Allergic/Non-allergic (Vasomotor) Rhinitis
Nasal symptoms: Itching, sneezing, clear watery discharge or blockage, post-nasal drainage
Associated Conditions: Coughing secondary to post nasal drip, sore throat, mouth breathing, loss of smell, loss of taste, or poor sleeping patterns (fatigue), nasal polyps, asthma, sinusitis
Evaluation: History and physical, skin testing, rhinoscopy, spirometry (to rule out the co-existence of asthma), X-ray of the sinuses or Sinus CAT-scan
Triggers:
- Allergens
- Irritants: The most common form of non-allergic rhinitis is called “vasomotor rhinitis”. For these patients, irritants, rather than allergens, are the major triggers.
- Infections: Chronic sinus infections due to bacteria, viruses, or fungi
- Gastro-esophageal reflux
Treatment:
- Avoidance of allergens ( mites, smoke, molds, foods, etc)
- Rinsing of nasal cavity by salt water solution: Ocean spray, Sinus rinse
- Drugs:
- Rescue medicines: For immediate relief.
- Antihistamines -Primarily for drying the nose
- Long-acting (Non-sedating): Allegra, Claritin, Clarinex, Zyrtec
- Short-acting (sedating): Benadryl, Atarax
- Nasal spray; Astelin, Patanse
- Decongestant nose drops or spray: Afrin, Neosinephrine: Frequent use of nasal sprays can cause rebound congestion. Please do not use these sprays more than 3 days a week.
- Oral decongestant: Sudafed
- Combination of antihistamines and decongestants: Dymsita
- Controller: For long-term control of the symptoms
- Nasal steroid inhalers: Flonase, Nasonex, Rhinocort, Vancenase, Qnasal, Zetonna, etc
- Nasal Cromalyn inhalers
- Oral steroids: Predinisone tablets, Medral pack
- Allergen injection therapy: Effective in the majority of patients with allergic rhinitis as a long-term therapy
Sinusitis
Symptoms:
- Acute sinusitis: facial pain, purulent discharge, cough, fever, lethargy.
- Chronic sinusitis: Persistent coughing may be the major, sometimes the only symptom. Other symptoms include discolored nasal discharge, tiredness, postnasal discharge worsening of an underlying condition such as asthma, loss of smell sensation
Associated conditions: asthma, allergic rhinitis, gastro-esophageal enteritis, immunodeficiency ( for recurrent sinusitis)
Causes:
- Bacterial infections of upper airway: Streptococcus pneumoniae, Hemophilus influenza, & Moraxella catarrhalis are the most common pathogens. In order to get the organism, one has to get inside the cavity by puncturing it. The culture of the nasal cavity is useless because they are contaminated by resident bacteria (~25 %-40% of us have Strep. Pneumoniae in our nasal cavity.
- Viral infection of the nose often lead to bacterial infections
- Gastro-esophageal reflux can lead to chronic sinusitis
- In rare cases ( when patients are immunologically compromised), fungi can infect the sinus cavity
- If patients have frequent or persistent sinusitis, immune deficiency should be ruled out
- Recent animal studies show that lack of normal bacteria in the nasal linings may be associated with chronic sinusitis (Susan Lynch, UCSF: Microbial spray into the nasal cavity may be beneficial?)
Diagnosis
- Sinus CAT scan is the gold standard
- Rhinoscopy: Nose and pharynx can be inspected to see the drainage and inflammatory changes.
Treatment:
- Nasal rinse:
- Salt water solution is sprayed or squirted to the nose, twice a day.
- ¼-1/2 teaspoonful of sea salt and a pinch of baking soda in 8 oz of warm(body temperature) water.
- Ready-made salt packages are sold in pharmacies.
- Antibiotics:
- Acute infection: for 2 Wks
- Chronic or recurrent infection: 4-6 wks or until the infection subsides.
- Steroid: may help decrease the inflammation of sinus and nasal cavity and increase the drainage
- Surgery: If patients do not respond to medical therapy, sinus surgery may be considered. However, without treatment of underlying conditions, sinusitis may recur.
Nasal Polys
Symptoms: Nasal congestion and other symptoms of rhinitis. Most often nasal polyps are associated with chronic rhinosinusitis. The patient may be allergic, but more commonly not allergic.
Associated conditions: asthma, rhinitis, sinusitis, cystic fibrosis ( in children), aspirin-sensitivity
Treatment:
- Surgery: If underlying conditions are not treated, polyps tend to grow back
- Medical treatment:
- Burst of oral steroid initially
- Nasal steroid
- Sinus rinsed: 1 vial of 0.5 mg Pulmicort vials can be mixed with the salt pack in 2 oz water. Apply once with the head tilted back while lying flat on the back and let it soak for a few minutes
- Anti-leukotriene drugs such as Singulair and Ziflo (which is gaining popularity again ) orally
- Singulair nasal spray; Four of 10 mg tablets are crushed and dissolved in 1 oz of lukewarm water and sprayed once to each nostril every day
- Omalizumab(Xolair): one to several injections may decrease the polyp size for several months.
Asprin (ASA) Included Respiratory Illness
Symptoms: ASA and other nonsteroidal anti-inflammatory drugs may induce asthma, rhinitis, nasal polyps (Sampter’s Triad), or urticaria. The subject is very complicated and you need to ask Dr. Song for further information. You may avoid the drugs or maybe desensitized at his office over three day period and stay on ASA for a long time to have your symptoms under control;
