Nonallergic rhinitis should be a diagnosis of exclusion. Nonallergic rhinitis should be considered when appropriate, specific IgE or skin testing has been completed and the results are negative. To parse through the many causes of nonallergic rhinitis occurring with or without intermittent or chronic rhinorrhea, clinicians must obtain a thorough clinical and environmental history.1
Nonallergic rhinitis can be caused by exposure to strong irritant odors and strong fragrances, such as tobacco smoke, perfumes, air fresheners, car exhaust, and cleaning products.1
Vasomotor rhinitis. Vasomotor rhinitis is characterized by intermittent symptoms of congestion or watery nasal discharge. Vasomotor rhinitis is most commonly triggered by exposure to cold, dry air, as may occur when walking into an air-conditioned room from outside.1
Gustatory rhinitis. Gustatory rhinitis presents with prominent watery rhinorrhea that occurs as a result of a vagally mediated reflex that is most often associated with ingestion of hot or spicy foods.1
Rhinitis medicamentosa. Rhinitis medicamentosa is a common cause of recurrent nasal congestion that occurs after prolonged (and frequently, inappropriate) use of topical decongestant vasoconstricive catecholamines (phenylephrine) and imidazoles (oxymetazoline). Rhinitis medicamentosa will not be uncovered by the physician unless an adequate medication history, including prescription and over-the-counter medications, is obtained.1
Other medications commonly implicated in nasal congestion include alpha-blockers such as clonidine, as well as antihypertensives, antidepressants, and nonsteroidal anti-inflammatory drugs.
Anatomic and physical obstruction. Anatomic and physical obstruction of the nares are possible factors contributing to chronic rhinitis and will not be alleviated by traditional medications. Examples include enlarged turbinates, adenoid hypertrophy, foreign bodies, choanal atresia, and septal deviation.1
Postural reflex nasal congestion.Postural reflex nasal congestion, demonstrated by increased nasal congestion with supine position, is a normal nasal reflex unrelated to any disease process. Postural reflex nasal congestion is often reported as nasal symptoms that are worse immediately on awakening but that resolve once the patient is upright for a short period of time.1
Pregnancy. Pregnant adolescents may experience rhinitis of pregnancy. Rhinitis of pregnancy is attributed to increased overall blood volume during pregnancy, as well as to increased estrogen, which causes vascular congestion of mucous membranes. Nasal congestion with or without clear rhinorrhea may occur anytime during pregnancy but is typically at its worst during the first trimester.1
Sneezing on exposure to dramatic temperature extremes or bright light. Sneezing on sudden exposure to dramatic temperature extremes as well as to sudden exposures to bright light (such as stepping outside on a sunny day) is also a normal nasal reflex. Because these symptoms often occur when stepping outside, they are often inappropriately attributed to pollen exposure.1
Excessive consumption of sugar.It has been observed that there are associations between chronic cough, nasal congestion, and rhinorrhea in preschool-aged children who consume excessive amounts of food and beverages high in sugar, which can increase risk of gastroesophageal reflux or laryngopharyngeal reflux.4 Excessive consumption of sugar, along with fats, caffeine, carbonation, and acids may lead to prolonged gastric emptying and greater acidic stomach contents, both of which may potentiate reflux and vagally mediated rhinorrhea and congestion experienced during emesis. Habitual late-night eating or milk and/or snacks at bedtime may also lead to similar symptoms.4
When a parent states that their child has a “normal diet,” we do not always push for further details, especially when there does not appear to be overt obesity. However, the amount of sugar a child may be consuming on a daily basis through beverages and food can be sobering for both physicians and parents. This is a good opportunity for physicians to ask questions about a child's daily eating and drinking habits.