Allergy, Nose & Sinus
All you need to know about “Sensitive Nose” (Rhinitis)
February 10, 2020
What is Rhinitis?
Rhinitis is the medical term for “Sensitive Nose”. It refers to inflammation of the nasal cavity. Rhinitis is a common condition, affecting almost 10% to 30% of the population worldwide. Some people may trivialise the significance of Rhinitis but numerous studies have shown that it has significant socioeconomic cost, adversely affects quality of life of the patients, work productivity and may worsen symptoms in patients with Asthma. In fact, Asthma and Rhinitis often co-exist, with approximately 80% of patients with Asthma suffering from Rhinitis and about 20-50% of patients with Rhinitis have concomitant Asthma. Treatment of rhinitis may improve asthma control and early treatment of allergies may prevent the development of asthma.
What are the types of Rhinitis?
The types of Rhinitis can be broadly divided into:
a) Allergic Rhinitis (AR)
This is the most common form of Rhinitis and is caused by exposure to allergens which are proteins that trigger an allergic reaction. Common allergens include house dust mites, grass or tree pollens, animal danders, mold and cockroach. Traditionally, AR was classified as:
- Seasonal – This occur in Spring and Autumn (Fall) when there is more pollen from trees, grass or weed causing the allergy
- Perennial – This occurs all year round due to allergens that are present regardless of season. Common cause include House dust mites, animal danders, mold and cockroach.
The Allergic Rhinitis and its Impact on Asthma (ARIA) guideline has reclassified AR based on symptom frequency (“Intermittent” or “Persistent”) and symptom severity (“Mild”, “Moderate” or “Severe”). This classification provides a guide on the type of treatment required for Allergic Rhinitis.
b) Non-Allergic Rhinitis
This is Rhinitis that is not due to exposure to an allergen. Common causes include cigarette smoke, traffic fumes, perfume, strong odors, stress and a change of weather conditions. The symptoms are similar to Allergic Rhinitis.
c) Infectious Rhinitis
This is Rhinitis due to a viral infection. Cold and flu are common forms of infectious rhinitis.
What are the symptoms of Allergic Rhinitis?
Symptoms of Allergic Rhinitis include:
- Blocked nose
- Clear runny nose
- Itchiness in nose and eyes
- Watery eyes
- Mucous and phlegm in the throat (from “postnasal drip”)
What causes Allergic Rhinitis?
This is not completely understood. However, there is evidence of a hereditary cause and patients with family history of Allergic Rhinitis are more likely to have it than those who do not.
How do I tell if I have a cold and not Allergic Rhinitis?
Symptoms from Allergic Rhinitis can be similar to a cold. However, there are some differences and a cold tend to have more of the following symptoms:
- Coloured mucous (Yellow, green or brown)
- Thick mucous or phlegm
- Body ache and tiredness
- Usually resolves within a week
- Less itching of the nose and eyes
How is a cold different from Sinusitis?
Symptoms of sinusitis can be similar to a cold. However, sinusitis usually last longer than 10 days or the symptoms are not getting better after 5 days of infection. As sinusitis is usually caused by a bacterial infection, treatment with oral antibiotics is important. On the other hand, a cold is a viral infection and your body’s immune system should be able to fight it off. Antibiotics will not be helpful. Common symptoms of sinusitis include:
- Facial pressure or pain
- Nasal blockage
- Nasal congestion (feeling of mucous stuck in the nose)
- Coloured mucous (yellow, green or brown) or thick mucous/phelgm
- Loss or decreased sense of smell
How is Allergic Rhinitis diagnosed?
The diagnosis of Rhinitis can be made from a suggestive clinical history and findings on nasoendoscopy. Nasoendoscopy is performed in the clinic and involves the passing of a small lighted tube into the nose and down the back of the throat (Fig 1a). On nasoendoscopy, the inferior turbinates may be enlarged (Fig 2a&b). A skin prick test (a form of Allergy Test) can be performed to help differentiate between Allergic and Non-Allergic rhinitis (Fig 3a&b).
Figure 1a- Flexible nasoendoscope is a painless procedure that is done in the clinic under local anaesthesia
Figure 2a -An illustration of the front view of the nose showing the difference between a normal versus an enlarged inferior turbinate
What are the treatment options for Allergic Rhinitis?
The most common allergen amongst Singaporean is house dust mite. Hence, those with dust mite allergy should wash their bedsheets and pillow cases once a week with hot water (at least 60 degrees Celsius high) to get rid of the dust mite allergens. As it is not possible to avoid all allergens in the environment, you will need medications to keep your symptoms under control.
In patients with troubling symptoms from Rhinitis, the use of a nasal steroid spray is advised. Nasal steroid spray reduces inflammation in the nose and is effective in alleviating all symptoms of Allergic Rhinitis (Fig 4). While many people have concerns about the side effects of steroids, modern nasal steroid sprays have minimal absorption into the bloodstream. Hence the systemic side effects from the steroid is negligible. Some nasal steroid sprays can be used in children as young as 2 years old. Nasal steroid spray does take time to be effective (from days to 2 weeks for maximal effect) and has to be used on a daily basis. It is important that patients are diligent and comply with the use of nasal steroid spray before giving up this treatment modality. It is equally important that the correct application technique is used for the steroid to reach the correct areas in the nose. The patient should tilt his or her down, insert the spray into one nostril and aim the nozzle slightly away from the centre (towards the eye on the same side). Application of the spray should be timed with normal inhalation (a normal gentle breath in).
Other medications for Allergic Rhinitis include leukotriene receptor antagonists, anticholinergics and cromolyn. They are however not first line treatment in the management of Allergic Rhinitis. They may be useful under certain conditions and it is best to discuss with your doctor if these medications will benefit you.
In immunotherapy, the patient is presented with the known allergen in a small dose repeatedly to desensitise the patient from that allergen. It can be given via an injection into arm (Subcutaneous Immunotherapy – SLIT) or sprayed under the tongue (Sublingual Immunotherapy – SLIT). In Singapore, immunotherapy is most commonly applied under the tongue (Fig 5). Patients have to use SLIT for at 3 years as it takes time to change the body’s immune response to the allergen. However, improvement in symptoms can be expected after about 3-6 months of therapy.
Surgery for Allergic Rhinitis is aimed at relieving the symptoms. It does not alter the disease process of Allergic Rhinitis. Most commonly, surgery is performed to relieve nasal obstruction. This is achieved by reducing the size of the inferior turbinates (Fig 6). There are many ways to reduce the size of inferior turbinates. Less aggressive procedures (e.g. radiofrequency or coblation of the inferior turbinates) can be done in the clinic setting under local anaesthesia while more aggressive procedures (e.g inferior turbinoplasty) has to be done in the operating theatre under general anaesthesia (patient asleep during the procedure).
Figure 6a – Enlarged left inferior turbinate (indicated by yellow arrow) almost touching the nasal septum (indicated by yellow asterisk)
Figure 6b- After a turbinate reduction surgery (in this case inferior turbinoplasty). There is a lot more space in the left nasal cavity with a smaller left inferior turbinate (indicated by yellow arrow) that is far away from the nasal septum (indicated by yellow asterisk). In the endoscope view, one can see all the way to the back of the patient’s nose (postnasal space – indicated by yellow square)
Dr Gan Eng Cern
ENT Specialist Singapore