Vasomotor rhinitis (VMR)
Unlike allergic rhinitis, vasomotor rhinitis is caused by an oversensitive response to everyday environmental triggers rather than allergens. Learn about symptoms, triggers and treatment.
What is vasomotor rhinitis?
Vasomotor (irritant) rhinitis is a type of rhinitis (inflammation of the inside of the nose) that is not caused by allergies or infection.
"Vaso" means blood vessels, and "motor" refers to the nerves, which innervate the nasal tissue and the blood vessels. It is sometimes referred to as idiopathic non-allergic rhinitis. It is estimated that up to 10% of the population suffers from non-allergic rhinitis.
What are the symptoms of vasomotor rhinitis?
Vasomotor rhinitis is chronic rhinitis that is characterised by 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 that don't bother most people.
People with vasomotor rhinitis fall into 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. People 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 non-specific response to virtually any change or impurity in the air, as opposed to allergic rhinitis (or hay fever), which involves a response to a specific protein in pollen, dust, mould, or animal dander.
Key features of vasomotor rhinitis
- There is usually no history of allergies and an irritant may or may not be identified by the patient.
- There is no infection causing these symptoms.
- Vasomotor rhinitis can have a variable presentation.
- 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 (thick or scanty), 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.
What triggers vasomotor rhinitis?
Many cases are associated with a specific agent or condition. Examples of such agents/conditions are:
- 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 tablets
- Sexual arousal
- Stress (emotional or physical)
Other causes of non-allergic rhinitis
Nonallergic rhinitis with eosinophilia syndrome (NARES)
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
Occupational rhinitis
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
Hormonal rhinitis
Hormonal rhinitis is caused by hormonal imbalances such as pregnancy, hypothyroid states, puberty, and oral contraceptive use, conjugated estrogen use.
Drug-induced rhinitis
Drug-induced rhinitis
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 oestrogens, and oral contraceptives.
Rhinitis medicamentosa
Rhinitis medicamentosa
Rhinitis medicamentosa (commonly known as ‘rebound congestion’) is considered a drug-induced rhinitis and results from using over-the-counter nasal decongestant sprays for more than three days in a row. 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. This can cause lasting damage to the inside of the nose.
Gustatory rhinitis
Gustatory rhinitis
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.
How is vasomotor rhinitis diagnosed?
Vasomotor rhinitis is usually diagnosed by taking a careful history and performing a thorough clinical examination of the nose and throat. In addition, allergy testing (skin prick test) should be performed to make sure there is no allergic basis for some of the symptoms, since this would affect the treatment approach.
In some cases, a CT scan of the sinuses may be required to exclude chronic sinusitis or polyposis. Occasionally, (a few usually mild) positive skin prick test reactions are found in patients with VMR, but it does not fit the history and are therefore not relevant to the cause of the rhinitis.
Conditions often confused with non-allergic rhinitis include:
- Nasal polyps
- Previous trauma to the nose
- Structural abnormalities e.g. deviated nasal septum.
What vasomotor rhinitis treatments are available?
- Saline nasal douches
- Antihistamines
- Atrovent (Ipratropium bromide) nasal spray
- Intra-nasal corticosteroids
- Decongestants
- Surgery (if the rhinitis does not respond to drug therapy, very rarely, surgical procedures may be considered)