Vasomotor Rhinitis

<!DOCTYPE HTML> <html lang="en-US"> <head> <meta charset="UTF-8"/> <title>Vasomotor Rhinitis | AAFP</title> <meta name="description" content="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."/> <meta name="template" content="aafp-article-page"/> <meta name="tags" content="aafp:publications/filters/discipline/otolaryngologic,aafp:publications/afp/article-types/feature,aafp:taxonomy/afp/rhinitis,aafp:taxonomy/afp/ent%2C-nose"/> <meta name="pubdate" content="2005-09-15"/> <meta name="nav-title" content="Vasomotor Rhinitis"/> <meta name="category" content="Publications"/> <meta name="subcategory" content="American Family Physician"/> <meta content="American Family Physician" name="citation_journal_title"/> <meta content="afp" name="citation_journal_abbrev"/> <meta content="Vasomotor Rhinitis" name="citation_title"/> <meta content="2005/09/15" name="citation_publication_date"/> <meta content="72" name="citation_volume"/> <meta content="6" name="citation_issue"/> <meta content="1057" name="citation_firstpage"/> <meta content="1062" name="citation_lastpage"/> <meta content="https://www.aafp.org/pubs/afp/issues/2005/0915/p1057.pdf" name="citation_pdf_url"/> <meta content="https://www.aafp.org/pubs/afp/issues/2005/0915/p1057.xml" name="citation_xml_url"/> <meta content="PATRICIA W. WHEELER" name="citation_author"/> <meta content="STEPHEN F. WHEELER" name="citation_author"/> <meta content="A treatment algorithm starts with a targeted history and physical examination,followed by a stepwise management approach that reflects evidence from theAgency for Healthcare Research and Quality." name="citation_abstract"/> <meta content="True" name="citation_fulltext_world_readable"/>       <meta content="Otolaryngologic" name="facet_discipline"/>   <meta content="articleAlgFlag" name="resource-type"/> <link href="https://ssl.aafp.org" rel="preconnect" crossorigin/> <link href="https://img.aafp.net" rel="preconnect" crossorigin/> <link href="https://css.aafp.net" rel="preconnect" crossorigin/> <link href="https://js.aafp.net" rel="preconnect" crossorigin/> <link href="https://ui.aafp.net" rel="preconnect" crossorigin/> <link href="https://img.aafp.net" rel="preconnect"/> <link href="https://accdn.lpsnmedia.net" rel="preconnect"/> <link href="https://lptag.liveperson.net" rel="preconnect"/> <link href="https://www.google-analytics.com" rel="preconnect"/> <link href="https://stats.g.doubleclick.net" rel="preconnect"/> <link href="https://aafp.tt.omtrdc.net" rel="preconnect"/> <link href="https://www.facebook.com" rel="preconnect"/> <link href="https://connect.facebook.net" rel="preconnect"/> <script type="text/javascript"> function onDOMContentLoaded() { if (document) { //document.body.classList.remove("adl-page--hidden"); //document.body.classList.add("adl-page--loaded"); var classes = ''; if(classes !== ""){ classes.split(',').forEach((x, i) => document.body.classList.add(x)); } } } window.addEventListener("DOMContentLoaded", onDOMContentLoaded); window.isAEM = true; </script>  <script type="text/javascript"> (function(w,d,s,l,i){ w[l]=w[l]||[]; w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'}); var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:''; j.async=true; j.src= '//www.googletagmanager.com/gtm.js?id='+i+dl; f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-PXLQG7'); </script>  <meta name="viewport" content="width=device-width, initial-scale=1"/> <meta property="og:title" content="Vasomotor Rhinitis"/> <meta property="og:description" content="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."/> <meta property="og:image" content="https://www.aafp.org/dam/brand/aafp/pubs/afp/issues/2005/0915/cover.jpg"/> <meta property="og:image:alt" content="AAFP logo in blue with orange flame in torch"/> <meta property="og:url" content="https://www.aafp.org/pubs/afp/issues/2005/0915/p1057.html"/> <meta property="og:type" content="article"/> <meta name="twitter:card" content="summary_large_image"/> <meta name="twitter:site" content="@aafp"/> <meta name="twitter:title" content="Vasomotor Rhinitis"/> <meta name="twitter:description" content="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."/> <meta name="twitter:image" content="https://www.aafp.org/dam/brand/aafp/pubs/afp/issues/2005/0915/cover.jpg"/> <meta name="twitter:image:alt" content="AAFP logo in blue with orange flame in torch"/> <script src="https://code.jquery.com/jquery-1.8.3.min.js" integrity="sha256-YcbK69I5IXQftf/mYD8WY0/KmEDCv1asggHpJk1trM8=" crossorigin="anonymous"></script> <script type="text/javascript" src="https://www.aafp.org/jsparse/AAFPUser.js"></script> <script type="text/javascript" src="https://js.aafp.org/global/libs/utils.js"></script> <link rel="stylesheet" href="/etc.clientlibs/brand/aafp/clientlibs/clientlib-base.min.css" type="text/css"> <link rel="stylesheet" href="/apps/brand/aafp/clientlibs/responsive-grid.min.css" type="text/css"> <script type="module" src="https://ui.aafp.net/aafp-brand-components/2/components/aafp-web-components/aafp-web-components.esm.js"></script> <script nomodule="" src="https://ui.aafp.net/aafp-brand-components/2/components/aafp-web-components/aafp-web-components.js"></script> <script async="" src="//www.googletagmanager.com/gtm.js?id=GTM-PXLQG7"></script> <script type="text/javascript"> try{ var prop14 = Utils.getWebLoginValue(); 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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. 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</aafp-search></div> </div> </aafp-global-nav> <aafp-secondary-nav slot="flyout-nav"> </aafp-secondary-nav> </div> </div> </div> </div> </div> <div class="aafp-article-primary-content-container responsivegrid aem-GridColumn aem-GridColumn--default--12"><div class="adl-primary-content-container adl-space__sm__p-t-sm adl-space__sm__p-b-lg"> <div class="adl-grid adl-grid--no-padding"> <div class="adl-grid__col-sm-12 adl-grid__col-md-flex adl-space__md__p-r-sm adl-space__lg__p-r-md adl-space__sm__m-b-sm adl-space__md__m-b-none"> <div> <aafp-next-and-previous class="adl-space__sm__m-b-md" previous-link="/pubs/afp/issues/2005/0915/p1049.html" previous-label-mobile="PREV" previous-label-desktop="PREV ARTICLE" next-link="/pubs/afp/issues/2005/0915/p1065.html" next-label-mobile="NEXT" next-label-desktop="NEXT ARTICLE" parent-link="/pubs/afp/issues/2005/0915.html" parent-title="Sep 15, 2005"> </aafp-next-and-previous> <noscript> <a href="/pubs/afp/issues/2005/0915/p1049.html">PREV</a> <a href="/pubs/afp/issues/2005/0915.html">Sep 15, 2005</a> <a href="/pubs/afp/issues/2005/0915/p1065.html">NEXT</a> </noscript> </div> <article class="adl-space__sm__m-b-lg"> <header class="adl-space__sm__m-b-md"> <img class="adl-layout__screen-hide adl-layout__print-show adl-space__sm__m-b-md" style="display: block; max-height: 40px; max-width: 740px;" src="/content/dam/AAFP/images/logos_internal/afp-masthead-2024_old.jpg" alt="brand logo"/> <div> <aafp-journal-article-title-and-kicker article-title="Vasomotor Rhinitis"> </aafp-journal-article-title-and-kicker> </div> <div> <aafp-journal-article-supporting-links pdf-link="/pubs/afp/issues/2005/0915/p1057.pdf" comments-jump-link-target="#article-comment-area"> </aafp-journal-article-supporting-links> </div> <div class="adl-layout__sm-only adl-space__sm__m-t-sm adl-space__sm__m-b-md adl-layout__print-hide"> </div> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="aafp-byline aem-GridColumn aem-GridColumn--default--12"> <p class="adl-body adl-space__sm__m-t-xs adl-space__sm__m-b-sm"> PATRICIA W. WHEELER, M.D., AND STEPHEN F. WHEELER, M.D. </p> </div> </div> <div> <aafp-journal-article-information> <aafp-journal-article-information-item icon="info"> <p><i>Am Fam Physician.</i> 2005;72(6):1057-1062</p> </aafp-journal-article-information-item> <aafp-journal-article-information-item icon="local_library"> <p><a href="https://www.aafp.org/afp/2018/0801/p171.html">A more recent article on rhinitis is available.</a></p> </aafp-journal-article-information-item> <aafp-journal-article-information-item icon="assignment"> <p>Author disclosure: Nothing to disclose.</p> </aafp-journal-article-information-item> </aafp-journal-article-information> </div> <nav class="adl-layout__sm-only adl-space__sm__m-v-md adl-layout__print-hide"> <h2 class="adl-block-heading">Article Sections</h2> <aafp-link-pile data-linked-list="[{"text":"Abstract","url":"#abstract"},{"text":"Laboratory Testing","url":"#laboratory-testing"},{"text":"Management","url":"#management"},{"text":"Special Populations","url":"#special-populations"},{"text":"Prognosis and Additional Therapies","url":"#prognosis-and-additional-therapies"},{"text":"References","url":"#references"}]" data-linked-list-type="TEXT"> <div slot="data-links"> <aafp-link data-text="Abstract" data-url="#abstract"> </aafp-link> </div> <div slot="data-links"> <aafp-link data-text="Laboratory Testing" data-url="#laboratory-testing"> </aafp-link> </div> <div slot="data-links"> <aafp-link data-text="Management" data-url="#management"> </aafp-link> </div> <div slot="data-links"> <aafp-link data-text="Special Populations" data-url="#special-populations"> </aafp-link> </div> <div slot="data-links"> <aafp-link data-text="Prognosis and Additional Therapies" data-url="#prognosis-and-additional-therapies"> </aafp-link> </div> <div slot="data-links"> <aafp-link data-text="References" data-url="#references"> </aafp-link> </div> </aafp-link-pile> </nav> <div> <span id="abstract"></span> </div> <div> <div class="adl-abstract"> <p> <p>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. </p> </p> </div> </div> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> </div> </header> <div class="adl-space__sm__m-b-md"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="aafp-tables-content-well aafp-figure aem-GridColumn aem-GridColumn--default--12"> <aafp-journal-article-table-and-figure enlarge-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_tables_content.enlarge.html" print-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_tables_content.print.html" id="sort" heading="<h3>SORT: KEY RECOMMENDATIONS FOR PRACTICE</h3>" description="<p><i>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<a href="https://www.aafp.org/afpsort.xml">https://www.aafp.org/afpsort.xml</a></i>.</p>"> <div class="adl-table-scroller"> <table><thead><tr><th align="left"><i>Clinical recommendation</i></th><th align="left"><i>Evidence rating</i></th><th align="left"><i>References</i></th></tr></thead><tbody><tr><td align="left">Topical anticholinergics should be used for rhinorrhea caused by vasomotor rhinitis.</td><td align="left">A</td><td align="left"><sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b13">13</a></sup> </td></tr><tr><td align="left">Azelastine (Astelin) may be used for vasomotor rhinitis associated with rhinorrhea, sneezing, postnasal drip, and nasal congestion.</td><td align="left">B</td><td align="left"><sup><a href="#afp20050915p1057-b6">6</a></sup> </td></tr><tr><td align="left">Topical corticosteroids may be used for vasomotor rhinitis associated with nasal obstruction and congestion.</td><td align="left">B</td><td align="left"><sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b11">11</a></sup> </td></tr><tr><td align="left">Cromolyn sodium (Intal) may be used for vasomotor rhinitis associated with sneezing and congestion in patients older than two years.</td><td align="left">B</td><td align="left"><sup><a href="#afp20050915p1057-b6">6</a></sup> </td></tr></tbody></table> </div> </aafp-journal-article-table-and-figure> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b1">1</a></sup> The symptoms of allergic and nonallergic rhinitis overlap significantly, but the causes appear to be entirely different.<sup><a href="#afp20050915p1057-b2">2</a></sup> 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.<sup><a href="#afp20050915p1057-b3">3</a></sup> Nonallergic rhinitis, a diagnosis of exclusion, can be sporadic or perennial.<sup><a href="#afp20050915p1057-b1">1</a></sup> 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 <i>(<a href="#afp20050915p1057-t1">Table 1</a>)</i>.<sup><a href="#afp20050915p1057-b1">1</a></sup> </p> </div> </div> <div class="aafp-tables-content-well aafp-figure aem-GridColumn aem-GridColumn--default--12"> <aafp-journal-article-table-and-figure enlarge-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_tables_content0.enlarge.html" print-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_tables_content0.print.html" id="afp20050915p1057-t1" number-text="TABLE 1" heading="<h3>Types of Nonallergic Rhinitis</h3>" description="<p><i>Information from reference <a href="#afp20050915p1057-b1" data-transform-type="sup">1</a></i>.</p>"> <div class="adl-table-scroller"> <table><tbody><tr><td align="left">Drug induced</td></tr><tr><td align="left">Gustatory</td></tr><tr><td align="left">Hormonal</td></tr><tr><td align="left">Infectious</td></tr><tr><td align="left">Nonallergic rhinitis with eosinophilia syndrome</td></tr><tr><td align="left">Occupational</td></tr><tr><td align="left">Vasomotor</td></tr></tbody></table> </div> </aafp-journal-article-table-and-figure> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b2">2</a></sup> 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.<sup><a href="#afp20050915p1057-b1">1</a></sup> 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).<sup><a href="#afp20050915p1057-b1">1</a></sup> 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,<sup><a href="#afp20050915p1057-b4">4</a></sup> researchers concluded that autonomic system dysfunction is significant in patients with vasomotor rhinitis (<i>P</i> < .005). Possible compounding factors included previous nasal trauma and extraesophageal manifestations of gastroesophageal reflux disease.<sup><a href="#afp20050915p1057-b4">4</a></sup> </p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b5">5</a></sup> An evidence report<sup><a href="#afp20050915p1057-b6">6</a></sup> 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.<sup><a href="#afp20050915p1057-b6">6</a></sup> The total annual cost of allergic rhinitis in the mid-1990s, including lost productivity to employers and society, was $5.6 billion.<sup><a href="#afp20050915p1057-b6">6</a></sup> </p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b3">3</a></sup> 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.<sup><a href="#afp20050915p1057-b3">3</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b6">6</a></sup> </p> </div> </div> <div class="aafp-pin aem-GridColumn aem-GridColumn--default--12"> <span id="laboratory-testing"></span> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h2>Laboratory Testing</h2><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b7">7</a></sup> According to the AHRQ,<sup><a href="#afp20050915p1057-b6">6</a></sup> 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.”<sup><a href="#afp20050915p1057-b8">8</a></sup> 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.<sup><a href="#afp20050915p1057-b1">1</a></sup> The minimum level of testing needed to confirm or exclude a diagnosis of vasomotor rhinitis has not been established in the literature.<sup><a href="#afp20050915p1057-b6">6</a></sup> </p> </div> </div> <div class="aafp-pin aem-GridColumn aem-GridColumn--default--12"> <span id="management"></span> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h2>Management</h2><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p><i><a href="#afp20050915p1057-f1">Figure 1</a></i> outlines an algorithm for effective pharmacologic management of vasomotor rhinitis. <i><a href="#afp20050915p1057-t2">Table 2</a></i><sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b9">9</a><span data-transform-type="sup-inbetween">–</span><a href="#afp20050915p1057-b13">13</a></sup> displays stepwise recommendations for treatment based on the AHRQ Evidence Report and on additional treatments empirically employed but not discussed by the AHRQ.</p> </div> </div> <div class="aafp-figure aem-GridColumn aem-GridColumn--default--12"> <aafp-journal-article-table-and-figure enlarge-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_figure.enlarge.html" print-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_figure.print.html" id="afp20050915p1057-f1" number-text="Figure 1." heading="<h3>Suggested Approach to the Pharmacologic Management of Vasomotor Rhinitis</h3>" description="<p>Algorithm for the pharmacologic management of vasomotor rhinitis.</p>"> <img src="/content/dam/brand/aafp/pubs/afp/issues/2005/0915/p1057-f1.jpg"/> </aafp-journal-article-table-and-figure> </div> <div class="aafp-tables-content-well aafp-figure aem-GridColumn aem-GridColumn--default--12"> <aafp-journal-article-table-and-figure enlarge-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_tables_content1.enlarge.html" print-url="/pubs/afp/issues/2005/0915/p1057/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_tables_content1.print.html" id="afp20050915p1057-t2" number-text="TABLE 2" heading="<h3>Treatment Recommendations for Vasomotor Rhinitis: A Stepwise Approach</h3>" description="<p><i>AHRQ = Agency for Healthcare Research and Quality</i>.</p><p><sc>note</sc>:<i> Use of topical antihistamines and corticosteroids is approved by the U.S. Food and Drug Administration</i>.</p><p><i>Information from references <a href="#afp20050915p1057-b6" data-transform-type="sup">6</a> and <a href="#afp20050915p1057-b9" data-transform-type="sup">9</a> through <a href="#afp20050915p1057-b13" data-transform-type="sup">13</a></i>.</p>"> <div class="adl-table-scroller"> <table><thead><tr><th align="left"><i>Medication class</i></th><th align="left"><i>Product</i></th><th align="left"><i>Effect</i></th><th align="left"><i>Side effects</i></th></tr></thead><tbody><tr><td align="left">Topical antihistamines<sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b9">9</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b10">10</a></sup> </td><td align="left">Azelastine (Astelin)</td><td align="left">Improvement in rhinorrhea, sneezing, postnasal drip, and nasal congestion<sup><a href="#afp20050915p1057-b9">9</a></sup> </td><td align="left">No serious or unexpected adverse events; bitter taste<sup><a href="#afp20050915p1057-b9">9</a></sup> </td></tr><tr><td align="left">Topical corticosteroids<sup><a href="#afp20050915p1057-b11">11</a></sup> </td><td align="left">Mometasone furoate (Nasonex)</td><td align="left">Improvement in nasal obstruction and congestion scores<sup><a href="#afp20050915p1057-b11">11</a></sup> </td><td align="left">Epistaxis, nasal irritation<sup><a href="#afp20050915p1057-b11">11</a></sup> </td></tr><tr><td align="left">Topical corticosteroids<sup><a href="#afp20050915p1057-b6">6</a></sup> </td><td align="left">Budesonide (Rhinocort), beclomethasone (Beclovent), triamcinolone acetonide (Kenalog)</td><td align="left">Improvement in nasal obstruction and congestion scores<sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b12">12</a></sup> </td><td align="left">Epistaxis, headache, nasal congestion</td></tr><tr><td align="left">Topical cromoglycate<sup><a href="#afp20050915p1057-b6">6</a></sup> </td><td align="left">Cromolyn sodium (Intal)</td><td align="left">Decrease in sneezing and congestion scores<sup><a href="#afp20050915p1057-b6">6</a></sup> </td><td align="left">Nasal irritation, headache, nasal congestion<sup><a href="#afp20050915p1057-b6">6</a></sup> </td></tr><tr><td align="left">Topical anticholinergics<sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b13">13</a></sup> </td><td align="left">Ipratropium (Atrovent)</td><td align="left">Reduced rhinorrhea only<sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b13">13</a></sup> </td><td align="left">Minor adverse effects; nasal dryness and irritation<sup><a href="#afp20050915p1057-b13">13</a></sup> </td></tr><tr><td align="left" colspan="4"><b>Other agents not recommended by AHRQ</b></td></tr><tr><td align="left">Oral antihistamines</td><td align="left">Sedating and nonsedating</td><td align="left">AHRQ outcome not identified</td><td align="left">Somnolence, dizziness, dry mouth, headache</td></tr><tr><td align="left">Oral sympathomimetics</td><td align="left">Only phenylpropanolamine (not available in the United States) was studied.</td><td align="left">Withdrawn from the market; no other oral decongestant was identified or specifically studied.</td><td align="left"></td></tr><tr><td align="left">Leukotriene modifiers</td><td align="left">Not identified in any trial on nonallergic rhinitis</td><td align="left"></td><td align="left"></td></tr><tr><td align="left" colspan="4"><b>Other agents not discussed by AHRQ: evidence for use lacking, empiric use possible</b></td></tr><tr><td align="left">Topical decongestants</td><td align="left">Oxymetazoline (Nezeril, Afrin, Dristan)</td><td align="left">Improvement in congestion</td><td align="left"></td></tr><tr><td align="left">Oral decongestants</td><td align="left">Pseudoephedrine</td><td align="left">Improvement in congestion</td><td align="left"></td></tr></tbody></table> </div> </aafp-journal-article-table-and-figure> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b14">14</a></sup> With nasal congestion and obstruction only, topical corticosteroids would be a wise starting point for therapy.<sup><a href="#afp20050915p1057-b6">6</a></sup> If the patient presents with the full range of symptoms including rhinorrhea with sneezing, postnasal drip, and congestion, a topical antihistamine may be initiated.<sup><a href="#afp20050915p1057-b6">6</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b9">9</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b10">10</a></sup> After an adequate trial period, changes and additions may be made if the response is inadequate. <i><a href="#afp20050915p1057-f1">Figure 1</a></i> describes a possible approach.</p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b2">2</a></sup> The effect of exercise on nasal decongestion is short-lived, but it has numerous other benefits and can be repeated.</p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b3">3</a></sup> According to the AHRQ report,<sup><a href="#afp20050915p1057-b6">6</a></sup> 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.<sup><a href="#afp20050915p1057-b15">15</a></sup> </p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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 study<sup><a href="#afp20050915p1057-b16">16</a></sup> 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 study<sup><a href="#afp20050915p1057-b16">16</a></sup> 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.</p> </div> </div> <div class="aafp-pin aem-GridColumn aem-GridColumn--default--12"> <span id="special-populations"></span> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h2>Special Populations</h2><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h3>CHILDREN</h3><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b2">2</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b6">6</a></sup> However, anticholinergics have no effect on the other symptoms of vasomotor rhinitis. Investigators conducted a multicenter, double-blind, placebo-controlled, parallel-group trial<sup><a href="#afp20050915p1057-b13">13</a></sup> in 204 children (six to 12 years of age) and adolescents (13 to 18 years of age) with allergic or nonallergic perennial rhinitis.</p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b13">13</a></sup> </p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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 study<sup><a href="#afp20050915p1057-b11">11</a></sup> 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.<sup><a href="#afp20050915p1057-b11">11</a></sup> 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.<sup><a href="#afp20050915p1057-b12">12</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b17">17</a></sup> Cromolyn sodium (Intal) can be used to manage symptoms of sneezing and congestion in children older than two years.<sup><a href="#afp20050915p1057-b6">6</a></sup> </p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.</p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h3>ATHLETES</h3><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b18">18</a></sup> 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.</p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h3>PREGNANT WOMEN</h3><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b20">20</a></sup> Vasomotor rhinitis in pregnancy responds well to intranasal saline instillation.<sup><a href="#afp20050915p1057-b20">20</a></sup> 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.<sup><a href="#afp20050915p1057-b1">1</a></sup> </p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h3>OLDER ADULTS</h3><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b2">2</a></sup> All three types respond well to ipratropium nasal spray. Narrow-angle glaucoma is a relative contra-indication to the use of ipratropium.<sup><a href="#afp20050915p1057-b2">2</a></sup> </p> </div> </div> <div class="aafp-pin aem-GridColumn aem-GridColumn--default--12"> <span id="prognosis-and-additional-therapies"></span> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p></p><h2>Prognosis and Additional Therapies</h2><p></p> </div> </div> <div class="cmp cmp-text aem-GridColumn aem-GridColumn--default--12"> <div class="adl-rte-wrapper adl-space__sm__m-t-none adl-space__sm__m-b-none"> <p>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.<sup><a href="#afp20050915p1057-b21">21</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b22">22</a></sup> 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.<sup><a href="#afp20050915p1057-b23">23</a></sup> The submucosal injection of botulinum toxin type A (Botox) has been studied in dog models<sup><a href="#afp20050915p1057-b24">24</a><span data-transform-type="sup-inbetween">,</span><a href="#afp20050915p1057-b25">25</a></sup> and may yet prove to be of value.</p> </div> </div> </div> </div> <div> <aafp-journal-article-author-info class="adl-space__sm__m-b-md" heading="Author Information" author-info="<p>PATRICIA W. WHEELER, M.D., is assistant professor and director of faculty development in the Department of Family and Geriatric Medicine at the University of Louisville (Ky.) School of Medicine. Dr. Wheeler received her medical degree from the University of Louisville, where she also completed a family medicine residency.</p><p>STEPHEN F. WHEELER, M.D., is associate professor in the Department of Family and Geriatric Medicine at the University of Louisville School of Medicine, where he also serves as program director of the Family and Geriatric Medicine residency program. Dr. Wheeler received his medical degree from the University of Louisville, where he also completed a family medicine residency.</p><p><i>Address correspondence to Patricia W. Wheeler, M.D., University of Louisville, Department of Family and Geriatric Medicine, 3430 Newburg Rd., Suite 202, Louisville, KY 40218. Reprints are not available from the authors</i>.</p>" author-disclosures="<p>Author disclosure: Nothing to disclose.</p>"> </aafp-journal-article-author-info> </div> <div> <span id="references"></span> </div> <div> <aafp-journal-article-references class="adl-space__sm__m-b-md" heading="Reference(s)" references="[{"anchorId":"afp20050915p1057-b1","label":"1.","text":"\u003cp\u003eDykewicz MS, Fineman S, Skoner DP, Nicklas R, Lee R, Blessing-Moore J, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma and Immunology. \u003ci\u003eAnn Allergy Asthma Immunol. \u003c/i\u003e 1998;81(5 pt 2):478-518.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b2","label":"2.","text":"\u003cp\u003eDruce HM. Allergic and nonallergic rhinitis. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF, Busse WW, eds. Allergy principles and practice. 5th ed. St. Louis: Mosby, 1998:1005–16.\u003c/p\u003e","publicationType":"other"},{"anchorId":"afp20050915p1057-b3","label":"3.","text":"\u003cp\u003eLau J, Long A. Chronic rhinitis: allergic or nonallergic? [Editorial]. \u003ci\u003eAm Fam Physician. \u003c/i\u003e 2003;67:705-6.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b4","label":"4.","text":"\u003cp\u003eJaradeh SS, Smith TL, Torrico L, Prieto TE, Loehrl TA, Darling RJ, et al. Autonomic nervous system evaluation of patients with vasomotor rhinitis. \u003ci\u003eLaryngoscope. \u003c/i\u003e 2000;110:1828-31.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b5","label":"5.","text":"\u003cp\u003eSettipane RA, Lieberman P. Update on nonallergic rhinitis. \u003ci\u003eAnn Allergy Asthma Immunol. \u003c/i\u003e 2001;86:494-507.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b6","label":"6.","text":"\u003cp\u003eManagement of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. AHRQ Publication No. 02-E024, May 2002. Rockville, Md.: Agency for Healthcare Research and Quality, 2002. Accessed online August 5, 2005, at: http://www.ahrq.gov/clinic/rhininv.htm.\u003c/p\u003e","publicationType":"other"},{"anchorId":"afp20050915p1057-b7","label":"7.","text":"\u003cp\u003eLi JT. Allergy testing. \u003ci\u003eAm Fam Physician. \u003c/i\u003e 2002;66:621-4.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b8","label":"8.","text":"\u003cp\u003eNg ML, Warlow RS, Chrishanthan N, Ellis C, Walls R. Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort. \u003ci\u003eClin Exp Allergy. \u003c/i\u003e 2000;30:1314-31.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b9","label":"9.","text":"\u003cp\u003eBanov CH, Lieberman P for the Vasomotor Rhinitis Study Groups. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. \u003ci\u003eAnn Allergy Asthma Immunol. \u003c/i\u003e 2001;86:28-35.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b10","label":"10.","text":"\u003cp\u003eGehanno P, Deschamps E, Garay E, Baehre M, Garay RP. Vasomotor rhinitis: clinical efficacy of azelastine nasal spray in comparison with placebo. \u003ci\u003eORL J Otorhinolaryngol Relat Spec. \u003c/i\u003e 2001;63:76-81.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b11","label":"11.","text":"\u003cp\u003eSchenkel EJ, Skoner DP, Bronsky EA, Miller SD, Pearlman DS, Rooklin A, et al. Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. \u003ci\u003ePediatrics. \u003c/i\u003e 2000;105:E22.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b12","label":"12.","text":"\u003cp\u003eSkoner DP, Rachelefsky GS, Meltzer EO, Chervinsky P, Morris RM, Seltzer JM, et al. Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate. \u003ci\u003ePediatrics. \u003c/i\u003e 2000;105:E23.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b13","label":"13.","text":"\u003cp\u003eMeltzer EO, Orgel HA, Biondi R, Georgitis J, Milgrom H, Munk Z, et al. Ipratropium nasal spray in children with perennial rhinitis. \u003ci\u003eAnn Allergy Asthma Immunol. \u003c/i\u003e 1997;78:485-91.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b14","label":"14.","text":"\u003cp\u003eDolovich J, Kennedy L, Vickerson F, Kazim F. Control of the hypersecretion of vasomotor rhinitis by topical ipratropium bromide. \u003ci\u003eJ Allergy Clin Immunol. \u003c/i\u003e 1987;80(3 pt 1):274-8.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b15","label":"15.","text":"\u003cp\u003eBroms P, Malm L. Oral vasoconstrictors in perennial non-allergic rhinitis. \u003ci\u003eAllergy. \u003c/i\u003e 1982;37:67-74.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b16","label":"16.","text":"\u003cp\u003eGraf P, Enerdal J, Hallen H. Ten days’ use of oxymetazoline nasal spray with or without benzalkonium chloride in patients with vasomotor rhinitis. \u003ci\u003eArch Otolaryngol Head Neck Surg. \u003c/i\u003e 1999;125:1128-32.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b17","label":"17.","text":"\u003cp\u003eBenninger MS, Ahmad N, Marple BF. The safety of intranasal steroids. \u003ci\u003eOtolaryngol Head Neck Surg. \u003c/i\u003e 2003;129:739-50.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b18","label":"18.","text":"\u003cp\u003eWorld Anti-Doping Agency. The World Anti-Doping Code. The 2005 prohibited list: international standard. Accessed online August 5, 2005, at: http://www.wadaama.org/rtecontent/document/list_2005.pdf.\u003c/p\u003e","publicationType":"other"},{"anchorId":"afp20050915p1057-b19","label":"19.","text":"\u003cp\u003eU.S. Anti-Doping Agency. Drug Reference Online. Accessed online August 5, 2005, at: \u003ca href\u003d\"http://www.usantidoping.org/dro/\"\u003ehttp://www.usantidoping.org/dro/\u003c/a\u003e.\u003c/p\u003e","publicationType":"other"},{"anchorId":"afp20050915p1057-b20","label":"20.","text":"\u003cp\u003eLekas MD. Rhinitis during pregnancy and rhinitis medicamentosa. \u003ci\u003eOtolaryngol Head Neck Surg. \u003c/i\u003e 1992;107(6 pt 2):845-9.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b21","label":"21.","text":"\u003cp\u003eBhargava KB, Abhyankar US, Shah TM. Treatment of allergic and vasomotor rhinitis by the local application of silver nitrate. \u003ci\u003eJ Laryngol Otol. \u003c/i\u003e 1980;94:1025-36.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b22","label":"22.","text":"\u003cp\u003eal-Samarrae SM. Treatment of “vasomotor rhinitis” by the local application of silver nitrate. \u003ci\u003eJ Laryngol Otol. \u003c/i\u003e 1991;105:285-7.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b23","label":"23.","text":"\u003cp\u003ePrasanna A, Murthy PS. Vasomotor rhinitis and sphenopalantine ganglion block. \u003ci\u003eJ Pain Symptom Manage. \u003c/i\u003e 1997;13:332-8.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b24","label":"24.","text":"\u003cp\u003eShaari CM, Sanders I, Wu BL, Biller HF. Rhinorrhea is decreased in dogs after nasal application of botulinum toxin. \u003ci\u003eOtolaryngol Head Neck Surg. \u003c/i\u003e 1995;112:566-71.\u003c/p\u003e","publicationType":"journal"},{"anchorId":"afp20050915p1057-b25","label":"25.","text":"\u003cp\u003eBushara KO. Botulinum toxin and rhinorrhea [Letter]. \u003ci\u003eOtolaryngol Head Neck Surg. \u003c/i\u003e 1996:114-507.\u003c/p\u003e","publicationType":"journal"}]"> </aafp-journal-article-references> <noscript> <ol> <li id="afp20050915p1057-b1" data-label="1."><p>Dykewicz MS, Fineman S, Skoner DP, Nicklas R, Lee R, Blessing-Moore J, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma and Immunology. <i>Ann Allergy Asthma Immunol. </i> 1998;81(5 pt 2):478-518.</p></li> <li id="afp20050915p1057-b2" data-label="2."><p>Druce HM. Allergic and nonallergic rhinitis. In: Middleton E Jr, Ellis EF, Yunginger JW, Reed CE, Adkinson NF, Busse WW, eds. Allergy principles and practice. 5th ed. St. Louis: Mosby, 1998:1005–16.</p></li> <li id="afp20050915p1057-b3" data-label="3."><p>Lau J, Long A. Chronic rhinitis: allergic or nonallergic? [Editorial]. <i>Am Fam Physician. </i> 2003;67:705-6.</p></li> <li id="afp20050915p1057-b4" data-label="4."><p>Jaradeh SS, Smith TL, Torrico L, Prieto TE, Loehrl TA, Darling RJ, et al. Autonomic nervous system evaluation of patients with vasomotor rhinitis. <i>Laryngoscope. </i> 2000;110:1828-31.</p></li> <li id="afp20050915p1057-b5" data-label="5."><p>Settipane RA, Lieberman P. Update on nonallergic rhinitis. <i>Ann Allergy Asthma Immunol. </i> 2001;86:494-507.</p></li> <li id="afp20050915p1057-b6" data-label="6."><p>Management of allergic and nonallergic rhinitis. Evidence Report/Technology Assessment Number 54. AHRQ Publication No. 02-E024, May 2002. Rockville, Md.: Agency for Healthcare Research and Quality, 2002. Accessed online August 5, 2005, at: http://www.ahrq.gov/clinic/rhininv.htm.</p></li> <li id="afp20050915p1057-b7" data-label="7."><p>Li JT. Allergy testing. <i>Am Fam Physician. </i> 2002;66:621-4.</p></li> <li id="afp20050915p1057-b8" data-label="8."><p>Ng ML, Warlow RS, Chrishanthan N, Ellis C, Walls R. Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort. <i>Clin Exp Allergy. </i> 2000;30:1314-31.</p></li> <li id="afp20050915p1057-b9" data-label="9."><p>Banov CH, Lieberman P for the Vasomotor Rhinitis Study Groups. Efficacy of azelastine nasal spray in the treatment of vasomotor (perennial nonallergic) rhinitis. <i>Ann Allergy Asthma Immunol. </i> 2001;86:28-35.</p></li> <li id="afp20050915p1057-b10" data-label="10."><p>Gehanno P, Deschamps E, Garay E, Baehre M, Garay RP. Vasomotor rhinitis: clinical efficacy of azelastine nasal spray in comparison with placebo. <i>ORL J Otorhinolaryngol Relat Spec. </i> 2001;63:76-81.</p></li> <li id="afp20050915p1057-b11" data-label="11."><p>Schenkel EJ, Skoner DP, Bronsky EA, Miller SD, Pearlman DS, Rooklin A, et al. Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. <i>Pediatrics. </i> 2000;105:E22.</p></li> <li id="afp20050915p1057-b12" data-label="12."><p>Skoner DP, Rachelefsky GS, Meltzer EO, Chervinsky P, Morris RM, Seltzer JM, et al. Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate. <i>Pediatrics. </i> 2000;105:E23.</p></li> <li id="afp20050915p1057-b13" data-label="13."><p>Meltzer EO, Orgel HA, Biondi R, Georgitis J, Milgrom H, Munk Z, et al. Ipratropium nasal spray in children with perennial rhinitis. <i>Ann Allergy Asthma Immunol. </i> 1997;78:485-91.</p></li> <li id="afp20050915p1057-b14" data-label="14."><p>Dolovich J, Kennedy L, Vickerson F, Kazim F. Control of the hypersecretion of vasomotor rhinitis by topical ipratropium bromide. <i>J Allergy Clin Immunol. </i> 1987;80(3 pt 1):274-8.</p></li> <li id="afp20050915p1057-b15" data-label="15."><p>Broms P, Malm L. Oral vasoconstrictors in perennial non-allergic rhinitis. <i>Allergy. </i> 1982;37:67-74.</p></li> <li id="afp20050915p1057-b16" data-label="16."><p>Graf P, Enerdal J, Hallen H. Ten days’ use of oxymetazoline nasal spray with or without benzalkonium chloride in patients with vasomotor rhinitis. <i>Arch Otolaryngol Head Neck Surg. </i> 1999;125:1128-32.</p></li> <li id="afp20050915p1057-b17" data-label="17."><p>Benninger MS, Ahmad N, Marple BF. The safety of intranasal steroids. <i>Otolaryngol Head Neck Surg. </i> 2003;129:739-50.</p></li> <li id="afp20050915p1057-b18" data-label="18."><p>World Anti-Doping Agency. The World Anti-Doping Code. The 2005 prohibited list: international standard. Accessed online August 5, 2005, at: http://www.wadaama.org/rtecontent/document/list_2005.pdf.</p></li> <li id="afp20050915p1057-b19" data-label="19."><p>U.S. Anti-Doping Agency. Drug Reference Online. Accessed online August 5, 2005, at: <a href="http://www.usantidoping.org/dro/">http://www.usantidoping.org/dro/</a>.</p></li> <li id="afp20050915p1057-b20" data-label="20."><p>Lekas MD. Rhinitis during pregnancy and rhinitis medicamentosa. <i>Otolaryngol Head Neck Surg. </i> 1992;107(6 pt 2):845-9.</p></li> <li id="afp20050915p1057-b21" data-label="21."><p>Bhargava KB, Abhyankar US, Shah TM. Treatment of allergic and vasomotor rhinitis by the local application of silver nitrate. <i>J Laryngol Otol. </i> 1980;94:1025-36.</p></li> <li id="afp20050915p1057-b22" data-label="22."><p>al-Samarrae SM. Treatment of “vasomotor rhinitis” by the local application of silver nitrate. <i>J Laryngol Otol. </i> 1991;105:285-7.</p></li> <li id="afp20050915p1057-b23" data-label="23."><p>Prasanna A, Murthy PS. Vasomotor rhinitis and sphenopalantine ganglion block. <i>J Pain Symptom Manage. </i> 1997;13:332-8.</p></li> <li id="afp20050915p1057-b24" data-label="24."><p>Shaari CM, Sanders I, Wu BL, Biller HF. Rhinorrhea is decreased in dogs after nasal application of botulinum toxin. <i>Otolaryngol Head Neck Surg. </i> 1995;112:566-71.</p></li> <li id="afp20050915p1057-b25" data-label="25."><p>Bushara KO. Botulinum toxin and rhinorrhea [Letter]. <i>Otolaryngol Head Neck Surg. </i> 1996:114-507.</p></li> </ol> </noscript> </div> </article>  <div class="adl-space__sm__m-b-md"> <aafp-comments data-id="article-comment-area" data-path="/content/aafp/afp/2005/0915/p1057" default-visibility-state="hidden" hide-ads-when-shown> </aafp-comments> </div> <div> <h2 class="adl-h2 adl-layout__print-hide">Continue Reading</h2> <aafp-journal-preview journal-is-current="false" journal-preview-title="Sep 15, 2005" journal-issue-date="Sep 15, 2005" flexible-image-width="true" previous-article-link="/pubs/afp/issues/2005/0915/p1049.html" previous-article-title="Rheumatoid Arthritis: What You Should Know" next-article-link="/pubs/afp/issues/2005/0915/p1065.html" next-article-title="Coenzyme Q10"> <aafp-cta-tertiary href="/pubs/afp/issues/2005/0915.html" label="View the full table of contents" is-external-link="false" slot="cta-button" is-active="true"> </aafp-cta-tertiary> </aafp-journal-preview> </div> 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