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IS IT AN ALLERGY?

You may think you have allergies because you have nasal congestion, runny nose, and maybe even sneezing. However, when you doctor performs allergy tests you are told that there is no evidence of allergy. What could this possibly be?

Vasomotor rhinitis is a disorder which is frequently seen in allergy practice but has nothing at all to do with true allergic disease. See the sections on allergic disease to understand how the allergic antibody, or IgE, works and how this leads to allergy symptoms. Vasomotor rhinitis is a poorly understood disorder which mimics many of the symptoms of nasal allergy, but has a completely different basis. Failure to recognize these differences has led to a great deal of misunderstanding about this disorder.

To understand vasomotor rhinitis (VMR) otherwise known as non-allergic rhinitis it is worthwhile to first discuss allergic rhinitis. Nasal allergies, or allergic rhinitis, have two distinct clinical forms. One form is referred to as "hayfever" or seasonal allergic rhinitis, which occurs at a particular time or season of the year due to exposure to "pollens" or "allergens" such as grass and ragweed. Another form is associated with nasal symptoms throughout the year without definite seasonal variation, and more commonly is due to the allergens such as house dust, mold, mildew, and animal dander. This year round form is called perennial allergic rhinitis. Patients may frequently have both.

Nasal allergies tend to occur in families with a predisposition to "react" to exposure to "allergens" by producing antibodies against these "allergens". In other words, there is a genetic component to allergies, so if someone in your family has allergies you may be at increased risk. These "antibodies", called IgE (Immunoglobulin E) are produced in the blood stream, but also occur in the skin, which makes it possible to demonstrate these "antibodies" by allergy skin tests. A positive test produces a large red area and possibly even a "hive" at the site of the skin test. The reactions seen in the skin mirror the reactions which occur in other organs such as the eyes and nose.

The basis of the nasal symptoms in allergic individuals is due to the interaction of the "allergens", or the things that you are allergic to such as grass pollen, with the antibodies produced against them. Once this interaction takes place there is recruitment of other allergy cells into the site of the allergic reaction. These cells are a type of white blood cells called "eosinophils". In the case of nasal allergies they can be found in the nasal cavity and secretions by looking at a nasal smear. This is done with a q-tip placed into the nose and a small sample or smear is taken to be looked at under the microscope. Nasal smears are rarely done during the evaluation of nasal allergies outside of research.

The symptoms of nasal allergy usually include runny nose and nasal congestion, and are usually associated with frequent sneezing episodes and itching of the nose, eyes, ears, and roof of the mouth on exposure to an "allergen". Other evidence of allergy frequently is present in the same individuals, such as asthma or eczema. Treatment of these allergic disorders involves avoidance of the allergens when possible, nasal sprays, antihistamines, and sometimes "allergy shots" or "immunotherapy" to reduce sensitivity to those allergens which cannot be avoided completely.

Patients with VMR may have very similar symptoms and goes years treating themselves for presumed allergies. In fact, VMR is frequently missed or misdiagnosed as allergies by patients and primary care providers alike. It is important to make the correct diagnosis, both for education about avoidance as well as for treatment options.

TRIGGERS AND IRRITANTS WHICH AGGRAVATE VASOMOTOR RHINITIS

The main trigger for VMR is changes in the weather, and changes in the barometric pressure. You may notice that you get significant nasal congestion or stuff nose when there is a front moving in, with a rain storm or on days with changes in the humidity. This is essentially due to sensitive nerve endings in the nasal passages leading to over reaction that results in swelling of blood vessels. This leads to the congestion, runny nose, and post nasal drip found in VMR.

In addition to changes in the weather, there are several chemicals and smells that serve as irritants and may worsen the symptoms of VMR. In particular, this non-specific reactivity maybe aggravated by some of the following:

1. Highly scented cosmetics such as cologne and perfumes.

2. Cigarette or other types of tobacco smoke.

3. Smoke from fireplaces and environmental smoke such as a forest fire or brush fire.

4. Strongly scented soaps, and shampoos.

5. Room deodorants, paints and varnishes, insecticides, and bug sprays.

6. Plants with a strong fragrance such as roses, violets, lilacs, goldenrods, and crysanthemums.

7. Kerosene, lighter fluid, fuel oil, and gas fumes.

8. Dust particles.

9. Pollution.

If there is expected unavoidable intense exposure to any of the above, as well as any strong fumes, smoke, paint odors, household odors, industrial exposure, or dust, the use of a mask over the nose and mouth during this exposure is recommended. These masks can be obtained from the hardware store. However, there are times when triggers or irritants simply can not be avoided, such as changes in the weather.

These irritants are not capable of acting as "allergens" or causing "antibodies" like we see with true allergies. The symptoms of vasomotor rhinitis are thus due to a completely different trigger and mechanism than nasal allergies.

IF IT'S NOT AN ALLERGY, THEN WHAT IS IT?

Vasomotor rhinitis produces many symptoms which are very similar to the symptoms of nasal allergy. The difference is that this disorder is not caused by the allergic antibody and allergy skin tests are usually negative. Occasionally positive skin tests may be observed and patients may have a mixture of allergic and non-allergic rhinitis. If a nasal smear is performed, there are usually no allergy cells or "eosinophils" in the nasal secretions in patients with vasomotor rhinitis.

The cause of the symptoms of vasomotor rhinitis is not totally understood. Nevertheless, it causes a great deal of chronic nasal problems. Currently, it is felt that the disorder is due to changes in the blood vessels of the nose, producing swelling of the mucosa or lining of the nose which in turn produces chronic nasal obstruction and nasal discharge. This is why the disorder is referred to as vasomotor rhinitis; the "vaso" refers to "vascular" or "blood vessels" and "motor" refers to the nerves supplying these blood vessels controlling whether they swell up (dilate) or shrink down (constrict). The nose is richly supplied with blood vessels which enhance its function as a sensory organ and as a filtration system for the air we breathe. These blood vessels are supplied by opposing sets of nerves which automatically control their dilation and con­striction.

In most people, there is an even balance and no problems are encountered with the nose. For some reason, people with vasomotor rhinitis have an imbalance of the nerve supply to the nose with the end result being that the blood vessels tend to swell up (dilate) to a wide variety of non-specific things which we have already mentioned.

In other words, VMR is due to very sensitive nerve endings, that when irritated lead to the congestion and stuffy nose frequently observed in allergic rhinitis or hay fever. However, the process has nothing to do with the allergic antibody IgE.

WHY ME?

We really don't understand why one gets this disorder. Since the disorder occurs more frequently in adults, it has also been postulated that hormonal changes may be a factor. Others feel that global warming, increases in pollution, and the increasing number of chemicals in our daily life may lead to the growing amount of VMR. There is no firm proof that any one of these is definitely the cause of vasomotor rhinitis. The important thing is that the disorder is not inherited, does not seem to run in families, and has nothing at all to do with allergies. Because of this, there is no cure for this disease and management is primarily avoidance and treatment with medications. Your doctor may use similar medications as those used for allergic rhinitis but they may not work as well. Furthermore, higher doses may be needed.

WHAT CAN BE DONE?

Unfortunately, the disorder of vasomotor rhinitis cannot be cured at the present time but represents a disease with a protracted course of chronic nasal symptoms. Management is focused on managing the symptoms of nasal congestion, runny nose, and post nasal drip. There is no use for allergy injections in the setting of VMR as patients do not have an allergy.

There are some general measures which may reduce your symptoms of vasomotor rhinitis, and are as important as specific medications in the overall management of this problem. Obviously, avoidance of things which are known to precipitate symptoms should be encouraged. One can not avoid changes in the weather but avoidance of strong odors and especially smoke may be helpful. Nearly all patients require some form of medication to improve symptoms.

Other non-specific irritants should also be avoided. This is particularly true of house dust which is a strong irritant in many patients with vasomotor rhinitis. Instructions for avoidance of house dust will be given separately. Ingestion of alcoholic beverages, particularly beer and wine, often aggravate the symptoms of vasomotor rhinitis and should be recognized as possible factors to be avoided. Occasionally, drugs you may be taking for other reasons, such as aspirin and drugs for high blood pressure such as Reserpine and Propranalol, may make these symptoms worse. If you are taking other medications you should discuss each with your doctor to see if they are a factor.

The most common medications include nose drops and decongestant tablets. The over the counter nose drops that are vasoconstrictors (shrink the blood vessel in the nose) such as Afrin, Neosynephrine, and others may produce a dramatic improvement in symptoms. Unfortunately, frequent use of these sprays irritates the nose and eventually does more harm than good. When used more than 3 to 5 days patients develop a rebound of symptoms and an increased dependence on the sprays. In general, the over the counter nose sprays should be avoided as controller medications for VMR, given the risk of rebound and "nasal addiction".

Specific treatment of vasomotor rhinitis involves the administration of "decongestants". These work by shrinking down the blood vessels in the nose. These medications can be in the form or a prescription nasal spray or a tablet taken by mouth. Of the currently approved prescription nasal sprays only a nasal antihistamine spray (Astelin) has been proven in studies for the FDA to treat the symptoms of VMR. However, your doctor may start with a nasal steroid since it may also decrease the inflammation in the nasal passage found in VMR. Decongestant tablets (like pseudofed) and combination antihistamine-decongestant tablets work better than pure antihistamines. In fact, over the counter antihistamines like benadryl, zyrtec and claritin have not been shown to work well for VMR as these products tend to treat allergy. Chronic daily, therapy seems to work better than intermittent therapy. However, the decongestant tablets can lead to potential problems such as high blood pressure, other heart problems. Therefore, treatment with nasal sprays is encouraged and patients may use oral decongestants as periodic rescue therapy for times of severe symptoms. Furthermore, you will not develop rebound or "nasal addiction" to the prescription nasal sprays and these are generally considered some of the safest medications that you may take.

Treatment of complicating diseases such as nasal polyps, chronic sinusitis, and nasal septal deviation often require cooperation between the allergist and the ear­nose-and-throat physicians. In addition, if you do have allergies, avoidance of treatment of the allergic responses will help with your over all symptoms.

DON'T GET DISCOURAGED! Although we can't cure the disorder, it can usually be controlled with medications. You may have to try a few different types of sprays before you find the one the works for you. Your best efforts should be to find a good allergist who can help and guide you through this process.

 

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