Non allergic rhinitis (vasomotor rhinitis)

 

IMPORTANT The information provided is of a general nature and should not be used as a substitute for professional advice. If you think you may suffer from an allergic or other disease that requires attention, you should discuss it with your family doctor. The content of the information articles and all illustrations on this website remains the intellectual property of Dr Raymond Mullins and cannot be reproduced without written permission.

Introduction
Not everyone with a snuffly nose has an allergy. Some have a sinus infection. Others have polyps or twisted nasal anatomy. A dry nose can also feel blocked. In non allergic rhinitis (vasomotor rhinitis), there appears to be an imbalance between the function of nerves supply the blood vessels and glands in the nose.


What is non allergic rhinitis?

Not everybody with a blocked or snuffly nose has allergy. Some will have a sinus infection. Others will have a blocked nose due to twisted anatomy, or an overgrowth of the lining of the nose and sinuses known as polyps. A dry nose sometimes develops with age, or after sinus surgery, in dry climates, with age and air-conditioning and winter heating. In non-allergic rhinitis, there appears to be an imbalance in the function of nerves that make mucous glands secrete fluid and which cause blood vessels to swell or contract. Patients may complain of blockage, runny nose, postnasal drip and even sneezing and itching. The condition usually lasts for years.


Can you have allergic and non allergic rhinitis?

Yes. It is estimated that around a third of people with allergic noses will have an element of non allergic rhinitis as well. For example, a person has hay fever like symptoms all year around, is much worse in spring and summer, but is found to be allergic on testing to grass pollen only; not dust mite or pets or mold. Immunotherapy/desensitisation directed against grass pollen may help the worsening symptoms over spring and summer but will not help the wintertime symptoms.

 

What makes it worse?
Patients with non allergic rhinitis (also known as vasomotor rhinitis) have an "irritable" nose. Changes in temperature or humidity, or exposure to irritants such as cigarette smoke, perfume or hair sprays can aggravate symptoms. Occasionally dietary factors can, such as spicy food or alcohol which can increase blood flow in the nose and make blocked nose worse. Taking out dairy and wheat rarely makes any difference and strict elimination diets only help the occasional person.


Are tests necessary?
Allergy tests (either skin tests or blood tests) are usually performed to exclude an allergic cause. An examination of the anatomy of the nose is also important. Sometimes additional blood tests or x-rays are needed to exclude other conditions that can give similar symptoms, like nasal polyps or sinus infection.


How can non-allergic rhinitis be treated?
It is often harder to treat non-allergic than allergic rhinitis. This is because there are fewer options; there are no allergens to avoid and immunotherapy does not help, as there is no allergy to switch off. Options include:

  1. •Avoid environmental irritants (where possible)

  2. •Use steam or salt water sprays to soothe and unblock the nose

  3. •Tablets (like antihistamines and pseudoephedrine) will often dry the nose if it is runny, but pseudoephedrine is hard to buy these days and often gives side-effects like the shakes, agitation or sleep disturbance.

  4. •Nasal sprays sometimes unblock and dry the nose if used regularly. The most common are nasal steroid sprays like Nasonex, Rhinocort or Flixonase.

  5. •Azelastine/Azep antihistamines nasal spray may also assist.

  6. •A combined steroid/Azep spray called Dymista (in Australia) is also often effective but requires a prescription to purchase at the moment.

  7. •Capsaicin is found in peppers and capsicum (“Pepper spray”) and gives them their pungent taste and smell. Regular application of the spray to the nose depletes the chemical transmitters that make nerves fire off in the nose. The end result is a nose lining that is less sensitive to environmental irritants. The dose is 1-2 sprays to each nostril, 3 times/day for at least 3-5 consecutive days, although it may take up to 2 weeks to work. Keep going until you no longer feel any burning or stinging. That means These 3 doses are best applied about 30 minutes apart. Apply the spray by directing it away from the nasal septum and up and backwards. Normally relief is experienced for about 2 weeks, at which point you can use again if symptoms start to return. It is important to NOT breath in or sniff, as otherwise you may get throat irritation. If you get it into the mouth, you will get a chilli like sensation of burning. Mild nasal irritation and a runny nose for about an hour may occur after using the spray. Wash your hands after use so you do not get the “capsicum spray” into your eyes. You do not need a script but the sprays are hard to find at your pharmacy, so you will often end up buying them online. Brands include Sinol spray (easiest to get: https://sinoloz.com.au/products/), Rinar spray (hard to buy as of 2019), or you can import Capsinol spray from the USA (https://capsinol.com/en/). Sprays usually contain 80-100 doses and one usually needs 2 bottles to obtain relief from symptoms.

  8. •Surgery certainly has a place in patients who have polyps, which are overgrowths of the lining of the soft tissues of the nose and sinuses. It is also useful to correct anatomical abnormalities, which can contribute to nasal blockage. Sometimes, cautery of some of the tissues can reduce the amount of mucous produced in the nose. Review by an ear nose and throat surgeon may sometimes be necessary.  Cutting one of the nerves to the nose (vidian neurectomy) may reduce the severity of runny nose.

  9. •Botox injections have been used in some centres with benefit

  10. •Restricted diets. Although some people find that foods may make their nose a little worse (eg. spicy food or alcohol), the results of strict "elimination diets" are usually disappointing.


References

Ozcan C, Ismi O. Botulinum Toxin for Rhinitis. Curr Allergy Asthma Rep. 2016 Aug;16(8):58. doi: 10.1007/s11882-016-0636-3.


Marshak T, Yun WK, Hazout C, Sacks R, Harvey RJ. A systematic review of the evidence base for vidian neurectomy in managing rhinitis. J Laryngol Otol. 2016 Jul;130 Suppl 4:S7-S28. doi: 10.1017/S0022215116008008.


Singh U, Bernstein JA, Lorentz H, Sadoway T, Nelson V, Patel P, Salapatek AM.  A Pilot Study Investigating Clinical Responses and Biological Pathways of Azelastine/Fluticasone in Nonallergic Vasomotor Rhinitis before and after Cold Dry Air Provocation. Int Arch Allergy Immunol. 2017;173(3):153-164. doi: 10.1159/000478698.


Lieberman PL, Smith P. Nonallergic Rhinitis: Treatment. Immunol Allergy Clin North Am. 2016 May;36(2):305-19. doi: 10.1016/j.iac.2015.12.007. Epub 2016 Feb 26. Review. PubMed PMID: 27083104.  


Halderman A, Sindwani R. Surgical management of vasomotor rhinitis: a systematic review. Am J Rhinol Allergy. 2015 Mar-Apr;29(2):128-34. doi: 10.2500/ajra.2015.29.4141.


Singh U, Bernstein JA. Intranasal capsaicin in management of nonallergic (vasomotor) rhinitis. Prog Drug Res. 2014;68:147-70.


Berger WE, Shah S, Lieberman P, Hadley J, Price D, Munzel U, Bhatia S. Long-term, randomized safety study of MP29-02 (a novel intranasal formulation of  azelastine hydrochloride and fluticasone propionate in an advanced delivery system) in subjects with chronic rhinitis. J Allergy Clin Immunol Pract. 2014 Mar-Apr;2(2):179-85. doi: 10.1016/j.jaip.2013.09.019..  


Gawlik R, Jawor B, Rogala B, Parzynski S, DuBuske L. Effect of intranasal azelastine on substance P release in perennial nonallergic rhinitis patients. Am  J Rhinol Allergy. 2013 Nov-Dec;27(6):514-6. doi: 10.2500/ajra.2013.27.3955.


Bernstein JA. Nonallergic rhinitis: therapeutic options. Curr Opin Allergy Clin Immunol. 2013 Aug;13(4):410-6. doi: 10.1097/ACI.0b013e3283630cd8

Last reviewed 10 April 2020