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Wise et al.

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III.C.10. Vasomotor rhinitis (nonallergic rhinopathy)— Vasomotor rhinitis is the most common cause of NAR, and is found in 71% of cases. 189-191 The absence of an IgE mediated immune response differentiates vasomotor from allergic forms of rhinitis. 101 Therefore, the term “non-allergic rhinopathy” is recommended to replace vasomotor rhinitis, as inflammation is not regarded as a crucial part in the pathogenesis of non-allergic rhinopathy. In Europe, “idiopathic rhinitis” has also been used to describe this condition. Non-allergic rhinopathy is a diagnosis of exclusion, and other etiologic factors for rhinopathy must be evaluated. These include CRS, NARES, AERD, infectious rhinitis, anatomical abnormalities, RM, drug side effects, cerebrospinal fluid (CSF) rhinorrhea, and rhinitis of pregnancy. Clinical characteristics of non-allergic rhinopathy have been summarized in a consensus paper by Kaliner et al. 40 Non-allergic rhinopathy represents a chronic disease with primary symptoms of rhinorrhea. Associated symptoms of nasal congestion, postnasal drip in the absence of acid reflux, throat clearing, cough, Eustachian tube dysfunction, sneezing, hyposmia, and facial pressure/headache may also be present with non-allergic rhinopathy. These symptoms may be perennial, persistent, or seasonal, and are typically elicited by defined triggers, such as cold air, climate changes (ie, temperature, humidity, barometric pressure), strong smells, tobacco smoke, changes in sexual hormone levels, environmental pollutants, physical exercise, and alcohol. While often associated with non-allergic rhinopathy, the lack of a defined trigger does not preclude this diagnosis. In addition, nasal hyperreactivity to nonspecific stimuli may occur in both allergic and non allergic rhinitis. 192 Non-allergic rhinopathy is primarily found in adults, with a female-to-male ratio of 2:1 to 3:1. On physical exam, the nasal mucosa usually appears normal, but may show signs of erythema and clear rhinorrhea. While systemic allergy testing (skin or in vitro testing) is typically sufficient to differentiate between AR and non-allergic rhinopathy, a diagnosis of LAR may be considered in the setting of negative systemic testing. Individuals with LAR suffer from typical allergic symptoms upon allergen exposure, but display a lack of systemic IgE sensitization. Local provocation is necessary to definitively exclude this diagnosis. 193,194 While the exact pathophysiology of non-allergic rhinopathy remains incompletely described, neurosensory abnormalities are thought to play a crucial role. 40 In a prior study of central responses to olfactory stimuli, subjects with non-allergic rhinopathy underwent functional magnetic resonance imaging following exposure to different odors (vanilla and hickory smoke). Findings included increased blood flow to the olfactory cortex, leading to the hypothesis of an altered neurologic response in non-allergic rhinopathy. 195,196 Patients with non-allergic rhinopathy with a predominant symptom of rhinorrhea will often respond to treatment with intranasal anticholinergics such as ipratropium bromide (IPB). III.C.11. Age-related rhinitis (ie, elderly)— Age-related changes occur in every organ system, including the respiratory system. Specific to the nasal cavity, the physiological process of aging results in neural, hormonal, mucosal, olfactory, and histologic alterations that cause morphological and functional changes in the aging nose. 197,198 This makes the elderly population more vulnerable to symptoms such as rhinorrhea, nasal congestion,

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.