Non-Allergic Rhinitis Revisited

In a prior post, I broached the topic of non-allergic rhinitis (NAR), which refers to the condition in which other factors beyond conventional allergens (e.g.hay fever, animal dander, pollens) cause an individual to suffer from chronic congestion, stuffiness or a runny nose. Now, we delve deeper into this condition, because it has the potential to affect so many OSA/UARS patients.

To start, we are working on a scientific publication on nonallergic rhinitis and will update this post at a later time if it is accepted for publication. The main finding in the study was that approximately 70% of the sleep patients who reported chronic nasal congestion at the point of intake to our sleep center suffered from NAR symptoms; while NAR presents with several symptoms, we used three common triggers in which either 1) changes in weather; 2) changes in temperature; or 3) changes in wind blowing in your face caused congestion, runny nose, and stuffiness. While classic allergic rhinitis (AR) might include all three of these nasal conditions, these triggers described fit more with NAR than with AR.

Right off the bat, among those of you who may notice these circumstances affecting your nasal breathing, please read this post carefully, because the presence of NAR especially based on wind blowing in your face equates to PAP therapy itself causing congestion. In fact, a hallmark finding is to use PAP all night yet wake up in the morning feeling congested; in other cases, the congestion is so bad the patient consciously or unconsciously rips off the mask at night. Unfortunately, many sleep professionals remain unaware of the problem of NAR and mistakenly assume most rhinitis is of the allergic type. As such, you might be told over-the-counter (OTC) meds or nasal steroid sprays (which can be obtained either OTC or prescription) will solve the problem. But, the problem may intensify because the nasal steroids may not work as well as other treatments on NAR cases and in occasional cases actually could make the congestion worse.

NAR is an odd condition in that any sort of stimulation makes it worse. So, if you use nasal saline sprays, netipot washes, other sinus rinses or most other nasal sprays (especially Afrin), all these treatment efforts could and often do make your nasal congestion worse. The classic presentation of a NAR patient, then, is one who declares: “I’ve tried everything and nothing works” or “they make things worse.”

NAR treatment mirrors Thomas Jefferson’s famous quote: “That government is best which governs least.” The same with NAR, the best treatment is almost always the least treatment. Here’s where a new spray comes into play based on the innovative concept of intranasal antihistamines. You might wonder if OTC antihistamines as pills work on NAR, but they do not. The most common antihistamine spray is generically called azelastine and can be found under brand names like Astelin or Astepro. Another version is olopatadine sold as Patanase. There are others on or coming to the marketplace. These nasal sprays are miracle drugs for many people, because this single treatment often completely eliminates or radically reduces NAR. As a bonus, if the patient suffers allergic rhinitis in combination with NAR (an extremely common co-occurrence), many patients report the newer sprays solve both problems. In other instances, a patient might try Dymista, a drug that has both a nasal steroid and the azelastine for patients with both AR and NAR, although in some cases it may prove less expensive to buy and both sprays independently.

Figuring out whether or not you suffer from NAR is tricky because so many medical professionals do not have the condition on their radar screens. There are at least four out-of-the-ordinary scenarios that should make you consider the presence of a NAR problem: 

  • - Post-nasal drip: many with this problem can never seem to figure out what might be causing the condition, yet NAR can cause a chronic post-nasal drip.
  • - Silent reflux: this problem needs an ENT evaluation of the lower throat and esophagus; for some reason the irritation from the reflux is not noticed like typical reflux where heartburn and related symptoms arise; instead the irritation triggers a NAR response in the lower part of the throat, which then eventually manifests as chronic nasal congestion; use of acid reflux treatments remarkably eliminate NAR.
  • - Afrin abuse: many patients get hooked on the relief/rebound cycles of oxymetazolone, a drug that provides instant relief of congestion because it rapidly vasoconstricts the blood vessels in the nasal passages; but, the effect does not last and the ensuing rebound makes the congestion temporarily worse, leading some individuals to squirt more Afrin into the nose. What started this cycle? Often it’s NAR, where the patient had tried all sorts of other treatments and nothing provided relief, so the patient switched to Afrin and some temporary relief was achieved. Then, the patient stayed with this spray and eventually developed the relief/rebound cycle. It can be very difficult as well as a long and arduous process to help someone taper off of Afrin even after successful treatment of NAR with intranasal antihistamines.
  • - Chronic sinus inflammation: many patients with chronic sinus problems suffer from chronic infections or flare-ups as well as actual objective findings of sinus disease by medical examination or special radiographic scans. However, it is well known that nasal steroids often relieve sinus problems in a great many patients without further interventions needed. The nasal spray reduces the swelling in and around the sinus openings and thus drainage commences and symptoms such as headaches, congestion and other inflammation are relieved. What many medical professionals may not realize is nasal steroids only work in some patients; whereas use of the antihistamine nasal sprays in a chronic sinusitis case may also bring relief, which often indicates the actual problem was a NAR-induced sinus inflammation.

Last, it is worth noting NAR has a long and unusual list of triggers, which may help a patient recognize the nasal congestion is more than just chronic allergies. For example, in the list below notice how many types of environmental stimuli can induce non-allergic rhinitis:

  • - Cold air
  • - Changes in climate (such as temperature, humidity, and/or barometric pressure)
  • - Strong smells (such as perfume, cooking smells, flowers, and chemical odors)
  • - Environmental tobacco smoke
  • - Changes in sexual hormone levels
  • - Pollutants and chemicals (eg, volatile organics)
  • - Exercise
  • - Alcohol ingestion
  • - Certain foods

With this information in mind, it is valuable for a PAP therapy patient to pay close attention to their nasal congestion, because it almost always interferes with efforts to attain an optimal response. If some of the triggers described in this post seem relevant to your nasal congestion, it is well worth your time to investigate whether it is a NAR problem, after which you should then discuss this possibility with your sleep specialist or primary physician to learn about the newer intranasal antihistamine sprays.


Key Reference:

Useful Reference on NAR: Kaliner MA. Nonallergic Rhinopathy (Formerly Known as Vasomotor Rhinitis) Immunol Allergy Clin N Am 31 (2011) 441–455.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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