Gustatory Rhinitis

Gustatory rhinitis is watery nasal discharge, with or without nasal blockage, triggered within minutes of eating, particularly hot or spicy food. It is a non-allergic rhinitis caused by parasympathetic reflex.

It is common, especially in older adults, and occurs in about 33% to 50% of people with chronic rhinitis when asked. It is not allergic, and tests for allergy are negative. The triggers include hot soup, peppers, curry, alcohol and sometimes cold food.

Pathophysiology.

Stimulation of trigeminal nerve endings in the mouth (by capsaicin and heat) triggers a vagal reflex that increases glandular secretion in the nasal mucosa through cholinergic nerve fibres. Anticholinergic drugs block this response.

Clear watery rhinorrhoea starting during or shortly after meals, sometimes with sneezing, and no itching, fever or purulent discharge. Symptoms are brief and resolve after eating.

Red flags.

• Unilateral clear discharge after head injury or surgery (cerebrospinal fluid leak).
• Bloody discharge.
• Persistent unilateral obstruction.

Diagnosis is clinical from the temporal relation to eating. Nasal endoscopy is normal or shows watery secretions and pale mucosa. Allergy testing (skin prick or specific IgE) is negative. Test the discharge for beta-2 transferrin if cerebrospinal fluid is suspected.

Differential diagnosis.

• Allergic rhinitis.
• Vasomotor rhinitis.
• Cerebrospinal fluid rhinorrhoea.
• Infectious rhinosinusitis.
• Rhinitis medicamentosa.
• Hormonal rhinitis.

Reassure the patient and advise avoidance of trigger foods. Use an anticholinergic nasal spray before meals for troublesome symptoms.

• Ipratropium bromide 0.03% nasal spray (21 micrograms for each spray): 2 sprays into each nostril 15 to 30 minutes before meals, up to 3 times daily; for as long as needed; maximum 6 sprays in each nostril daily; monitor for nasal dryness, epistaxis and urinary retention; use with caution in glaucoma and prostatic enlargement, and avoid with other anticholinergic drugs.

No other drug is needed. Nasal steroid sprays and antihistamines do not help this type.

Monitoring. Review at 4 to 6 weeks.

Referral and escalation. ENT if there is no response, or if a red flag appears.

Special groups. Older adults need review for glaucoma and prostate disease.