering the valve to prevent collapse.
• Addressing the nerve responsible for nasal drip.  Often referred to the vidian nerve and some of its branches, this is predominately responsible for the signal to produce inflammation and liquid in the nose. The nerve can be addressed via clinic or OR procedures to “reset” and prevent the over signal.  Several treatments are available including in office cryotherapy, injections, and procedures in the operating room that focus on cutting the nerve and severing the signal.

Allergic and nonallergic rhinitis can be overwhelming, as symptoms are often chronic and can cause distress in many people’s lives. The treatment of these symptoms can feel daunting, but we here at Mount Sinai can help you navigate the treatment steps and help you select the treatment that both improves your quality of life and enjoy living again.