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# Nonallergic rhinitis

A runny or blocked nose that is not caused by allergy or infection: triggered by weather, smells, drugs, hormones or nasal spray overuse.

Updated Nov 12, 2026

On this page

- The basics What it is
- Who gets it
- Causes
- Risk factors
- Pathophysiology
- Classification
- In ENT

- Clinical Symptoms and signs
- Red flags
- Diagnosis
- Differential diagnosis
- Complications
- Prognosis

- Treatment Goal of treatment
- Treatment

- Study Test yourself

- Connections Connections

## What it is

Chronic nasal symptoms (rhinorrhea, congestion, postnasal drip) without an allergic or infectious cause. It is a group of conditions: idiopathic vasomotor rhinitis, drug-induced rhinitis including rhinitis medicamentosa, hormonal rhinitis, NARES and atrophic rhinitis.

See it in 3D

- [Nasal cavity](https://durgical.com/en/anatomy/nasal-cavity/)
- [Inferior nasal conchae](https://durgical.com/en/anatomy/inferior-nasal-concha-bone/)
- [Nasal septum](https://durgical.com/en/anatomy/nasal-septum/)
- [Maxillary sinus](https://durgical.com/en/anatomy/maxillary-sinus/)

## +3

- [Ethmoid cells](https://durgical.com/en/anatomy/anterior-cells-of-ethmoid-bone/)
- [Olfactory nerve (I)](https://durgical.com/en/anatomy/olfactory-nerve/)
- [V2 maxillary](https://durgical.com/en/anatomy/maxillary-nerve/)

## Who gets it

Nonallergic rhinitis accounts for roughly a quarter to a half of chronic rhinitis, usually starts after age 20 and is more common in women; mixed allergic and nonallergic rhinitis is frequent. Rebound congestion from over-the-counter decongestant sprays is common in Colombia and Latin America, where these sprays are easy to buy.

## Causes

- Vasomotor (idiopathic): autonomic imbalance with parasympathetic dominance, triggered by temperature or humidity change, strong odors, smoke, alcohol or spicy food (gustatory rhinitis)
- Rhinitis medicamentosa: rebound congestion after prolonged use of topical decongestants (oxymetazoline, xylometazoline, phenylephrine) or intranasal cocaine
- Other drug-induced: alpha-blockers, beta-blockers, ACE inhibitors, phosphodiesterase-5 inhibitors, oral contraceptives, and aspirin or NSAIDs in aspirin-exacerbated respiratory disease
- Hormonal: pregnancy, puberty, menstrual cycle, hypothyroidism
- NARES: nonallergic rhinitis with eosinophilia syndrome
- Atrophic rhinitis: primary (Klebsiella ozaenae is classically associated) or secondary to extensive nasal surgery, radiation, trauma or granulomatous disease
- Occupational and irritant exposure, cold air (skier's nose), aging (senile rhinitis)

## Risk factors

- Topical decongestant spray use beyond a few days
- Pregnancy, especially the second and third trimester
- Antihypertensive drugs and other systemic drugs listed above
- Occupational irritants, tobacco smoke and air pollution
- Previous radical nasal or turbinate surgery (atrophic rhinitis, empty nose syndrome)
- Cocaine use
- Older age

## Pathophysiology

The nasal mucosa is controlled by sympathetic fibres (vasoconstriction, open airway) and parasympathetic fibres (glandular secretion and vascular engorgement). In vasomotor rhinitis neural hyperreactivity to non-specific stimuli produces watery rhinorrhea and turbinate swelling without IgE involvement. In rhinitis medicamentosa repeated alpha-agonist exposure causes tachyphylaxis, down-regulated receptors and rebound vasodilation, so the patient uses more spray. In atrophic rhinitis the mucosa, glands and turbinate bone atrophy, the cavity widens paradoxically, and thick crusts colonised by bacteria give a foul smell.

## Classification

- Vasomotor (idiopathic) rhinitis: the most common type, a diagnosis of exclusion
- Drug-induced rhinitis: local (rhinitis medicamentosa) or systemic drugs
- Hormonal rhinitis: pregnancy rhinitis resolves within weeks after delivery
- NARES: eosinophils on nasal smear with negative allergy tests
- Gustatory rhinitis: watery rhinorrhea while eating
- Atrophic rhinitis (ozaena): primary or secondary
- Occupational, irritant and senile rhinitis

## Symptoms and signs

- Nasal congestion and clear rhinorrhea, often perennial
- Postnasal drip and throat clearing
- Little itching, sneezing or eye symptoms (unlike allergic rhinitis)
- Symptoms triggered by cold air, odors, smoke, alcohol or meals
- Rhinitis medicamentosa: constant congestion despite (or because of) frequent spray use
- Atrophic rhinitis: crusting, foul odor noticed by others (ozaena) while the patient often has anosmia, paradoxical sensation of obstruction, epistaxis

## Red flags

- Unilateral symptoms, especially obstruction, bloody discharge or epistaxis (rule out tumor or foreign body)
- Unilateral clear watery discharge that increases on bending forward, after head trauma or surgery (CSF leak)
- Facial pain, numbness, loose teeth, diplopia or proptosis
- Septal perforation, saddle nose or crusting with systemic symptoms (granulomatosis with polyangiitis, cocaine)
- Persistent loss of smell

## Diagnosis

**Clinical**
Diagnosis of exclusion based on history (triggers, timeline, medication and spray use, pregnancy, occupation) and anterior rhinoscopy or nasal endoscopy. Turbinates are swollen but often not pale-blue; in rhinitis medicamentosa the mucosa is red, swollen, with punctate bleeding; in atrophic rhinitis the cavity is wide with greenish crusts.

**Tests**
[Skin](https://durgical.com/en/anatomy/skin/) prick or specific IgE tests are negative (this separates it from allergic rhinitis). A nasal smear with eosinophils supports NARES. Beta-2 transferrin on the fluid if CSF leak is suspected. Thyroid function when clinically indicated. Culture of crusts in atrophic rhinitis.

**Imaging**
Not needed in typical cases. CT of the sinuses if chronic rhinosinusitis, polyps, a unilateral mass or atrophic rhinitis needs to be assessed.

## Differential diagnosis

- Allergic rhinitis (itching, sneezing, positive allergy tests)
- Chronic rhinosinusitis with or without nasal polyps
- Structural obstruction: septal deviation, adenoid hypertrophy, foreign body
- Sinonasal tumor (unilateral)
- CSF rhinorrhea
- Granulomatosis with polyangiitis, sarcoidosis, cocaine-induced midline destruction
- Infectious rhinitis (common cold)

## Goal of treatment

Identify and remove the trigger or the offending drug, control symptoms, and refer the cases with red flags or treatment failure.

## Treatment

**Lifestyle**
Avoid triggers (smoke, odors, cold air when possible) and use saline nasal irrigation; in pregnancy rhinitis, saline and head elevation are first line.

**Medical**
Rhinitis medicamentosa: stop the decongestant spray (abruptly or one nostril at a time), bridging with an intranasal corticosteroid; explain that rebound congestion lasts days to a few weeks.

**Medical**
Intranasal ipratropium (an anticholinergic) for predominant watery rhinorrhea, including gustatory rhinitis.

**Medical**
Intranasal azelastine (an antihistamine with action in nonallergic rhinitis) and intranasal corticosteroids for congestion and postnasal drip; corticosteroids work especially well in NARES. Change or stop a culprit systemic drug when possible.

**Medical**
Atrophic rhinitis: regular saline irrigation to remove crusts, plus topical or systemic antibiotics guided by culture during exacerbations.

**Surgical**
Refer to otolaryngology for red flags or failure of medical treatment: inferior turbinate reduction, septoplasty, or posterior nasal nerve ablation or cryotherapy in refractory rhinorrhea; in atrophic rhinitis, surgery to narrow the cavity (for example Young's operation).

## Complications

- Chronic sleep disturbance and reduced quality of life
- Septal perforation (chronic spray or cocaine use)
- Worsening of asthma or sinus disease when rhinitis is uncontrolled
- Atrophic rhinitis: anosmia, social isolation from fetor, epistaxis, rarely myiasis

## Prognosis

Benign but often chronic. Rhinitis medicamentosa usually resolves once the spray is stopped; pregnancy rhinitis disappears after delivery. Vasomotor rhinitis is controlled rather than cured.

## Test yourself

Think of the answer, then tap the question to see it.

## A woman with perennial watery rhinorrhea triggered by cold air and perfumes has negative skin prick tests and no eosinophils on nasal smear. Diagnosis?

Vasomotor (idiopathic nonallergic) rhinitis.

## A patient has used a decongestant nasal spray for 6 weeks and now has constant congestion with red, swollen turbinates. What is it and how is it managed?

Rhinitis medicamentosa: stop the spray, with an intranasal corticosteroid as bridge.

## Which intranasal drug best treats predominant watery rhinorrhea, including gustatory rhinitis?

Ipratropium, an anticholinergic.

## Wide nasal cavities, greenish crusts and a foul smell that the patient cannot perceive suggest what disease, and which organism is classically linked?

Primary atrophic rhinitis (ozaena), associated with Klebsiella ozaenae.

## Which test result separates NARES from allergic rhinitis?

Eosinophils on the nasal smear with negative skin prick or specific IgE tests.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/nonallergic-rhinitis/)

## In ENT

- [ENT medicines: ear drops, nasal sprays, decongestants and gargles](https://durgical.com/en/ent/ent-medicines-ear-drops-nasal-sprays-decongestants-and-gargles/)

## Connections

## Related conditions 11

- [Allergic rhinitis](https://durgical.com/en/conditions/allergic-rhinitis/)
- [Chronic rhinosinusitis and nasal polyps](https://durgical.com/en/conditions/chronic-rhinosinusitis-and-nasal-polyps/)
- [Acute rhinosinusitis](https://durgical.com/en/conditions/acute-rhinosinusitis/)
- [Deviated nasal septum](https://durgical.com/en/conditions/deviated-nasal-septum/)
- [Granulomatosis with polyangiitis](https://durgical.com/en/conditions/granulomatosis-with-polyangiitis/)
- [Sarcoidosis](https://durgical.com/en/conditions/sarcoidosis/)
- [Cocaine and sympathomimetic toxicity](https://durgical.com/en/conditions/cocaine-and-sympathomimetic-toxicity/)
- [Hypothyroidism](https://durgical.com/en/conditions/hypothyroidism/)
- [Asthma](https://durgical.com/en/conditions/asthma/)
- [Epistaxis (nosebleed)](https://durgical.com/en/conditions/epistaxis/)
- [Laryngopharyngeal reflux](https://durgical.com/en/conditions/laryngopharyngeal-reflux/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Nonallergic Rhinitis (Vasomotor Rhinitis)](https://www.ncbi.nlm.nih.gov/books/NBK547704/) (StatPearls (NCBI Bookshelf), 2026); [Rhinitis Medicamentosa](https://www.ncbi.nlm.nih.gov/books/NBK538318/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/nonallergic-rhinitis/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/nonallergic-rhinitis/