Allergic
Rhinitis
The body
has a number of mechanisms to defend itself from the outside environment.
One of these involves specific protein and chemical reactions
within the body and is called the allergic response. This specific
mechanism can affect any area of the body where a foreign substance
is encountered. One of the principal functions of the nose is
to remove particles from the air before it goes into the lungs.
These particles become trapped in the mucus lining of the nose
and are subsequently destroyed. Because of the amount of foreign
material processed in the nose, the allergic response can become
quite noticeable and troublesome.
Histamine is one of the principal chemicals involved in the allergic
response. It is responsible for many of the symptoms of allergy,
including swelling, itchiness, and sneezing. It can also cause
the overproduction of mucus, leading to a runny nose. This is
the reason that antihistamines, drugs that block the action
of this chemical, are often used in treating allergies. Other
methods of therapy include nasal steroid sprays or cromolyn nasal
sprays.
Common allergens are dust mites, proteins from pet fur called
dander, molds, and pollen. Avoiding the specific item that provokes
an allergic response - called an allergen - is a key element in
treatment. In some cases the item is obvious, as when cutting
the grass or petting the dog provoke an allergic response. In
others, the offending allergen may not be so easily identified
or there may be many allergens, complicating the diagnosis and
treatment of the problem. In many cases, conferring with an allergist
can help sort out these issues. After a thorough history and physical
examination, allergy testing may be warranted. Occasionally, allergy
shots can help to blunt the individual's reaction to the allergen.
All of these issues can be addressed by a qualified allergist.
Often allergic rhinitis is associated with other conditions, such
as asthma and sinusitis. The lining of the nose, or mucosa, is
made up of the same type of cells as those that line the sinuses
and lungs. All of these areas of the body often can react together
to an allergy or infection. It is for this reason that a multi-disciplinary
team made up of an allergist and an otolaryngologist can best
treat these connected conditions.
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Nasal Polyps
Patients
are often told that they have polyps or growths within their nose
or sinuses. It should be stated from the outset that polyps in
the nose, unlike polyps elsewhere in the body, are rarely
associated with any sort of tumor or neoplasm. They typically
result from a brisk inflammatory response that makes the swollen
nasal lining balloon out into what looks like clusters of grapes.
Nasal polyps can obviously block the sinus openings and precipitate
chronic sinus infections.
When polyps are seen in association with asthma and sensitivity
to aspirin, they form a three-part symptom complex called "triad
asthma" or "Samter's triad."
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Nasal Airway Obstruction
When
patients find it difficult to breathe through their noses, physicians
label this condition nasal airway obstruction. This condition
can cause discomfort due to the need to breathe through the mouth,
leading to a dry mouth and throat irritation. It may also contribute
to snoring, which can be the first symptom of a condition known
as "obstructive sleep apnea."
Nasal airway obstruction can result from swelling of the lining
within the nose (the "mucosa") or from structural narrowing within
the nose. Medications to control the mucosal swelling (See "How
is sinusitis treated?") are often effective in relieving the
sense of obstruction. When the problem is a structural one, often
surgery is necessary to resolve the problem.
The first step in resolving a structural narrowing is defining
the precise location of the obstruction. The nose can be compared
to a hallway through which air passes from the outside environment
on its way in and out of the lungs. The hallway has shelves that
hang off of the walls, called "turbinates," and also has a narrowing
at its beginning, called a "nasal valve." Narrowing or collapse
of this valve or enlargement of the shelf-like turbinates can
impede the movement of air through the nasal hallway. Moreover,
there is a curtain that runs the length of the hallway and divides
it into more or less equal halves. If the curtain is crooked,
the air will not pass down the hallway properly, also giving the
sensation of nasal obstruction. Proper identification and correction
of the structural problem can restore normal airflow through the
nose.
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Rhinitis
Medicamentosa
Nasal
decongestant sprays (See "How is sinusitis
treated?") are effective ways of diminishing swelling within
the nose. Nevertheless, when used for more than three days in
a row, they can lead to worsening of the swelling. This occurs
because of a "rebound effect" that occurs as the spray wears off.
This phenomenon leads to a cycle where patients will then increase
the dosage or the frequency with which they use the sprays in
order to diminish the rebound swelling. This leads to a vicious
cycle of decongestion followed by rebound swelling followed by
more decongestion, etc. This condition is known as "rhinitis medicamentosa."
Treatment is relatively simple: complete discontinuation of the
nasal decongestant sprays. Because this course of action often
results in severe rebound swelling, other medications to diminish
swelling can be prescribed by your physician to assist in getting
through this short-term phase.
Unusual Conditions Affecting the Nose A number
of rare conditions such as those that follow can affect the nose
and sinuses. These are often amenable to repair or treatment using
nasal endoscopes.
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Mucocele
A
mucocele is a closed collection of mucus that typically expands
over months to years. It results from a sinus being completely
blocked and continuing to secrete mucus into this closed cavity.
The cavity continues to slowly expand and may begin to erode the
surrounding bone. Because this occurs over such a long period
of time, there are usually few if any symptoms. This condition
often becomes unmasked when it begins to affect the structures
surrounding the sinuses, specifically the brain or eyes.
Treatment of mucoceles of the sinuses involves opening the cavity
and providing drainage into the nose. Typically this can be done
using nasal telescopes, even when the mucocele has completely
eroded the bone between the sinuses and the brain or eyes. Rarely
is removal of the entire mucocele through facial or scalp incisions
necessary.
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Cerebrospinal Fluid
(CSF) Leak
Also
known as CSF rhinorrhea, this condition involves a defect in the
bone and soft tissue barrier between the brain and the sinuses.
Fluid that surrounds the brain called cerebrospinal fluid (CSF)
can then leak into the nose. What results is a watery, salty fluid
leaking from the nose, especially with exertion or straining.
This condition can be dangerous because the opening between the
brain and the sinuses gives bacteria from the nose access into
the critical brain area. This can result in meningitis, or infection
of the lining of the brain.
CSF leaks can occur spontaneously or can be the result of trauma,
most often car accidents. Nasal or sinus surgery can rarely cause
this problem as well.
Formerly, closure of such leaks involved a craniotomy, or opening
of the skull and brain cavity. Recent advances in endoscopic sinus
techniques now allow repair of this problem through the nose without
the need for facial or scalp incisions. Successful closure can
be achieved in greater than 90% of cases using this approach.
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Allergic fungal sinusitis
This
condition occurs when a patient has a brisk reaction to fungus
within the nose and sinuses. Fungus is all around us in the environment
and can cause an allergic reaction, particularly in patients with
known allergies to mold (a type of fungus). Allergic fungal sinusitis
is more prevalent in the Midwest, particularly in the Ohio River
valley, due to the presence of these particular types of fungus.
In allergic fungal sinusitis, the body's reaction to the fungus
causes production of a very thick mucus. The sinuses become inflamed
and obstructed, as in normal sinusitis, but the thick mucus fills
the sinuses and allows for more fungal growth. The sinus may begin
to expand from the pressure of the thick mucus and cause problems
in the eyes or soft tissues of the face.
The best treatment of allergic fungal sinusitis is surgical opening
of the sinuses and removal of the thick mucus. Inhibiting the
allergic process using steroids and allergy shots can prevent
the disease from returning.
