Non-Allergic Rhinitis

By Tamara Liller, M.A.

For those of us who have endured a harsh winter and struggled against the colds and flu which that season entails, the tiny little buds and flowers which emerge on trees hint of spring and offer hope and relief. For those with allergies, however, the story is far different. Those same little buds and flowers bristle with sticky pollen causing weeping or wheezing or wheals on the skin. Noses swell and run, eyes itch, and sinuses clog. It's not a pretty picture but one we are all familiar with, either from personal experience or from the endless advertisements for miracle cures that march across our television screens or the pages of our magazines. In medical circles, this condition is known as "allergic rhinitis" (literally inflammation of the tissue of the nose) since it is the nose which takes much of the abuse. Of course, allergic rhinitis is not only associated with hay fever. It can also occur in reaction to mold, animal danders, dust mites, and a host of other offenders.

As a group, persons with fibromyalgia (FM) exhibit many similar symptoms: a chronic runny nose, a congested head, a throat-clearing cough, or a maddening postnasal drip. While a sign of allergic reaction in some, for most with FM it is not, for there is no immune reaction in the body (i.e., antibodies that are detected by skin testing) and very little itching or inflammation occurs in the eyes and nose, respectively. When allergies are not present, the condition is usually referred to as "non-allergic rhinitis" (also known as vasomotor rhinitis or irritant rhinitis). Much is still unknown about the body mechanisms that cause such rhinitis, but a few theories have been advanced.

Because fibromyalgia can cause muscular pain and spasm in the face and head just as it does in other parts of the body, tight muscles can press on fluid passages thereby narrowing them and causing a backup in the sinuses.¹ The result is often an unrelenting postnasal drip-drip-drip which occurs even though the nose itself may be dry. This drainage can in turn cause a chronic hacking cough or raw, angry throat that can be mistaken for a cold or allergy. In addition, an estimated one-third of fibromyalgia patients have pain or dysfunction in the temporomandibular joints (or TMJ) which are located where the jaw meets the ear. If the muscles around the jaw go into spasm or develop trigger points, this, too, can cause sinus symptoms, a sore throat, throat clearing, and clogged "itchy" ears.

The large and powerful sternocleidomastoid muscles which sit bilaterally at the front of the neck can also produce allergic-like symptoms. Myofascial trigger points in these muscles can cause nasal discharge, congestion in the maxillary sinuses, a chronic sore throat or cough, and even dizziness or dysequilibrium.² Unlike other types of rhinitis, upper respiratory symptoms which are triggered by excessive muscle spasm or TMJ can often be helped by treating the underlying disorder.

Many individuals with FM experience a different sort of phenomenon than that described above. Simply stated, we become sensitive to a variety of elements in our environment: perfumes, tobacco smoke, odors/fumes, foods, medications, and even changes in weather or humidity. Our friends and relatives may label us fussy or neurotic, but the reaction is real and is aptly called "irritant rhinitis". Although the exact mechanism which causes it is still unknown, irritant rhinitis is thought to be the result of overly sensitive nerves and nerve reflexes,^3,4 perhaps similar to the hyperactive central nervous system response which causes the brain/body to overreact to other sensory stimuli with FM, such as noise, light, and touch.

Irritant rhinitis is problematic for another reason. Not only are its symptoms annoying and even debilitating when severe, they are also exceedingly difficult to treat. Unlike its cousin, allergic rhinitis, whose immune responses and inflammation can at least be countermanded with antihistamines and anti-inflammatory medications, irritant rhinitis has no obvious antidote other than avoidance of the offending stimulus. In a society where we are often bombarded with environmental stimuli, this is not always practical or possible. While medications can be prescribed to control severe bouts of irritant rhinitis, it is simply not safe to take them day after day to manage chronic symptoms. For example, prolonged use of nasal decongestants can cause rebound symptoms which are more problematic than the original complaint.⁵ In addition, persistent coughing can aggravate already sore chest/back muscles and worsen symptoms of gastrointestinal (acid) reflux in FM patients.

The good news is that environmental sensitivity in FM is finally being taken more seriously by medical science, and new research on irritant rhinitis is beginning to take place, largely at Georgetown University Medical Center in Washington, DC. In a 1998 study published in the American Journal of Rhinology, Baraniuk, Clauw, Yuta, et al., compared 27 non-allergic patients who had both FM and chronic fatigue syndrome (CFS) to three control groups consisting of seven allergic rhinitis patients, seven cystic fibrosis patients, and nine healthy subjects.⁶ Their goal was to compare the nasal secretions of the FM/CFS group to each of the other control groups and determine the extent to which there was evidence of inflammation or allergy. Although both the FM/CFS group and the allergic rhinitis group had comparable symptoms and severity of complaints which were much greater than those of the healthy controls, there were no significant differences between the nasal secretions of the FM/CFS group and the healthy controls. In short, the study confirmed that while non-allergic FM/CFS patients can have the same type/severity of allergy symptoms as those with true allergies, their bodies don't exhibit the immune or inflammatory response the way those with allergy or cystic fibrosis do.

In a larger study funded by the Environmental Protection Agency and the Public Health Service and published in 2000 in the Journal of Chronic Fatigue Syndrome, Baraniuk, Naranch, et al., studied 114 CFS patients and 120 controls.⁷ They used a Rhinitis Score which measured the severity of ten different symptoms in study subjects on a five-point scale: itchy nose, sneezing, runny nose, congestion/fullness, generalized headache, facial pain, blowing out of thick mucus, postnasal drip, throat clearing, and hoarse voice. They also developed an Irritant Rhinitis Score (IRS) which measured on a five-point scale the severity of nasal congestion and mucus secretion provoked by nine different variables: humidity/weather changes, cold air, air conditioning, perfume, strong smells/odors/fumes, tobacco smoke, beer/wine, emotions/stress, or other irritants. Subjects were also tested for allergy with prick skin tests and were measured for multiple chemical sensitivity using a questionnaire containing 25 separate items.

What the investigators found was that irritant rhinitis, as defined by the IRS, was present in 47% of CFS subjects compared to only 11% of controls.⁸ They also discovered that three categories of irritants caused significant congestion and rhinorrhea (i.e., excessive nasal mucus secretion): tobacco smoke, perfumes/odors/fumes, and humidity/weather changes/cold air. In addition, they found that those CFS subjects who had positive IRS scores (i.e., severe reactions to many different irritants) also tended to experience significantly more fatigue than those who had lower scores.^{9, 10} The investigators noted that while each of the irritants might be capable of triggering defensive responses (i.e., mucus formation) in anyone, the question one must ask is why persons with CFS and Multiple Chemical Sensitivity have heightened or prolonged responses compared to normal controls. They further hypothesized that the body mechanisms involved in irritant rhinitis probably operated through the activation of various nerves but suggested that this topic would need to be studied in much greater detail.¹¹

So what can persons with fibromyalgia do in the meantime? If you have persistent rhinitis which has never been evaluated by a medical professional, consider consulting an allergist, preferably one who is also familiar with FM. (S)he has several ways of testing you to determine whether you are allergic or non-allergic and can prescribe medication to help you endure severe attacks. If you feel your symptoms are induced by TMJ or myofascial pain/trigger points in the face, head, or neck, ask your physician to refer you to a TMJ specialist or an appropriate physical therapist for further evaluation and treatment. Non-allergic rhinitis is a part of FM for many people, but relief is available if you know where to find it.

REFERENCES

1. Shankland W with J Boyd and D Starlanyl. Face the Pain: The Challenges of Facial Pain, Columbus (OH): AOmega Publishing Co., p.149.

2. Starlanyl D. The Fibromyalgia Advocate: Getting the Support You Need to Cope with Fibromyalgia and Myofascial Pain Syndrome, Oakland (CA): New Harbinger Publications, Inc., 1998, p. 115.

3. Baraniuk JN. Presentation to the National Fibromyalgia Partnership, Inc., July 1995.

4. See also, Bell IR, Baldwin CM, and Schwartz GE."Illness from Low Levels of Environmental Chemicals: Relevance to Chronic Fatigue Syndrome and Fibromyalgia," Am J Med (1998 Sept 28) 105(3A), 74S-82S.

5. Ibid, Baraniuk.

6. Baraniuk JN, Clauw DJ, et al. "Nasal Secretion Analysis in Allergic Rhinitis, Cystic Fibrosis, and Non-allergic Fibromyalgia/Chronic Fatigue Syndrome Subjects," American Journal of Rhinology, Vol. 12, No. 6, November-December 1998, pp. 435-440.

7. Baraniuk JN, Naranch K, Maibach H, and Clauw DJ. "Irritant Rhinitis in Allergic, Non-allergic, Control, and Chronic Fatigue Syndrome Populations," Journal of Chronic Fatigue Syndrome, Vol. 7, #2, 2000, pp. 3-31.

8. Ibid, p. 12.

9. Ibid, p. 24.

10. Ibid, p. 15.

11. Ibid, pp. 24-29.

Reprinted from Fibromyalgia Frontiers (2001, Vol. 9 #1),

the official quarterly journal of the National Fibromyalgia Partnership.