Allergy, Nose & Sinus

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.

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”)

What is Sinusitis (or Rhinosinusitis)?

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.

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.

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).

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.

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.