Texas Allergy Experts
texasallergyexperts.com

References on Vasomnotor rhinitis

Vasomotor Rhinitis

PATRICIA W. WHEELER, M.D., and STEPHEN F. WHEELER, M.D., University of Louisville School of Medicine, Louisville, Kentucky Am Fam Physician. 2005 Sep 15;72(6):1057-1062.

Vasomotor rhinitis affects millions of Americans and results in significant symptomatology. Characterized by a combination of symptoms that includes nasal obstruction and rhinorrhea, vasomotor rhinitis is a diagnosis of exclusion reached after taking a careful history, performing a physical examination, and, in select cases, testing the patient with known allergens. According to a 2002 evidence report published by the Agency for Healthcare Research and Quality (AHRQ), there is insufficient evidence to reliably differentiate between allergic and nonallergic rhinitis based on signs and symptoms alone. The minimum level of diagnostic testing needed to differentiate between the two types of rhinitis also has not been established. An algorithm is presented that is based on a targeted history and physical examination and a stepwise approach to management that reflects the AHRQ evidence report and U.S. Food and Drug Administration approvals. Specific approaches to the management of rhinitis in children, athletes, pregnant women, and older adults are discussed.ORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation

Evidence rating

References

Topical anticholinergics should be used for rhinorrhea caused by vasomotor rhinitis.

A

6,13

Azelastine (Astelin) may be used for vasomotor rhinitis associated with rhinorrhea, sneezing, postnasal drip, and nasal congestion.

B

6

Topical corticosteroids may be used for vasomotor rhinitis associated with nasal obstruction and congestion.

B

6,11

Cromolyn sodium (Intal) may be used for vasomotor rhinitis associated with sneezing and congestion in patients older than two years.

B

6


A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 983 or http://www.aafp.org/afpsort.xml.

The classification of rhinitis has long been debated in the literature. Rhinitis is categorized as allergic or nonallergic, with vasomotor rhinitis in the nonallergic family.1 The symptoms of allergic and nonallergic rhinitis overlap significantly, but the causes appear to be entirely different.2 The major manifestations of allergic rhinitis are triggered by exposure to allergens and include nasal pruritus, clear rhinorrhea, postnasal drip, and nasal obstruction caused by inflammation of the nasal mucous membranes.3 Nonallergic rhinitis, a diagnosis of exclusion, can be sporadic or perennial.1  It includes a highly diverse group of rhinitis syndromes united by their pervasive symptoms of clear rhinorrhea or congestion with less prominent sneezing, nasal pruritus, and conjunctival irritation (


Types of Nonallergic Rhinitis

Drug induced

Gustatory

Hormonal

Infectious

Nonallergic rhinitis with eosinophilia syndrome

Occupational

Vasomotor


Informat

ion from reference 1.Vasomotor rhinitis is characterized by prominent symptoms of nasal obstruction, rhinorrhea, and congestion. These symptoms are excessive at times and are exacerbated by certain odors (e.g., perfumes, cigarette smoke, paint fumes, inks); alcohol; spicy foods; emotions; and environmental factors such as temperature, barometric pressure changes, and bright lights.2 Patients with vasomotor rhinitis are further divided into two subgroups: “runners,” who demonstrate “wet” rhinorrhea; and “dry” patients, who exhibit nasal obstruction and airflow resistance with minimal rhinorrhea.1 Many studies have attempted to clarify the pathogenic mechanisms for these subgroups. Current theories include increased cholinergic glandular secretory activity (for runners), and nociceptive neurons with heightened sensitivity to usually innocent stimuli (for dry patients).1 These theories have not been adequately proven. The vasomotor nasal effects of emotion and sexual arousal also may be caused by autonomic stimulation. In one small study,4 researchers concluded that autonomic system dysfunction is significant in patients with vasomotor rhinitis (P < .005). Possible compounding factors included previous nasal trauma and extraesophageal manifestations of gastroesophageal reflux disease.4

Whatever their causal mechanisms, the various rhinitis syndromes result in significant morbidity in the United States. The National Rhinitis Classification Task Force concluded that 17 million Americans have nonallergic rhinitis.5 An evidence report6 from the Agency for Healthcare Research and Quality (AHRQ) estimated that 20 to 40 million Americans have allergic rhinitis, making it the sixth most prevalent chronic illness. Treatment costs are at least $1.8 billion annually for physician visits and medications, or nearly 4 percent of the $47 billion annual direct cost for treatment of respiratory illnesses in the United States.6 The total annual cost of allergic rhinitis in the mid-1990s, including lost productivity to employers and society, was $5.6 billion.6

The AHRQ found no prospective studies in the literature that explicitly differentiated allergic from nonallergic rhinitis. Making a specific diagnosis is most important if treatments vary between the conditions. Because of the crossover in treatments, differentiation is primarily significant when considering environmental control and institution of oral antihistamines and immunotherapy, which have proven benefit only in the treatment of allergic rhinitis.3 Because asthma and sinusitis are associated with allergic rhinitis, and a growing body of literature shows the increased effectiveness of intranasal steroids over oral antihistamines in the management of allergic rhinitis, it may be useful to establish a more specific diagnosis through diagnostic testing.3,6

Laboratory Testing

No specific test is available to diagnose vaso-motor rhinitis. In studies and in practice, allergic rhinitis is excluded or implicated as the cause of symptoms by using conventional skin testing or by evaluation for specific IgE antibodies to known allergens.7 According to the AHRQ,6 the results of “only one small recent study suggest that total serum IgE may be as useful as specific allergy skin prick tests, which, in turn, are more useful than radioallergosorbent testing in confirming a diagnosis of allergic rhinitis.”8 The lack of sensitivity and specificity of nasal cytology, total serum IgE, and peripheral blood eosinophil counts, which have been favored in the past for differentiating among rhinitis syndromes, makes their clinical use problematic.1 The minimum level of testing needed to confirm or exclude a diagnosis of vasomotor rhinitis has not been established in the literature.6

Management

Figure 1 outlines an algorithm for effective pharmacologic management of vasomotor rhinitis. Table 26,913 displays stepwise recommendations for treatment based on the AHRQ Evidence Report and on additional treatments empirically employed but not discussed by the AHRQ.


Suggested Approach to the Pharmacologic Management of Vasomotor RhinitisFigure 1.

Algorithm for the pharmacologic management of vasomotor rhinitis.

View/Print Table

TABLE 2

Treatment Recommendations for Vasomotor Rhinitis: A Stepwise Approach

Medication class

Product

Effect

Side effects

Topical antihistamines6,9,10

Azelastine (Astelin)

Improvement in rhinorrhea, sneezing, postnasal drip, and nasal congestion9

No serious or unexpected adverse events; bitter taste9

Topical corticosteroids11

Mometasone furoate (Nasonex)

Improvement in nasal obstruction and congestion scores11

Epistaxis, nasal irritation11

Topical corticosteroids6

Budesonide (Rhinocort), beclomethasone (Beclovent), triamcinolone acetonide (Kenalog)

Improvement in nasal obstruction and congestion scores6,12

Epistaxis, headache, nasal congestion

Topical cromoglycate6

Cromolyn sodium (Intal)

Decrease in sneezing and congestion scores6

Nasal irritation, headache, nasal congestion6

Topical anticholinergics6,13

Ipratropium (Atrovent)

Reduced rhinorrhea only6,13

Minor adverse effects; nasal dryness and irritation13

Other agents not recommended by AHRQ

Oral antihistamines

Sedating and nonsedating

AHRQ outcome not identified

Somnolence, dizziness, dry mouth, headache

Oral sympathomimetics

Only phenylpropanolamine (not available in the United States) was studied.

Withdrawn from the market; no other oral decongestant was identified or specifically studied.

Leukotriene modifiers

Not identified in any trial on nonallergic rhinitis

Other agents not discussed by AHRQ: evidence for use lacking, empiric use possible

Topical decongestants

Oxymetazoline (Nezeril, Afrin, Dristan)

Improvement in congestion

Oral decongestants

Pseudoephedrine

Improvement in congestion


AHRQ = Agency for Healthcare Research and Quality.

note: Use of topical antihistamines and corticosteroids is approved by the U.S. Food and Drug Administration.

Information from references 6 and 9 through 13.

Once a working diagnosis of vasomotor rhinitis has been made, the patient can be empowered to avoid known environmental triggers as much as possible. These may include odors (e.g., cigarette smoke, perfumes, bleach, formaldehyde, newspaper or other inks); auto emission fumes; light stimuli; temperature changes; and hot or spicy foods. A stepwise pharmacologic approach may then be employed, choosing the initial intervention based on the patient’s predominant symptoms. If the presenting symptom is solely rhinorrhea, a topical anticholinergic is the logical first step.6,14 With nasal congestion and obstruction only, topical corticosteroids would be a wise starting point for therapy.6 If the patient presents with the full range of symptoms including rhinorrhea with sneezing, postnasal drip, and congestion, a topical antihistamine may be initiated.6,9,10 After an adequate trial period, changes and additions may be made if the response is inadequate. Figure 1 describes a possible approach.

Exercise, beneficial for overall health, may be a useful treatment addition because it produces decreased airway resistance and assists natural nasal decongestion by I-adrenergic–mediated mechanisms.2 The effect of exercise on nasal decongestion is short-lived, but it has numerous other benefits and can be repeated.

Traditional oral antihistamines have no established beneficial effect in patients with vasomotor rhinitis and may be associated with sedation. Newer, less-sedating antihistamines also have no proven effectiveness for vasomotor rhinitis, and their administration delays proper treatment while incurring significant cost and burden to the health care system.3 According to the AHRQ report,6 there has been only one study regarding the use of oral antihistamines, and that study used an antihistamine-decongestant combination product, so the benefit of individual components could not be determined.15

The empiric use of the topical decongestant ephedrine on a chronic basis has resulted in tolerance and development of rhinitis medicamentosa. The inclusion of benzalkonium chloride as a preservative has been speculated to contribute to the development of these problems. In a small study16 of 35 patients, investigators examined the use of a newer agent, oxymetazoline, both with benzalkonium chloride preservative (Nezeril, Afrin No Drip 12 Hour, 4-Way 12-Hour, Dristan 12 Hour) and without. Results of this study16 demonstrated the short-term safety of the newer agent and the avoidance of rhinitis medicamentosa, with or without preservative, during use up to three times daily for 10 days.

Special Populations

CHILDREN

Preventive and nonpharmacologic approaches should be tried before beginning medication in children. Approved for use in patients six years and older, nasal anticholinergics such as ipratropium (Atrovent) often reduce rhinorrhea without the undesirable side effects of sedation and fatigue sometimes associated with oral antihistamine use.2,6 However, anticholinergics have no effect on the other symptoms of vasomotor rhinitis. Investigators conducted a multicenter, double-blind, placebo-controlled, parallel-group trial13 in 204 children (six to 12 years of age) and adolescents (13 to 18 years of age) with allergic or nonallergic perennial rhinitis.

Patients with nonallergic perennial rhinitis who used ipratropium had a 41 percent mean decrease in severity and a 37 percent decrease in duration of rhinitis with excellent tolerability, compared with decreases of 15 and 17 percent in severity and duration, respectively, in the placebo group.13

Certain nasal corticosteroids, such as mometasone furoate (Nasonex), are approved by the U.S. Food and Drug Administration (FDA) for children older than two years and improve the symptoms of congestion and nasal obstruction. Investigators conducted a randomized, double-blind, placebo-controlled, 12-month study11 to monitor growth in children during treatment with mometasone furoate. A total of 82 patients, three to nine years of age, completed the study. There was no evidence of growth retardation or hypothalamic-pituitary-adrenal axis suppression.11 Although short-term use studies purporting safety are quoted in the literature, budesonide (Rhinocort), beclomethasone (Beclovent), and triamcinolone acetonide (Kenalog) are not recommended for children younger than six years because of continued concern over possible long-term growth suppression by these older agents.12,17 Cromolyn sodium (Intal) can be used to manage symptoms of sneezing and congestion in children older than two years.6

As in adults, traditional oral antihistamines and newer less-sedating antihistamines have no established beneficial effects on vasomotor rhinitis in children. Prolonged use of topical nasal decongestants can cause irritation and rhinitis medicamentosa without proven benefit. If a therapeutic trial of one of these agents is attempted because of treatment failures with recommended agents, judicious and time-limited use should be considered.

ATHLETES

Topical antihistamines, topical corticosteroids, and topical anticholinergics are treatments permitted by the U.S. Olympic Committee and the International Olympic Committee. As of January 1, 2005, the World Anti-Doping Code no longer bans the use of pseudoephedrine, but systemic decongestants are included in the 2005 monitoring program.18 The code does not prohibit the use of topical decongestants. The stepwise approach to manage athletes should be the same as that used with other populations. A topical antihistamine (e.g., azelastine [Astelin]), topical corticosteroids (e.g., budesonide), and topical anti-cholinergics (e.g., ipratropium) may be tried. The 2005 World Anti-Doping Code requires an Abbreviated Therapeutic Use Exemption form to notify relevant agencies about the use of topical corticosteroids.19 Empiric short-term treatment with topical decongestants may be considered if these agents fail.

PREGNANT WOMEN

Symptoms of rhinitis can increase during pregnancy. This increase is thought to be caused by progesterone- and estrogen-induced glandular secretion, augmented by nasal vascular pooling from vasodilation and increased blood volume.20 Vasomotor rhinitis in pregnancy responds well to intranasal saline instillation.20 Potential risks versus benefits should be considered in the use of FDA-approved topical anticholinergics (pregnancy category B), topical antihistamines (pregnancy category C), and topical corticosteroids (pregnancy category C). Topical decongestants (pregnancy category C) can provide good short-term relief. Exercise appropriate for physical condition and gestational age also may reduce symptoms.1

OLDER ADULTS

Three types of nonallergic rhinitis commonly occur in older patients. The first, vasomotor rhinitis, is thought to be caused by increased cholinergic activity and is similar to that occurring in younger patients. The second type, gustatory rhinitis, is associated with profuse, watery rhinorrhea that may be exacerbated by eating. The third form is believed to arise from alpha-adrenergic hyperactivity, stimulated by the regular use of antihypertensives.2 All three types respond well to ipratropium nasal spray. Narrow-angle glaucoma is a relative contra-indication to the use of ipratropium.2

Prognosis and Additional Therapies

Although no single agent is uniformly effective in controlling the many and varied symptoms of vasomotor rhinitis, available evidence supports a stepwise application of several agents after a careful history and physical examination. Additional therapies, for which AHRQ felt there was no strong evidence base, may be tried if the approved approaches fail. These therapies include topical decongestants, oral decongestants, and local application of silver nitrate solutions by an otolaryngologist.21,22 Sphenopalatine blocks, also performed by otolaryngologists, are reserved for seriously affected patients who do not respond to other interventions and whose lives are altered significantly by their symptoms.23 The submucosal injection of botulinum toxin type A (Botox) has been studied in dog models24,25 and may yet prove to be of value.

 

VASOMOTOR RHINITIS

Rhinitis is defined as an inflammation of the nasal mucosa and it is characterized by nasal congestion, runny nose (rhinorrhea), sneezing, and (itching) pruritus.The causes of rhinitis can be

Non-allergic, Non-Infectious - Vasomotor Rhinitis (or Irritant rhinitis). "Vaso" means blood vessels and "motor" refers to the nerves, which innervates nasal tissue and the blood vessels. This is sometimes referred to as idiopathic non-allergic rhinitis. It is estimated that up to 10% of the population suffers from non-allergic rhinitis. It looks like allergy- but it doesn’t itch. Mixed Allergic and Non-allergic Rhinitis probably account for the majority of cases which is why one medication or just avoidance may not be of great help.

How Vasomotor Rhinitis looks

Key features of VMR

• There is usually no history of allergies  There is no infection causing these symptoms.

• Most patients seem to be older than the typical patients with hay fever.• Can sometimes present with a seasonal pattern due to changes in temperature and humidity. • Patients present with rhinorrhea, frontal headaches, and congested turbinates but usually no (itching) pruritus.• Some patients will find that eating (especially, spicy foods) causes more nasal dripping or congestion. 

Vasomotor Rhinitis shows intermittent (coming and going) episodes of sneezing, watery nasal drainage (rhinorrhea), and blood vessel congestion of the nasal mucus membranes. There appears to be a hypersensitive response to stimuli such as a dry atmosphere, air pollutants, spicy foods, alcohol, strong emotions, and some medications. Indeed any particulate matter in the air, including pollens, dust, mould, or animal dander can bother people with VMR, even though they are not actually allergic to these things. People with VMR are unusually sensitive to irritation and will have significant nasal symptoms even when exposed to low concentrations of irritants. Thus, vasomotor rhinitis seems to be an exaggeration of the normal nasal response to irritation, occurring at levels of exposure, which doesn't bother most people.   There are two general groups: "runners"who have "wet" rhinorrhea, and "dry"subjects with predominant symptoms of nasal congestion and blockage to airflow, and minimal rhinorrhea. These reactions can be provoked by non-specific irritant stimuli such as cold dry air, perfumes, paint fumes, and cigarette smoke. Subjects with predominantly rhinorrhea (sometimes referred to as cholinergic rhinitis) appear to have enhanced cholinergic glandular secretory activity, since atropine effectively reduces their secretions.  It is important to understand that VMR is a nonspecific response 

Triggers of Vasomotor Rhinitis

Changes in temperature or barometric pressure, turbulent air
Perfumes, strong cooking odours, smoke
Inorganic dust (which is separate from house dust mite), air pollution
Spicy foods, alcohol Some medications, like some blood pressure tablet Sexual arousal Stress (emotional or physical). Other causes of non-allergic rhinitis are:

Nonallergic rhinitis with eosinophilia syndrome (NARES). Eosinophilic rhinitis (ie, perennial intrinsic rhinitis) accounts for up to 20% of rhinitis diagnoses. Some researchers believe that this may be a precursor to the aspirin triad of intrinsic asthma, nasal polyposis, and aspirin intolerance. Abnormal prostaglandin metabolism also has been implicated as a cause of NARES. Elevated eosinophil counts are present in approximately 20% of the general population's nasal smears. However, not everyone with eosinophilia has symptoms of rhinitis. A distinguishing feature of NARES is the presence of eosinophils, usually between 10-20%, on nasal smear. Generally, patients with NARES present with nasal congestion, sneezing, rhinorrhea, nasal pruritus, and hyposmia.

Occupational rhinitis is usually caused by an inhaled irritant or allergen (eg, laboratory animal antigens, grains, wood dusts, and chemicals). Frequently patients with occupational rhinitis present with concurrent occupational asthma.

Hormonal rhinitis is caused by hormonal imbalances such as pregnancy, hypothyroid states, puberty, and oral contraceptive use, conjugated estrogen use.

Drug-induced rhinitis is caused by several medications including angiotensin-converting enzyme inhibitors, reserpine, guanethidine, phentolamine, methyldopa, beta-blockers, chlorpromazine, gabapentin, penicillamine, aspirin, nonsteroidal anti-inflammatory drugs, inhaled cocaine, exogenous estrogens, and oral contraceptives.

Rhinitis medicamentosais considered a drug-induced rhinitis and results from prolonged use (ie, longer than 5-10 days) of over-the-counter topical nasal decongestants. Typically, these patients present with extensive nasal congestion and rhinorrhea, resulting from loss of sympathetic nerve tone, rather than from the original cause of rhinitis. Normal nasal function should resume within 7-21 days following cessation of decongestants. Symptoms usually improve with nasal steroids.

Gustatory rhinitis occurs following consumption of hot and spicy foods. This is a "wet" (profuse watery) runny nose, secondary to nasal vasodilatation (dilated blood vessels) and it is due to stimulation of the vagus nerve, generally occurring within a few hours of eating the food.

Conditions often confused with non-allergic rhinitis include:

Nasal polyps
Previous trauma to the nose
Structural abnormalities eg deviated nasal septum

Diagnosis of VMR

VMR is usually diagnosed by taking a careful history and performing a thorough exam of the nose and throat. In addition, allergy testing  should be performed to make sure there is no allergic basis for some of the symptoms, since this would affect our treatment approach. In some cases a CT scan of the sinuses may be required to exclude chronic sinusitis or polyposis. Occasionally, (few usually mild) positive skin prick test reactions are found in patients with VMR, but it does not fit the history and is therefore not relevant to the cause of the rhinitis.

Treatment of Vasomotor Rhinitis

Non-drug, non-surgical Normal saline nasal douches

Drug Therapy Antihistamines seem to help a few patients whose main symptom is runny nose, and usually when the rhinitis is mixed vasomotor and allergic. The nasal spray antihistamines have been cleared for this diagnosis

Anticholinergic agents Atrovent (Ipratromium bromide) nasal spray is effective in patients who have runny nose as their main symptom.

Nasal steroidshelp with congestion, runny nose, and sneezing. They suppress the local inflammatory response caused by vasoactive mediators by inhibiting Phospholipase A2, reduce the activity of acetylcholine receptors, and decrease basophil, mast cell, and eosinophil counts. They do not start working immediately, but when they do, they seem to control all the symptoms. Some adverse effects are mucosal swelling, mild redness, burning or stinging upon application, drying of the mucosa, nosebleeds, and nasopharyngeal thrush.

Decongestantsor sympathomimetic agents, are used mostly for congestion.  Pseudoephedrine (Sudafed) tablets. effects include nervousness, insomnia, irritability, and difficulty urinating in elderly males. They are contraindicated in persons with labile or overt hypertension. Decongestants have not been shown to have an effect on blood pressure in normotensive patients.

Oxymetazoline (Afrin) nasal sprays.   Topically, these drugs can cause Rhinitis Medicamentosa (a rebound congestion which occurs after taking topical formulations of these drugs for more than five days).

Surgery

If the rhinitis does not respond to drug therapy, very rarely surgical procedures can be considered. Some of the procedures that have been performed in the past include:   Cryosurgery affects the mucosa and submucosa, making it a quite successful procedure for congestion. However, there is sometimes prolonged post-operative nasal congestion and the possibility of damage to the nasal septum.   If chronic hypertrophic changes appear in the mucosa, a number of surgical procedures can be tried. These include:

Cauterization can be accomplished via silver nitrate or electrical current, however it only affects the mucosa. Cryosurgery is considered superior to cauterization because it also affects the submucosa.

Submucosal resection of the conchal bone is a difficult procedure with much post-operative bleeding. Partial or total inferior turbinate resection works well for nasal congestion but can give post-operative bleeding and crusting.

 

Gustatory rhinitis: a syndrome of food-induced rhinorrhea.


Raphael G, Raphael MH, Kaliner M.      J Allergy Clin Immunol 1989 Jan;83(1):110-5The consumption of certain foods causes watery rhinorrhea (gustatory rhinitis) in many individuals. To examine the underlying mechanisms responsible for this common phenomenon, 12 subjects ingested control foods and positive foods (foods that cause rhinorrhea). Nasal lavages performed 10 minutes after each food challenge were analyzed for albumin and total protein. Positive food challenge, but not control food challenge, induced rhinorrhea in all subjects. Positive food challenge increased albumin (7.8 +/- 1.9 to 24.5 +/- 7.6 mg/L; p less than 0.025) and total protein (79 +/- 9 to 258 +/- 41 mg/L; p less than 0.001) without altering the ratio of albumin to total protein (albumin percent). Nasal pretreatment with atropine clinically blocked the positive food-induced rhinorrhea and significantly inhibited secretion of both albumin and total protein, again without affecting the albumin percent. Thus, gustatory rhinitis is produced by spicy foods that stimulate atropine-inhibitable muscarinic receptors (probably on submucosal glands), and the syndrome can be treated prophylactically by use of topical atropine. Atropine= Atrovent

ALLERGY NEGATIVE NASAL DRIPPING AND CONGESTION 

There are two major choices

 vasomotor rhinitis  ( Below) 

 rhinitis associated with Gastroesophageal Reflux ( check it out)