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Rhinorrhea in Parkinson's disease by Joseph H. Friedman, MD

Rhinorrhea in Parkinson's disease by Joseph H. Friedman, MD

Rhinorrhea is the technical term for runny nose. It literally means "fluid from the nose" and can refer to anything flowing from it. Carol Jacques, the nurse practitioner who worked with me for several years, pointed out many years ago that a lot of our patients with Parkinson's disease had a runny nose. I didn't think much of it. She found that a nasal spray worked very well and she'd prescribe it, with wonderful results. I patted her on the back and paid little attention.

Last year one of my patients, who had fairly advanced PD said, "I can tolerate the problem with walking, but what really bothers me is that my nose is always running and it gets so bad when I eat that I can't eat in front of anyone because it drips into my food." So I prescribed the drug Carol told me worked, and it did, but more importantly, I got to wondering how common a problem this was. Clearly it wasn't life threatening, and it didn't cause "serious" problems like falls, aspirating (liquid or food going down the windpipe into the lungs, or inappropriate behavior), but it could be just as bothersome as bad tremors. So I did a search on Pubmed, the list of all medical and publications, and found nothing. I then called an otolaryngologist (ear nose throat specialist) who told me that "we see it all the time," but wasn't aware of any description of it in the medical literature. And when I looked into the medical literature on rhinorrhea, PD wasn't listed as a cause. My PD colleagues hadn't heard of it either.

At this point I decided to do a study. Better late than never.I simply compared people with PD to people without PD to determine if runny nose was more common in PD. After all, if rhinorrhea is common in PD, it also may be common in older folks in general, just like constipation or arthritis.

In our first study, runny nose was five times as common in PD than in people without PD of the same age! Rhinorrhea affected half of people with PD! So we did another study. At the May symposium of the RIPSA I gave out questionnaires for people with PD and people without PD to fill out. This time rhinorrhea was only twice as common, but still affected about half the PD patients, and again, the results were statistically significant.

Our third study was to find out if the runny nose occurred early in the disease, or later, and check that it wasn't related to medications for PD. Apomorphine (Apokyne), for example, can cause yawning and runny nose, which the other PD medications aren't known to do. We asked consecutive, newly diagnosed PD patients, who weren't taking any medications for PD, and found out that they had runny noses, just like the original group, 50% again.

This raised another question. There has been a lot of interest in the last several years in finding "pre-motor" symptoms of PD. That is, identifying people with PD even before they have their first symptom of tremor, slowness, stiffness or anything else like that. If we finally find a medicine that will slow the progression, then if we can identify people who have PD before they have movement problems, maybe we will prevent them, or at least forestall them. There are few markers found so far that suggest that PD will devleop, but only one is useful. This is a peculiar and rare type of sleep disorder (REM sleep behavior disorder) which is common in PD but rare outside of PD, and which may develop years before the first movement symptom of PD. Another one involves reduced smell but this is less useful because it is such a common problem. PD patients have reduced smell abilities, and this often occurs years before any evidence of PD emerges, but reduced smell is common in elderly people, and also occurs early in Alzheimer's disease, after head injuries, in people who smoke and people with allergies or sinus conditions. Therefore the presence of rhinorrhea might be another useful tip off of developing PD. In addition, it raises the question of whether the rhinorrhea may be causing the smell problem in PD patients. Although there are brain changes that explain reduced smell in PD, it still could be the case that some of the problem is due to an excessively moist nose.

In our studies we've had conflicting results about the connection between smell and runny nose, so we don't know whether runny nose interferes with smell or not. 

We are hoping to extend our study to see if the problem of rhinorrhea affects all of PD patients in the US or whether it is only a Rhode Island problem, possibly due to something in the air. As Yogi Berra said, "You can see a lot just by looking." Keep tuned.



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