xRead - Nonallergic Rhinitis (September 2025)

BAROODY ET AL

1445

J ALLERGY CLIN IMMUNOL PRACT VOLUME 12, NUMBER 6

minimal cross-sectional area by acoustic rhinometry, and mea surement of nasal air fl ow. All showed signi fi cant improvement in these measures after turbinate reduction. Peak bene fi t was ach ieved between 3 and 6 months of follow-up and there were no differences in the response to therapy based on surgical tech niques or between AR and NAR. 67 Vidian neurectomy disrupts the autonomic supply to the nasal mucosa and leads to improvement in rhinorrhea and nasal obstruction. The procedure was fi rst described by Golding-Wood in the early 1960s 68 for the management of intractable NAR. Endoscopic approaches have replaced the originally described transantral approaches and reports, with limited number of pa tients, indicate signi fi cant improvements in both rhinorrhea and congestion starting at around 6 weeks postoperatively and lasting up to 2 years. 69 Up to 82% of 45 patients reported improvement of symptoms of NAR in 1 series. 70 Because the vidian nerve provides innervation to the palate and the lacrimal gland, vidian neurectomy can be associated with postoperative dry eyes or palate numbness, which are usually temporary. Because of the potential complications involved with vidian neurectomy, recent procedures have focused on targeting the posterior nasal nerve, which courses distal to the sphenopalatine ganglion. Targeting the postganglionic parasympathetic branches of the posterior nasal nerve at the level of the sphenopalatine foramen avoids the potential negative sequalae related to the lacrimal gland and the palate. Instead of surgery to resect the nerve, more recent procedures have utilized cryotherapy 71 and radiofrequency neurolysis 72 to target its fi bers. Both techniques are performed in the of fi ce with the patient under local anesthesia and have shown signi fi cant improvements in total nasal symp toms (including rhinorrhea and congestion) compared with baseline up to 9 months to a year after the procedure in patients with AR and NAR. 71,72 CONTROVERSIES AND RESEARCH PRIORITIES 1. Nonallergic rhinopathy remains underinvestigated and undermanaged in clinical allergy. Nomenclature remains a debate with some researchers using a broad, all-encompassing de fi nition, and others arguing for a more nuanced classi fi ca tion based on the underlying cause. 2. The clinical overlap of AR and NAR is high with up to 50% of patients with AR having a component of NAR. This has several implications for evidence-based clinical practice because there are minimal studies on patients with MR. This is even more important when initiating and reviewing the ef fi cacy of immunotherapy or AR therapies. Patients with MR may improve symptoms owing to their allergic triggers with immunotherapy, but still have a rhinitis burden owing to NAR. 73 This may invalidate the evidence that exists for immunotherapy and the results of AR studies that fail to assess NAR in their patient populations before and after treatment. Clinically, performing a Cincinnati IIS 7 is encouraged if patients give a history of NAR triggers, and a medical intervention such as immunotherapy is planned. 3. In airway disease, we have seen a separation of asthma and chronic obstructive pulmonary disease (COPD), and evidence was strong for treatment of the individual entities, but there is no pathway forward by the U.S. Food and Drug Adminis tration (FDA) to develop therapies for asthma-COPD over lap. Similarly, the FDA has set forth a dif fi cult pathway for

NAR drug development without any guidance for MR because they consider speci fi c triggers as subtypes of NAR rather than recognizing that NAR patients experience symp toms from heterogeneous triggers that activate the same nociceptive and cholinergic pathways. 74 4. The burden of NAR and its impact on asthma is important to ensure proper treatment of the united airways. This is not a new concept. In 1941, Urbach 75 reported that 38% of his patients with asthma had NAR and NAR is an independent risk factor for asthma. 76 More studies are required to look at the long-term effect of NAR on asthma. 5. Whereas we know that there is increased TRPV1 expression on sensory nerves in patients with NAR, we still do not know why this occurs. 6. Patients with NAR (n ¼ 19) compared with control subjects (n ¼ 74) have been demonstrated to have signi fi cant impair ment of autonomic function as determined by sudomotor, cardiovagal, and adrenergic subscores and composite scores. 23 In addition, hypervagal autonomic responses have been demonstrated in 78 patients with NAR studied in a cardiac laboratory. 77 Autonomic dysfunction is a common feature of long COVID-19 condition. 78,79 Although there are no objec tive reports of NAR increasing in the last 4 years being linked to either vaccination or acquired disease, even though dysauto nomia has been linked with both, patients with dysautonomia are often nonatopic and have features of NAR, suggesting this condition may likely be part of the dysautonomic syndrome, which requires further investigation. 80,81 7. The impact of overuse of nasal decongestants leading to rhinitis medicamentosa is poorly studied. 82 It is a very com mon problem with a high burden and huge economic impact for patients and the society. 82 However, similar to studies conducted for SAR and PAR, combination oxymetazoline and INCS are likely to be well tolerated, which requires further investigation. 83-85 PROGNOSIS/OUTCOMES Proper characterization of patients with NAR leading to a tailored medical regimen and less commonly requiring alternative procedures such as cryotherapy or surgical interventions can signi fi cantly improve clinical outcomes and prevent comorbid conditions. 10,86,87 The prognosis is dependent on the clinical experience of the treating physician and the complexity of the patient ’ s underlying conditions and comorbidities. CONCLUSIONS Nonallergic rhinopathy is a common clinical entity that affects a sizeable portion of the United States and world population that, if not diagnosed and treated properly, can lead to a negative impact on quality of life. These conditions are related to different triggers and in up to 50% of cases can coexist with AR. Neurogenic mechanisms seem to be the most important path ways involved in the pathophysiology of NAR and require further investigation. A limited number of FDA-approved medical therapies are currently available to treat NAR and sur gical interventions are a possibility if medical therapy fails. A correct diagnosis is essential Because it will in fl uence the choice and ef fi cacy of these selected therapies. However, there is a clear unmet need for development of more effective novel therapies.