What is Vasomotor Rhinitis?
Nonallergic rhinitis (NAR) is a condition that causes constant symptoms like a stuffed nose and runny nose, but these issues aren’t caused by specific allergies. Nonallergic rhinitis can further be categorized into various types, with vasomotor rhinitis (VMR) being the most common. Vasomotor rhinitis is typically used to refer to nose symptoms triggered by non-allergic, non-infectious causes, which are hard to pinpoint even after thorough medical tests.
The root cause of nonallergic rhinitis is complicated and not fully understood yet. Part of it is thought to be an irregular balance between two nervous system responses in the nasal lining. To successfully diagnose vasomotor rhinitis, a full medical history and physical examination are crucial.
The most effective treatment for vasomotor rhinitis is to avoid whatever is known to cause the symptoms, with medication also being helpful. If no other treatments work, surgery might be considered as a possible option.
What Causes Vasomotor Rhinitis?
Vasomotor rhinitis is a condition that we don’t fully understand yet. However, we do think it has something to do with the malfunction of certain nerves in the nose. These nerves include sympathetic and parasympathetic nerves, as well as ones related to the pain and sensory response, known as nociceptive nerves.
An imbalance in factors controlled by these nerves can cause the blood vessels in the nose to become ‘leaky’, and can lead to an increase in mucus being made by the glands in the nose.
To understand this better, it might help to know that the parasympathetic nervous system – part of our bodies that manage non-emergency functions – is primarily what controls our mucus production. On the other hand, the sympathetic nervous system – which is responsible for our fight or flight response, i.e., the body’s reaction to danger or stress – controls the ‘tone’ of our blood vessels.
Acetylcholine, a type of chemical that acts on our parasympathetic nervous system, controls mucus production and a runny nose. Other chemicals like norepinephrine and a type of protein called neuropeptide Y, working under the sympathetic nervous system, control the state of our blood vessels in the nose and also help adjust the mucus produced by the parasympathetic system.
Nose-related responses like itching and sneezing are influenced by certain sensory proteins and the pain-detecting type C fibers of a nerve in our face called the trigeminal nerve. This nerve also contributes to the release of substances from mast cells (a type of white blood cell that is involved in allergic reactions), which plays a role in allergic reactions.
Risk Factors and Frequency for Vasomotor Rhinitis
Rhinitis, or inflammation of the nose, is a condition that affects around 20% of the population in developed countries. This includes two types: allergic and nonallergic. Allergic rhinitis is thought to impact between 20 to 40 million people and costs over $1.9 billion each year. Nonallergic rhinitis, on the other hand, affects around 17 to 19 million Americans.
- Allergic rhinitis is common and costly, affecting up to 40 million people and costing over $1.9 billion annually.
- Nonallergic rhinitis usually begins in adulthood, typically between the ages of 30 and 60.
- Nonallergic rhinitis is more common in women, with 70% of women between 50 and 64 experiencing some symptoms in a given year.
Signs and Symptoms of Vasomotor Rhinitis
Vasomotor rhinitis is a condition that is diagnosed in the clinic. Doctors use a detailed medical history, a thorough examination of the head and neck, and diagnostic tests to rule out problems like infections, allergies, and inflammation. Common symptoms of both allergic and nonallergic rhinitis include headaches, facial pressure, postnasal drip, coughing, and throat clearing.
People with vasomotor rhinitis are often divided into two categories based on their primary symptoms: “blockers” experience congestion, while “runners” suffer from a runny nose. Individuals with a runny nose may have an increased cholinergic response. Those with nasal blockage may have pain-sensing neurons that are overly reactive to harmless stimuli. Vasomotor rhinitis tends to occur all year round. However, seasonal changes in barometric pressure, temperature, and humidity can worsen symptoms, often leading to a mistaken diagnosis of allergic rhinitis.
The condition can be triggered or worsened by environmental factors such as strong smells, exposure to cold air, drinking alcohol, and eating spicy foods. A physical examination often shows swollen, spongy nasal lining with clear, mucus-like secretions. Redness and overgrown lymphoid tissues such as tonsils, adenoids, and lingual tonsils may be observed. In some cases, a patch of pale tissue surrounding noticeable blood vessels may be seen in people who have chemical sensitivities.
An examination of the nasal cavity and the nasopharynx can help identify the primary or secondary causes of rhinitis. For example, obvious signs of infection like pus draining from the middle part of the nasal passageway would essentially rule out vasomotor rhinitis.
Testing for Vasomotor Rhinitis
If your doctor suspects you have vasomotor rhinitis, a condition where the blood vessels within your nose expand and cause runny nose and/or nasal congestion, they may want to run several tests. These could include skin testing and blood tests for specific antibodies. As vasomotor rhinitis is often diagnosed when other possibilities are ruled out, these tests usually come back negative for any allergens.
Your doctor may also perform nasal cytology, which allows them to examine the types of cells present in your nasal mucus. This could involve taking a small scraping from inside your nose, using a nasal wash, or analyzing your mucus after blowing your nose. Finding between 5 to 25 specific types of white blood cells known as eosinophils often suggests a related condition known as Nonallergic Rhinitis with Eosinophilia Syndrome (NARES).
Your doctor might also use a detailed questionnaire to see how likely it is that you have vasomotor rhinitis. For example, if your symptoms started after you turned 35 and you don’t have any family history of allergies, it’s pretty probable. Other factors that increase the likelihood include not having symptoms caused by outdoor allergens or cats, and having symptoms when you’re exposed to perfumes and other fragrances.
Sometimes, your doctor might expose you to an allergen on purpose to provoke a reaction. Tests that measure the airflow in your nose help your doctor monitor the response to the allergen, which confirm the diagnosis. Also, if other conditions are suspected, imaging technologies like CT-scans and MRIs can be used. Though, in cases of vasomotor rhinitis, these imaging tests usually do not reveal any significant abnormalities.
Determining if you have vasomotor rhinitis or allergic rhinitis can be difficult, as both can present with similar symptoms like runny nose or congestion. Allergic rhinitis occurs when exposure to an allergen causes an immune response in your nose. However, the timing of symptoms and any past exposures to allergens could hint your doctor towards allergic rhinitis. No matter what, your personal medical history always plays a vital role in providing important information needed for the accurate diagnosis.
Importantly, allergy testing should not be taken on its own; it is more valuable when used in combination with a detailed medical history and physical exam. This can help to differentiate between vasomotor rhinitis and allergic rhinitis.
Finally, infectious rhinitis, where the symptoms closely resemble those of nonallergic rhinitis, is generally identified with a patient’s detailed history. The presence of certain symptoms such as nasal discharge, nasal obstruction and facial pressure for ten days or longer can suggest an infection. A physical examination may reveal signs of infection in the nasal area. However, a fever may not always be present depending on the type and severity of the infection.
Treatment Options for Vasomotor Rhinitis
Before diving into the various ways of treating vasomotor rhinitis, it’s important to note that one of the first steps to managing this condition involves adjusting your environment. By avoiding or limiting exposure to things that can trigger symptoms, like perfumes, tobacco smoke, and cleaning products, you might see a significant decrease in your symptoms.
If avoiding triggers isn’t feasible, medications can be a helpful way to manage any discomfort. Which medication is used might depend on the specific symptoms you’re experiencing.
Nasal sprays containing steroids are often the go-to because they can help reduce congestion and other symptoms by reducing inflammation in the nose. Side effects are rare but can include a dry nose, crustiness, and irritation. Out of all the options, fluticasone propionate and beclomethasone are specifically approved for vasomotor rhinitis, which are a kind of steroid medication. There’s also Budesonide, which is the only one deemed safe for use during pregnancy.
Another medication to control a runny nose is called an anticholinergic. Although some are oral, the most common for this condition is a nasal spray called ipratropium bromide. Side effects are rare, but you could notice nosebleeds and a dry nose. It’s generally considered safe for a broad range of patients, including pregnant women and children as young as six years old.
Oral antihistamines, which are often used for allergies, might help if you’re experiencing sneezing or itching. There’s also a nasal spray antihistamine called azelastine which can help with a runny nose and congestion.
Sympathomimetic medications, which are usually a type of nasal decongestant, might provide temporary relief from a runny nose and congestion by constricting blood vessels in the nose. However, it’s important to use these carefully because long-term use can lead to increased congestion.
A treatment that might surprise you is capsaicin, the active component of chili peppers, which has been found to help with symptoms of vasomotor rhinitis. But, its irritating quality can make it challenging for some patients to tolerate.
Then there’s a unique treatment called botulinum toxin, better known as Botox, which might help treat rhinitis by inhibiting the release of a molecule involved in muscle contraction. The effect typically lasts for about four weeks.
When medications aren’t enough, surgical procedures might be considered. One common surgery is called turbinate reduction surgery, which helps reduce obstruction and works well with other medical therapies. Another is Vidian neurectomy, which aims to disrupt the nerve supply of the nasal cavity and thereby reduce nasal secretions.
If all else fails, the best course of action might be conservative therapy, which can simply involve nasal saline irrigations. And if medications are necessary, there are many safe options for pregnant women and children. Diphenhydramine might be an option, along with the nasal sprays mentioned earlier. Topical decongestants can also be used, albeit on a limited basis, especially for children as young as six and pregnant women.
In summary, there are numerous management options available for vasomotor rhinitis, which can be tailored according to your specific symptoms, and your comfort with taking medications or considering surgical approaches. It’s always best to consult with your doctor or healthcare provider about which treatment might be most suitable for you.
What else can Vasomotor Rhinitis be?
Nonallergic rhinitis can be caused by a number of different things and are normally grouped into two categories: primary causes and secondary causes.
Primary causes include:
- Drug-induced rhinitis
- Gustatory rhinitis
- Hormonal induced rhinitis
- Nonallergic rhinitis with eosinophilia syndrome
- Senile rhinitis
- Atrophic rhinitis
- Cerebral spinal fluid leak
- Idiopathic nonallergic rhinitis
On the other hand, secondary causes are tied to other medical conditions or syndromes such as:
- Granulomatous disease
- Autoimmune diseases (like lupus)
- Sjogren syndrome
- Cystic fibrosis
- Pregnancy
- Chronic fatigue syndrome
- Metabolic syndromes
Regarding drug-induced rhinitis, it usually comes from certain kinds of medication, the most common being antihypertensive drugs, erectile dysfunction medication, and some psychiatric drugs.
Hormone-induced rhinitis often occurs due to a rise in estrogen and progesterone levels. It’s common for many women to report having a stuffy nose at some point during their pregnancy.
Another type of rhinitis is occupational rhinitis, caused by exposure to certain agents at work. This can happen due to either allergic reactions, irritants, or a combination of both. Some high-risk jobs include bakers, livestock breeders, and veterinarians.
What to expect with Vasomotor Rhinitis
Nonallergic rhinitis is a long-term condition that often lasts a lifetime. This was confirmed by a study conducted by Rondon and colleagues, which followed 180 patients with this condition 3 to 7 years after they were initially diagnosed.
According to their findings, over half of the patients experienced a worsening of their symptoms. In particular, there was a 12% rise in the condition’s persistence and a 9% increase in the severity of nasal symptoms.
What’s more, some patients developed new related health issues, with asthma being the most common. There was also an increase in the occurrence of chronic sinusitis, which is a condition where the areas around nasal passages (sinuses) become inflamed and swollen for a prolonged period.
Possible Complications When Diagnosed with Vasomotor Rhinitis
Chronic vasomotor rhinitis often disrupts people’s work or school schedule because it leads to decrease in productivity and frequent trips to the doctor. Living with chronic non-allergic rhinitis can be both physically and economically challenging. According to a survey, 25% of people with rhinitis have changed their jobs or places of residence to ease their symptoms.
Medical treatments can help control symptoms but can sometimes cause unwanted side effects like a dry nose, fast heartbeat, nosebleeds, and sleepiness. These side effects can make the impact of nonallergic rhinitis even worse.
Chronic nonallergic rhinitis is often found together with other health issues, such as headaches, ear tube dysfunction, nasal polyps, sleep apnea, and chronic cough. These additional problems can make treatment more complicated and can lower the person’s quality of life.
Negative Effects of Chronic Non-allergic Rhinitis:
- Interrupts work or school
- Decreased productivity
- Frequent doctor visits
- Physical and economic burdens
- Job or locational changes
- Undesirable side effects from treatments, e.g., dry nose, fast heartbeat, nosebleeds, sleepiness
- Associated with other health conditions, for example headaches, ear tube dysfunction, nasal polyps, sleep apnea and chronic cough
- Complicates treatment
- Lowers quality of life
Preventing Vasomotor Rhinitis
It’s extremely vital for patients to understand how to manage vasomotor rhinitis, a condition where the inside of the nose becomes inflamed due to non-allergic triggers. If you have this condition and know what specifically irritates your nose, it’s essential to avoid these triggers as much as possible. This could involve exposure to certain environments, non-immune based substances, and different irritants.
Avoiding these irritants is the main method of treatment. By staying away from these triggers and following a doctor-recommended medical therapy plan, you’ll likely notice a reduction in symptoms and the nose inflammation related to non-allergic rhinitis.
However, if you can’t avoid these triggers, it’s important to know how to reduce symptoms beforehand. This involves the use of nasal sprays or histamines, which limit symptoms by reducing inflammation and allergic reactions respectively.
