Vasomotor Rhinitis Is Not a Wastebasket Diagnosis

The impact of chronic rhinitis on patients, health care systems, and resources is substantial, resulting in more than 25 million office visits per year and resulting in total indirect and direct costs of $6 billion annually. It is estimated that more than 10% of the population has chronic or recurrent nasal obstruction or congestion, rhinorrhea, sneezing, and pruritus. Approximately half of these patients are classified as having allergic rhinitis and half as having nonallergic rhinitis, including vasomotor rhinitis. These forms of chronic, noninfectious rhinitis represent a spectrum of nasal disorders that are best categorized as a hyperreactivity of the nasal mucosa to a variety of stimuli. Allergic rhinitis is diagnosed when specific antigens can be identified and is often subclassified as seasonal or perennial allergic rhinitis. When specific antigens are not identifiable, chronic rhinitis is often classified as vasomotor or nonallergic. These nonallergic forms of chronic rhinitis can be further evaluated by nasal cytology. Nasal scrapings of the inferior turbinate can yield epithelial lining, and detailed analysis of different cell types can be made. Patients with nonallergic rhinitis and abundant eosinophils on nasal cytology have the so-called nonallergic rhinitis with eosinophilia syndrome, which is sometimes associated with aspirin intolerance. Patients with nonallergic rhinitis and unremarkable nasal smear findings could have rhinitis medicamentosa, pregnancy, or hypothyroidism, but most are thought to have vasomotor rhinitis. Most of the literature concerning vasomotor rhinitis and its relationship to the autonomic nervous system came from investigations 50 years ago. These authors discuss the role of the autonomic nervous system in maintaining sinonasal health through the regulation of vascularity and mucosal gland function, and they speculate that the autonomic nervous system regulates the reactivity of the nasal and sinus mucous membranes and glands. They note that the inferior turbinate in particular contains mucous and serous glands, vascular channels, and autonomic nervous system branches that constitute a delicately sensitive and reactive organ. Vasomotor rhinitis was thought to represent either hyperfunction of the parasympathetic nervous system in the nose and paranasal sinuses or an imbalance between the parasympathetic nervous system and sympathetic nervous system. Does vasomotor rhinitis exist, and if so, what is its etiology? Is it a specific entity and part of a continuum of disease or is it a “wastebasket” diagnosis? This article hypothesizes the former.