ENT Conditions

Nose

• Sinusitis
• 20 Questions and Answers About Your Sinuses
• Snoring/Sleep Apnoea
• Allergic Rhinitis
• Nose bleeds
• What is Post-Nasal Drip?

:: Sinusitis

Septoplasty

Patients often become confused between what is an allergic reaction and the symptoms of sinusitis or rhinitis and therefore often treat the wrong problem, a misdiagnosis. The most common mistake that people make is blaming everything on allergies. Problems arising from allergic rhinitis are certainly very common, but all too often those with acute or chronic nasal infections have been treating allergies. The point is, it is easy to be mistaken about the underlying problem and if you treat the wrong problem, you will not likely get the best relief.

The symptoms of allergic rhinitis may mimic those of sinusitis or a viral respiratory tract infection (the common cold). The table below serves as a guideline to differentiate between the signs and symptoms of these common conditions.

Sinusitis/Sinus Headaches

Not every headache is the consequence of sinus and nasal passage problems. For example, many patients visit an ear, nose, and throat specialist to seek treatment for a sinus headache and learn they actually have a migraine or tension headache. The confusion is common, a migraine can cause irritation of the trigeminal or fifth cranial nerve (with branches in the forehead, cheeks and jaw). This may produce pain at the lower-end branches of the nerve, in or near the sinus cavity.

Symptoms of sinusitis

Pain in the sinus area does not automatically mean that you have a sinus disorder. On the other hand, sinus and nasal passages can become inflamed leading to a headache. Headache is one of the key symptoms of patients diagnosed with acute or chronic sinusitis. In addition to a headache, sinusitis patients often complain of:

• Pain and pressure around the eyes, across the cheeks and the forehead
• Achy feeling in the upper teeth
• Fever and chills
• Facial swelling
• Nasal stuffiness
• Yellow or green discharge

However, it is important to note that there are some cases of headaches related to chronic sinusitis without other upper respiratory symptoms. This suggests that an examination for sinusitis be considered when treatment for a migraine or other headache disorder is unsuccessful. 

Treatment for a sinus headache

Sinus headaches are associated with a swelling of the membranes lining the sinuses (spaces adjacent to the nasal passages). Pain occurs in the affected region – the result of air, pus, and mucus being trapped within the obstructed sinuses. The discomfort often occurs under the eye and in the upper teeth (disguised as a headache or toothache). Sinus headaches tend to worsen as you bend forward or lie down. The key to relieving the symptoms is to reduce sinus swelling and inflammation and facilitate mucous drainage from the sinuses.

There are several at-home steps that help prevent sinus headache or alleviate its pain. They include:

• Breathe moist air: Relief for a sinus headache can be achieved by humidifying the dry air environment. This can be done by using a steam vaporizer or cool-mist humidifier, steam from a basin of hot water, or steam from a hot shower.
• Alternate hot and cold compresses: Place a hot compress across your sinuses for three minutes, and then a cold compress for 30 seconds. Repeat this procedure three times per treatment, two to six times a day.
• Nasal irrigation: Some believe that when nasal irrigation or rinse is performed, mucus, allergy creating particles and irritants such as pollens, dust particles, pollutants and bacteria are washed away, reducing the inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better and will reduce the symptoms. Nasal irrigation helps shrink the sinus membranes and thus increases drainage. There are several over-the-counter nasal rinse products available. Consult your ear, nose, and throat specialist for directions on making a home nasal rinse or irrigation solution.
• Over-the-counter medications: Some over-the-counter (OTC) drugs are highly effective in reducing sinus headache pain. The primary ingredient in most OTC pain relievers is aspirin, acetaminophen, ibuprofen, naproxen, or a combination of them. The best way to choose a pain reliever is by determining which of these ingredients works best for you. Discussion with your pharmacist can help here.
• Decongestants: Sinus pressure headaches caused by allergies are usually treated with decongestants and antihistamines. In difficult cases, nasal steroid sprays may be recommended.
• Alternative medicine: Chinese herbalists use Magnolia Flower as a remedy for clogged sinus and nasal passages. In conjunction with other herbs, such as angelica, mint, and chrysanthemum, it is often recommended for upper respiratory tract infections and sinus headaches, although its effectiveness for these problems has not been scientifically confirmed.

If none of these preventative measures or treatments is effective, a visit to an ear, nose, and throat specialist may be warranted. During the examination, a flexible nasendoscope will usually be used to inspect the status of your nose and sinuses. A CT scan of the sinuses may be ordered to determine the extent of blockage caused by chronic sinusitis. If no chronic sinusitis were found, treatment might then include allergy testing and desensitization (allergy shots). Acute sinusitis is treated with antibiotics and decongestants. If antibiotics fail to relieve the chronic sinusitis and accompanying headaches, endoscopic or image-guided surgery may be the recommended treatment.

Only with an appropriate history of long term problems, and a CT scan showing changes of chronic sinusitis, is a diagnosis certain. Even then there are several types of chronic sinusitis, and they are treated differently. These are

• Chronic bacterial sinusitis
• Variations of Allergic fungal sinusitis
• Anatomic chronic sinusitis

In some cases, even after examination and CT scan, it can be difficult to know the underlying process causing chronic sinusitis.

So how is it treated, and can any over the counter treatments be helpful?

It is important to remember that chronic sinusitis is a disease spectrum from fairly minor symptoms, to persistent severe symptoms. It is also important to remember that chronic sinusitis is usually not dangerous. People can live their whole lives with chronic sinusitis, most would rather not have to.

Over the counter medicines such as pseudoephedrine and codeine/paracetamol help with the symptoms of pain and congestion. The occasional use of decongestant type sprays (Drixine, Otrovin) can relieve flare ups of congestion and pain, but should only be used four sprays a day 5 to 7 days total, alternate sides to get the most out of this limited use medicine. Saline nasal sprays, such as FESS, Sterimar or better saline rinses such as Flo can be helpful to relieve some symptoms. You can purchase these from most major pharmacy stores in Australia.

What can Dr Mooney do to help sinusitis?

An ENT doctor is very familiar with chronic sinusitis, it is an unfortunately common problem. Initially a decision will be made to treat or to confirm the diagnosis with a CT scan.

Treatment begins with maximizing medicines: steroid nasal sprays, sometimes decongestants, sometimes oral steroids, leukotriene receptor antagonist and long duration broad spectrum antibiotics. Depending on the symptoms, duration, and physical exam; antibiotics and other medicines may be used for 3 to 5 weeks.

At that point, a decision is made to confirm resolution of the process by obtaining a CT scan, or if things are going well, to see how symptoms progress over time.

Assume that at the end of the first regimen of antibiotics a CT is decided on. If it shows significant persistent sinus disease, a decision is made as to if another long round of antibiotic might be helpful, perhaps oral steroids, or other medicine changes. Some findings at this juncture would suggest that the problem will likely not be remedied by further medicines and some type of surgical intervention should be discussed. Obstructing cysts, allergic fungal disease, significant polyps, anatomic obstructions, prominent disease despite adequate medicines are the common findings that may benefit from surgical intervention.

Allergic Rhinitis

Nasal Septal Deviations

Nasal septal deviations are common. In fact, it is rare to see a perfectly straight nasal septum. Septal deviations do not always cause problems. The main problem that is commonly caused by a septal deviation is airway obstruction. Nasal septal deviations
can also cause sinus pain and contribute to infections.

The most common problem arising from nasal septal deviations is that you just can't breath well through your nose. This is especially likely to bother people at night. It is
not usually clear that the problem is entirely from the septal deviation.

For many symptomatic deviations, the only effective treatment is surgery.

Medical treatment for nasal septal deviations

Nasal steroids sprays are the best medical treatment for problems associated with nasal septal deviations. These medicines do not change the position of the crooked bone or cartilage, but they do reduce the thickness of the mucous membranes and allow a bit more room for airflow. Shrinking the mucous membranes can also be helpful when contact points cause sinus pain or pressure.

Dr Mooney prescribes a steroid spray and recommends you use 2 squirts in each side of your nose before bed every night. Sometimes it is all that is needed to tip the scale in your favor. Give this type of medicine about a week before drawing any conclusion about its effectiveness.

If the problem is more intermittent, you should get a decongestant spray, such as      dump half of the bottle out, fill with a saline nasal spray, such as      to dilute this in half. You can use this diluted decongestant spray sparingly and not have a great chance of developing the rebound phenomenon. You can use it at full strength, but it works fine at 1/2 strength, and you can us it longer before it causes problems. I would guess that if you could limit yourself to 8 total pumps per week of 1/2 strength, you will be OK even for the long haul. Try treating just one side each night, alternating, and see if that can allow you to get more total comfort out of this medicine despite its limitations. Beware the urge to use it more frequently, people end up with worse nasal congestion if they exceed a certain amount of use.

If this problem is every night and day, then you need to see a specialist. Sometimes, simple minor procedures done in the consulting room can relieve the problem, other times minor outpatient surgical procedures are needed. Trouble breathing through the nose is the symptom that is most reliably correctable if surgery is needed.

Surgery for deviated nasal septum (septoplasty) - When is it needed?

The wall the separates the left and right sides of your nose is called the nasal septum. In the front of your nose it is made of flexible cartilage. Farther back in your nose, it is made of bone. Almost no one has a perfectly straight nasal septum. Minor abnormalities are very common and usually don't cause any problems.

People benefit from a septoplasty when they have:

• a significant nasal septal abnormality
• symptoms that typically result from nasal septal deviations
• medications have not adequately relieved the symptoms

The most common reason for a septoplasty is when a patient doesn't breath well though one or both sides of the nose. When a significant deviation is present, correcting this abnormality can improve the airflow.

When a nasal septal deviation interferes with sinus drainage, it can be a contributor to repeated infections or chronic infections. In conjunction with endoscopic sinus surgery, correcting significant septal deviations can help improve drainage. In some cases it is necessary to correct septal deviations during sinus surgery simply to help access the sinus cavities.

Sinus pain can be caused when the septum is deviated such that it touches the side wall of the nose or indents one of the turbinates. Pain from a septal deviation may be felt in the ear or on the side of the face or near the eye.

Surgery for deviated nasal septum - How is it performed?

The nasal septum is made of cartilage in the front and bone deeper in the nose. Each side is also covered by the mucous membrane on the surface. A small incision is made through the covering layers near the front where you can touch with your finger. In some cases, an endoscope is used to begin the operation farther back, skipping over the front part if it is not crooked. Special instruments are used to lift up the membranes and to access the crooked area of the bone or cartilage directly. All of the work takes place with an attempt made to avoid making any unwanted holes in the mucous membrane that covers the septum.

Once certain crooked portions are removed and others are repositioned and special straightening techniques are used, then the covering layers are returned to their original position. Dissolvable sutures are used to sew the membranes down to the septal bone and cartilage. In some cases, it is necessary to place foam type material in the nasal passages on each side. This places additional pressure on the membranes so that they will heal down to the bone/cartilage. This "packing" may stay from 1 to 3 nights. If the membranes do not heal directly to the septal bone, blood can accumulate under the layers which is not very good for the healing process.

The best method of determining your personal options is to schedule a personal consultation with Dr. Mooney. He will be able to answer specific questions related to your situation.

:: 20 Questions and Answers About Your Sinuses

Q. How common is sinusitis?

A. More than 3 million Australians suffer from at least one episode of acute sinusitis each year. The prevalence of sinusitis has soared in the last decade due to increased pollution, urban sprawl, and increased resistance to antibiotics.

Q. What is sinusitis?

A. Sinusitis is an inflammation of the membrane lining of any sinus. Acute sinusitis is a short-term condition that responds well to antibiotics and decongestants; chronic sinusitis is characterized by at least four recurrences of acute sinusitis, or symptoms present for more than three months continually. Either medication or surgery is a possible treatment.

Q. What are the signs and symptoms of acute sinusitis?

A. For acute sinusitis, symptoms include facial pain/pressure, nasal obstruction, nasal discharge, diminished sense of smell, and cough (not due to asthma in children). Additionally, sufferers of this disorder could incur fever, bad breath, fatigue, dental pain, and cough (in adults). Acute sinusitis can last four weeks or more. This condition may be present when the patient has two or more symptoms and/or the presence of thick, green or yellow nasal discharge. Acute bacterial infection might be present when symptoms worsen after five days, persist after ten days, or the severity of symptoms is out of proportion to those normally associated with a viral infection.

Q. How is acute sinusitis treated?

A. Acute sinusitis is generally treated with 10 to 14 days of antibiotic care. With treatment, the symptoms disappear and antibiotics are no longer required for that episode. Oral and topical decongestants also may be prescribed to alleviate the symptoms.

Q. What are the signs and symptoms of chronic sinusitis?

A. Victims of chronic sinusitis may have the following symptoms for 12 weeks or more: facial pain/pressure, facial congestion/fullness, nasal obstruction/ blockage, thick nasal discharge/ discolored post-nasal drainage, pus in the nasal cavity, and at times, fever. They may also have headache, bad breath, and fatigue.

Q. What measures can be taken at home to relieve sinus pain?

A. Warm moist air may alleviate sinus congestion. A vaporizer or steam from a pan of boiled water (removed from the heat) are both recommended (humidifiers should have a clear filter to preclude spraying bacteria or fungal spores into the air). Warm compresses can be useful in relieving pain in the nose and sinuses. Saline nose drops are safe for use at home.

Q. How effective are non-prescription nose drops or sprays?

A. Use of non-prescription drops or sprays might help control symptoms. However, non-prescription drops should not be used beyond their label recommendation.

Q. How does a physician determine the best treatment for acute or chronic sinusitis?

A. To obtain the best treatment option, the physician needs to properly assess the patient's history and symptoms and then progress through a structured physical examination.

Q. What should one expect during the physical examination for sinusitis?

A. At a specialist's office, the patient will receive a thorough ear, nose, and throat examination. During that physical examination, the physician will explore the facial features where swelling and erythema (redness of the skin) over the cheekbone can exist. Facial swelling and redness are generally worse in the morning; as the patient remains upright, the symptoms gradually improve. The physician may feel and press the sinuses for tenderness. Additionally, the physician may tap the teeth to help identify an inflamed paranasal sinus. Attention is then turned to nasal examination; the surgeon will inspect the nose cavity and may use a flexible endoscope.

Q. What other diagnostic procedures might be taken?

A. Other diagnostic tests may include a study of a mucus culture, endoscopy, x-rays, allergy testing, or CT scan of the sinuses.

Q. What is nasal endoscopy?

A. An endoscope is a special fiberoptic instrument for the examination of the interior of a canal or hollow viscus. It allows a visual examination of the nose and sinus drainage areas. It is an simple and painless examination that can be performed with the patient awake.

Q. Why does a physician specialist carry out nasal endoscopy?

A Nasal endoscopy offers the physician specialist a reliable, visual view of all the accessible areas of the sinus drainage pathways. First, the patient's nasal cavity is anesthetized; a rigid or flexible endoscope is then placed in a position to view the structure of the nasal cavity. The procedure is utilized to observe signs of obstruction as well as detect nasal polyps hidden from routine nasal examination. During the endoscopic examination, the physician specialist also looks for pus as well as polyp formation and structural abnormalities that will cause the patient to suffer from recurrent sinusitis.

Q. What course of treatment will the physician recommend?

A. To reduce congestion, the physician may prescribe nasal sprays, nose drops, or oral decongestants. Antibiotics will be prescribed for any bacterial infection found in the sinuses (antibiotics are not effective against a viral infection). Antihistamines may be recommended for the treatment of allergies. Antifungal medicine will be the treatment for any fungal infection.

Q. Will any changes in lifestyle be suggested during treatment?

A. Smoking is never condoned, but if one has the habit, it is important to refrain during treatment for sinus problems. A special diet is not required, but drinking extra fluids helps to thin mucus.

Q. When is sinus surgery necessary?

A. Mucus is developed by the body to act as a lubricant. In the sinus cavities, the lubricant is moved across mucous membrane linings toward the opening of each sinus by millions of cilia (a mobile extension of a cell). Inflammation from an allergy causes membrane swelling and the sinus opening to narrow, thereby blocking mucus movement. If antibiotics are not effective, sinus surgery can correct the problem.

Q. What does the surgical procedure entail?

A. The basic endoscopic surgical procedure is performed under general anesthesia. The patient returns to normal activities within about a week; full recovery takes about four weeks.

Q. What does sinus surgery accomplish?

A. The surgery should enlarge the natural opening to the sinuses, leaving as many cilia in place as possible. Otolaryngologist-head and neck surgeons have found endoscopic surgery to be highly effective in restoring normal functioning to the sinuses. The procedure removes areas of obstruction, resulting in the normal flow of mucus.

Q. What are the consequences of not treating infected sinuses?

A. Not seeking treatment for sinusitis will result in unnecessary pain and discomfort. In rare circumstances, meningitis or brain abscess and infection of the bone or bone marrow can occur. Abscesses and infection can affect the eye also.

Q. Where should sinus pain sufferers seek treatment?

A. If you suffer from severe sinus pain, you should seek treatment from a physician who can treat your condition with medical and/or surgical remedies.

With thanks to American Academy of Otolaryngology-Head and Neck Surgery

:: Snoring/Sleep Apnoea

What is sleep apnoea (snoring)?

During sleep all the body's muscles become less active and more floppy. In most parts of the body this does not matter and indeed helps one to relax and sleep comfortably. When the muscles that help hold open the throat behind the tongue relax, this leads to partial collapse and narrowing in this area. Even in normal people this increases the resistance to the flow of air when breathing in, but this is usually of no significance. When this narrowing that occurs with sleep is more than normal, then the airway behind the tongue collapses much more. To start with, this causes snoring and then, when the collapse is complete, it causes apnoea, which means "without breath" - actually stopping breathing. Fortunately, the body is able to sense this increased obstruction to breathing (thank goodness it does!) and the sufferer wakes briefly, before suffocation can occur, takes a few deep breaths, followed by a rapid return to sleep. This obstruction and waking often becomes a continuous cycle, every minute or so, that can go on hundreds of times a night, every night. Usually though, the individual does not remember all these episodes of waking.

What causes sleep apnoea (snoring)?

The things that cause sleep apnoea do so by increasing the normal narrowing of the throat during sleep. Anything that makes the throat narrower to start with (for example enlarged tonsils or a set-back lower jaw) means that it is easy for the throat to close off a bit more and block the airway. A partially blocked nose generates lower pressures in the throat whilst taking a breath in, which tends to suck the walls of the throat together. Probably the most important factor is being overweight with a big neck. Extra fat in the neck squashes the throat from outside, particularly when the throat muscles become floppier with sleep.

Who gets sleep apnoea (snoring)?

The most common sufferer of heavy snoring and sleep apnoea is a middle-aged man who is overweight with a big neck. However there are many patients with sleep apnoea who are not particularly overweight. In some patients we simply do not understand why they have sleep apnoea. In children the commonest cause is enlarged tonsils. Today sleep apnoea is a common reason for recommending that a young child has a tonsillectomy. Sleep apnoea and heavy snoring, severe enough to interfere with sleep quality, is probably much more common than is realised. At least three in every thousand men have severe sleep apnoea.

Symptoms of sleep apnoea (snoring)

Because sleep can be so disrupted by the body having to wake up briefly to reverse the upper airway obstruction, sufferers experience severe daytime sleepiness. To start with this occurs only during potentially boring activities such as reading, watching television or driving on motorways. However when the sleepiness gets worse it begins to interfere with most activities, with patients falling asleep talking or eating sometimes. Snoring will usually have been present for many years, and have gone well beyond a joke within the family. There are many other symptoms that one would predict in someone seriously sleep deprived (irritability for example) but the twin symptoms of snoring and daytime sleepiness are the best pointers to the diagnosis.

Treatment

When sleep apnoea (and snoring) are not severe then simple approaches can help. Losing some weight, not drinking alcohol after 6.00 pm (alcohol relaxes the upper airway muscles even more), keeping the nose as clear as possible, and sleeping on one's side or semi-propped up can all help. There are also now simple dental devices which can be worn at night, some of which are like sports-type gum shields, that can greatly reduce snoring. When snoring is very objectionable, with the patient and the patient's partner is desperate for a solution, then an operation on the back of the throat may help as a last resort.

Surgery

While making lifestyle changes should be the first step in treating your snoring, these measures are not always effective. If that is the case, you might want to consider a form of surgery called laser-assisted uvulopalatoplasty (LAUP). This relatively new procedure has been found to stop or reduce snoring in most people.

LAUP involves removal of excess tissue from your soft palate and uvula with a small, hand-held laser. The operation makes your airway larger, so vibrations are decreased. The procedure is performed under a local anaesthetic and takes about 30 minutes. Depending on the severity of your snoring, you may need more than one session - some people may need up to five or six sessions before their snoring is improved. If you need multiple treatments, they will likely be spaced four to six weeks apart.

In general, this surgery does not have serious side effects and you can continue your regular activities immediately after the procedure. Some people may have a sore throat for about one week. In a very few cases, laser surgery can raise or lower the pitch of the voice. Before you decide on laser surgery, talk it over with your doctor.

There are also several other surgical options for sleep apnoea, depending on the cause:

• If your sleep apnoea is caused by a jaw deformity, an operation to correct the deformity (which usually involves lengthening of the jaw bone) will be performed. This is successful in most people.
• If no cause can be found for your sleep apnoea and it is not considered to be life-threatening, a procedure called uvulopalatopharyngoplasty (UPPP) can be performed, where a surgeon trims and tightens throat tissues while you are under a general anaesthetic. However, this procedure has only a 30-50% success rate and can affect your ability to have CPAP therapy at a later date.

If your sleep apnoea is caused by large tonsils and/or adenoids, these can be removed in a simple operation called a tonsillectomy or adenoidectomy.

:: Allergic Rhinitis

Allergic rhinitis, more commonly referred to as hay fever, is an inflammation of the nasal passages caused by allergic reaction to airborne substances.

There are two types of allergic rhinitis: seasonal and perennial. Seasonal AR occurs in the spring, summer, and early fall, when airborne plant pollens are at their highest levels. In fact, the term hay fever is really a misnomer, since allergy to grass pollen is only one cause of symptoms for most people. Perennial AR occurs all year and is usually caused by home or workplace airborne pollutants. A person can be affected by one or both types. Symptoms of seasonal AR are worst after being outdoors, while symptoms of perennial AR are often worst after spending time indoors.

Both types of allergies can develop at any age, although onset in childhood through early adulthood is most common. Although allergy to a particular substance is not inherited, increased allergic sensitivity may "run in the family." While allergies can improve on their own over time, they can also become worse over time.

Causes and symptoms

Causes

Allergic rhinitis is a type of immune reaction. Normally, the immune system responds to foreign microorganisms, or particles, like pollen or dust, by producing specific proteins, called antibodies, that are capable of binding to identifying molecules, or antigens, on the foreign particle. This reaction between antibody and antigen sets off a series of reactions designed to protect the body from infection. Sometimes, this same series of reactions is triggered by harmless, everyday substances. This is the condition known as allergy, and the offending substance is called an allergen.

The number of possible airborne allergens is enormous. Seasonal AR is most commonly caused by grass and tree pollens, since their pollen is produced in large amounts and is dispersed by the wind. Showy flowers, like roses or lilacs, that attract insects produce a sticky pollen which is less likely to become airborne. Different plants release their pollen at different times of the year, so seasonal AR sufferers may be most affected in spring, summer, or fall, depending on which plants provoke a response. The amount of pollen in the air is reflected in the pollen count, often broadcast on the daily news during allergy season. Pollen counts tend to be lower after a good rain that washes the pollen out of the air and higher on warm, dry, windy days.

Perennial AR is often triggered by house dust, a complicated mixture of airborne particles, many of which are potent allergens.

Other potential causes of perennial allergic rhinitis include the following:

• cigarette smoke
• perfume
• cosmetics
• cleansers
• copier chemicals
• industrial chemicals
• construction material gases

Symptoms

Inflammation of the nose, or rhinitis, is the major symptom of AR. Inflammation causes itching, sneezing, runny nose, redness, and tenderness. Sinus swelling can constrict the eustachian tube that connects the inner ear to the throat, causing a congested feeling and "ear popping." The drip of mucus from the sinuses down the back of the throat, 'post nasal drip', combined with increased sensitivity, can also lead to throat irritation and redness. AR usually also causes redness, itching, and watery eyes. Fatigue and headache are also common.

Diagnosis

Diagnosing seasonal AR is usually easy when symptoms appear in spring or summer and disappear with the onset of cold weather. Other causes of rhinitis, including infection, can usually be ruled out by a physical examination and a nasal smear, in which a sample of mucus is taken on a swab for examination.

Allergy tests , including skin testing and provocation testing, can help identify the precise culprit, but may not be done unless a single source is suspected and subsequent avoidance is possible.

Treatment

Avoidance of the allergens is the best treatment, but this is often not possible. When it is not possible to avoid one or more allergens, there are two major forms of medical treatment, drugs and immunotherapy.

ANTIHISTAMINES

Antihistamines block the histamine receptors on nasal tissue, decreasing the effect of histamine release by mast cells. They may be used after symptoms appear, though they may be even more effective when used preventively, before symptoms appear. A wide variety of antihistamines are available. We find they are best for very bad sufferers or as adjunctive use on 'bad days', such as high pollen count days.

Newer antihistamines that do not cause drowsiness are available by prescription and include the following:

• astemizole (Hismanal)
• loratidine (Claritin)
• fexofenadine (Allegra)
• azelastin HCl (Astelin).

DECONGESTANTS

Decongestants constrict blood vessels to counteract the effects of histamine. Nasal sprays are available that can be applied directly to the nasal lining and oral systemic preparations are available. Decongestants are stimulants and may cause increased heart rate and blood pressure, headaches, and agitation. Use of topical decongestants for longer than several days can cause loss of effectiveness and rebound congestion, in which nasal passages become more severely swollen than before treatment. We suggest using these on a very limited basis, and only for a few days at a time.

TOPICAL CORTICOSTEROIDS

Topical corticosteroids are nasal sprays that reduce mucous membrane inflammation and are available by prescription. Allergies tend to become worse as the season progresses because the immune system becomes sensitized to particular antigens and can produce a faster, stronger response. Topical corticosteroids are especially effective at reducing this seasonal sensitization because they work more slowly and last longer than most other medication types. As a result, they are best started before allergy season begins. Side effects are usually mild, but may include headaches, nosebleeds, and unpleasant taste sensations. These sprays are the first line treatment of this problem and are in most cases very effective. They are expensive however, and they also take a couple of weeks to really begin working properly. Good patient compliance is also very important.

:: Nose bleeds

When the nose is dry and crusted, it may bleed, especially if one goes to a dry or cold area at high altitude. For the acute nose bleed try nose drops, such as Neosynephrine. Place on cotton ball, place the cotton in the nose and press gently from the outside. Sitting up is best. Ice to the face may also help. Try to stay calm, the more the excitement/stress the higher your blood pressure will go and hence more bleeding.

For chronic nose bleeds, Use lots of saline nose spray and an antibiotic ointment such as Neosporin Ointment. This has a pointed tip you can insert into the nose, the soft part, then squeeze the nose from the outside to spread it around. Do this 2 or 3 times a day. In most cases of bleeding the nose is infected and the antibiotic ointment helps. If you are taking aspirin or aspirin substitutes, including non steroidal anti-inflammatory medication such as Nurofen or Ibuprofen, this may cause you to bleed as well.

Dry climates are a frequent cause of bleeding; in this case, use lots of saline nose spray available from chemists. Most importantly, keep the bedroom moist at night. Hang a wet towel, put water in a bowl, have a plant that takes lots of water. If you need to pick your nose for crusts, your nose is too dry - use an enhanced nasal moisturizing spray and/or gel, whatever works best for you. Absolutely avoid any preparations with additives or preservatives - these usually cause more problems than they solve.

Nosebleeds are seldom fatal. It does look bad and it feels bad but it isn’t serious in most cases. If you have generally fragile blood vessels, Rutin taken by mouth daily is also helpful.

:: What is Post-Nasal Drip?

Insight into normal and abnormal secretions

The glands in your nose and throat continually produce mucus. It moistens and cleans the nasal membranes, humidifies air, traps and clears inhaled foreign matter, and fights infection. Although mucus normally is swallowed unconsciously, the feeling that it is accumulating in the throat or dripping from the back of your nose is called post-nasal drip.

This feeling can be caused by excessive or thick secretions or by throat muscle and swallowing disorders.

Increased thin clear secretions can be due to colds and flu, allergies, cold temperatures, bright lights, certain foods/spices, pregnancy, and other hormonal changes. Various drugs (including birth control pills and high blood pressure medications) and structural abnormalities can also produce increased secretions. These abnormalities might include a deviated or irregular nasal septum (the cartilage and bony dividing wall that separates the two nostrils).

Increased thick secretions in the winter often result from too little moisture in heated buildings and homes. They can also result from sinus or nose infections and some allergies, especially to certain foods such as dairy products. If thin secretions become thick and green or yellow, it is likely that a bacterial sinus infection is developing. In children, thick secretions from one side of the nose can mean that something is stuck in the nose (such as a bean, wadded paper, or piece of toy, etc.).

Sinuses are air-filled cavities in the skull. They drain into the nose through small openings. Blockages in the openings from swelling due to colds, flu, or allergies may lead to acute sinus infection. A viral "cold" that persists for 10 days or more may have become a bacterial sinus infection. With this infection you may notice increased post-nasal drip. If you suspect that you have a sinus infection, you should see your physician for antibiotic treatment.

Chronic sinusitis occurs when sinus blockages persist and the lining of the sinuses swell further. Polyps (growths in the nose) may develop with chronic sinusitis. Patients with polyps tend to have irritating, persistent post-nasal drip. Evaluation by an otolaryngologist may include an exam of the interior of the nose with a fiber optic scope and CAT scan x-rays. If medication does not relieve the problem, surgery may be recommended.

Vasomotor rhinitis describes a no allergic "hyperirritable nose" that feels congested, blocked, or wet.