It makes sense to think that when you have a runnyor stuffy nose that you’re either coming down with a coldor your allergies are acting up. However, what if you geta runny or stuffy nose but you’re not coming down witha cold and you’re not allergic to anything?

Over the last 15 years, physicians have started splittingrhinitis—runny, itchy, stuffy noses—into two broad cate-gories: allergic rhinitis and non-allergic rhinitis. Allergicrhinitis is caused by an allergic reaction. According toMelissa McBrien, MD, a physician with the Adult andPediatric Ear, Nose & Throat Clinic at William BeaumontHospital in Royal Oak, MI, “Non-allergic rhinitis is aform of rhinitis that is not associated with positive skintesting for allergies, but other than that it’s kind of acatchall term for a wide variety of all sorts of problems.”

Know Your Nose

Your nose may well be as plain as the, er, nose onyour face, but most people probably don’t give it toomuch thought when it’s functioning normally.

B. Lauren Charous, MD, director of AdvancedHealthcare’s Allergy and Respiratory Care Center inMilwaukee, WI, says, “The nose is designed to warm

and humidify air that you’re breathing. It warms air bytransferring heat, and it transfers heat from storedblood, which is sitting trapped in your nasal lining.Your nasal lining can swell prodigiously, and it humidi-fies the air by secreting mucous and evaporating someof the moisture out of the mucous to load that air withsome moisture.”

The nose also acts as a filter, trapping small particlesin the air using mucous and small hair-like protrusionscalled cilia. Mucous is part liquid and part gelatinous,and it’s the balance between the two that makes a healthynasal environment. “People with chronic rhinitis tend tohave a watery, runny nose, and thicker, viscous secre-tions, and they’ve lost some of their function” says Dr.Charous. “You need mucous. You don’t want a dry nose,but you need the right kind of mucous. It needs to flowright. And the nasal lining itself has to be intact and un-inflamed or the cilia don’t work properly. It’s a fairlycomplex arrangement.”

Non-Allergic Rhinitis

William S. Silvers, MD, an allergist with the Allergy,Asthma and Immunology Clinic of Colorado in

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By Mark Terry

When YouCan’t BlameYour NoseProblemso n Allergies

When YouCan’t BlameYour NoseProblemso n Allergies

Understanding Non-Allergic Rhinitis

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Englewood, CO, says, “There are many subsets of non-allergic rhinitis, one of which is vasomotor rhinitis,which is irritant rhinitis, and the manifestations are asneezy, stuffy, or runny nose.”

Physicians have further split non-allergic rhinitis intoa number of categories based loosely on what seems tocause the rhinitis reaction.

• Vasomotor rhinitis. Sometimes also called irritant rhini-tis. This is usually caused by pollution, smoke, or par-ticulate matter in the air.

• Eosinophilic rhinitis. Sometimes called “skier’s nose,”though skier’s nose is sometimes called vasomotorrhinitis. This often resembles allergic rhinitis and ofteninvolves sneezing, but allergy tests are negative. Itseems to be related to changes in air pressure or weath-er. Skier’s nose is often associated with cold weather.

• Rhinitis medicamentosa. This is a form of “rebound”rhinitis caused by overuse of over-the-counter nasal sprays.

• Neutrophilic rhinosinusitis. Also called infectious rhini-tis, and is caused by a cold, flu, or sinus infection.

• Structural rhinitis. This type of rhinitis is caused by adeviated septum, or other nasal birth defect, brokennose or injury.

• Nasal polyps. These are growths on the inside of thenose in the mucous membranes. They may beremoved by surgery.

• Hormonal rhinitis. Also sometimes called primaryvasomotor instability or endocrine rhinitis, and is typi-cally associated with pregnancy, thyroid problems, orbirth control pills.

In short, if your runny, sneezy, or stuffy nose isn’tcaused by a reaction to a specific allergen like ragweed,dog dander, or dust mites and you test negative on askin test, a wide variety of things could be causingyour symptoms. These may include cold weather, tem-perature changes, air conditions, pollution, injuries,polyps, medications, and hormones.

Although it’s not clearly understood why, non-aller-gic rhinitis patients’ nasal linings become over-sensi-tized to stimuli. “In actuality it’s really kind of hard tosay whether someone’s allergic or non-allergic,” saysJames Baldwin, MD, clinical associate professor ofAllergy and Immunology at the University of MichiganHealth System in Ann Arbor, MI. “Most patients havenon-allergic triggers as well as allergic triggers. Andanyone who has allergic rhinitis, it’s very rare that it’s

pure allergic rhinitis. Most people are more what Iwould call mixed rhinitis, mixed being both allergicand non-allergic.”

The Asthma Connection

As most people with asthma can attest, problemswith the nose and sinus can aggravate asthma. “To fullycontrol asthma—the lower airways—you need to stabi-lize the upper airways,” explains Dr. Silvers.

Dr. Charous compares non-allergic rhinitis to anupper airway (nasal) version of non-allergic asthma. Thedifference between allergic and non-allergic asthma iswhat types of things trigger the asthmatic response. Forthose with non-allergic asthma, the triggers tend to bethings that irritate the lungs rather than cause an allergicreaction. Dr. Chalous explains, “I take an asthmatic andmanipulate their airways in ways that ‘normals’ wouldn’thave any problems with. I can stimulate them with cold;I can stimulate them with laughter; or I can stimulatethem with strong odors. All of those things will maketheir airways twitchy.” In people with non-allergic rhini-tis, the response is similar—they have an exaggeratedresponse (although not an allergic response) to stimuli,but the response is in the nose instead of the airways.

Another connection between non-allergic responsesin the nose and in the airways of the lungs is Samter’sTriad or Aspirin Triad. The Aspirin Triad is a connec-tion between nasal polyps, severe asthma, and aspirinsensitivity. There is also a fourth category, inflamedsinuses (sinusitis), that some physicians refer to as theAspirin Tetrad. Timothy J. Craig, DO, professor ofMedicine and Pediatrics at the Pennsylvania StateUniversity College of Medicine in Hershey, PA, says, “Afair number of people with non-allergic rhinitis mightgo on to develop aspirin sensitivity, and those individu-als sometimes go on to develop asthma and nasalpolyps. Some people who have aspirin sensitivity areallergic, but some people who have aspirin sensitivity are

If unchecked, a congestednose is an excellent breeding

ground for bacteria andviruses leading to increasedsusceptibility to colds, flu,

and sinus infections.

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non-allergic—a flip of a coin. We don’t know why theassociation [exists], but a fair number of people withnon-allergic rhinitis go on to have nasal polyps andaspirin sensitivity.”

Treating Non-Allergic Rhinitis

There is a range of treatments for non-allergic rhini-tis, and they vary greatly depending on the specific com-bination of symptoms. Dr. McBrien gives a broad over-view, saying, “Nasal steroids, like Rhinocort or Flonaseand Singulair—an anti-leukotriene medication—doseem to help some people with non-allergic rhinitis, butoral antihistamines don’t seem to help. Decongestantsseem to help, too.”

Dr. Charous emphasizes that treatments for non-allergic rhinitis need to be geared to the patient’ssymptoms. “What’s the complaint? Non-allergic rhini-tis doesn’t tell me what the complaint is. Some peoplecomplain of diffuse runny nose; some complain ofhaving post-nasal drip; some complain of nasal stuffi-ness; some complain of nasal block. There are all sortsof permutations and combinations and they affect howone treats it. The one thing you can say about purenon-allergic rhinitis is that oral antihistamines do verylittle. That’s the one unifying thing.”

In terms of possible over-the-counter treatments,there seems to be agreement on the potential benefitsof saline nasal sprays, such as Ocean, or Ayr, which is asaline gel. McBrien says, “The best non-medical treat-

ment is probably good old-fashioned saline irrigation.Saline irrigation seems to be helpful, just becausethey’re removing the irritant, whatever it is.”

Happier Nose, Happier Person

Anyone with chronic rhinitis or sinus problemscan attest to the misery they feel. Also, if unchecked,a congested nose is an excellent breeding ground forbacteria and viruses leading to increased susceptibilityto colds, flu, and sinus infections. Furthermore, if theperson also has asthma, each of these can furtheraggravate that condition.

For patients with chronic nasal and sinus problemsnot related to allergies, there are ways to reduce theirdiscomfort. Dr. McBrien explains, “They need toknow it might take a couple tries to find a medicationor regimen that works for them. They need to stickwith their doctor and be good about feedback on whatworked and what didn’t.” With persistence, DrMcBrien assures us, one can usually find a treatmentregimen that works!

Mark Terry is a freelance writer and editor specializing in health and medicine. He is also a novelist. His latest novel is Dirty Deeds.

Reprint requests: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone 314-453-4350.doi:10.1016/j.asthmamag.2005.08.009

We don’t know why the association [exists], but a fair numberof people with non-allergic rhinitis go on to have nasal polyps

and aspirin sensitivity.

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