Vasomotor Rhinitis (VMR)

Definition:

• Non-allergic, non-infectious rhinitis, also called irritant rhinitis or idiopathic non-allergic rhinitis.
• “Vaso” refers to blood vessels; “motor” refers to nerves innervating nasal tissue and blood vessels.
• Affects up to 10% of the population.

Features of Vasomotor Rhinitis:

• Symptoms:
  • Intermittent episodes of sneezing, watery nasal drainage (rhinorrhea), nasal congestion.
  • Hypersensitive response to stimuli (e.g., dry atmosphere, air pollutants, spicy foods, alcohol, strong emotions, medications).
  • Exaggerated nasal response to low concentrations of irritants (pollens, dust, mold, animal dander).
• Types of Patients:
  • “Runners”: Predominant wet rhinorrhea.
  • “Dry Subjects”: Predominant nasal congestion and blockage with minimal rhinorrhea.

Triggers:

• Environmental changes (temperature, barometric pressure).
• Perfumes, strong odors, smoke.
• Inorganic dust, air pollution.
• Spicy foods, alcohol.
• Medications (e.g., some blood pressure tablets).
• Emotional or physical stress.
• Sexual arousal.

Diagnosis:

• Based on patient history and nasal/throat examination.
• Allergy testing to rule out allergic causes.
• CT scan may be required to exclude chronic sinusitis or nasal polyps.

Key Features:

• No history of allergies.
• No infection causing symptoms.
• Variable presentation.
• Often affects older individuals.
• Seasonal pattern possible.
• Symptoms: Rhinorrhea, frontal headaches, congested turbinates, usually no itching (pruritus).
• Eating (especially spicy foods) can worsen symptoms.

Other Non-Allergic Rhinitis Causes:

• Nonallergic rhinitis with eosinophilia syndrome (NARES).
• Occupational rhinitis.
• Hormonal rhinitis.
• Drug-induced rhinitis.
• Rhinitis medicamentosa.
• Gustatory rhinitis.

Conditions Confused with Non-Allergic Rhinitis:

• Nasal polyps.
• Previous trauma to the nose.
• Structural abnormalities (e.g., deviated nasal septum).

Treatment:

Non-drug, Non-surgical:

• Normal saline nasal douches.

Drug Therapy:

• Antihistamines:
  • Variable response; useful in mixed vasomotor and allergic rhinitis.
• Anticholinergic Agents:
  • Atrovent (Ipratropium bromide) nasal spray for runny nose.
• Nasal Steroids:
  • Help with congestion, runny nose, and sneezing.
  • Examples: Fluticasone, budesonide.
  • Side effects: Mucosal swelling, redness, burning, drying, nosebleeds, nasopharyngeal thrush.
• Decongestants:
  • For nasal congestion.
  • Examples: Pseudoephedrine (Sudafed) tablets, oxymetazoline (Drixine) nasal spray, xylometazoline (Otrivine) nasal spray.
  • Side effects: Nervousness, insomnia, irritability, difficulty urinating in elderly males.
  • Risk of rhinitis medicamentosa with prolonged use of nasal sprays.

Surgery:

• Rarely considered if drug therapy is ineffective.
• Procedures:
  • Cryosurgery: Affects mucosa and submucosa; may cause post-operative congestion.
  • Vidian neurectomy: Disrupts sympathetic and parasympathetic fibers, reducing rhinorrhea.
  • Other surgical options: Cauterization, submucosal resection of the conchal bone, partial/total inferior turbinate resection.

Key Takeaways:

• Vasomotor rhinitis is a non-allergic response to irritants.
• Diagnosis involves excluding allergic rhinitis and other causes.
• Management includes avoiding triggers, nasal irrigation, and medications (antihistamines, anticholinergics, nasal steroids, decongestants).
• Surgery is a last resort for refractory cases.