Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU
What is rhinitis?
Rhinitis is inflammation of the nasal passages. This inflammation can cause a different symptoms such as sneezing, itching, nasal congestion, runny nose, and postnasal drip (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 (also called common cold). Chronic rhinitis can be caused by allergies (allergic rhinitis) or nonallergic causes (nonallergic rhinitis).
What is nonallergic rhinitis?
Nonallergic rhinitis is inflammation of the nasal passages without a known allergic cause. You may have any of the following symptoms:
- Runny nose
- Stuffy nose (congestion)
- Postnasal drip
Symptoms are usually present year-round, although they may be worsened by certain weather conditions (eg, those that accompany changes of season).
What are the causes of nonallergic rhinitis?
The exact 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 usually bothered by pollen or furred animals (the common triggers in allergic rhinitis). However, 50% of people with this condition may also have allergic rhinitis (this is called mixed rhinitis).
What are the treatments of nonallergic rhinitis?
Treatment of nonallergic rhinitis includes trigger avoidance, nasal medications, nasal rinsing or irrigation.
How to avoid the triggers of nonallergic rhinitis?
Exposure to strong perfumes and scented products may be more difficult to avoid. 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.
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.
How to do nasal rinsing and 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. Nasal rinsing is particularly useful for symptoms of postnasal drainage. Nasal rinsing should be done 5 minutes before use of nasal medication, so that the nasal lining is freshly cleansed when the nasal spray 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. Nasal sprays are easy to use, but they do not rinse the nasal passages as thoroughly as nasal irrigation. Nasal irrigation is more effective but it also takes more time.
A variety of devices, including bulb syringes, irrigation pots (which look like small kettles), and bottle sprayers, may be used to perform nasal irrigation; instructions for the technique are provided separately. At least 200 mL (about three-quarters 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. Very rare brain infections have been reported from the use of water that was contaminated (tap water straight from the tap).
What medications help nonallergic rhinitis?
Nasal sprays. Daily use of a nasal glucocorticoid (steroid) and/or an antihistamine nasal spray can be helpful for people with nonallergic rhinitis. These medications may be used alone or in combination.
Nasal steroid spray. A nasal steroid such as fluticasone (eg, Flonase, generic equivalents) is effective for symptoms of nonallergic rhinitis. The dose is one squirt in each nostril twice per day. Other steroid nasal sprays may also be effective. Some symptom relief may occur on the first day of treatment, although the maximal effect may not be noticeable for 5 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.
Nasal antihistamine spray. A prescription nasal antihistamine spray, such as azelastine (eg, Astelin, Astepro), can relieve symptoms of postnasal drip, congestion, and sneezing. These sprays start to work within 15 minutes after use and can be used to treat symptoms after they develop. However, they are 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 ipratropium spray. A runny nose with profuse, watery discharge from the nose (rhinorrhea) can be treated with ipratropium bromide (0.03 percent or 0.6 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis (runny nose during/after eating).
Combination nasal steroid and nasal antihistamine. There is a nasal spray (Dymista) that contains both azelastine and fluticasone in one bottle.
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.
The head should be positioned 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).
How long will the treatment has to be?
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. A good starting point is to use a steroid nasal spray twice a day for 2 months.
Why decongestants may not be a good option for treatment nonallergic rhinitis?
Oral decongestant medications (like pseudoephedrine or phenylephrine) help to relieve symptoms of congestion (stuffiness) in some people. However, this treatment is not usually recommended unless nasal antihistamines and nasal glucocorticoids (steroids) do not improve symptoms. Oral decongestants elevate blood pressure and may not be appropriate for people with high blood pressure or certain cardiovascular conditions. In addition, oral decongestants can cause nervousness and difficulty sleeping. Men with an enlarged prostate who have difficulty urinating may notice a worsening of this problem when they take decongestants.
Several decongestant nasal sprays also are available, including oxymetazoline (Afrin) and phenylephrine (Neo-synephrine). Nasal decongestants should not be used for more than 2-3 days at a time because they may cause a type of rhinitis called rhinitis medicamentosa.
Avoid medications that worsen symptoms of nonallergic rhinitis
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.
Type of nonallergic rhinitis
Vasomotor rhinitis. This is watery nasal discharge triggered by nonallergic causes, for example, cold air.
Gustatory rhinitis. This is sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Rhinitis medicamentosa. It develops as a result of overuse of over-the-counter decongestant nasal sprays. It does not happen with use of nasal steroid, antihistamine or anticholinergic sprays. Oral medications can also cause rhinitis medicamentosa. Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition.