History and exam
Key diagnostic factors
common
nasal congestion
Nasal congestion is not diagnostic of NAR but is the most common symptom along with postnasal drainage. May interfere with continuous positive airway pressure usage if obstructive sleep apnea is also present.
postnasal drainage
Patients with NAR have more postnasal drainage, whereas those with allergic rhinitis often have more rhinorrhea; however, there is quite a bit of overlap.
rhinorrhea
Patients with NAR complain of increased secretions from the front of their nose.
sore throat
This can occur as a result of nasal congestion leading to mouth breathing and chronic postnasal drainage.
Other diagnostic factors
common
ear plugging
Congestion of the Eustachian tube causes this problem. Equalizing the ear canal similar to what is done when flying (pinching the nose and gently blowing into it) may help alleviate this condition.
sinus headaches
Often considered a form of tension headaches by neurologists. These headaches often respond to medications used to treat NAR, such as intranasal azelastine, olopatadine, corticosteroids, and oral decongestants.
postural change triggers
Suggestive of NAR.
absence of fever
Fever may suggest sinusitis or other infection.
sneezing
Common but not specific for NAR.
uncommon
purulent discharge
May suggest infection.
bilateral symptoms
Unilateral symptoms may suggest another diagnosis such as obstruction or tumor.
sinus pain
Although a common symptom experienced by patients with chronic rhinitis, it may suggest infection, tumor, or other destructive lesion.[21]
Risk factors
strong
symptom onset age >35
Patients with NAR often present later in life than patients with allergic rhinitis. The reason is unknown. Although 35 years old is cited in the literature, the likelihood of NAR rather than allergic rhinitis increases linearly with age.[9] Patients with allergic rhinitis are exposed early in life to seasonal and perennial aeroallergens and therefore tend to manifest symptoms earlier. Although NAR can manifest at a younger age, patients tend to experience symptoms later in life for unknown reasons.
no symptom exacerbation by cats
Exacerbation by cat dander is strongly suggestive of allergic rather than non-allergic disease, if present.
no family history of allergies
If one parent has a history of allergic rhinitis then their offspring will have a 25% risk of developing allergies. If both parents have allergies then the risk increases to 50% to 60% for each offspring.
weak
no seasonal symptoms
Seasonality suggests an allergic component to the disease.
exposure to fragrance
Patients with allergic rhinitis can have mild symptoms around odorants/fragrances, but the magnitude of response manifested as symptom severity is significantly more common in most NAR patients.[18]
exposure to smoke (e.g., wood, tobacco)
Patients with allergic rhinitis can have mild symptoms around odorants/fragrances, but the magnitude of response manifested as symptom severity is significantly more common in most NAR patients.[18]
exposure to hairspray
Patients with allergic rhinitis can have mild symptoms around odorants/fragrances, but the magnitude of response manifested as symptom severity is significantly more common in most NAR patients.[18]
exposure to potpourris
Patients with allergic rhinitis can have mild symptoms around odorants/fragrances, but the magnitude of response manifested as symptom severity is significantly more common in most NAR patients.[18]
changes in temperature
Exacerbation of symptoms in response to changes in temperature and barometric changes can be seen in NAR as well as in allergic rhinitis.[5]
barometric changes
Exacerbation of symptoms in response to changes in temperature and barometric changes can be seen in NAR as well as in allergic rhinitis.[5]
high estrogen state
Whether from pregnancy, puberty, estrogen supplementation, or oral contraceptive use, estrogens may cause secondary rhinitis symptoms.
beta-blocker use
Can cause rhinitis.
intranasal drug abuse
Can cause rhinitis.
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