Patient Information | Prof. Dr. Gediz Murat Serin
When Allergy Tests Are Negative But Symptoms Persist…
One of the patient groups I frequently encounter in my clinical practice are those who have been treated for “allergies” for years, yet their tests come back negative, and despite this, their complaints of nasal congestion, discharge, and postnasal drip continue. This situation often suggests a group of diseases called non-allergic rhinitis.
Non-allergic rhinitis encompasses chronic nasal diseases that occur without allergy, infection, or a specific microbial cause. While the most common type is vasomotor rhinitis (idiopathic rhinitis), there are many subtypes that develop through different mechanisms.
Treatments administered without proper diagnosis are often inadequate. Therefore, detailed evaluation and personalized approach are of great importance.
What is Non-Allergic Rhinitis?
In non-allergic rhinitis, vascular dilation and increased secretion are seen in the nasal mucosa. Patients typically have the following allergy-like complaints:
- Continuous or periodic nasal congestion
- Clear and watery nasal discharge
- Postnasal drip
- Frequent throat clearing
- Cough
- Feeling of fullness in the nose
These symptoms often continue throughout the year and are not seasonal.
Vasomotor Rhinitis: The Most Common Cause
Vasomotor rhinitis develops as a result of an imbalance in the autonomic nervous system that controls the nasal mucosa.
Normally:
- The parasympathetic system increases secretion
- The sympathetic system constricts blood vessels
When the balance is disrupted:
- Nasal blood vessels dilate
- Edema forms in the mucosa
- Watery discharge and congestion develop
Patients generally fall into two groups:
- Those with predominant discharge
- Those with predominant congestion
Factors That Worsen Symptoms
In non-allergic rhinitis, environmental irritants play a role more than allergens:
- Perfume and chemical odors
- Cigarette smoke
- Cold air and sudden temperature changes
- Humidity and pressure changes
- Alcohol
- Spicy foods
- Stress
Patients typically express this as “I suddenly get worse in certain environments.”
Other Subtypes of Non-Allergic Rhinitis
The following causes should also be considered in clinical evaluation:
Drug-induced rhinitis
Prolonged use of nasal decongestant sprays (rhinitis medicamentosa)
NARES
Eosinophil increase despite negative allergy tests
Hormonal rhinitis
Pregnancy or thyroid diseases
Senile rhinitis
In advanced age, discharge increasing especially during meals
Gustatory rhinitis
Watery discharge triggered by eating
Occupational rhinitis
Chemical and irritant exposure
Atrophic rhinitis
Important: Differential Diagnosis
Before diagnosing non-allergic rhinitis, the following conditions must be excluded:
- Allergic rhinitis
- Chronic sinusitis
- Nasal polyp or mass
- Septal deviation
- Turbinate hypertrophy
If there is unilateral and continuous clear discharge, evaluation for cerebrospinal fluid leak is necessary.
Diagnostic Process
In my own practice, diagnosis is evaluated in three steps:
- Detailed patient history
- Nasal endoscopic examination
- If necessary:
- Allergy tests
- Nasal cytology
- Sinus tomography
On endoscopy, pale and edematous mucosa with clear secretion is typically observed.
Treatment Approach
-
Trigger Control
- Avoiding chemical odors
- Staying away from cigarette smoke
- Protection from sudden temperature changes
- Limiting alcohol and spices
-
Medical Treatment
Corticosteroid nasal sprays
This is the basic and most effective treatment. It is used for a long time.
Ipratropium bromide
Effective in patients with predominant discharge.
Topical antihistamines
Beneficial in combined complaints.
The best results are usually obtained with combination therapy.
-
Important Warning
When nasal decongestant sprays are used for more than 5 days, medication dependency and rebound congestion may develop.
Surgical Options for Resistant Patients
In patients who do not improve despite medication:
- Mucosa-preserving inferior turbinate reduction
- Advanced functional surgeries in selected cases
These procedures increase the effectiveness of medical treatment by expanding the airway.
An Important Point from Clinical Experience
A significant portion of non-allergic rhinitis patients have accompanying structural problems (septal deviation, turbinate hypertrophy, valve insufficiency). Without correcting these conditions, adequate results may not be achieved with medication alone.
Therefore, for each patient:
- Endoscopic evaluation
- Functional analysis
- Personalized treatment plan
are of great importance.
Conclusion
Non-allergic rhinitis, particularly vasomotor rhinitis, is a chronic disease that can be controlled with accurate diagnosis and personalized treatment.
Current approach:
- Trigger control
- Appropriate medical treatment
- If necessary, functional surgery can significantly improve the quality of life in the majority of patients.
