Novel Treatment for Non-Allergic Rhinits

Non-allergic rhinitis is an extremely frustrating sino-nasal disorder that is characterized by all the same symptoms of sinusitis and allergies, but NOT due to sinusitis or allergies. Rather, I consider non-allergic rhinitis to be the over-sensitive nose syndrome whereby breathing in air containing particulates (whether smoke, perfume, dust, pollen, etc) PHYSICALLY irritates the nose causing symptoms.

This is in contrast to allergies where the pollen causes an immunologic reaction causing symptoms or sinusitis which is due to an infection.

Non-allergic rhinitis is diagnosed by a negative allergy test (meaning symptoms are not due to allergies) and normal CT sinus scan (meaning symptoms are not due to a sinus infection).

Usually, treatment encompasses avoiding triggers (ie, perfume, smoke, dust, etc), applying a barrier nasal emollient (ie, ponaris), anti-histamine nasal spray (ie, astelin, astepro, patanase), and nasal hygiene using saline flushes which washes away the irritants causing symptoms.

Well, a new study published this month have shown another mode of treatment is quite helpful... ICX72, a proprietary homeopathic preparation of Capsicum annum and Eucalyptol, otherwise known as Sinus Buster!

When used twice daily over two weeks, symptoms were found to be significantly improved when compared to placebo. Furthermore, sinus buster alleviates symptoms attributable to non-allergic rhinitis within 52.6 seconds on average.

Past studies have shown improvement using Sinus Buster, but this is the first controlled study demonstrating efficacy.

Of note, unlike nasal decongestant sprays like Afrin which can result in addiction over time (rhinitis medicamentosa), there does not appear to be any addictive component with this nasal spray.

Read the study abstract here.

Read more about this condition here.



Reference:
A randomized, double-blind, parallel trial comparing capsaicin nasal spray with placebo in subjects with a significant component of nonallergic rhinitis. Annals of Allergy, Asthma & Immunology. Volume 107, Issue 2, Pages 171-178 (August 2011)

Intranasal Capsicum spray in idiopathic rhinitis: a randomized prospective application regimen trial. Acta Otolaryngol. 2009 Apr;129(4):367-71.

Intranasal capsaicin reduces nasal hyperreactivity in idiopathic rhinitis: a double-blind randomized application regimen study. Allergy. 2003 Aug;58(8):754-61.

The long-term effects of capsaicin aqueous spray on the nasal mucosa. Clin Exp Allergy. 1998 Nov;28(11):1351-8.

Beneficial effects of intranasal applications of capsaicin in patients with vasomotor rhinitis. Eur Arch Otorhinolaryngol. 1991;248(4):191-4.

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New and Only Over-The-Counter Anti-Histamine Nasal Spray

Up until now, there has been three anti-histamine nasal sprays in the United States market available only by prescription... Astelin, Astepro, and Patanase.

However, in May 2011, Meda Pharma announced a new anti-histamine nasal spray Rhinolast Allergy that is available over-the-counter.

The active ingredient is azelastine, the same one as found in the prescription nasal spray Astelin and Astepro.

Azelastine has a triple mode of action: anti-histamine effect, m,ast-cell stabilizing effect, and anti-inflammatory effect. Azelastine has a rapid onset of action of 15 minutes.

It can be used from the age of 5 years.

This nasal spray can be used in combination with other over-the-counter anti-histamines medications taken orally like zyrtec, claritin, allegra, and benadryl.

Read more about this new nasal spray here.

Read more about allergy medications in general here.

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Got Allergies? Maybe It's Actually Non-Allergic Rhinitis

USA Today published a story on Aug 22, 2010 describing a condition called "Non-Allergic Rhinitis" or "Vasomotor Rhinitis" which essentially is having pretty much all the symptoms of classic nasal allergies, but caused NOT by allergies!

Such symptoms include:

- Runny nose
- Nasal congestion
- Post-nasal drainage
- Nasal obstruction
- Sinus pressure
- Sneezing
etc

These individuals also report that their nasal symptoms are triggered not only by pollen and dust, but also perfumes, strong odors, cigarette smoke, chemicals, cold air, high wind, humidity, and certain foods, especially spicy ones.

The way I try to explain this condition from those suffering from it is to consider their nasal lining to be hypersensitive... so hypersensitive that things which ordinarily shouldn't cause any problems, do.

The best way to address this condition is by avoiding known triggers and keeping the nose clean by regular saline washes. The saline washes are quite important in that they clean out the substances which are irritating the nose (much like washing your skin reduces the irritation if you get poison ivy).

Some patients may benefit from medications like anti-histamine and steroid nasal sprays, but such medications do not work as well as for those suffering from classic nasal allergies.

Barrier type of medications like ponaris may also be helpful. Such medications work by creating an oily barrier such that the irritating substances don't actually touch the lining itself when breathed in (much like chapstick on lips).

Some patients with non-allergic rhinitis and large turbinates may benefit from a surgical procedure called turbinate reduction, but rarely cure the problem. At best, there is perhaps a 50% reduction in symptoms.

One should also be aware that you can have BOTH allergic and non-allergic rhinitis.

Read the USA Today article here.

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NYT: Kids with Allergies

The New York Times published a story on pediatric allergies on March 5, 2010 titled "A Child’s Allergies Are Serious but Can Be Treated Effectively."

Some treatments mentioned in the article include allergy shots, medications, and avoidance.

Our office is able to provide allergy shots, allergy drops, medications, as well as allergy testing.

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New Webpage on Rhinitis Medicamentosa (Nasal Decongestant Spray Addiction)

A new webpage has been created and uploaded to our website on rhinitis medicamentosa, a devastating sinus/nasal condition with symptoms of severe chronic obstruction/congestion. This condition occurs when over-the-counter nasal decongestant sprays are used more frequently (every 12 hours) and longer (3-5 days) than directed.

Such nasal decongestant sprays include the common and popular Afrin and Zicam nasal sprays. These sprays contain one of these active ingredients: phenylephrine, neo-synephrine, oxymetazoline, and xylometazoline.

This condition has also been portrayed in the New York Times and the article can be read here.

Check out the webpage here.

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Runny Nose Due to Spinal Fluid Leakage and Not Allergies!

Image from Wikipedia

The Washington Post published a story on January 19, 2010 entitled "Doctors changed diagnosis after woman said allergies weren't causing runny nose." In this story, the patient's runny nose from only one side was actually due to a CSF leak (cerebrospinal fluid leakage) and puts her at major risk for meningitis. Unfortunately for this particular patient, the hole through which this fluid was coming out from also had some brain tissue. She required major surgery in order to correct this problem.

An interesting trivia related to CSF leaks is that actor George Clooney suffered one after a blow to the head while filming a torture scene in the 2005 movie "Syriana".

The take-home message is that not all runny noses are due to allergies, especially if it is continuous and only occurs on one side.

Typically, if CSF leak is suspected, a red-top tube is provided to the patient to collect some of this fluid. The specimen is than sent to be tested for beta2-transferrin which is ONLY found in CSF.

A high resolution CT scan of the sinuses and/or temporal bone is also obtained to localize WHERE the abnormal leak is coming from.

What type of surgery is performed utterly depends on where the leak is coming from... if truly sinus in origin, endoscopic sinus surgery is performed. If coming from the bone around the ear, a middle cranial fossa approach to fixing the leak is performed.

Read the story here.

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You May Have a Condition Called Local Allergic Rhinitis Even If Allergy Testing Negative!!!

Image from Wikipedia

A recent study was published describing a condition called "Local Allergic Rhinitis." This condition is when a patient appears to have sino-nasal allergies, but yet, have negative allergy test results whether on skin prick or RAST.

Up to 40% of patients with negative allergy test results may have this condition.

In order to diagnose this condition, it requires the detection of local antigen specific IgE in nasal secretions during natural exposure to aero-allergens as well as positive nasal allergen provocation test with local production of tryptase, eosinophil cationic protein and antigen specific IgE.

Read the study here.

Please note, our office is not able to perform these testing. We recommend getting evaluated at University of Virginia Allergy Department if you suspect you have Local Allergic Rhinitis.

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Botox Treatment for Vasomotor Rhinitis (Idiopathic or Non-Allergic Rhinitis)

A new research paper has been published Oct 16, 2009 in Head & Face Medicine entitled "Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis" in which researchers successfully treated patients with a persistent runny nose not due to any known problems like allergy. Such a condition is called vasomotor rhinitis or idiopathic rhinitis or non-allergic rhinitis.

In this new described method of treatment, a sponge soaked with 40 Units of botulinum toxin type A was inserted into a patient's nose and left in place for 30 minutes. Apparently, this did result in a significant reduction in rhinitis (but not congestion) and lasted for as long as 12 weeks.

Read the abstract here.

Of course, this is a non-FDA approved use of Botox.

Historically, this condition is often treated with nasal sprays (ie, astelin) and decongestants with some success in some patients, but not all patients respond.

Surgical treatment include turbinate reduction which reduces (usually about 50%), but does not cure this condition.

Before you ask... NO we do not offer this procedure until further research and data becomes available.

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NYT: Does Snotty Colored Discharge Require Antibiotics? No!!!

The New York Times published a story on Oct 6, 2009 entitled "The Claim: With a Runny Nose, Green Calls for an Antibiotic." It actually is a pretty good article though I'm not sure how much impact this will have in clinical practice.

The story reports that green discharge from the nose is NOT indicative of a bacterial sinus infection and as such, this symptom should not be the sole reason why antibiotics should be prescribed.

It does reference a research paper that backs this claim up. There are others.

In any case, the last sentence of the story is worth reiterating: "THE BOTTOM LINE: The color of nasal discharge should not dictate the medicine."

Not sure how accepting patients will be of this factoid given how ingrained colored discharge has been equated with sinus infection.

I personally have encouraged saline nasal flushes starting from as early as 5 years old as the main treatment for this issue which some patients have been more accepting than others.

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