xRead - Nonallergic Rhinitis (September 2025)

BAROODY ET AL

1441

J ALLERGY CLIN IMMUNOL PRACT VOLUME 12, NUMBER 6

TABLE V. Comorbid conditions associated with NAR 6 Medical comorbidities

TABLE IV. NAR-associated disease and differentiating clinical characteristics 2 NAR-associated disease Clinical characteristics CRS with nasal polyps

Quality of life comorbidities

Acute and chronic rhinosinusitis Acute and chronic otitis media

Sleep disturbances

Decreased smell, taste, nasal congestion, asthma, aspirin intolerance Facial pain, pressure, headache, mucopurulent discharge, decreased smell Congestion worse on the side of the deviation Nasal congestion; poor response to medication Can be severe congestion unilaterally or bilaterally; primary or compensatory Unilateral intermittent clear drainage worse with head in dependent position, associated with recent surgery or head trauma Child with recurrent infections (otitis media), snoring, congestion, sleep disturbance

Fatigue

Conjunctivitis

Absenteeism or presenteeism from work or school Decreased cognitive function Absenteeism or presenteeism from work or school

CRS without nasal polyps

Eustachian tube dysfunction

Headaches

Septal deviation

Chronic cough secondary to postnasal drainage Nasal dyspnea

Nasal valve collapse

Nasal polyps Sleep apnea

Turbinate hypertrophy with or without concha bullosa

Cerebrospinal fl uid leak

This condition is often associated with nasal valve collapse, which refers to any weakness or further narrowing of the anterior nasal valve resulting in change of air fl ow perceived as nasal conges tion. 2 Turbinate hypertrophy with or without concha bullosa can cause severe unilateral or bilateral obstruction producing nasal congestion. Turbinate hypertrophy can be primary (eg, from AR and NAR) or compensatory, secondary to congenital or trau matic septal deviation. 2 Cerebrospinal fl uid leak usually presents as a unilateral clear rhinorrhea without congestion following head trauma or surgery that worsens in the upright position; however, some cases may be spontaneous. 2 Measurement of b 2 -transferrin in the fl uid and poor response to ipratropium bromide are helpful in making a diagnosis. 41 Imaging studies such as mag netic resonance imaging or high-resolution computed tomogra phy scans are required to fi nd the leak and surgery is usually required to cure this condition. Adenoidal hypertrophy is among the most common anatomic causes of nasal obstruction in children and can be assessed with a lateral x-ray of the naso pharynx, and/or by a nasopharyngolaryngoscopic examination. 2 Nasal foreign bodies, common among young children, most commonly present with unilateral obstruction and foul-smelling purulent rhinorrhea. 2 Ciliary dyskinesia manifests as a primary rare genetic disorder, referred to as immotile-cilia syndrome, that may present with symptoms of chronic cough, nasal congestion. asthma, situs inversus, and congenital heart disease. Physical examination often shows characteristic pooling of secretions on the nasal fl oor. This condition is also associated with CRS with nasal polyps (in children and adults), bronchiectasis, recurrent otitis, and rhinitis as a secondary condition, resulting from chronic infections, irritants, or multiple nasal surgeries that might be transient and reversible. 2 Pharyngonasal re fl ux sec ondary to prematurity or neuromuscular diseases may present as congestion in early life. 2 In addition, esophageal re fl ux can cause nasal symptoms in adults and children and may even predispose to obstructive sleep apnea. 2 Finally, nasal tumors usually present with unilateral nasal obstruction that can be progressive and are often accompanied by epistaxis or pain. COMORBID ILLNESSES Poorly controlled NAR can be accompanied by several different comorbidities, which can signi fi cantly impact its man agement and further impair quality of life (Table V). 1 Common associated conditions include acute and chronic rhinosinusitis

Adenoid hypertrophy

Foreign body

Unilateral, mucopurulent discharge

Nasal tumors

Progressive unilateral congestion, bloody discharge, nasal or ear pain

Rhinitis of the elderly or senile rhinitis typically presents in patients older than 65 years and is characterized by clear, watery rhinorrhea. 10 Atrophic rhinitis is usually a result of atrophy of the glands of the nasal mucosa and presents with nasal crusting and dried nasal secretions as well as nasal obstruction caused by bacterial in fections or secondary to nasal surgery with over-resection of nasal turbinates. 10 Occupational rhinitis is frequently related to the irritant effects of substances that workers are exposed to in different workplace environments including janitorial services, health care, agriculture, fi re fi ghting, food service, laboratory an imal care, power plants and re fi neries, commercial painting, printing, mining, roo fi ng, paving, welding, woodworking, and swimming pool maintenance. 10,39 Rhinitis medicamentosa is rebound nasal congestion that oc curs after prolonged use of adrenergic agonists (eg, intranasal decongestants) causing adrenergic receptor downregulation leading to edematous nasal mucosa and hyperresponsiveness. 10,40 Localized or entopic allergic rhinitis may be confused with NARES because speci fi c IgE testing to aeroallergens is negative but it clinically responds to similar treatments used for AR. Diagnosis is con fi rmed by nasal provocation that elicits symptoms in response to the speci fi c allergen(s) endorsed by the patient. 14 Numerous structural conditions mimic or can occur with rhinitis (Table IV). Chronic rhinosinusitis with and without nasal polyps can present with nasal obstruction, nasal drainage, and NHR. Nasal septal deviation is a common cause of fi xed nasal obstruction leading to nasal congestion and is usually persistent with episodic worsening, alternating from side to side every 1 to 2 hours coinciding with the nasal respiratory cycle.