Patient education: Nonallergic rhinitis (runny or stuffy nose) (Beyond the Basics)
- Phillip L Lieberman, MD
Phillip L Lieberman, MD
- Clinical Professor of Medicine and Pediatrics
- University of Tennessee College of Medicine
NONALLERGIC RHINITIS OVERVIEW
Rhinitis refers to inflammation of the nasal passages. This inflammation can cause a variety of annoying symptoms, including sneezing, itching, nasal congestion, runny nose, and postnasal drip (the 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 (eg, the common cold). Chronic rhinitis is usually caused by allergies, but it can also occur from overuse of certain drugs, some medical conditions, and other unidentifiable factors.
This topic discusses nonallergic rhinitis. A separate topic discusses rhinitis caused by allergies. (See "Patient education: Allergic rhinitis (seasonal allergies) (Beyond the Basics)".)
WHAT IS NONALLERGIC RHINITIS?
"Nonallergic rhinitis" is the medical term used to describe the following symptoms when they occur without a known allergic cause for weeks to months at a time for at least a year:
●Stuffy nose (congestion)
Symptoms are usually present year-round, although they may be worsened by certain weather conditions (eg, those that accompany changes of season). The condition does not usually develop until adulthood.
NONALLERGIC RHINITIS CAUSES
The cause of nonallergic rhinitis is not known. However, many triggers of symptoms are known. These include tobacco smoke, traffic fumes, strong odors, and perfumes, as well as weather conditions (such as the arrival of a weather front). People with nonallergic rhinitis are not bothered by pollen or furred animals (the common triggers in allergic rhinitis) unless they also happen to have allergic rhinitis. About one-half of all patients with long-standing nasal symptoms have both allergic and nonallergic rhinitis. (See "Patient education: Allergic rhinitis (seasonal allergies) (Beyond the Basics)".)
NONALLERGIC RHINITIS TREATMENT
Treatment of nonallergic rhinitis includes trigger avoidance, medications, and/or nasal rinsing or irrigation.
Trigger avoidance — Exposure to tobacco smoke can be reduced if household members stop smoking or smoke only outside of the home. It is also important to avoid smoke exposure in the workplace.
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.
Exposure to strong perfumes and scented products may be more difficult. 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.
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, as well as for other rhinitis conditions. Nasal rinsing is particularly useful for symptoms of postnasal drainage. Nasal rinsing can be done before use of nasal medication so that the lining is freshly cleansed when the medication 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 do not rinse the nasal passages as thoroughly as nasal irrigation. However, nasal irrigation is less convenient and 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 in the table (table 1). 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 when symptoms are more severe. Nasal irrigation carries few risks when performed correctly. Very rare brain infections have been reported from the use of water that was contaminated.
Medications that worsen symptoms — Certain medications can cause or worsen nasal symptoms (especially congestion). These include 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.
Some patients with nonallergic rhinitis resort to using over-the-counter nasal sprays containing a nasal decongestant (eg, oxymetazoline or phenylephrine). Although these sprays can give rapid relief of congestion when used occasionally, the effects lessen if they are used regularly. Over time, many patients become tolerant to their effects. When this occurs, decongestant sprays actually worsen symptoms, causing the nose to swell UNLESS the spray is used. In such instances it may be difficult to discontinue the spray and to do so the medical professional may be needed.
Medications that may help symptoms — 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 antihistamines — 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 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 glucocorticoids (steroids) — Nasal glucocorticoids (steroids) have been shown to be effective for symptoms of nonallergic rhinitis. Some are available over-the-counter in the United States (sample brand names: Flonase Allergy Relief, Rhinocort Allergy), while others require a prescription.
Some symptom relief may occur on the first day of treatment, although the maximal effect may not be noticeable for days to weeks. For this reason, these agents are most effective when used regularly. Some people are able to use lower doses when symptoms are less severe. (See 'How to use a nasal spray' below.)
Nasal ipratropium — A runny nose with profuse, watery discharge from the nose (rhinorrhea) can be treated with ipratropium (0.03 percent or 0.6 percent) nasal spray. Ipratropium is the best treatment for gustatory rhinitis. (See 'Gustatory rhinitis' below.)
Combination nasal antihistamine and nasal glucocorticoid (steroid) — There is a nasal spray (Dymista) that contains both azelastine and fluticasone.
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. Some people find that holding one nostril closed with a finger improves their ability to draw the spray into the upper nose. Medicine that drains into the throat should be spit out, since the medicine is only effective when it remains in the nose.
The head should be positioned normally or 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). The spray is dispensed and then sniffed in slightly to pull it into the higher parts of the nose. Sniffing too hard will result in the medicine draining down the throat and should be avoided.
Decongestants — 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.
Several decongestant nasal sprays also are available (see 'Medications that worsen symptoms' above). Examples include oxymetazoline (Afrin) and phenylephrine (Neo-synephrine). Nasal decongestants should not be used for more than two to three days at a time because they may cause a type of rhinitis called rhinitis medicamentosa. (See 'Rhinitis medicamentosa' below.)
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. (See "Patient education: Benign prostatic hyperplasia (BPH) (Beyond the Basics)".)
How long will I need treatment? — 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.
OTHER TYPES OF NONALLERGIC RHINITIS
Gustatory rhinitis — "Gustatory rhinitis" is the term used to describe the sudden onset of watery nasal discharge with eating, especially foods that are spicy or heated (such as soup).
Rhinitis medicamentosa — Rhinitis medicamentosa is a type of rhinitis that develops as a result of overuse of over-the-counter decongestant nasal sprays or from snorting cocaine (this does not happen with use of nasal glucocorticoid [steroid] sprays). Oral medications can also cause rhinitis medicamentosa. (See 'Medications that worsen symptoms' above.)
Rhinitis medicamentosa is treated by discontinuing the drug that is causing the condition. Steroid nasal sprays can speed the recovery from this condition.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Allergen avoidance in the treatment of asthma and allergic rhinitis
An overview of rhinitis
Chronic nonallergic rhinitis
Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis
Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis
Pathogenesis of allergic rhinitis (rhinosinusitis)
Pharmacotherapy of allergic rhinitis
Recognition and management of allergic disease during pregnancy
Etiologies of nasal symptoms: An overview
The following organizations also provide reliable health information.
- Carr WE, Van Bavel J, Lieberman P, et al. MP29-02 provides rapid and more complete nasal symptom relief than two first-line therapies: A retrospective analysis of a randomized, double-blind, placebo-controlled trial. J Allergy Clin Immunol 2013; 131:AB114.
- Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998; 81:478.
- van Rijswijk JB, Blom HM, Fokkens WJ. Idiopathic rhinitis, the ongoing quest. Allergy 2005; 60:1471.
- Settipane RA, Lieberman P. Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001; 86:494.
- Berger WE, Schonfeld JE. Nonallergic rhinitis in children. Curr Allergy Asthma Rep 2007; 7:112.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.