Diagnosing Rhinitis:

Allergic vs. Nonallergic

DAVID M. QUILLEN, M.D., and DAVID B. FELLER, M.D.
University of Florida Family Medicine Residency Program, Gainesville, Florida
R
hinitis is an inflammation of the
nasal mucosa. Associated clini-
cal symptoms include excessive
mucus production, congestion,
sneezing paroxysm, watery eyes, and nasal
and ocular pruritus. The differential diagno-
sis of rhinitis is extensive (Table 1
1
). Allergic
rhinitis is considered a systemic illness and
may be associated with constitutional symp-
toms such as fatigue, malaise, and headache.
It also may be a comorbidity in patients with
asthma, eczema, or chronic sinusitis. Differ-
entiating allergic rhinitis from other causes
of rhinitis can be difficult because the diag-
nostic criteria for various forms of rhinitis
are not always clear-cut. Accurate diagnosis
is important because therapies that are effec-
tive for allergic rhinitis (i.e., antihistamines
and nasal corticosteroids) may be less effec-
tive for other types of rhinitis.
2

Since 1998, three expert panels
1-3
have pub-
lished reviews of rhinitis. The first report
1

was created by the American Academy of
Allergy, Asthma, and Immunology (AAAAI)
as a complete guideline for the diagnosis and
management of rhinitis.
The second report,
3
coordinated by the
World Health Organization (WHO), focuses
on allergic rhinitis and asthma but includes
an extensive section on the differential diag-
nosis of rhinitis. This report is intended to
be a complete evidence-based guideline on
the diagnosis and management of allergic
rhinitis and asthma. The authors proposed
a new classification for allergic rhinitis,
arguing that the current subdivisions (i.e.,
seasonal and perennial) were not satisfac-
tory. Traditionally, pollens and molds were
considered possible causes of seasonal aller-
gic rhinitis. However, in some places, such
as California and Florida, these allergens are
present year-round. The WHO authors sug-
gested a classification system based on the
symptoms of intermittent, persistent, mild,
and moderate-severe rhinitis.
The third report
2
was coordinated by the
Agency for Healthcare Research and Quality
(AHRQ) in collaboration with the Ameri-
can Academy of Family Physicians and the
AAAAI. Unlike the first two reports, the
AHRQ report is not a clinical guideline but
an evaluation of the evidence on rhinitis.
The report did not identify any studies
differentiating allergic rhinitis and nonal-
lergic rhinitis based on clinical symptoms,
physical examination findings, or associated
Allergic rhinitis, the most common type of rhinitis, generally can be
differentiated from the numerous types of nonallergic rhinitis through
a thorough history and physical examination. Allergic rhinitis may be
seasonal, perennial, or occupational. The most common cause of
nonallergic rhinitis is acute viral infection. Other types of nonallergic
rhinitis include vasomotor, hormonal, drug-induced, structural, and
occupational (irritant) rhinitis, as well as rhinitis medicamentosa and
nonallergic rhinitis with eosinophilia syndrome. Since 1998, three
large expert panels have made recommendations for the diagnosis
of allergic and nonallergic rhinitis. Allergy testing (e.g., percutane-
ous skin testing, radioallergosorbent testing) is not necessary in all
patients but may be useful in ambiguous or complicated cases. (Am
Fam Physician 2006;73:1583-90. Copyright 2006 American Acad-
emy of Family Physicians.)
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May 1, 2006
comorbidities. The AHRQ report noted that
the treatment conclusions may have been
biased because pharmaceutical companies
supported many of the trials.
2
Evaluation
Although few studies exist on how to dif-
ferentiate among types of rhinitis, a thor-
ough and comprehensive history usually
suggests the correct diagnosis. Physicians
should focus on symptoms (i.e., duration,
exposures, magnitude of reaction, patterns,
and chronicity); triggers; seasonal variation;
environmental influences; allergies; medical
history (i.e., trauma, family, and treatment
histories); and current treatments (Table 2
1
and Figure 1). An acute onset of one week
or less has a limited differential and usually
suggests a viral etiology; an acute exacerba-
tion of allergic rhinitis; or, less commonly,
a foreign body (more common in children,
particularly when symptoms are unilateral
with purulent discharge). The differential
diagnosis for chronic symptoms is broader.
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation
Evidence
rating

References
An allergy test should be performed if the patient has severe
symptoms or an unclear diagnosis or if he or she is a potential
candidate for allergen avoidance treatment or immunotherapy.
C 7
A comprehensive history and physical examination should be
used to help diagnose the cause of rhinitis.
C 4
An allergen-specific Immunoglobulin E antibody test (radioallergo-
sorbent test) is recommended when percutaneous testing is not
practical or available or when patients are taking medications
that interfere with skin testing.
C


10


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 1495 or http://www.aafp.org/afpsort.xml.
Rhinitis
TABLE 1
Differential Diagnosis of Rhinitis
Allergic rhinitis
Episodic rhinitis
Occupational rhinitis
(allergen)
Perennial rhinitis
Seasonal rhinitis
Nonallergic rhinitis
Atrophic rhinitis
Chemical- or irritant-induced
rhinitis
Drug-induced rhinitis
Antihypertensive medications
Aspirin
Nonsteroidal anti-inflammatory
drugs
Oral contraceptives
Rhinitis medicamentosa
Emotional rhinitis
Exercise-induced rhinitis
Information from reference 1.
Conditions that may mimic
symptoms of rhinitis
Cerebrospinal fluid rhinorrhea
Inflammatory or immunologic
conditions
Midline granuloma
Nasal polyposis
Sarcoidosis
Sjgrens syndrome
Systemic lupus erythematosus
Wegeners granulomatosis
Relapsing polychondritis
Structural or mechanical conditions
Choanal atresia
Deviated septum
Enlarged adenoids
Foreign bodies
Hypertrophic turbinates
Nasal tumors
Nonallergic rhinitis (continued)
Gustatory rhinitis
Hormone-induced rhinitis
Hypothyroidism
Menstrual cycle
Oral contraceptives
Pregnancy
Infectious rhinitis
Acute (usually viral)
Chronic (rhinosinusitis)
Nonallergic rhinitis with
eosinophilia syndrome
Occupational rhinitis (irritant)
Perennial nonallergic rhinitis
Vasomotor rhinitis
Postural reflexes
Primary ciliary dyskinesia
Reflux-induced rhinitis or
gastroesophageal reflux disease
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Rhinitis
Allergic rhinitis or an environmental cause
usually is suggested if triggers are identified.
Chronic symptoms accompanied by seasonal
variations suggest seasonal allergic rhinitis.
Constitutional symptoms such as headache,
malaise, and fatigue are also common pre-
sentations. Medical history can be helpful
(e.g., the patients age at onset of symptoms).
Allergic rhinitis usually develops at a young
age (80 percent before 20 years of age).
1
Fam-
ily history also is helpful, because allergic
symptoms and asthma tend to be hereditary.
Finally, the success of past and current treat-
ments may help identify the cause and direct
future treatment.
A focused physical examination should
follow the history (Table 2
1
). Acute illness
with a viral infection will cause more gen-
eralized symptoms and occasional fevers.
Patients with chronic allergic symptoms may
have allergic shiners (i.e., blue-gray or pur-
ple discoloration under the lower eyelids),
or they may breathe through their mouths.
Conjunctivitis can be a component of aller-
gic rhinitis or acute viral upper respira-
tory infection (URI). A careful examination
of the nose is important to identify struc-
tural abnormalities, obvious polyps, muco-
sal swelling, and discharge. Fiberoptic
visualization provides the best evaluation,
but it is not always available or necessary.
Examining the pharynx for enlarged tonsils
or pharyngeal postnasal drip also can help
identify viral causes or chronic drainage
from chronic rhinitis. Lymphadenopathy
with associated symptoms may suggest a
viral or bacterial cause of rhinitis, and
wheezing or eczema suggests an allergic
cause. Table 3
4
compares allergic and nonal-
lergic rhinitis.
Allergy Testing
None of the three reports
1-3
on rhinitis pro-
vides specific recommendations on when
to perform allergy testing for patients with
rhinitis. General recommendations for
allergy testing vary.
5-7
An extensive sys-
tematic review
7
of the evidence on allergy
testing showed that in general, physicians
should select tests that will change outcomes
or treatment plans; that empiric treat-
ment is appropriate in patients with classic
TABLE 2
Physical Examination Findings That Suggest Rhinitis
General
Constitutional symptoms suggest allergic rhinitis.
Mouth versus nose breathing is a symptom
of chronic congestion.
Eyes
Allergic shiners (i.e., dark areas under the eyes)
suggest allergic rhinitis.
Conjunctivitis suggests allergic rhinitis.
Ears
Air fluid levels can suggest chronic congestion.
Nose
A deviated or perforated septum and polyps
are structural causes of rhinitis.
Purulent or bloody discharge can be a sign
of sinusitis.
Fiberoptic visualization can detect structural
causes of rhinitis.
Adapted with permission from 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 Immu-
nology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998;81(pt 2):492.
Mouth
Enlarged tonsils and pharyngeal postnasal
discharge are associated with nonallergic
rhinitis.
Neck
Lymphadenopathy suggests an infectious
cause of rhinitis.
Chest
Allergic or atopic disease (e.g., asthma)
supports the diagnosis of allergic rhinitis.
Skin
Allergic or atopic disease (e.g., eczema)
supports the diagnosis of allergic rhinitis.
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May 1, 2006
Rhinitis
symptoms; that diagnostic tests may be
appropriate if severe symptoms or an
unclear diagnosis is present, or if the patient
is a potential candidate for allergen avoid-
ance treatment or immunotherapy; and that
observation may be appropriate for patients
with mild symptoms or an unclear history.
Diagnostic Testing
The most common diagnostic tests for aller-
gic rhinitis are the percutaneous skin test
and the allergen-specific immunoglobulin E
(IgE) antibody test. Less common diagnostic
tools include nasal provocation testing, nasal
cytology (e.g., blown secretions, scraping,
lavage, biopsy), nasolaryngoscopy, and intra-
dermal skin testing. The WHO report
3
offers
limited recommendations on when to use
these tests but notes that they generally are
used by subspecialists or in research and do
not play a role in the routine evaluation of
rhinitis. The AHRQ report
2
did not include
the less common tests, and the authors could
not make a conclusion regarding the mini-
mum amount of testing needed to achieve a
diagnosis. The AAAAI report
1
included the
less common tests but noted that many are
unproved or inappropriate.
Evaluating Patients with Suspected Rhinitis
Figure 1. Algorithm for evaluating patients with suspected rhinitis.
Patient presents with rhinitis
Acute symptoms (one week or less)?
Chronic symptoms
(seasonal or perennial)?
Symptoms are unclear
Will testing change treatment?
Attempt treatment
(e.g., nasal spray,
steroids, antihistamines).
Positive response?
Test for allergies.
History and physical
examination to
exclude sinusitis
Diagnose
allergic rhinitis.
Diagnose nonallergic
rhinitis. Consider
other causes (Table 2).
Diagnose
allergic rhinitis.
No
No Yes
No Yes
No Yes
Diagnose
allergic rhinitis.
Diagnose nonallergic
rhinitis. Consider
other causes (Table 2).
No Yes
No Yes
A
B
Viral history?
After managing as viral
condition, symptoms last
longer than one week.
Evaluate for
sinusitis and
treat if present.
Common diagnosis:
acute exacerbation
of allergic rhinitis.
Check history.
Uncommon diagnosis:
obstruction, especially
in children.
Yes
No Yes
No Yes
Return to A
Go to B
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Rhinitis
Skin testing involves introducing con-
trolled amounts of allergen and control
substances into the skin. Percutaneous test-
ing is the most common type of skin testing
and is preferred in primary care. It is conve-
nient, safe, and widely accepted.
8
Occasion-
ally, intradermal testing is used (mostly by
researchers and allergy subspecialists); it is
more sensitive but less specific than percuta-
neous testing.
2,7
It is unclear which method
is superior; however, increased safety con-
cerns exist with intradermal skin testing.
9

Allergic rhinitis can have an immediate or
delayed response.
1
Skin testing elicits both
types of responses; however, the primary
goal of skin testing is to detect the immedi-
ate allergic response caused by the release of
mast cell or basophil IgE-specific mediators,
which create the classic wheal and flare reac-
tion after 15 minutes. The delayed response
occurs four to eight hours after exposure to
the sensitizing allergen and is less useful in
clinical diagnosis.
Allergen-specific IgE antibody testing
(radioallergosorbent testing [RAST]) is
particularly useful in primary care if percuta-
neous testing is not practical (e.g., problems
with reagent storage, expertise, frequency
of use, staff training) or if a patient is tak-
ing a medication that interferes with skin
testing (e.g., tricyclic antidepressants, anti-
histamines).
10
RAST is highly specific but
generally not as sensitive as skin testing.
2,7

Although the available commercial RAST
products generally are reliable, they do not
always provide reproducible, accurate data.
11

RAST is useful for identifying common
allergens (e.g., pet dander, dust mites, pol-
len, common molds), but it is less useful for
identifying food, venom, or drug allergies.
Allergy testing in children has its own
challenges. Authors of a large literature
review
12
provided evidence-based recom-
mendations for allergy testing in children
with various allergic diseases (e.g., rhi-
nitis, asthma, food allergy). The review
TABLE 3
Allergic vs. Nonallergic Rhinitis
Clinical characteristic Allergic rhinitis Nonallergic rhinitis
Ancillary studies Positive skin tests Negative skin tests
Exacerbating factors Allergen exposure Irritant exposure, weather changes
Family history of allergies Usually present Usually absent
Nasal eosinophilia Usually present Present in patients with nonallergic
rhinitis with eosinophilia syndrome
Nature of symptoms
Congestion Common Common
Postnasal drip Not prominent Prominent
Pruritus Common Rare
Rhinorrhea Common Usually uncommon, but may be
present in some patients
Sneezing Prominent Usually not prominent, but may
predominate in some patients
Other allergic symptoms Often present Absent
Physical appearance
of nasal mucosa
Variable, described
as pale, boggy,
and swollen
Variable, erythematous
Seasonality Seasonal variation Usually perennial, but symptoms may
worsen during weather changes.
Adapted with permission from Mastin T. Recognizing and treating non-infectious rhinitis. J Am Acad Nurse Pract
2003;15:403.
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May 1, 2006
Rhinitis
demonstrated that percutane-
ous skin testing is appropriate
for children three years and
older and that RAST testing
is appropriate at any age. The
authors recommend that phy-
sicians base testing decisions
on clinical history and, similar to the adult
recommendations, perform tests only when
needed to change therapy or to clarify a
diagnosis.
12

Allergic Rhinitis
Allergic rhinitis can be categorized into
three basic subgroups: seasonal, perennial,
and occupational. IgE mediates seasonal,
perennial, and occupational responses to
different allergens. Tree, grass, and weed
pollens generally cause seasonal symptoms.
Mold spores may cause seasonal and peren-
nial symptoms. Indoor allergens such as
dust mites, pet dander, and molds usually
cause perennial symptoms.
Occupational rhinitis is triggered by
exposure to irritants and allergens. Aller-
gen-related occupational rhinitis clearly is
in the allergic rhinitis category, whereas irri-
tant-related occupational rhinitis is better
categorized as nonallergic rhinitis. Causes of
the allergen subtype include laboratory ani-
mals (e.g., rats, mice, guinea pigs), grains,
coffee beans, and wood dust. Causes of the
irritant subtype include tobacco smoke, cold
air, formaldehyde, and hair spray.
Allergic rhinitis symptoms include early
and late responses similar to those of aller-
gic response to skin testing. Early and late
allergic rhinitis present as sneezing, con-
gestion, and rhinorrhea; however, the late
response tends to include more conges-
tion. Seasonal and perennial allergic rhinitis
can be associated with systemic symptoms
including malaise, weakness, and fatigue.
Patients with seasonal and perennial allergic
rhinitis also may have allergic conjunctivitis,
asthma, and eczema.
Nonallergic Rhinitis
The diagnosis of nonallergic rhinitis is
made after eliminating allergic or IgE-medi-
ated causes. The most common cause of
nonallergic rhinitis is an acute viral infec-
tion. Less common chronic causes include
vasomotor rhinitis, hormonal rhinitis, non-
allergic rhinitis with eosinophilia syndrome,
occupational rhinitis (irritant subtype), gus-
tatory rhinitis, rhinitis medicamentosa, and
drug-induced rhinitis.
Controversy surrounds nonallergic rhini-
tis because the epidemiology and diagnostic
criteria are confusing. The main controversy
is how to differentiate allergic rhinitis from
nonallergic rhinitis. Furthermore, current
research appears to delineate a third category
that includes characteristics of both allergic
and nonallergic rhinitis. Research shows
that the prevalence of pure allergic rhinitis
in the adult population with symptoms is
43 percent, combination allergic rhinitis and
nonallergic rhinitis is 34 percent, and pure
nonallergic rhinitis is 23 percent.
13
Manage-
ment of allergic and nonallergic rhinitis is
slightly different; therefore, as more clinical
data become available, determining the dif-
ference between the two types will become
more important.
13

A patient-administered screening tool
(Patient Rhinitis Screen) to help physicians
identify patients with combination rhini-
tis is not commonly discussed in the lit-
erature.
14,15
Because of the lack of published
research, the tools use beyond gathering
demographic data is unclear.
4
ACUTE VIRAL RHINITIS AND RHINOSINUSITIS
Viral URIs are the leading cause of acute
rhinitis. Viruses known to cause acute viral
rhinitis include rhinoviruses, respiratory
syncytial virus, parainfluenza, influenza,
and adenoviruses. In most patients, viral
infections are self-limited and require only
symptomatic treatment. Occasionally, a bac-
terial superinfection exists or the patient
develops rhinosinusitis. In these patients,
symptoms generally worsen (e.g., facial pain,
nasal obstruction, fever). Sinusitis is best
diagnosed through history, physical exami-
nation, and prediction rules, and not through
computed tomography.
16-18
Common bacte-
ria include Streptococcus pneumoniae, group
A beta-hemolytic streptococci, and Hae-
mophilus influenzae.
The most common diagnos-
tic tests for rhinitis are the
percutaneous skin test and
the allergen-specific immu-
nogobulin E antibody test.
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Rhinitis
VASOMOTOR RHINITIS
Vasomotor rhinitis is not thought to be
related to a specific allergen, infection, or
causation. It includes patients with peren-
nial symptoms that are associated with
temperature changes, humidity, alcohol
ingestion, and odors. Vasomotor rhinitis
is diagnosed through exclusion; patients
should have normal serum IgE levels, nega-
tive skin testing or RAST, and no inflamma-
tion on nasal cytology.
13
The term vasomotor
implies an increased blood supply to the
nasal mucosa, although this suggestion has
not been proven. Symptoms mainly con-
sist of congestion; hypersecretion; and, less
commonly, pruritus and sneezing. Because
some patients with vasomotor rhinitis pres-
ent after eating hot or spicy foods (gustatory
rhinitis), the vagus nerve may be involved.
HORMONAL AND DRUG-INDUCED RHINITIS
Hormonal causes of rhinitis include preg-
nancy, oral contraceptive use, and hypo-
thyroidism. Pregnancy-induced rhinitis
generally improves after delivery. Symptom
improvement after hypothyroidism treat-
ment remains unclear. These types of rhini-
tis are difficult to diagnose, and the medical
literature documenting them is limited.
Numerous medications have been associ-
ated with rhinitis; these include angioten-
sin-converting enzyme inhibitors, reserpine,
guanethidine, phentolamine (Rogitine, not
available in the United States), methyl-
dopa (Aldomet), prazosin (Minipress), beta
blockers, chlorpromazine (Thorazine), topi-
cal nasal decongestants, aspirin, and nonste-
roidal anti-inflammatory drugs.
RHINITIS MEDICAMENTOSA
Repetitive use of topical alpha-adrenergic
decongestant sprays (for five to seven con-
secutive days) may induce rebound nasal
congestion after withdrawal (rhinitis medi-
camentosa). Extensive use may cause inflam-
matory mucosal hypertrophy and chronic
congestion. The mucosa becomes red and
inflamed with occasional bleeding. Discon-
tinuation of the topical decongestant resolves
the problem, although many patients find
this process difficult.
NONALLERGIC RHINITIS WITH
EOSINOPHILIA SYNDROME
Nonallergic rhinitis with eosinophilia syn-
drome presents as congestion and nasal
eosinophilia with no obvious allergic source
detected on skin testing or RAST. The cause
of eosinophilia is unclear; however, the prev-
alence of nonallergic rhinitis with eosino-
philia in adults may be 15 to 33 percent.
13
The condition may be associated with non-
IgEmediated asthma, aspirin intolerance,
and nasal polyps. Nonallergic
rhinitis with eosinophilia is
characterized by eosinophilic
infiltration on nasal cytology.
A subtype of this condition is
blood eosinophilia nonallergic
rhinitis syndrome. It is unclear whether
these two conditions differ from other non-
allergic rhinitis syndromes or if they are
simply variants of allergic rhinitis without
identifiable allergens.
Conditions That Can Mimic Rhinitis
A number of conditions can produce the
same signs and symptoms as rhinitis. Some of
these conditions are relatively rare. Structural
conditions that may mimic rhinitis include
deviated septum, nasal tumors, enlarged
adenoids, and hypertrophic turbinates.
Immunologic conditions include Wegeners
granulomatosis, sarcoidosis, relapsing poly-
chondritis, Sjgrens syndrome, and midline
granuloma.
2
Members of various family medicine departments develop
articles for Problem-Oriented Diagnosis. This is one in
a series from the Department of Family Medicine at the
University of Florida College of Medicine, Gainesville, Fla.
Coordinator of the series is R. Whit Curry, Jr., M.D.
The Authors
DAVID M. QUILLEN, M.D., is assistant professor in the
Department of Community Health and Family Medicine at
the University of Florida College of Medicine, Gainesville.
He received his medical degree from the University of
North Carolina-Chapel Hill School of Medicine and com-
pleted a family medicine residency at Duke University
School of Medicine, Durham, N.C.
DAVID B. FELLER, M.D., is assistant professor in the
Department of Community Health and Family Medicine
at the University of Florida College of Medicine, where
he received his medical degree and completed a family
medicine residency.
Vasomotor rhinitis should
be diagnosed through
exclusion.
1590 American Family Physician www.aafp.org/afp Volume 73, Number 9

May 1, 2006
Rhinitis
Address correspondence to David M. Quillen, M.D.,
University of Florida College of Medicine, Department
of Community Health and Family Medicine, Family
Medicine Residency Program, 625 SW Fourth Ave.,
Gainesville, FL 32601. Reprints are not available from
the authors.
Author disclosure: Nothing to disclose.
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