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March 2020

Occupational rhinitis


  • In all patients (newly diagnosed as well as previously diagnosed) with adult-onset rhinitis, occupational rhinitis should be considered.
  • A brief assessment of occupational history can improve the diagnosis of occupational rhinitis.
  • Nasal provocation test (NPT) can be considered for diagnosis of occupational rhinitis when immunological tests are not available or unreliable and when a definite diagnosis is needed.

Why this matters

  • The diagnosis of occupational rhinitis is challenging as the clinical presentation is non-specific and frequent lack of assessment of occupational history.
  • NPT, a strong diagnostic tool, has been previously described in guidelines for detection of standardised high-molecular weight (HMW) allergens.
  • The current review discusses the use of NPT in non-standardised allergens in the diagnosis of occupational rhinitis.

Key highlights

  • Thinking about the possibility of occupational rhinitis is important in every patient with adult-onset rhinitis, including patients who failed to improve in spite of adequate treatment.
  • A brief occupational history, including job title, tasks and exposure to vapours, gases, dust, fumes or chemicals can improve the diagnosis of occupational rhinitis.
  • Although immunological tests such as specific immunoglobulin E, skin prick tests or basophil activation test are useful to detect sensitisation, there are several drawbacks with these tests.
  • NPT may be indicated for the diagnosis of occupational rhinitis when immunological tests are not available or unreliable and when local allergic rhinitis is suspected, or when a definite diagnosis is needed.
  • NPT could be performed in a hospital setting or at work, and the delivery of the agent largely depends on its nature.
  • Method of exposure for NPT:
    • Water-soluble HMW agents—administered as aqueous solutions.
    • Low-molecular-weight and water-insoluble agents—exposure depends on the physical state and chemical properties of the agent.
  • Assessment of response for NPT: 
    • Subjective assessments: symptoms such as sneezing, nasal pruritus, rhinorrhoea, nasal obstruction and ocular symptoms can be assessed using Lebel score or visual analogue scale.
    • Objective assessments: peak nasal inspiratory flow, acoustic rhinometry, active anterior rhinomanometry and four-phase-rhinomanometry are the commonly used methods for objective assessment of nasal patency.
  • NPT is contraindicated in those with previous anaphylactic reaction to the allergen, acute inflammation of the nose or paranasal sinuses, uncontrolled lower airway disease, pregnancy and other severe comorbidities.


  1. Ronsmans S, Steelant B, Backaert W, Nemery B, Van Gerven L. Diagnostic approach to occupational rhinitis: the role of nasal provocation tests. Curr Opin Allergy Clin Immunol. 2019 Dec 12 [Epub ahead of print]. doi: 10.1097/ACI.0000000000000608.. PMID: 31833858