My first story was about ragweed seasonal allergic rhinitis (allergy induced inflammation of the nose), which is ongoing as we speak. However, what if you never had a family history or personal history of allergies, but have all the rhinitis symptoms that seem to occur seasonally. These often end up causing symptoms such as nasal stuffiness, post-nasal drainage, headaches and/or ear plugging that are mistaken as a sinus infection that interfere with daily activities. You go to your doctor who gives you an antibiotic and possibly a nasal spray to use until you are better. This goes on for years and you finally see an allergist or ear, nose and throat surgeon who does testing and tells you that you have allergies and offers treatment options including allergy injections.
Being a good patient, you opt for the allergy injections, which seem like the only curative treatment, but after 2-3 years you are still getting sick several times a year. Is this acceptable? Do I really have allergies? During my inaugural story, I mentioned the importance of the positive and negative predictive value and sensitivity and specificity for a diagnostic test. What does this mean? It means that every diagnostic test has limitations. No test is 100% predictive of a diagnosis (except perhaps a pathology report). This means the test always should be correlated with the patient’s history. Previously, I published a paper entitled, “Questionnaire evaluation and risk factor identification for nonallergic vasomotor rhinitis,” which found that affirmative responses to five questions in the medical history, 1) absence of outdoor symptoms during a season, 2) no family history of allergies, 3) no symptoms around cats or other furry pets, 4) symptoms around perfumes, fragrances and other chemical irritants and 5) a later onset of symptoms in life after age 35, there was over 96-98% predictive likelihood that the patient will have a “non-allergic rhinitis” diagnosis or a component of non-allergic rhinitis (mixed rhinitis where patients may have sensitization to an allergen, but non-allergic rhinitis triggers) before skin testing or blood testing to aeroallergens.
Up to 75% of patients with chronic rhinitis have non-allergic rhinitis or a component of non-allergic rhinitis triggered by mechanical, osmotic, temperature and chemical stimuli. In fact, one type of non-allergic rhinitis, called gustatory rhinitis, occurs when patients experience a runny nose after eating. What is going on here? The mechanism is not IgE “allergic antibody” mediated. We use to refer to this condition as “idiopathic rhinitis,” or rhinitis of unknown cause, but it is now recognized to be induced through neurogenic pathways. These non-specific triggers can activate neurogenic pathways that can cause blood vessel dilation and increased mucus secretions that manifest as stuffy nose, increased post-nasal drainage, headaches and ear plugging, typically misdiagnosed as acute sinusitis, but if left untreated can lead to an actual chronic rhinosinusitis. These patients have often been misclassified as “difficult to treat” allergic rhinitis patients rather than correctly as “non-allergic rhinitis.” Unfortunately, if this condition is treated like allergies, patients don’t get better. They won’t respond to allergy injections without also requiring daily medications, nor will they respond to the same medications that are often prescribed for allergic rhinitis.
If diagnosed and managed properly, patient morbidity and quality of life can be significantly improved. It is likely that for many of you reading this article, this scenario will sound familiar. Prior to seeing your physician, having a better understanding of your symptoms and underlying potential diagnosis will help them tailor a medical regimen appropriate for you. Unfortunately, there is no “cure” for non-allergic rhinitis and often chronic medications are required for control. However, this is a small price to pay for not being sick monthly or being on antibiotics 4-6 times a year. Like everything in medicine, there are always caveats, but these we will save for the next time.
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