Allergy, Nose & Sinus

All you need to know about “Sensitive Nose” (Rhinitis)

February 10, 2020
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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
  • Sneezing
  • 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:

 

 

  1. Fever
  2. Sorethroat
  3. Coloured mucous (Yellow, green or brown)
  4. Thick mucous or phlegm
  5. Body ache and tiredness
  6. Usually resolves within a week
  7. 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:

 

 

  1. Facial pressure or pain
  2. Nasal blockage
  3. Nasal congestion (feeling of mucous stuck in the nose)
  4. Coloured mucous (yellow, green or brown) or thick mucous/phelgm
  5. 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).

 

 

Rhinitis Diagnosed

Figure 1a- Flexible nasoendoscope is a painless procedure that is done in the clinic under local anaesthesia

 

 

Rhinitis Sensitive Nose

Figure 2a -An illustration of the front view of the nose showing the difference between a normal versus an enlarged inferior turbinate

 

 

Rhinitis

An nasoendoscopic view of the front part of the left nasal cavity. The enlarged left inferior turbinate (indicated by yellow arrow) is almost touching the nasal septum (wall between the right and left nose indicated by yellow asterisk).

 

 

Skin Prick Test

 

 

What are the treatment options for Allergic Rhinitis?

 

 

Allergen Avoidance

 

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.

 

 

Medication

 

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).

 

 

Avamys Nasonex Product

Figure 4 – Common nasal steroid sprays available in Singapore

 

 

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.

 

 

Immunotherapy

 

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.

 

 

Oral Spray

Figure 5  – Sublingual immunotherapy (SILT) involves spraying the allergen under the tongue on a daily basis to desensitize the patient from that allergen

 

 

Surgery

 

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)

 

 

Rhinitis

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)

 

 

Best wishes,

 

Dr Gan Eng Cern
ENT Specialist Singapore

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

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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.

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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

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