SINUSITIS

Overview

Sinus disease is a major health problem. It afflicts 31 million people in the United States. Americans spend more than $1 billion each year on over-the-counter medications to treat it. Sinus disease is responsible for 16 million doctor visits and $150 million spent on prescription medications. People who have allergies, asthma, structural blockages in the nose or sinuses, or people with weak immune systems are at greater risk.

Sinusitis symptoms

A bad cold is often mistaken for sinusitis (sinus disease). Many symptoms are the same, including headache or facial pain, runny nose and nasal congestion. Unlike a cold, sinus disease symptoms may be caused by bacterial infections. It often requires treatment with antibiotics (drugs that kill the germs causing the infection).

Sinusitis diagnosis

If you think you have sinus disease, see your doctor for proper diagnosis. In most cases, sinus disease treatment is easy. By stopping a sinus infection early, you avoid later symptoms and complications.

What is sinusitis?

Sinusitis is an inflammation of the sinuses. It is often caused by bacterial (germ) infection. Sometimes, viruses and fungi (molds) cause it. People with weak immune systems are more likely to develop bacterial or fungal sinusitis. Some people with allergies can have "allergic fungal sinusitis." Acute sinus disease lasts three to eight weeks. Sinus disease lasting longer than eight weeks is considered chronic.

The sinuses are air-filled cavities. They are located:

• Within the bony structure of the cheeks
• Behind the forehead and eyebrows
• On either side of the bridge of the nose
• Behind the nose directly in front of the brain

An infection of the sinus cavity close to the brain can be life threatening, if not treated. In rare cases, it can spread to the brain.

Normal sinuses are lined with a thin layer of mucus that traps dust, germs and other particles in the air. Tiny hair-like projections in the sinuses sweep the mucus (and whatever is trapped in it) towards openings that lead to the back of the throat. From there, it slides down to the stomach. This continual process is a normal body function.

Sinus disease stops the normal flow of mucus from the sinuses to the back of the throat. The tiny hair-like "sweepers" become blocked when infections or allergies cause tiny nasal tissues to swell. The swelling traps mucus in the sinuses.

Some people have bodily defects that contribute to sinus disease. The most common of these defects are:

• Deformity of the bony partition between the two nasal passages
• Nasal polyps (benign nasal growths that contain mucus)
• A narrowing of the sinus openings

People with these defects often suffer from chronic sinus disease.

Related resources:

• Rhinitis
• Allergy symptoms
• Find an allergist

What Are the Symptoms of Sinusitis?

Common symptoms of sinusitis include:

• Postnasal drip
• Discolored nasal discharge (greenish in color)
• Nasal stuffiness or congestion
• Tenderness of the face (particularly under the eyes or at the bridge of the nose)
• Frontal headaches
• Pain in the teeth
• Coughing
• Fever
• Fatigue
• Bad breath

Sinus disease is often confused with rhinitis, a medical term used to describe the symptoms that accompany nasal inflammation and irritation. Rhinitis only involves the nasal passages. It could be caused by a cold or allergies.

Allergies can play an important role in chronic (long-lasting) or seasonal rhinitis episodes. Nasal and sinus passages become swollen, congested, and inflamed in an attempt to flush out offending inhaled particles that trigger allergies. Pollen are seasonal allergens. Molds, dust mites and pet dander can cause symptoms year-round.

Asthma also has been linked to chronic sinus disease. Some people with a chronic nasal inflammation and irritation and/or asthma can develop a type of chronic sinus disease that is not caused by infection. Appropriate treatment of sinus disease often improves asthma symptoms.

How is sinusitis diagnosed?

Diagnosis depends on symptoms and requires an examination of the throat, nose and sinuses. Your doctor will look for:

• Redness
• Swelling of the nasal tissues
• Tenderness of the face
• Discolored (greenish) nasal discharge
• Bad Breath

If sinus disease lasts longer than eight weeks, or if standard antibiotic treatment is not working, a sinus CT scan may help your doctor diagnose the problem. An allergist or an otolaryngologist (a doctor specializing in the ear, nose and throat) may examine your nose or sinus openings. The exam uses a long, thin, flexible tube with a tiny camera and a light at one end that is inserted through the nose. It is not painful. Your doctor may give you a light anesthetic nasal spray to make you more comfortable.

Mucus cultures: If your sinus disease is chronic or has not improved after several rounds of antibiotics, a mucus culture may help to determine what is causing the infection. Most mucus samples are taken from the nose. However, it is sometimes necessary to get mucus (or pus) directly from the sinuses.

Knowing what kind of bacteria is causing the infection can lead to more effective antibiotic therapy. A fungus could also cause your sinus disease. Confirming the presence of fungus is important. Fungal sinusitis needs to be treated with antifungal agents, rather than antibiotics. In addition, some forms of fungal sinus disease—allergic fungal sinusitis, for example—do not respond to antifungal agents and often require the use of oral steroids.

Your doctor may consider ordering a sinus CT. This test can help to define the extent of the infection. Your doctor may also send you to a specialist in allergy and immunology. The specialist will check for underlying factors such as allergies, asthma, structural defects, or a weakness of the immune system.

Biopsies: A danger of more serious types of fungal sinus disease is that the fungus could penetrate into nearby bone. Only a bone biopsy can determine if this has happened. Biopsies involving sinus tissue are taken with flexible instruments inserted through the nose.

Biopsies of the sinus tissue are also used to test for immotile cilia syndrome, a rare disorder that can cause people to suffer from recurrent infections, including chronic sinusitis, bronchitis and pneumonia.

Sinusitis Treatment

Antibiotics

Antibiotics are standard treatments for bacterial sinusitis. Antibiotics are usually taken from 3 to 28 days, depending on the type of antibiotic. Because the sinuses are deep-seated in the bones, and blood supply is limited, longer treatments may be prescribed for people with longer lasting or severe cases.

Overuse and abuse of antibiotics have been causing a major increase in antibiotic resistance. Therefore, patients with sinus symptoms should consider taking an antibiotic only if symptoms (including discolored nasal discharge) persist beyond 7-10 days.

Antibiotics help eliminate sinus disease by attacking the bacteria that cause it, but until the drugs take effect, they do not do much to alleviate symptoms. Some over-the-counter medications can help provide relief.

Nasal decongestant sprays

Topical nasal decongestants can be helpful if used for no more than three to four days. These medications shrink swollen nasal passages, facilitating the flow of drainage from the sinuses. Overuse of topical nasal decongestants can result in a dependent condition in which the nasal passages swell shut, called rebound phenomenon.

Antihistamines

Antihistamines block inflammation caused by an allergic reaction so they can help to fight symptoms of allergies that can lead to swollen nasal and sinus passages.

Nasal decongestants and antihistamines

Over-the-counter combination drugs should be used with caution. Some of these drugs contain drying agents that can thicken mucus. Only use them when prescribed by your doctor.

Topical nasal corticosteroids

These prescription nasal sprays prevent and reverse inflammation and swelling in the nasal passages and sinus openings, addressing the biggest problem associated with sinusitis. Topical nasal corticosteroid sprays are also effective in shrinking and preventing the return of nasal polyps. These sprays at the normal dose are not absorbed into the blood stream and could be used over long periods of time without developing "addiction."

Nasal saline washes

Nasal rinses can help clear thickened secretions from the nasal passages.

Surgery

If drug therapies have failed, surgery may be recommended as a last resort. It is usually performed by an otolaryngologist. Anatomical defects are the most common target of surgery.

Your surgeon can fix defects in the bone separating the nasal passages, remove nasal polyps, and open up closed passages. Sinus surgery is performed under either local or general anesthesia, and patients often can go home on the same day.

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Otitis media

Introduction

Otitis media is an ear infection of the middle ear, the area just behind the eardrum. It happens when the eustachian tubes, which connect the middle ear to the nose, get blocked with fluid. Mucus, pus, and bacteria can also pool behind the eardrum, causing pressure and pain.

Ear infections usually start with a cold. Although adults can get ear infections, they are most common in infants and young children. That's because a child's eustachian tubes are narrower and shorter than an adults', and it's easier for fluid to get trapped in the middle ear. In fact, 75% of all children get ear infections. They happen most often between the ages of 6 - 11 months. By age 1, 60% of children will have had at least one ear infection and 17% will have 3 or more.

Ear infections usually clear up on their own. Although it used to be common for doctors to give antibiotics to children with ear infections, now guidelines from the American Academy of Pediatricians (AAP) suggest taking a wait and see approach for the first 72 hours.

With a severe ear infection, pressure may build up and cause the eardrum to rupture. Pus and blood may drain out. This usually relieves pain and pressure, and in most cases the eardrum heals on its own.

Signs and Symptoms

There are two main types of ear infections: acute otitis media (AOM), and otitis media with effusion (OME), where fluid remains trapped in the ear even after the infection is gone.

Acute otitis media causes pain, fever, and difficulty hearing. If a child is too young to talk, signs of an ear infection can include crying, irritability, trouble sleeping, and pulling on the ears.

Other symptoms that may be associated with an ear infection include sore throat (pharyngitis), neck pain, nasal congestion and discharge (rhinitis), headache, and ringing (tinnitus), buzzing, or other noise in the ear.

Causes

Ear infections happen when the eustachian tubes are blocked. Blockages can be caused by:

• A respiratory infection, such as cold or flu
• Allergies
• Exposure to cigarette smoke
• Infected or overgrown adenoids (tonsils)
• For infants, being fed lying down (drinking a bottle while lying on the back)

Ear infections happen most often in the winter. They are not contagious, but a cold may spread among a group of children and cause some of them to get ear infections.

Risk Factors

Risk factors for otitis media include:

• Age -- children between 6 - 36 months are most likely to get ear infections
• Attending daycare
• Recent illness, such as a cold or sinus infection
• History of allergies, like hay fever, also called allergic rhinitis, or sinusitis
• Exposure to secondhand smoke
• Having family members who are prone to ear infections; studies show a clear genetic component for bot hacute and recurrent otitis media 
• Using a pacifier
• Having a history of gastroesophageal reflux disease (GERD) 

Diagnosis

The doctor will ask questions about whether you (or your child) have had ear infections in the past and ask you to describe the current symptoms. He or she will use an otoscope to look inside the ear. If infected, there may be areas of dullness or redness or there may be air bubbles or fluid behind the eardrum. The fluid may be bloody or filled with pus. The doctor will also check for any sign of perforation -- a hole or holes -- in the eardrum.

Your doctor may also do other tests:

• Tympanometry, which uses a small handheld instrument to measure changes in air pressure in the ear. It can indicate if the eardrum is ruptured
• Reflectometry, in which a doctor places a small instrument near the ear that makes a sound. That allows the doctor to see if fluid is present behind the eardrum.
• A hearing test if your child has had persistent ear infections.

Preventive Care

You can reduce your child's risk of ear infection. Here are some tips:

• Don't expose your child to secondhand smoke.
• Keep your child away from other children who are sick.
• Always hold your infant in an upright, seated position during bottle feeding.
• Breastfeeding for at least 6 months can make a child less prone to ear infections.
• Don't use a pacifier.

The pneumococcal vaccine (Prevnar) prevents infections such as pneumonia and meningitis, and studies show it slightly reduces the risk of ear infections.

Treatment Approach

The goals for treating ear infections include curing the infection, relieving pain and other symptoms, and preventing future ear infections. If a bacterial infection is present, your doctor may prescribe antibiotics (see section titled Medications).

However, most ear infections clear up on their own. One review of the scientific literature found that the symptoms of otitis media got better in two-thirds of children by 24 hours and in 80% of children at 2 - 7 days. Because antibiotics tend to be overused for treating ear infections, and because childdren may become resistant to antibiotics most commonly used to treat otitis media, the AAP and the American Academy of Family Physicians guidelines suggest taking a wait and see approach for 72 hours if:

• The child is older than 6 months
• The child is otherwise healthy
• The child has mild symptoms or an unclear diagnosis.

Your doctor may suggest using an over-the-counter pain reliever (see Medications). There are also alternative ways to treat the symptoms of ear infections and to prevent persistent and recurrent ear infections. For example, herbal ear drops and homeopathic remedies may help treat or prevent ear infections.

Before giving any medication to a child -- whether over the counter, an herbal remedy, or a dietary supplement -- you should talk to your pediatrician.

Lifestyle

Applying a warm, moist cloth over the affected ear may help relieve pain.

Medications

• Antibiotics -- If your doctor prescribes antibiotics, be sure to give your child all the doses. The antibiotic most often prescribed for an ear infection is amoxicillin, unless your child is allergic to penicillin. If that's the case, there are several options. Children who are treated with antibiotics are more likely to develop vomiting, diarrhea, or a rash.
• Ear drops -- If your child has recurring ear infections, a perforated eardrum, or develops infection after ear tubes have been placed (see Surgery and Other Procedures), your doctor may prescribe antibiotic ear drops instead of oral antibiotics, to be used over a period of time, such as a few months. If your child doesn't have ear tubes in place and doesn't have any drainage from the ear, your doctor may also prescribe anesthetic ear drops to relieve pain.
• Ibuprofen, acetaminophen -- Ask your doctor about using over-the-counter oral medications for pain or fever, such as ibuprofen (Advil, Motrin) or acetaminophen (Tylenol). Children under 19 should not take aspirin, due to the risk of developing a rare but serious illness called Reye's syndrome.

Surgery and Other Procedures

Drainage tubes (myringotomy) -- If your child has recurring ear infections that don't respond to antibiotics or if the fluid in the ear affects his hearing, your doctor may suggest putting in drainage tubes. During this surgery, which requires general anesthesia, the surgeon inserts a small drainage tube through the eardrum. Fluid behind the eardrum can drain out, equalizing the pressure between the middle and outer ear, which should improve your child's hearing. The tubes usually come out on their own as your child grows and the drainage holes heal.

If ear infections persist after age 4, your doctor may suggest having your child's adenoids (tonsils) removed.

Nutrition and Dietary Supplements

Because supplements (like those described below) may have side effects or interact with medications, you should take them only under the supervision of a knowledgeable health care provider. If you think your child has an ear infection, you should always talk to your doctor -- don't try to treat the child yourself.

• Probiotics (Lactobacillus) -- So-called “good” bacteria or probiotics help prevent infections in the intestines, and there is preliminary evidence that they might help prevent colds, too. One study found that children in daycare centers who drank milk fortified with Lactobacillus had fewer and less severe colds. However, it's not clear whether that would help reduce ear infections. A study found that children who took probiotics did not get any fewer ear infections than those who took placebo -- although they did get fewer colds. People with weakened immune systems or who take drugs to suppress the immune system should not take probiotics without their doctor's supervision.
• Xylitol -- A sugar alcohol produced naturally in birch, strawberries, and raspberries, it may help fight a type of bacteria that's associated with ear infections. In one study, children who chewed sugarless gum sweetened with xylitol reduced their risk of developing an ear infection by more than a third. However, children in the study were given the gum 5 times a day, which makes it hard to keep up with the regimen. Another study found that taking xylitol only when a child showed symptoms of a cold or respiratory infection didn't prevent the child from developing an ear infection. More research is needed.
• Elimination diet -- Some doctors believe food allergies contribute to chronic ear infections. Your doctor may ask you to try an elimination diet, which cuts out common food allergens such as wheat or dairy. If symptoms get better, you gradually add back the foods until symptoms return. Then you are able to identify the problem food.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner. Before giving any herbs to a child to treat an ear infection, talk to your pediatrician.

• Herbal ear drops (Calendula officinalis, Hypericum perfoliatum, Verbascum thapsus, Allium sativum) -- A few studies suggest that ear drops containing calendula, mullein, St. John's wort, and garlic were as effective at relieving pain as prescription ear drops. However, using oily ear drops can make it hard for the doctor to examine your child's middle ear, so always talk to your doctor before using them. If you have a ruptured ear drum, do not use herbal ear drops.
• Belladonna, as a homeopathic medicine -- In one study, children who took a homeopathic preparation of belladonna had fewer ear infections, and the ones they got didn't last as long as children who took antibiotics. (See Homeopathy section.)
• Echinacea (Echinacea purpurea) -- Although it has not been studied for ear infections, some doctors may suggest echinacea to help prevent recurring ear infections. Only give echinacea to a child under your doctor's supervision. Women who are pregnant or breastfeeding should not take echinacea. If you are allergic to ragweed, you may be allergic to echinacea.

Homeopathy

Although not many studies have examined the effectiveness of specific homeopathic therapies in general, there have been several studies evaluating homeopathy for ear infections. Some of the homeopathic remedies included in such studies or that a professional homeopath might consider for the treatment of ear infections are listed below. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Aconitum -- for throbbing ear pain that comes on suddenly after exposure to cold or wind; and in children with high fever and whose ears have a bright red coloring
• Belladonna -- for sudden onset of infection with piercing pain that often spreads to the neck, flushed face including reddened ears, agitation (even impaired consciousness and nightmares), wide-eyed stare, high fever, and swollen glands; this remedy is most appropriate for children who feel relief when sitting upright and from warm compresses to the ear; this remedy should not be used in children whose symptoms have persisted for more than 3 days
• Chamomilla -- for intense ear pain and extreme irritability and anger (including screaming); this remedy is most appropriate for children who are difficult to comfort unless being rocked or carried by a person who is walking back and forth
• Hepar Sulphuricum -- for sharp pains and a smelly, yellowish-green discharge that occur in the middle and late stages of an ear infection, particularly when the child is extremely moody and clearly angry; this remedy is most appropriate for individuals whose symptoms are worsened by cold air and improved by warmth
• Lycopedium -- for right side ear pain that is worse in the late afternoon and early evening; the child will generally say that his ears feel stuffed up and he may hear a ringing or buzzing sound; the appropriate individual tends to be insecure and need others around, although the personality type may act like a bully as a defense mechanism
• Mercurius -- good for chronic ear infections; for acute or chronic pain that is worse at night and may extend down into the throat; relief comes from nose blowing; and the appropriate child may sweat or drool a lot and have bad breath
• Pulsatilla -- for infection following exposure to cold or damp weather; the ear is often red and may have a yellowish/greenish discharge; ear pain worsens when sleeping in a warm bed and is relieved somewhat by cool compresses; this remedy is most appropriate for children who tend to be gentle, weepy, and mildly whiny, and who are easily soothed by affection
• Silica -- for chronic or late stage infection when the child feels chilly, weak, and tired; sweating may also be present.

Other Considerations

Warnings and Precautions

If you think your child has an ear infection, especially if your child is under 2, call your pediatrician.

Let your doctor know if your child's symptoms such as pain, fever, or irritability do not get better within 24 - 48 hours.

If severe pain suddenly stops, it may indicate a ruptured eardrum.

Swimming and diving underwater may make an ear infection worse. If your child has a ruptured eardrum, he should avoid swimming or diving completely. If your child has ear tubes, use earplugs or cotton balls coated with petroleum jelly when swimming to prevent infection.

Prognosis and Complications

Usually, an ear infection is a simple condition without complications. Most children will have minor, temporary hearing loss during and right after an ear infection. Permanent hearing loss is very rare, but the risk increases if the child has a lot of ear infections. Other potential complications include:

• Ruptured or perforated eardrum, which usually heals on its own
• Chronic, recurrent ear infections
• Enlarged adenoids or tonsils
• Mastoiditis, an infection of the bones around the skull
• Speech or language delay in a child who suffers lasting hearing loss from multiple, recurrent ear infections; very rare

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RHINITIS

• Rhinitis is defined as having two of the listed symptoms for ≥1 hour/day for ≥2 weeks
  • blockage
  • running (including postnasal drip)
  • sneezing (including nasal itch)
• Classification is shown in the chart below
• Nasal problems are often multifactorial, this needs to be taken into account when using the classification or considering treatment
• Allergic rhinitis:
  • is common and affects over 20% population every country
  • is diagnosed by history and examination, and should be backed up by specific allergy tests where identification of specific triggers will enable avoidance or affect choice of treatment
• Non-allergic rhinitis:
  • has a multifactorial aetiology
  • if eosinophilic, usually responds to treatment with corticosteroids
  • may be a presenting complaint for systemic disorders such as Wegener’s granulomatosis, Churg–Strauss syndrome and sarcoidoisis
• Infective rhinitis:
  • can be caused by viruses, and less commonly by bacteria, fungi and protozoa
  • is often more severe in allergic patients especially if infection occurs at the time of allergen exposure
  • treatment that addresses only the acute problem may result in incomplete resolution of the infection or a later recurrence
• Since the mucosa of the the nose and sinuses is continuous, rhinitis should be called rhinosinusitis

Diagnosis

• Take a history
• Nasal examination:
  • external and internal appearance
  • secretions (clear, discoloured, blood stained)
  • airflow
  • palpation
• Skin prick testing is safe, inexpensive and helps the clinician to identify an allergic trigger, as well as graphically demonstrating the problem to the patient. Consider:
  • RAST/specific IgE
  • blood tests, e.g. FBC, thyroid function

See chart below

Classification of rhinits

ALLERGIC	INFECTIVE	OTHER	PART OF SYSTEMIC DISORDER
Seasonal (SAR) Perennial (PAR) Occupational (OAR)	Acute Chronic	Idiopathic NARES (non-allergic rhinitis with eosinophilia) Drug induced: beta-blockers oral contraceptives aspirin NSAIDS local decongestants Autonomic (responds to anticholinergics) Atrophic Neoplastic	Primary defect in mucus cystic fibrosis Young's syndrome Primary ciliary dyskinesia Kartagener's syndrome Immunological systemic lupus erythematosus rheumatoid arthritis AIDS Antibody deficiency Granulomatous disease Wegener's sarcoidosis Hormonal hypothyroidism pregnancy old man's drip

* Check nasal inhalation technique and compliance.
INS=intranasal corticosteroids; SPT=skin prick test; RAST=radioallergosorbent test; QoL=Quality of Life; NSAID=non-steroidal anti-inflammatory drugs. Reproduced with kind permission from BSACI; http://www.bsaci.org

Treatment

Education

• The patient or carers should be informed about the potential impact of symptoms on sleep, work/school performance and the need for regular, prophylactic treatment
• Evidence-based education on effective forms of allergen avoidance and drug therapy, including safety and potential side effects, should be provided
• Treatment failure may be associated with poor compliance or with poor technique in the use of nasal sprays and drops, therefore appropriate training is imperative

Pharmacotherapy

• Despite allergen and trigger avoidance, many rhinitis sufferers continue to have persistent symptoms, the nature of which should determine the selection of medication
• Regular prophylactic medication, even in the absence of symptoms, is important
• Oral and topical antihistamines:
  • place in therapy:
    • first-line therapy for mild to moderate intermittent and mild persistent rhinitis
    • additional to intranasal steroids for moderate/severe persistent rhinitis uncontrolled on topical INS alone
• Oral H1-antihistamines:
  • effective predominantly on neurally mediated symptoms of itch, sneeze and rhinorrhoea
  • improve allergic symptoms at sites other than the nose such as the conjunctiva, palate, skin and lower airways
  • regular therapy is more effective than ‘as-needed’ use in persistent rhinitis
• Topical nasal H1-antihistamines (e.g. azelastine):
  • fast onset of action within 15 min, useful as rescue therapy
  • does not improve symptoms due to histamine at other sites, such as the eye, pharynx, lower airways and skin
• Topical intranasal corticosteroids (INS):
  • place in therapy:
    • first-line therapy for moderate to severe persistent symptoms and treatment failures with antihistamines alone
    • topical steroid drops should be used initially in nasal polyposis and severe obstruction
  • onset of action is 6–8 hours after the first dose, clinical improvement may not be apparent for a few days and maximal effect may not be apparent until after 2 weeks
  • starting treatment 2 weeks before a known allergen season improves efficacy
  • similar clinical efficacy for all INS but bioavailability varies considerably
  • systemic absorption negligible with mometasone and fluticasone, modest for the remainder and high for betamethasone and dexamethasone – these should be used short term only
  • long-term growth studies in children using fluticasone, mometasone and budesonide have reassuring safety data, unlike beclomethasone
  • concomitant treatment with CYP3A inhibitors such as itraconazole or ritonivir may increase systemic bioavailability of INS
  • raised intra-ocular pressure has been described with INS, patients with a history of glaucoma should be monitored more closely
• Systemic glucocorticosteroids:
  • rarely indicated in the management of rhinitis, except for:
    • severe nasal obstruction
    • short-term (25 mg/day for 7 days) rescue medication for uncontrolled symptoms on conventional pharmacotherapy
    • important social or work-related events, e.g. examinations, weddings
  • oral corticosteroids should be used briefly and always in combination with a topical nasal corticosteroid
• Anti-leukotrienes:
  • place in therapy:
    • montelukast is licensed in the UK for those with seasonal allergic rhinitis who also have concomitant asthma (UK license for age >6 months; zafirlukast UK license >12 years)
    • may be useful in patients with asthma and persistent rhinitis
• Topical anti-cholinergic (e.g. ipratropium bromide):
  • place in therapy:
    • in ‘old man’s drip’
    • as an ‘add on’ for allergic rhinitis when watery rhinorrhoea persists despite topical steroids and antihistamines
    • for autonomic rhinitis when the dominant symptom is profuse watery rhinorrhoea in response to irritant triggers or changes in temperature
  • decreases rhinorrhoea but has no effect on other nasal symptoms
  • needs to be used three times daily, and titrate dose according to response
  • also useful in the common cold
• Chromones (e.g. sodium cromoglicate):
  • place in therapy:
    • children and adults with mild symptoms only and sporadic problems in season or on limited exposure
    • cromoglicate and nedocromil eyedrops are useful in conjunctivitis as topical therapy
• Treatment failure should always provoke a review of compliance
• • If regular treatment has been unsuccessful, the diagnosis should be reviewed and the need for alternative treatment (e.g. surgery) should reassessed

Immunotherapy (desensitisation)

• For pollen-allergic patients who fail to respond sufficiently to conventional treatment

Treatment of rhinitis

*Check nasal inhalation technique and compliance
INS=intranasal corticosteroids; SPT=skin prick test; RAST=radioallergosorbent test; QoL=Quality of Life; NSAID=non-steroidal anti-inflammatory drugs. Reproduced with kind permission from BSACI; http://www.bsaci.org

Effect of therapies on rhinitis symptoms

Drug	Sneezing	Rhinorrhoea	Nasal obstruction	Nasal itch	Eye symptoms
H1-ANTIHISTAMINES
Oral	++	++	+	+++	++
Intranasal	++	++	+	++	0
Eye drops	0	0	0	0	+++
CORTICOSTEROIDS
Intranasal	+++	+++	+++	++	++
CHROMONES
Intranasal	+	+	+	+	0
Eye drops	0	0	0	0	++
DECONGESTANTS
Intranasal	0	0	++++	0	0
Oral	0	0	+	0	0
OT HER DRUGS
Anti-cholinergics	0	++	0	0	0
Anti-cholinergics	0	+	++	0	++

Referral

• ENT referral is needed for:
  • unilateral nasal problems
  • nasal perforations, ulceration or collapse
  • blood-stained discharge
  • crusting high in the nasal cavity
  • recurrent infection
  • periorbital cellulitis (refer urgently)
• Allergy clinic referral is needed for:
  • inadequate control of symptoms
  • allergen/trigger identification
  • to consider desensitisation
  • recurrent nasal polyps
  • multisystem allergy (e.g. rhinitis with asthma, eczema or food allergy)
  • occupational rhinitis

Asthma and rhinitis

• Asthma and rhinitis usually co-exist, with symptoms of rhinitis found in 75–80% of patients with asthma
• Rhinitis is a risk factor for the development of asthma
• Treatment of rhinitis is associated with benefits for asthma

Rhinitis in pregnancy

• Rhinitis affects at least 20% of pregnancies and can start during any gestational week
• Informing the patient that pregnancy-induced rhinitis is a self-limiting condition is often reassuring
• Regular nasal douching may be helpful
• Most medications cross the placenta, and should only be prescribed when the apparent benefit is greater than the risk to the foetus
• It is a good practice to start treatment with ‘tried and tested’ drugs
  • beclomethasone, fluticasone and budesonide appear to have good safety records as they are widely used in pregnant asthmatic women
  • cromoglicate may be helpful
  • chlorphenamine, loratidine and cetirizine may be added cautiously if additional treatment is needed but decongestants should be avoided
• Some antihistamines may increase the risk of spontaneous abortion or congenital malformation
• Topical corticosteroids have shown no evidence of harmful effects

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