xRead - Nonallergic Rhinitis (September 2025)

BAROODY ET AL

1437

J ALLERGY CLIN IMMUNOL PRACT VOLUME 12, NUMBER 6

treatments used to treat rhinitis. 2 The most common chronic nonallergic rhinitis condition is VMR comprising up to 80% of cases, which has also been referred to as nonallergic rhinopathy (NAR), idiopathic rhinitis, neurogenic rhinitis, or nasal hyper reactivity (NHR). 2-6 It has been challenging to develop consensus terminology for VMR because the diagnosis is solely made based on symptoms induced by nonallergic triggers and negative speci fi c IgE testing. 2-6 Expert panels have recommended replacing the term VMR with NAR because it is more descriptive of this condition that is characterized by symptoms triggered by chemical irritants and weather changes through chemosensors, mechanosensors, thermosensors, and/or osmosensors activated through different transient receptor potential (TRP) calcium ion channels. Therefore, the term NAR is used in this review in lieu of VMR that is associated with non e type 2 neuroin fl ammation and nasal hyperreactivity secondary to irritant triggers through neurogenic pathways. 7 It is also important to note that up to 50% of NAR sufferers may have a mixed rhinitis (MR) charac terized as having an IgE-mediated component based on sensiti zation to environmental allergens that correlates with symptoms when exposed in conjunction with symptoms induced by nonallergic triggers such as perfumes, fragrances, chemicals, and solvents. 8 Nonallergic rhinopathy is often an incorrectly diagnosed condition associated with signi fi cant patient morbidity because it can aggravate or impede management of many comorbid illnesses. 1 Thus, if not diagnosed or managed properly, this condition can result in unnecessary or inappropriate therapies causing unnecessary economic and health care burdens to the patient leading to signi fi cant impairment of their quality of life. This review provides a comprehensive overview of the classi fi cation, differential diagnosis, approach to diagnosis and treat ment, as well as controversies surrounding NAR and current needs for future investigations that could lead to more effective therapy tailored for this condition. CASE REPORT Joanne is a 42-year-old woman who presents to the allergy clinic with persistent nasal symptoms for the past 2 years con sisting of postnasal drainage and nasal congestion. She previously dismissed her symptoms as viral upper respiratory infections or owing to weather changes. She reports clear nasal discharge and embarrassing postnasal drip, leading to frequent coronavirus disease 2019 (COVID-19) testing. Joanne also describes pressure and pain behind her eyes, intensifying by evening, causing “ brain-fog. ” She also experiences throat and ear itchiness with intermittent ear plugging and pain. Her symptoms do not worsen during pollen seasons while outdoor gardening but are worsened during windy days and temperature drops. Indoors, she notices worsening symptoms after dusting her home and avoids strong fragrances, potpourris, and cleaning agents because they also aggravate her symptoms. Clinical examination by anterior rhinoscopy revealed swollen, erythematous nasal mucosa but no other abnormalities. Serological testing from her primary care doctor were negative for speci fi c IgE allergy to seasonal or perennial aeroallergens. Given the lack of allergen-speci fi c trig gers and her symptom pro fi le, Joanne was diagnosed with NAR, likely triggered by fragrances, volatile chemicals, and temperature changes. She had used intranasal corticosteroids (INCS) in the past with minimal improvement in symptoms. Treatment with

Abbreviations used

AR- Allergic rhinitis CGRP- Calcitonin gene e related peptide COPD- Chronic obstructive pulmonary disease COVID-19- Coronavirus disease 2019 CR- Chronic rhinitis CRS- Chronic rhinosinusitis FDA- U.S. Food and Drug Administration

IgE- Immunoglobulin E IIS- Irritant index score

INAH- Intranasal antihistamine INCS- Intranasal corticosteroids LAR- Localized entopic allergic rhinitis MR- Mixed rhinitis NAR- Nonallergic rhinopathy NARES- Nonallergic rhinitis with eosinophilia syndrome NHR- Nasal hyperreactivity

PAR- Perennial allergic rhinitis SAR- Seasonal allergic rhinitis TRP- Transient receptor potential

TRPA1- Transient receptor potential ankyrin 1 TRPV1- Transient receptor potential vanilloid 1 VMR- Vasomotor rhinitis

downregulation of transient receptor potential vanilloid 1 receptors by several therapeutic compounds provides symp tomatic relief for this condition. The classi fi cation of NAR is further complicated by its association with allergic rhinitis referred to as mixed rhinitis, which involves both immuno globulin E e mediated and neurogenic mechanistic pathways. Comorbidities associated with NAR, including rhinosinusitis, headaches, asthma, chronic cough, and sleep disturbances, underscore the need for comprehensive management. Treat ment options for NAR include environmental interventions, pharmacotherapy, and in refractory cases, surgical options, emphasizing the need for a tailored approach for each pa tient. Thus, it is extremely important to accurately diagnose NAR because inappropriate therapies lead to poor clinical outcomes and unnecessary health care and economic burdens for these patients. This review provides a comprehensive overview of NAR subtypes, focusing on classi fi cation, diag nosis, and treatment approaches for NAR. 2024 Amer ican Academy of Allergy, Asthma & Immunology (J Allergy Clin Immunol Pract 2024;12:1436-47) Key words: Nonallergic rhinitis; Nonallergic rhinopathy INTRODUCTION Chronic nonallergic rhinitis syndromes comprise at least 8 non e immunoglobulin E (IgE) e mediated conditions including vasomotor rhinitis (VMR), nonallergic rhinitis with eosinophilia syndrome (NARES), senile rhinitis, atrophic rhinitis, gustatory rhinitis, drug-induced rhinitis, hormone-induced rhinitis, and occupational nonallergic rhinitis induced by low molecular weight chemicals that affect approximately 25% of patients presenting with chronic rhinitis (CR) symptoms. 1-6 Some have included cerebrospinal fl uid leak in this classi fi cation but this structural problem is more appropriately considered in the dif ferential diagnosis of clear rhinorrhea not responsive to