Allergy, Nose & Sinus

Rhinitis (Sensitive nose)

What is Rhinitis (Sensitive nose)?

Many people often state that they “have sinus” when they have this condition. In actual fact, everybody has sinuses (Figure 1). They are part of the normal anatomy in your face and are air-filled cavities surrounding the nasal cavities. The lining of the sinuses produces mucous which then drain into the nasal cavities. When the sinuses are blocked, they can be infected and have symptoms of sinusitis (see section on sinusitis).

 

On the other hand, most patients with frequent clear runny nose, blocked nose, sneezing and itchy eyes suffer from Rhinitis (sensitive nose). Rhinitis is inflammation of the nasal cavity. Majority of the time, Rhinitis is allergic when it is triggered by exposure to a substance known as allergen (most commonly House Dust Mites). Sometimes, Rhinitis is non-allergic and can be triggered by cigarette smoke, temperature changes, strong odors, hormonal changes and dietary factors.

 

Rhinitis is diagnosed based on a combination of clinical history, physical examination and quite often, a flexbile nasoendoscopy. In some patients, a skin prick test or blood tests may be performed to aid in the diagnosis of Allergic Rhinitis.

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Majority of the time, Rhinitis can be treated medically with a combination of allergen or “trigger avoidance” (if possible), nasal steroid sprays (Figure 2) and antihistamines. In suitable patients with Allergic Rhinitis, immunotherapy (often called “Allergy Shots”) to desensitize the patient to the allergen may be indicated. Most of the time, immunotherapy is applied under the tongue (SLIT – Sublingual Immunotherapy – Figure 3a-b). If patients continue to suffer from persistent or troublesome blocked nose despite maximal medical treatment, procedures to reduce the size of the inferior turbinate may be indicated (see section on “inferior turbinate reduction hypertrophy”)

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Sinusitis (or Rhinosinusitis)

What is Sinusitis (or Rhinosinusitis)?

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When the sinuses are inflamed and blocked, mucous can be trapped in the sinuses, resulting in bacterial infection (Figure 1). This condition is known as sinusitis. Patients with sinusitis may have coloured nasal mucous (often yellow, brown or green and sometimes blood-stained), blocked and congested nose, pain in the face, postnasal drip and reduced sense of smell. These symptoms are different from patients with sensitive nose (refer to section on “Rhinitis”), although sometimes it can be hard to distinguish between these two conditions.

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Sinusitis is diagnosed based on a combination of clinical history, physical examination and a flexible nasoendoscopy. Nasoendoscopic findings include swelling of the lining of the nose and sinuses and mucopus (mixture of mucous and pus – Figure 2). In some patients, a CT scan of the sinuses may be required if the diagnosis is unclear, or if the patient has not responded adequately to medical treatment.

 

Sinusitis can be acute (less than 3 months duration) or chronic (more than 3 months duration). The treatment of sinusitis usually involves oral antibiotics, nasal douche (nasal saline wash – Figure 3) and nasal steroid sprays. In patients with chronic sinusitis, sometimes nasal polyps (fleshy non-cancerous outgrowths from the lining of the nose and sinuses) can develop. Patients with nasal polyps (See section on “Nasal Polyps”) require close follow ups and meticulous care to keep their condition under control.

In patients with sinusitis who have failed maximal medical treatment, sinus surgery often known as FESS (Functional Endoscopic Sinus Surgery – Figure 4) may be indicated. FESS is a minimally invasive surgery done through the nose without any external cuts on the nose or face. With the availability of image guidance system (IGS) during sinus surgery, the risks of major complications may be significantly reduced. Using IGS (Figure 5), the surgeon is able to confirm the position of the operating instruments in the nose and sinuses in relation to critical nearby structures such as the eye, brain or major blood vessels. This is particularly important in revision FESS (re-do sinus operation) whereby there may be a lot of scarring and distortion of important surgical landmarks from the previous surgery/ies or in cases where the sinus anatomy is complex.

Nasal polyps

What is Nasal polyps?

Nasal polyps (Figure 1a-d) are fleshy outgrowths from the lining of the nose or sinuses. Most of the time, they develop as a result of chronic sinusitis and are due to chronic inflammation. Occasionally, nasal polyps can be due to a tumour, which is most often benign (non-cancerous) and rarely malignant (cancerous). The management of nasal polyps can be complex and depends on the nature of the polyp (benign vs malignant).

 

It is best that you discuss with your ENT Specialist on the best management plan that is suitable for your condition. Additional tests such as biopsy (removal of a small piece of tissue for analysis) and imaging (CT scan or MRI scan) may be required to investigate nasal polyps (Figure 2).


Deviated nasal septum (Bent or crooked nasal septum)

What is nasal septum ?

A nasal septum is a bony-cartilaginous wall that separates the nasal cavity into a right side and left side (Figure 1a&b). In most people, the septum is slightly bent or crooked (called a deviated nasal septum). Sometimes, the bent septum can be bad enough to cause significant blockage of the nasal cavity on one side of the nose. The reason for a bent nasal septum is often unknown but may be attributable to congenital (born with it) or traumatic causes.

 

If a deviated nasal septum causes significant blocked nose, it should be corrected by septoplasty (surgery to correct a deviated nasal septum). Other reasons for septoplasty include nosebleed due to a vessel at or behind the bent septum and for surgical access to sinus surgery. Septoplasty is done through the nose without any external cuts on the nose or face.

Inferior turbinate hypertrophy

What is Inferior turbinate hypertrophy?

At the side wall of each nasal cavity, there are 3 sausage-like bony structures called the turbinates (Figure 1). The functions of the turbinates are to humidify, warm and direct the air as it passes through the nasal cavity. They also produce mucous that traps dirt and bacteria as it passes through the nose. The lowest most turbinate is called the inferior turbinate. Inferior turbinates are the largest and most prominent of the turbinates. They can cause significant nasal blockage when they are enlarged. Enlarged inferior turbinates (inferior turbinate hypertrophy – Figure 2) are the most common cause of nasal obstruction.

 

The size of the turbinate varies with many factors. Many people notice that one side of the nose is more congested at certain times of the day and then at a different time in the day the opposite side is congested; this alternating congestion is normal and is known as the nasal cycle. On the other hand, when there is infection or inflammation in the nose, the turbinates on both sides become swollen and you may feel blocked on both sides at the same time. This also happens very commonly in allergic rhinitis, a condition caused by hypersensitivity of the nose to environmental allergens.

 

The treatment of inferior turbinate hypertrophy is similar to the treatment of Rhinitis (See section on “Rhinitis). However, in patients who have failed maximal medical treatment, inferior turbinate reduction procedures can be considered. This range from radiofrequency or coblation ablation of the inferior turbinates under local anaesthesia to inferior turbinoplasty under general anaesthesia (Figure 3a-c). There are advantages and disadvantages of each procedure and it is best that you have a discussion with your ENT specialist to determine the procedure that is most suitable for you.

Epistaxis (Nosebleed)

What is Epistaxis (Nosebleed)?

Epistaxis is usually caused by a burst blood vessel in the nose. This is usually the case in children and in most adults. In many people, the front part of the nasal septum has many prominent blood vessels (telangiectasia) (Figure 1). These are benign and are not tumours or dangerous growths. We do not know why some people have more prominent vessels on the nasal septum but sometimes it can be hereditary (genetic). Often, when the child grows older, the vessels become less prominent and the frequency of nosebleed lessens. There are other local and systemic causes of epistaxis but fortunately these are less common.

The first thing that you should do if you have epistaxis is to pinch the nostrils of your nose together (soft part of your nose), tilt your head forward and breathe through your mouth (Figure 2). Do this in a sitting or standing position. This will help the blood clot in the front part of your nose. You should not tilt your head backwards or lie down as the blood will continue to flow to the back of your nose and down your throat. If you do this, you may end up swallowing the blood and feel nauseas or even vomit the blood out.

 

To make yourself more comfortable, you can place an icepack on your forehead while you continue to pinch your nose. You can also rinse your mouth off the blood with ice gargle (water or mouthwash through a straw and cup) to remove the blood that has gone down your throat and mouth.

 

If the bleeding does not stop, you should consult a doctor. Continue pinching your nose till you are seen by the doctor. For heavy bleed (e.g. does not stop after 20 minutes of pinching your nose), it is best to go to the Emergency Department in a hospital.

 

If you are not actively bleeding from the nose, your doctor will take a clinical history to find out more about the frequency, amount and possible causes of your nose bleed. A thorough ENT examination will be performed, which may include a nasoendoscopy.

 

The treatment of epistaxis depends on the underlying cause. If the cause of your epistaxis is due to prominent blood vessels in the nose, it is likely that your doctor will apply a stick with some chemical (silver nitrate cautery) in your nose to seal the blood vessels (Figure 3a-c) This is done after spraying a numbing agent (topical anaesthesia) to the front part of the nose. Silver nitrate application is a quick and relatively painless procedure (some patients may feel some mild discomfort or stinging sensation in the nose but most do not complain of pain). Over the next few weeks, there may be mild crust (dried mucous) and mild nosebleed or bloodstain in the mucous as the wound in the nose is healing. Your doctor may give you some medications to hydrate and moisturize your nose during this period.


When Should You See An ENT Specialist In Singapore?

  • Any Ear, Nose or Throat symptoms that you are troubled with or concerned of
  • Persistent blocked nose with mouth breathing or snoring

Dr Gan Eng Cern

Dr Gan Eng Cern is a fellowship trained Consultant Ear, Nose & Throat (ENT) Surgeon. He completed his ENT training in Singapore and obtained his subspecialty training in Rhinology and Endoscopic Skull Base Surgery at the world renowned St Paul’s Sinus Centre, University of British Columbia, Vancouver, Canada. He was also a Senior Clinical Lecturer at Yong Loo Lin School of Medicine at the National University of Singapore. Dr Gan was an avid researcher with numerous publications in reputable international ENT journals. He was also an invited speaker and surgical dissection teacher in many ENT conferences and courses.

Awards

  • 2020 – Reader’s Choice Gold Award for Best ENT Specialist
    (Expat Living Singapore)
  • 2016 – Best Educator Award (Eastern Health Alliance)
  • 2016 – “Wow” Award (Patient Compliment)
  • 2014 – Eastern Health Alliance Caring Award – Silver
  • 2014 – 19th Yahya Cohen Memorial Lectureship (awarded by the College
    of Surgeons, Academy of Medicine Singapore for best scientific surgical
    paper)
  • 2012 – Human Manpower Development Award (Ministry of Health,
    Singapore)
  • 2007 – Singhealth Best Doctor Award

Qualifications

  • MBBS - Bachelor of Science, Bachelor of Medicine, Bachelor of Surgery (University of New South Wales, Sydney, Australia)
  • MRCS (Edin) - Member of the Royal College of Surgeons Edinburgh, United Kingdom
  • MMed (ORL) - Master of Medicine in ENT (National University of Singapore)
  • FAMS - Fellow of the Academy of Medicine Singapore

Why Choose Dr Gan Eng Cern

1

Reliable & Reputable ENT Expert

Experienced and patient ENT Specialist who has your best interests at heart. We aim to provide you with accessible and specialized care for any ENT condition in a comfortable setting.

2

Friendly & Helpful Clinic Staff

Our friendly staff will assist you to the best of our ability and we are happy to accept most insurance providers and assist with E-filing with relevant insurance providers or Medisave.

3

Advanced ENT Equipment & Fully Equipped Facility

Our ENT Specialist, Dr Gan Eng Cern, will be able to diagnose and offer personalised treatments for your specific ENT condition. You can expect a high level of ENT care in a spacious setting with in-house minor surgical, endoscopy, allergy testing and microscopy services.

4

Financial Options

There are various financial options available for you to ensure that you are able to receive the most optimal treatment and care. Our ENT clinic staff will be able to assist you with your medical insurance claims and work with your chosen healthcare organization to minimize the hassle and paperwork required. In some cases, you may be able to utilise the funds in your Medisave account to defray part of the costs of your treatment. As our clinic is accredited by the Medisave board, we are able to process your claims from your Medisave for certain clinic procedures.

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