Runny Noses 101

 

Q: I was just seen by my allergist, and my testing was negative.  I just don’t understand.  My nose runs like crazy.  How can this not be allergy? When I asked this question to my allergist, he said that I most likely had vasomotor rhinitis.  Exactly what is vasomotor rhinitis and what can I do about it?

A: Everybody has vasomotor rhinitis. Even though you may have shown up negative on allergy skin testing, it doesn’t mean that you are not allergic.  The fact is, 20% of people who test negative are actually allergic.  They just don’t make the skin reaction necessary to be deemed allergic.  And if you don’t make that reaction, you probably won’t respond to allergy immunotherapy (allergy shots), because treatment depends on the body having that reaction to be effective.

The vasomotor response is the runny nose that happens when you go out into the cold air, when you sneeze when going from darkness to bright light, and the drainage that you might experience when eating.

Q: So, is vasomotor rhinitis a disease? Or is vasomotor rhinitis just a normal reflex gone crazy?

A: Vasomotor rhinitis is not a disease! An unusually noticeable clear, runny nose is often just a sign of an increased output as a result of some other issue. Vasomotor rhinitis is mediated by the parasympathetic nervous system.  These nerves regulate the amount of clear, watery nasal mucous produced by the nasal lining.  We need lots of clear, watery nasal mucous for a lot of reasons.  Mucous helps trap anything other than air traveling through the nose in its filtering function. A watery nose is essential for helping to humidify the air in its turbulent flow through the nasal passage.  The nasal turbinates, projections from the sides of the nose, are large, highly vascular, mucous membrane-lined structures that congest and decongest as part of the nasal cycle.  The decongested side gives up heat and moisture and filters the air that you breathe.  The other side of the nose decongests and takes over once the previous side congests to recover. A nose runs more as you age, when you are sick, with allergies, irritants, certain granulomatous diseases, some drugs, when you are aroused, pregnant, have migraine, are at bed rest, or have a brain-fluid leak. Just like sweating, VSMR isn’t a disease, but it can be a problem that needs treatment.

Q: Did I hear the words brain-fluid leak?!?

A: Just like with practically everything in medicine, there are caveats that must be remembered.  One-sided, clear, watery nasal drainage can be a sign of a cerebrospinal, or “brain-fluid” leak.  These can be somewhat difficult to diagnose and it can be a challenge to find the source.  There should be a high index of suspicion for this if there is a steady drip, drip, drip coming from one side of the nose when you hold your head forward and lean slightly down.  These should be repaired, as there is an increased risk of meningitis if they are not.

Q: What are the treatment options?

A: Medical management of vasomotor rhinitis includes the spray Ipratroprion that directly helps “shut off the faucet”.  The common brand name for this medicine is Atrovent Nasal Spray.  It comes in 0.03% and 0.06% solutions.  It works quickly and lasts roughly 4 hours when pumped up both sides of the nose. Other treatment options for vasomotor rhinitis focus on the processes that may be making you notice the rhinitis because of the effect those problems have on the nose.  One really can’t do much about aging, so the Ipratroprion is about the best thing available, and thankfully pregnancy is self-limiting.  Most people aren’t debilitated by rhinitis when aroused or could care less about treating it.  Hopefully, being at bedrest is a self-limiting situation as well. Treating the underlying allergy can be effective in alleviating the vasomotor problem, even when you have already tested falsely negative for allergy.   Steroid nasal sprays are generally “non-specific” in their effectiveness, meaning that you don’t necessarily have to know what is bothering your nose and making it run, because the anti-inflammatory spray inhibits multiple pathways of inflammation and works to alleviate 7 or more different things whose effect might be a runny nose.

If the rhinitis is discolored or thicker in quality, there may be an underlying sinus infection.  Since humans don’t usually die as a result of sinusitis, recover fully without antibiotics an estimated 85% of the time, and can function with a nagging cough, increased malaise, and a chronic post-nasal drainage, it is difficult to know when an antibiotic should be used.  But there is no doubt that the accompanying congestion, the recognition of the nasal cycle, and the rhinitis can be treated with the appropriate antibiotic if it is debilitating enough to merit the exposure.  Surgery on your septum or turbinates usually requires more of a complaint than “my nose runs too much”.