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