earnosethroatindia.com
Books and Articles About Us Facilities Contact Us
 


BOOKS AND ARTICLES


ARTICLES ON NOSE

ARTICLES ON HEAD

ARTICLES ON EAR

ARTICLES ON NECK

ARTICLES ON THROAT

ARTICLES ON COSMETIC & LASER TREATMENT

 


 



*Mischievous nature of Nasal Problems*

Complaints of nasal problems appear to be very simple to the patients and the practitioners. These complaints are often tolerable and so routine life of the individual remains undisturbed. Symptoms are easily but temporarily and partially controllable with the help of home remedies or advertised medication or over the counter sale of products by a chemist. So, in most of the nasal cases, self medication and mismanagement of treatment is commonly observed. When disease continue for few months or years in mild form, many patients consider mild nasal complaints as normal for them. As these so called simple and mild complaints continue to recur these tend to last longer after certain duration. In some cases, these symptoms develop tendency of recurrence as soon as treatment is discontinued. Insufficient doses, incomplete treatment, lack of preventive treatment over enough period makes these disease resistant to the treatment. So, response to the treatment varies from case to case. Response depends on immunity of the patient, severity of allergy, nature of infection, vasomotor phenomenon, life style of the patient and environmental factors, persistence of follow up at certain intervals etc. So, to improve resistance power or immunity, long-term response to treatment is uncertain. Family physician gets confused in adjusting the doses in majority cases, duration of the course of the drugs, interval at which patient is asked to keep follow up. There is nothing definite about exact extent of the disease, nature of the disease and tendency of recurrence of the disease or the persistence of the disease. He feels tenseness and may think that it is difficult to cure this so-called 'simple' problem. Patient may consider it as unavoidable problem in his life. Certain patient may have his own concepts of diagnosis in his mind. Clinical features of diseases like chronic rhinitis, deviated septum, allergy, he might misinterpret it as sinus problem, growth of some bone, mass or polyp or allergy phenomenon.


Many patients consider these as mild complaints of nose are due to simple nasal disease such as common cold and they do not report to their family doctor to take treatment in spite of recurrence of symptoms. Some patients unknowingly adjust with these so-called mild complaints. They occasionally take one or two doses of antihistaminics and use decongestant nasal drops 2-3 times. Once they feel relief from the symptoms, medicine is discontinued. They even forget about these complaints.


EPISTAXIS

Epistaxis is a common problem. Only 10% of nosebleeds seek medical attention and out of them very few turn to nose specialist for treatment.

Due to misconception, parents may neglect this complaint initially. They may think that it is due to some wrong food habits of child like eating excess sweet food or wrong food or so called ‘hot’ food. Parents may scold the child for his so called ‘fault’. Due to such misconcept, they may neglect proper treatment during initial phase. Here hot food means some food, which causes heat changes in body according to their knowledge of Ayurveda. One folk had love belief about epistaxis that is its' occurrence indicates 'you are in love'. Some have misbelief that one drop of blood from the nose commonly foretells death or a very severe illness. So in past, people used to give morning drink of whey with raisins, wearing a skein of scarlet silk thread with nine knots down the front, frying patient's own blood and using it as a snuff.

Common Causes: -

1) Trauma: -

Finger picking in Little's area is most common injury causing epistaxis. Often such bleeding is scanty in amount. But it can be in excess. Such type of bleeding can be easily controlled if soft part of the nose is pinched with fingers. Neglected sinusitis, exposure to hot and dry atmosphere, over use of direct fan air, nutritional deficiency provokes crusts formation. Crust creates urge for finger picking. This is more likely to occur in summer. In about 70% of cases, cause is due to epistaxis digitorum, i.e. trauma of finger picking in Little’s area of nasal septum, which has rich supply of blood. Little’s area is present just 1 cm behind the lower 1/3 rd part of margin of septum. This area is directly exposed to inhaled air so it has tendency to become dry. If it gets dry, patient feels irritation and itching in the nostril. So patient develops urge to put finger in his nose. Then, patient puts fingertip in the nostril the fingernails and the forceful removal of crust cause injury to delicate mucosa. Often patient is not aware of effect of such simple action and its repetition. If patient is child, the parents are not aware about effects of such finger picking and they neglect such habit or just scold the child for doing so. They do not take treatment to prevent this habit. They postpone to consult family physician for ‘how to avoid such habit’. Thus, often this problem is neglected during initial phase. In this way, epistaxis is often likely to become recurrent problem. Trauma and accidental injuries like road traffic accident and nasal surgery are less common causes of epistaxis.

2) High blood pressure: This disease causes bleeding in an elder patient. Such bleeding is generally from posterior part of nose. It trickles down in throat. Such patients may have haematemesis. Bleeding starts suddenly and in excess quantity.

3) Infection of nose like chronic rhinitis, atrophic rhinitis, sinusitis may cause epistaxis. Bleeding is scanty in amount. Acute viral rhinitis, nasal diphtheria and acute sinusitis rarely causes epistaxis.

4) General causes like: -Blood clotting disorders. Drugs taken for arthritis and prevention of thrombosis in heart vessels (Drug induced). Bleeding due to such cause is in excess and there is no definite site.

5) Foreign body- it is associated with unilateral foul smell discharge and excess oedematous nasal mucosa. Often it causes blood stained discharge. Frank bleeding is uncommon.

Investigations advised: -

If patient does not responds satisfactorily or if there is recurrence of bleeding or if bleeding is severe, one should advise for following investigations.


1) Blood clotting time, bleeding time, and prothrombin time.
2) CBC, platelet count, HB%.
3) Nasal endoscopy. It can be repeated at interval of 7-10 days to assess response to treatment.
4) CT Scan of paranasal sinuses. If facilities for CT scan are not available then X-ray of paranasal sinuses (water’s view) is advised.

Treatment: -


Give standing instructions to the patient. Explain Trotter’s method. Tell the patient that whenever the bleeding from nose occurs, sits down with head in forward down bending position. Then, pinch the nose by putting finger pressure on soft anterior 2/3rd part of nose from both sides. Keep such pressure for 10-20 minutes. Breathe through mouth and keep head tilted downward so that if bleeding continues it will come out through posterior part of nose in throat and then in mouth automatically. Patient can spit it out. In majority of cases, bleeding is from Little's area. So, this technique is often helpful. After certain duration, bleeding stops. If bleeding stops completely, one does not need immediate nasal packing. Put cotton ball of sufficiently large size in the vestibule so that current of airflow will not disturb the clot and patient will not put his finger to remove the clot. Change this cotton after every 3-4 hours. Continue to keep such cotton for 4-6 days i.e. till bleeding point heals. If the patient has recurrent bleeding, such cotton pack may be continued for longer period. Each and every case of recurrent mild epistaxis and severe epistaxis must be investigated as mentioned above. Persistent bleeding in spite of continued external pressure on the soft part of nostril gives us the warning that bleeding is from mid part or posterior part of the nose and patient needs nasal packing in the nose.

For keeping nasal pack, apply ice cold water to the face around the nose and head. Apply ice pack on the nose. Practitioner should use reasonable good light of head mirror or head light. Torchlight is not enough.

If bleeding continues or recurs at the site of anterior nasal packing, post nasal packing should be done at special centre.

After removal of pack, saline spray is advised to reduce crusts in nose. Ask the patient to keep cotton ball in vestibule to prevent flow of air through nose, dryness of nasal mucosa and to prevent urge of putting the fingertip in the nose. Change it 4 times a day for seven to ten days. In recurrent or resistant case, such duration should be extended over a period of a few weeks.

Advise suitable antibiotics. Antihistaminics and decongestant drugs are used to reduce allergic reaction to pack. Multivitamins are used for faster healing of bleeding point. Advise sedation and tranquillizers to prevent restlessness and anxiety in the patient and to keep the patient relaxed when pack is in position. Treat underlying chronic conditions of nose like sinusitis, deviated nasal septum and diseases of other part of the body. Patient is given haemostatic injection like ethamsylate, chromostat, Botropase, vitamin C and vitamin K. sedatives are given to allay patient’s anxiety. Once bleeding is controlled and patient has settled down, find out the cause of bleeding. Patient is investigated thoroughly. Treat the cause. It is second line of treatment in every case of epistaxis. Bleeding point is cauterised by electro cautery or trichloro acetic acid.

'Most common' features of common cold:

1. Common cold is the most common problem in the world. Everybody suffers from it 2-4 times in a year.
2. It is most ill understood and misunderstood.
3. It is also most neglected and mismanaged problem.
4. It is most under treated or over treated and mistreated.
5. Common cold is most uncertain and vague in responding to treatment and preventive care. Such uncertain nature of common cold is still unaltered in spite of advancement in treatment.
6. It is the most commonly gets self-limited within 10-14 days.
7. It is most common to see advertises of curing common cold over so many decades without challenging about their authenticity.

It is related to poor resistance power of the host which may be due to extreme fatigue, lack of rest, exposure to cold, unfamiliar weather, dry air in winter, allergy, poor nutrition, diabetes mellitus, vitamin deficiency, nasal blockage, chronic nasal infection etc. Environmental factors like dry cold air or dry hot air, high humidity, use of room heaters in winter without proportionate increase in humidity, working or sleeping in congested or non-ventilated rooms, air pollution, use of mosquito repellent, any chemical scent, longer exposure to frying process of food provoke this disease. Dry air in winter and use of room heaters cause dryness of mucosal blanket thereby increasing its susceptibility.

When child is brought by mother to clinic for frequent problem of lower respiratory tract infection and tonsillitis, she may not tell problem of recurrent attacks of common cold or persistent cold as she may think it as irrelevant or she may think that "in children, common cold is a common problem and it does need any treatment. In children, it is bound to develop and so why to bother for it." If coryza does not respond to treatment or home remedy, she may accept it as a usual part of healthy state of body in this age group. So parents may not attract the attention of medical practitioner to recurrent nasal problem in children but they may only complain of chest and throat problem of recurrent nature. Due to ignorance, they are not aware of relationship of recurrent common cold or neglected attack of common cold with its possible extension of infection in sinuses and lower respiratory tract.

CLINICAL FEATURES: -


Initially, Patient develops raw feeling in pharynx, tickling and dryness and irritation in nose and sneezing. It may be followed by excess watery rhinorrhea, and blockage of nose. Later on nose discharge may become thicker and yellow or green due to bacterial infection. Mucosa is congested and swollen and profuse mucopurulent discharge develops in later stage. He/ she may have associated fever, headache, bodyache, malaise, and feeling of exhaustion. Mucosa is congested and swollen and profuse mucopurulent discharge develops in later stage.

If patient has poor resistance power, the goblet cell population does not return to normal level. And so it tends to produces infective rhinitis, sinusitis, nosopharyngitis, adenoiditis, pharyngitis, pharyngotympanosalpingitis, otitis media, tonsillitis, and chest infections.


Preventive Measures: -


Avoid provocative and precipitating factors mentioned above. Use viral vaccines in population at risk like smokers, medical- paramedical professionals. As there are number of strains of these viruses it is difficult to cover all strains with vaccine.


a) Take enough rest.
b) Avoid over exertion during stress.
c) Take regular physical exercises. Practice yoga and pranayama.
d) Sleep in well-ventilated and warm room.
e) Take balanced diet.


Treatment: -


About common cold it is said if you take treatment you are cured in seven days and if you do not take treatment, you are cured within a week. In other words, in healthy individual, common cold is self-limiting disease. It does not require very active treatment but patient must take precautions to avoid provocative factors mentioned above and follow the instructions given in above chapter and below to control common cold in natural way. Often attack of common cold may be so mild that the individual may not notice it and so one may not follow the instructions given below. Later on such neglected mild common cold may likely to become severe and recurrent. So chronic rhinitis and sinusitis may develop in these patients. Even if some patients have severe symptoms, they may take treatment till symptoms are troublesome and then stop the treatment. Such incomplete treatment may keep distance in subclinical form and later may likely to create recurrent infection of nose and sinus.

Instructions:


1) Take enough rest for quick recovery. Keep regularity in routine life. Avoid over exertion, fatigue, late hours in night and irregular routine schedule life.

2) As it is contagious, contact with patient of common cold should be avoided.

3) Avoid predisposing factors mentioned above.

4) Avoid travelling. Avoid polluted atmosphere, exposure to cold air, and change of weather. Avoid environment in which dust and smoke is present.

5) Do not sit or sleep in closed room or in non- ventilated rooms. Stay in warm environment. In winter, air is dry. So if room heater is used, take precaution to humidify the air sufficiently.

6) Give understanding to the patient about the nature of the disease. Tell him, “It is viral infection where medicine is less effective and one must follow precautions religiously. Follow these precautions to prevent conversion of common cold in to chronic rhinitis or non-curable sinusitis. In case of recurrent common cold, these precautions should be followed strictly. Any attack of common cold may sow seed of chronic nasal problem.”

Medical therapy:


1. Hot baths and steam inhalation of menthol or Tincture Benzoine vapours (half teaspoonful in half litre of water) is helpful.


2. Analgesics reduce aches and fever.

3. Vitamin C 500 mg once a day for 2 weeks is advised to prevent further attack of cold and help in treatment.

4. Decongestant drugs relieve nasal obstruction. These are of two types: -1) Systemic Decongestant: -Phenyl epinephrine, pseudo ephedrine do help but these make the nose dry. 2) Local Decongestant: - Oxymetazoline. These are less often required and should be used only for 3 to 6 days. As far as possible, local vasoconstrictor drops should be avoided as they interfere with mucocilliary activities have a tendency of habit formation.

5. Advise antihistaminics to decrease hydrorrhea but they may make thick nasal secretions. In severe condition, antibiotics are used to prevent secondary infection.

6. Associated factors like deviated nasal septum, middle turbinate hypertrophy, may aggravate the problem. Treat them properly and completely to prevent frequent recurrences.

ALLERGIC RHINITIS: -


Allergic rhinitis is also called as an extrinsic rhinitis, because it is caused by the external problems. It is frequent rhinopathy characterised by sneezing, itching, watering and nasal blockage. Sneezing is more prominent symptom.


After common cold second most common condition of nose is allergic rhinitis. 10-30% of adults and 40% children suffer from it. Incidence of allergic rhinitis is more in teenager and in young adults. Positive family history increases the risk of allergy in an individual.


Out-door allergen are road dust, automobile smoke, fumes, pollens, chemicals, chemical gases in environment pollution changes in weather, food items, spores, cockroaches, latex particles, drugs, metals. These are less commonly observed. Indoor allergens are more common allergens in India. House dust, mites, smoke, animal fur, animal dander, systemic drugs and local nasal fungal molds, dandruff, leather etc. House mite dust are found in mattresses and pillows. Cigarette smoke, mosquito repellents are common indoor allergens, exposure in busy road traffic, exposure to polluted atmosphere at work place, kitchen (in case of house wife) cause allergy.

As environment is becoming more and more polluted, more unnatural for human being and complex in composition, number of substances having capacity of being potential allergen is on increase. We come across allergen through inhaled air, ingested food (fertilizers) and insecticide on green leafy vegetable and through injection.

Common allergens are: -

Pollens of grass and flower, moulds, fungi (like aspergillus, candida, cladosporium, mucor, penicillium etc.), house-mites etc. House mite feeds on dead human skin, it is present in bed sheets, mattresses, bedroom carpets, and soft furnishings. Animals like cat, dogs, cow, horses, sheep, rabbit and feathers of animals and birds cause allergy to owner. Ingestion of food like chocolate, eggs, use of cosmetics etc. are causes of allergy. Food induced allergic rhinitis is moe common in children. E.g. milk, eggs, peanut, wheat, soya, walnuts, cheese. In adults, nuts, walnuts, peanuts, fish, citrus fruits and seafood may provoke allergy. Salicylic acid may cause allergy. Food allergy is associated with attack of allergic rhinitis. Usual day to day allergy if often not severe it is not considered by the individual or family physician as important health issue.

Allergic rhinitis is of two types: -

Seasonal and Perennial. Seasonal allergy alone is less common than perennial allergy with or without seasonal symptoms.

Seasonal Allergic Rhinitis: (Hay fever)


Seasonal allergic rhinitis is triggered by pollen and mold. In seasonal allergic rhinitis, sneezing is very dominating symptoms as compared to other symptoms of allergy. Profused rhinorrhea is present. It is seromucinous. These patients are restless due to itching in nose and eyes. It may also be on palate, pharynx and in the ear. Patient develops excess lacrimation, burning or pain and congestion of conjunctiva. Symptoms progress with exacerbations and remissions during whole of allergic season. Patient may have fatigue, headache, cognitive impairement and other systemic symptoms. In acute stage, mucosa is pale and oedematous. Menstruation, menopause, ovarian dysfunction, pregnancy, hypothyroidism tend to increase allergy. Nutrition factors like deficiencies of Vit. C and D, trauma. Stress act as provoking factors. Temperature, humidity, movements of air, damp and stagnant atmosphere act as provoking factor. In chronic stage, mucosa may become bluish or purplish due to venous stasis. Patient gives typical history of attack of allergic rhinitis in particular season after exposure to certain pollens during pollination. At other times patient is absolutely free from symptoms. Seasonal allergy may get converted into perennial allergy. History of seasonal hypersensitivity, frequency and severity of symptoms help in diagnosis. Many patients of seasonal allergic rhinitis have concomitant asthma. Examination of secretion on their turbinate should be advised.


Common outdoor allergen: Pollens, molds, automobile smoke

Common indoor allergen: housemites, domestic animals, tobacco smoke, mosquito repellents

Common factors which aggravate effects of indoor allergen: congested room, ill-ventilated room, closed room.

 

Perennial Allergic Rhinitis: -

Fifty per cent of cases of perennial rhinitis are allergic and others are non-allergic in origin. Perennial rhinitis may be defined clinically as inflammatory condition of nose characterised by nasal obstruction, sneezing, rhinorrhea, itching, occurring for hours or more on most days throughout the year. Family history is present in 60 - 70% of cases. Perennial allergic rhinitis is more difficult to diagnose than seasonal allergy because former is more often present with sinusitis or other forms of recurrent rhinitis.

House-dust mite is one of the common allergen. In houses, bedroom is good breeding ground for house mites and these flourish on pillow, bedclothes, mattresses, carpets, and curtains and soft furnishes. Human skin scales are good food for house mite. Pets may also cause this type of rhinitis. Such patients feel better when they are in fresh open air and outside the house. Occupational allergens should also be considered.

Management: -

Training and education of patient: Create awareness among the patients and their relatives about allergy effects and prevention. Educate them on topics of allergy and its treatment and management. The patient should be told about what is allergy, how it is related to our routine life, life style, diet habits, certain foods, any new food, fruits, seasonal drink, environment at work place and residence results of pollution, use of mosquito repellents, fan, way of cleaning of dust in house / office etc. He should be explained why and how this disease responds dramatically but temporarily to the use of drugs and why it recurs again. Explain him that it is not failure of treatment but it is silent persistence of disease even after initial dramatic response to the treatment. Disease takes its own time to respond satisfactorily. Recurrence of symptoms and failure of cure does not mean that doctor is not able to diagnose or treat the case but it is a tendency of the disease itself. It indicates that it is resistant cases and allergic reaction in body are stronger and his immunity is less. Such thinking is due to anxiety, ignorance and lack of education about allergy. I take all precautions but still I get cold. This is due to allergy and infection.

Myths of allergy:

a) 'Allergy is infective': allergy is not infective or contagious. It is a hyperactive state of the body’s own defence mechanism.

b) 'Allergy means one must have skin rash.' Allergy can be in nose, skin, respiratory tract, etc.

c) “I am allergic to everything such as ….” He gives list but it is not a full list. No one is allergic to every thing.

d) “Allergy means skin rash, then, how can I have nasal problem and you say, it is allergy. What is allergy in nose?” Such question is due to inference drawn from limited information, half knowledge is more dangerous than ignorance. “I keep my surrounding free from any allergen. So, I shall not have allergy.” Keeping clean surrounding is not full proof method of getting rid of all allergic substances.

Such many more myths exist. These myths discourage the individuals to take proper & regular treatment. Myths, doubts, lack of confidence in oneself & in physician about results of medical & surgical treatment often motivates patient for over the counter drug.

The disease needs more intensive follow up and management to boost immunity of the patient. Tell him a difference between treatment of this disease and management of this disease. Convince him, “You yourself has to participate in the management of this problem by following precaution, observing restriction and reporting from time to time to me to take preventive treatment and to boost one’s own immunity.”

As these patients keep poor follow up, they have high drop out rates. They are often confused, anxious, frustrated and doubtful about the results of treatment. They have a tendency of medical shopping in various clinics and self-medication. So, physician must create good rapport with these patients, boost their faith, nurture their confidence and convince them the importance of keeping follow up with the same family doctor or an expert. Change of doctor without valid reason and without taking doctor into the confidence may likely to cause mismanagement of the treatment.

He should be explained, “We live in more polluted and allergen rich environment. Number of allergens may increase every year. Even type of allergens may change after certain period. Allergy might develop in anybody. It may reduce after treatment and may redevelop after exposure to allergen in the form of inhalants, contacts, and ingestants. It is not harmful condition but negligence may likely to convert it into more severe condition. It may affect throat, larynx, and lungs. It may provoke attack of bronchial asthma in some patients. Patient’s negligence and mismanagement may be the cause of his/her allergy to persist or increase. E.g. negligence in taking right time treatment, incomplete treatment, incomplete follow-up, self medication, delaying investigations, neglecting avoidance of allergic factors, maintaining unnatural routine habits, busy daily schedule, lack of physical exercise, emotional imbalance, staying and working in allergy provoking environment.

Tell the patient, “Even if you feel better after taking some part of course of medicine, you should complete course of medicine and report for follow-up from time to time. Even if you become asymptomatic, one needs to take booster doses of medication and immunization at certain intervals as suggested by family physician or nose specialist or allergy specialist from time to time.”

“Allergy may affect our physical and mental stamina. It decreases our capacity of concentration. It makes us more susceptible to emotional imbalances and mental irritation. Chronic severe allergic rhinitis affects our social life and may further reduces our social limitations and participation in social activities. Allergy is not just temporary disease but it is a persistent and / or recurrent phenomenon in our body, which has become apparent in some people. Accept it with open mind and learn to know more about it. Get trained to manage it by altering our routine life, place of work, environment in our bed room, place of stay, and certain factors in our life, at work place and home. Read literature about allergy and its management. Be more conscious to identify the factors, which provoke and aggravate attack of allergy. Keep contact and communication with other patients of allergy who have been relieved by treatment and those who are taking treatment for allergy. He should discuss with them about the precautions they follow and how they co-operated with their doctors to manage their problem of allergy successfully. Everybody in this world may likely to suffer from allergy sometimes in his life. So let us be more knowledgeable about it. Let us learn to manage it and avoid the factors, which provoke allergy in one's own case. Try to help yourself to increase your resistance power and immunity by seeking treatment from your doctor or consultant. Keep in mind, some cases of allergy may not get cured, but those can be certainly reduced to manageable level for the control of symptom or for prevention of its attack.”

“Many of the students study only when there is examination in near future. Most of them never study regularly from beginning of academic year. So how can their memory and intellectual capacity will increase? Thus, their memory and intellectual capacity remains weaker. In the same way, we take treatment only when there are troublesome symptoms. Once we feel better, often we do not report our doctor to take further necessary treatment for boosting our immunity power and preventing such recurrence of disease in future. So how can our health resistance power and immunity against this disease will improve? Thus due to lack of proper follow-up, we keep our capacity to face the disease at lower level. We are responsible to keep ourselves in such a weak condition which invites the recurrence of disease. So let us understand and practice how not to invite next attack this disease.”

Warn the patient against self-medication. When medicine is prescribed, patient takes the treatment and preserves that prescription. Many of them take complete course of medicines. But some of them stop the medicine as soon as they feel better. They preserve the rest of medicine for their use during next recurrence of the disease. Thus, they tend to take incomplete course of medicine. On the other side, they subconsciously prepare their mind to have such future attack. Such hopeful negative thinking and action may make them psychosomatically susceptible for the disease. “Do not take the same medicine prescribed previously by physician during similar attack in past. Reconsult your family doctor. If you take same medicine prescribed previously it is something like studying same syllabus of previous standard even in the next standard. Tell them that we do not study the same course of syllabus in next standard of the school. When we pass and enter in next standard, we study another prescribed syllabus of the next standard. Study of syllabus of previous standard helped us to pass examination of that previous standard. If we continue to study the same old syllabus during academic year of the next standard, we will surely be preparing ourselves for failure in examination of this next standard. Same is true about same self-medication again and again for every new attack of same disease. As a layman we are not aware of exact doses, exact duration of treatment and change in types of medicines for controlling recurrent attack. So let us consult our family physician or nose specialist every time to prevent next attack of allergy and to know what exact course of the medicine should be taken to boost our immunity.”

“Keep the diary of allergy and health everyday. Write down in diary about any exposure to old or new allergen about various symptoms, you experience and the health problem you faced. Write down about treatment taken. Understand this disease, its prevention and the treatment. Only taking medication according to prescription is not just enough. It is something like mugging up the studies for mere passing. Try to understand your symptoms, the cause of recurrence and factors which help to prevent further attack. Report from time to time even if you feel relief of symptoms. Take treatment to boost one's immunity at certain intervals in spite of absence of troublesome or symptoms. Such follow-up to boost the immunity at interval gives long-term relief.”

Let the patient realise that more often improper management and incomplete treatment of the initial problem of common cold more often leads to recurrence of the same initial problem of common cold after certain duration.

Initially, any fire is always smaller and can be easily extinguished. But once it is neglected and mishandled it increases and becomes uncontrollable. Same is true about allergy. The problem is often mild and insignificant. Patient takes it lightly. When recurrence takes place, such patient doesn't go to doctor. He/she may rather prefer to take medicines which are left over in past because of past incomplete course of medicine or he may purchase same. Thus patient by passes doctor. So most of them take medicine without consulting doctor and without being fully aware of severity and type of present problem. They are ignorant about exact strength and duration for which supportive medicine should be taken. Some of the patients tend to change doctor in next attack but do not inform him about past treatment. Change of doctor without maintaining link of previous treatment tends to cause mismanagement and inefficient treatment.

1. Educate the patient: This has high significance. It is family physician's and Ear-Nose-Throat expert's duty to educate the patient about the nature of disease, provoking factors in our environment and routine life, treatment plan, results of treatment and keeping follow-up. One must spare time for such awareness maintaining his / her positive expectation and preventing frustration. In case of associated recurrent chest problem. He should also be explained relation of allergic rhinitis and asthma and vice versa. Nowadays problem of allergy has become more common because of management failure, which is often wrongly considered as treatment failure. It is often precipitated by ignorancy about disease and way of management on the part of the patient. It is further precipitated by his lack of faith and understanding of limitations of therapy. Negative attitude provokes such precipitation. Negligence in effectively educating the patient about disease and plan of management may further aggravate failure. Let us understand ourselves between treatment and management. Treatment limits to care of the attack of disease. Spectrum of management extends beyond it to prevent the disease, to improve resistance power of the patient and to help oneself to keep healthy in all respects. Do not just treat the disease in the individual but also the human being in the individual.

2. Avoid contact of allergen: Recognition of an allergic cause for nasal symptoms is useful in long-term management, particularly when surgery is being considered.

3. Avoid contact of allergen: - Avoid allergen, or exposure to allergen and exposure to environmental irritants. Instead of carpets, avoid use of cotton or wool blankets. Practically it may not be possible to avoid all responsible allergens due to environmental pollution, dynamic life style and professional limitations of the patient. Many patients are not in position to change place of work or residence. So there are limitations in giving relief to the patient in spite of good drugs and best management. In one's busy routine schedule, consumption of certain foodstuffs and exposure to animal may not be possible to avoid. But patient should try to do his level best. In allergen rich environment, keep door and home windows closed. When windows are kept open, use moist curtains with water to attract pollens. Use air conditioners and change the filters regularly. Keep air filters clean. One must identify and avoid provoking allergen. When we sleep, dust and house mites present on bed covers enter in our body through breathing. To avoid house mite, change the bed cover everyday. Regularly clean bed sheets, mattresses, pillows, carpets and soft fur furnishings with vacuum cleaner. Cover mattresses and pillows with plastic covers. Remember, one old pillow is filled with dust having 10% weight of that pillow. Keep them in hot sun frequently. Keep damp corners of house clean to avoid fungal moulds. Do not keep old news paper, magazines and book in bed room. Avoid ready made food which contain sodium or potassium metabisulphite. Avoid cold drink. Instead take fruit juice. To avoid pollens, keep minimum ventilation in the room. To reduce effects of house dust mite, use acaroids, wet dusting, special bed covers. Avoid use of cotton or woollen blankets. Use cork, ring or hard floors instead of carpets. Keep pillow covers and bed covers for few minutes in hot water every day. Keep mattresses in hot sunlight to kill house mites and other germs present in it. Then wash them. Regularize proper ventilation and humidity at home. Furred pet animals like cats and dogs should be avoided in the house. Avoid pets, carpets, wool clothes, woollen blankets, garden areas, perfumes, deodorants, sprays, lotions, and humid places. Allergens from these animals may remain in home for many months even after their discontinuing presence. Avoid the use of mosquito repellents. Women should avoid smoke in kitchen. To reduce smoke, always use exhaust fan. Do not use home pollutants like mosquito repellents, burning of scent producing sticks etc. Avoid direct exposure to fan / wind. Do not use fan in environment having temperature less than body temperature, dry and cold air, humid atmosphere and congested room. Avoid the place where insecticide spraying is going on. Avoid walking in farms and fields. Avoid walking in open grassy spaces especially during evening and night. Avoid polluted air of certain locations. Wear sunglasses to reduce eye symptoms. Keep windows shut in cars and building if there are pollutants in outside air. These precautions work as complementary to medical treatment. Walk away from the place where cleaning and spraying is going on. Use facemask in polluted places and during travelling in busy traffic. Avoid motorcycle travelling in cold weather. In busy traffic, travel in air-conditioned car. Use filters to prevent dust circulation. Some patients are asked to change their nature of job, place of job and environment of job. Tell the patient that inspite of such avoidance, the symptoms may continue in some cases for variable period. So one needs to keep patience and take extra precautions. Some patients explain, " It is not possible to avoid any allergen at all. My life style, residence and place of work cannot be changed or altered because I will lose my job or business. I will not be able to continue my service or business. So you help me by effective treatment and cure this problem." Some may say, "If you do not cure me, what is the use of your knowledge or you as a doctor/ expert or your costly treatment." Due to confusion and irritative attitude, patient spends more energy in thinking and explaining how it is impossible to adjust rather than concentrating on efforts to changes and do adjustment in oneself and in one’s life for better future. Make awareness in patient about unfulfilled expectations and undue expectations lead to frustration and negativity. It results in self-mismanagement and mismanagement in follow up of treatment.

4. Change life style: -
a) Regularly take enough rest and sleep. Learn to relax and accept the changes in life with positive attitude.
b) Do aerobics and other physical exercises, pranayam, yoga and Sudarshan Kriya etc. Do relaxation exercises like yogasana. Learn to do breathing exercises, pranayama and auto relaxation exercises regularly. It helps to prevent vasomotor imbalances. Do all these practices regularly and religiously. If these are done in wrong way the problem gets aggravated.
c) Learn to keep ones mind peaceful, stable, relaxed through meditation and self relaxation sessions. Make positive changes in attitude, thoughts, habits and behaviour. Keep awareness of maintaining patience and hope.

5. Take vitamin rich diet. Take more green leafy vegetables (atleast 250 gm per day) and certain fruits. Avoid certain fruits, which one may find as a cause in aggravation of allergy in particular case.

6. Maintenance therapy: After initial recovery from allergic attack, continue to take treatment for some period. This period of treatment after control of symptom will vary according to duration and severity of symptoms and past history. This is called as maintenance therapy. After a gap of certain interval, patient needs intermittent booster therapy of medicines to improve the immunity status and to keep improved ventilation of sinuses. Advice of maintenance therapy or intermittent booster course of therapy may not appeal to some patients. So they may not keep follow up. So recurrence of problem may be seen more often in such cases. Treatment is given for long term with proper follow up and preventive therapy. Such incomplete or improper treatment or self-medication gradually makes the problem resistant to treatment. Indirectly patient may likely to develop habit of use of medicine i.e. sort of drug dependence and habit of provoking the disease. Thus, slowly he may likely to develop recurrent persistent favourable conditions for the disease.

7. Management of psyche of the patient: Due to recurrence of symptoms, or due to unexpected recurrence of more severe symptoms, patient may feel frustrated. His anxiety may get aggravated because of the doubts about cure of his disease. He often lands in mental state of indecision and apathy. Doubt reduces his self-confidence, confidence in treatment, and confidence in physician. He often loses the faith. He does not accept his faults in self-medication; follow up treatment and adopting suggested instructions. Such denial develops the tendency of over and wrong expectation. So he may face his problem of stress, depression and frustration in wrong way and aggravate them. Doubtful mind makes the patient a bad patient. Here bad patient means those who do not try to understand own problem and even if one tries to understand he may take wrong inferences from it. But he is not aware about these wrong inferences and misconcepts. Thus, his own ignorance and indifference act as his own enemies. So he remains subconsciously disturbed and emotionally sensitive. Such changes aggravate vasomotor change in some of these individuals. Thus, he may likely to become resistant to the treatment. Because of these changes, he may likely to be worse in terms of response to treatment and tendency in adopting the suggested instructions. These patients are difficult to handle successfully unless they themselves voluntarily and practically participate in understanding their problem, its cause. Limitations develop due to low immunity and wide variations in response to the treatment.

8. Pharmacotherapy: it is safe, effective and easy to administer.

a) Nasal drops and Spray: - There are various types of nasal sprays and nasal drops available in market. They have their own separate actions, effectivity and indications. So these should be used under the guidance of medical practitioner. Many patients more often wrongly think that as these nasal drops are meant for nose and so these can be used even without consulting doctor. Rather some of them keep the bottle of these sprays and drops in their first aid cupboard of the home and use them whenever they experience any nose problem. Although they do not have knowledge of the types of nasal drops, number of drops to be used and frequency of use of these nose drops, they continue to use without realisation of untoward effects of such use. Such self-medication leads to mismanagement of one's health problem and makes oneself more susceptible to the next attack of the nasal disease.

There are following types of intranasal sprays and drops available in market.

1) Preventive Nasal sprays and drops: - Sodium chromoglyconate sprays / drops and disodium chromoglycate sprays / drops are available in market to use as prophylactic medication. These sprays and drops can be used during pre-onset period of season, which provoke allergy. These can also be used before possible exposure to allergic environment. Sprays are more preferable than drops. Sodium chromoglycate drops are also available for allergic conjunctivitis.

2) Non steroidal decongestant nasal drops and sprays: - e.g. Oxymetazoline (Nasivion), Xylometazoline (Otrivin), and Naphazoline (Nazoline), Phenyl epinephrine (Dristan). These local decongestant act more rapidly and more effectively that oral decongestants but these should never be used for more than 10 days. These drops are meant to use for temporary period to relieve acute phase of the disease. These drops improve nasal airway and sinus drainage. Thus, recovery process is helped. But their action is temporary. These drops do not prevent recurrence of the symptoms and disease. These drops have side effects. They shrink the blood vessels. So, they may cause temporary ischaemic changes and tissue reaction. After some time, such effect may cause silent harm and dependency in that individual. Self-medication provokes these side effects. It may result into condition called rhinitis medica mentosa. These nasal drops should be used under medical guidance and that too for short period of 5 to 7 days. Use 4 to 6 drops two times in a day in each nostril. These drops can be used as prophylaxis in barotraumas of the sinuses and the middle ear.

3) Hypertonic saline drops: - These are available for decongestion of nose. They can be used for longer period as compared to oxymetazoline or xylometazoline nasal drops. The course should not be extended longer than 2-3 weeks. The course of these drops should be avoided for more than one course in two months in one course of therapy. It may be repeated after certain period.

4) Topical agents: - Iprotropium bromide sprays or drops are advised to prevent resistant watery rhinorrhea. This drug do not have systemic anti cholinergic activity. In allergic rhinitis, these drops are less commonly preferred. These are used in non-allergic perennial rhinitis or intrinsic rhinitis to prevent excess rhinorrhea.

5) Intranasal Steroid sprays and drops preparations: (beclomethasone dipropionate, fluticasone propionate. Budenoside, Flunisolide, mometasone, triamcinolone). These reduce nasal hyperactivity and nasal inflammation. So nasal congestion and effect on smell is reduced. Their maximal effects is observed after few days. Dose of intra nasal be clomethazone varies from 100 to 400 ug per day. If symptoms are severe, initial short oral course of corticosteroid therapy is effective. Nasal budenoside spray is more effective and can be given once in a day i.e. it has convenient dose. In seasonal allergy, the spray should be started before the beginning of the season to make it more effective. Sometimes nasal spray preservative itself may cause allergy and side effects on nasal mucosa. So observe the patient during the treatment for such effects. Steroid spray may encourage candida infection. In patients of diabetes, these should be used cautiously. This spray is used for 3 to 6 months. Nasal steroid spray gives advantage of low dose and prevention of systemic side effects. Spray provides direct delivery to intended site. It has minimal side effects. They may promote fungal growth. These nasal sprays are advised once or twice daily.


SYSTEMIC AGENTS: -


1. Corticosteroid: - Oral corticosteroid therapy or depot injections of corticosteroid should be reserved for patients with severe symptoms and for personal special events of the patient like examination, wedding or certain programmes.


2. Antihistaminics: - These drugs should be given in the sufficient doses and over sufficient duration. All these drugs are to be given as a course of therapy for 2 to 4 weeks. These drugs may be repeated after 1 or 2 months depending on duration of the disease, severity of problem and frequency of exposure to allergen. Such repeatition of the cause of medicine in spite of absence of symptoms may be helpful in suppressing sensitivity and silent persistant mucosal inflammation further and in preventing early tendency of blockage of sinus drainage. Second generation antihistaminics give less side effects and convenience of dosage. First generation antihistaminics show better response but have disadvantage of more side effects and sedation. In severe cases, long standing cases and resistant cases, one may continue such treatment for 2-3 weeks or over a longer period of time if patient is having severe or resistant allergic symptoms.

3. Systemic decongestant drugs: - Systemic decongestants are helpful in chronic cases in which oedema of nose blocks airway or sinus ventilation and drainage. For details see the chapter on 'Medicines used in nasal and sinus diseases'.


4. Antibiotics have no role to control allergy but are used to treat secondary bacterial infection.

5. Mast cell stabilizers may be used.

6. Leukotrine modifiers (antileukotrienes): These are used as long term control modification for associated treatment of mild persistant asthma. They may be preferred in seasonal allergic rhinitis. These drugs may reduce required dose of corticosteroid. Exercise induced asthma may be prevented. These are well tolerated.

7. Glycocorticoids and antileukotrienes are effective in treatment of both rhinitis and asthma. H1 antihistaminics are more effective in rhinitis than asthma. Optimum treatment of rhinitis may improve coexisting asthma. Prevention of rhinitis prevent recurrence of asthma.

8. Injection Histoglobe or Histoglobulin (SII) given subcutaneously may help to improve general immunity. These 3 injections are given subcutaneously at 5-7 days interval. This course is repeated at 3-5 months interval or before on set of change of season i.e. during May, October and February in India. Preserve these injections at 40 C.

Chemical cauterization: -

It is done to reduce sensitivity of the mucosa and size of the turbinate. In hypertrophy of turbinates, it is observed that cauterization help to improve airway patency in nose. To reduce sensitivity of the mucosa, chemical cauterisation may be advised on mucosa of the anterior end of inferior and middle turbinate or whole turbinate. It should be repeated 3-5 times at 4 – 7 days interval. Cauterization can also be done by electro cautery used on surface or submucosally. Cryosurgery and LASER may also be used. In long standing cases, it may be repeated after 6 month or one year for persistent results.

Role of surgery: - Surgery does not cure allergy. It only helps to relieve severity of symptoms like nasal obstructions. It also eradicates septic focus which easily provoke allergy. Surgery has a very limited role in selected patients with allergic rhinitis. It is done only when there are associated physical abnormalities of the nose and sinus. e.g. polyp, hypertrophic turbinates, deviated nasal septum. These structures block pathway of sinus ventilation and nasal cavity. If septic focus like sinusitis, adenoiditis and tonsillitis are present these are treated properly. Those who have persistent recurrent blockage of the nose and if medical line of treatment is not effective then one may need septal surgery, functional endoscopic sinus surgery, surgery of abnormal shape of nose or turbinates, antromeatal complex and of the growths like polyps. In chronic severe rhinorrhea, surgery of Vidian nerve. Surgery plays no part in management of nasal itching and sneezing for which medical line of treatment is used.


Many patients and general practitioners have misconception that after surgical correction of deviated nasal septum or after other surgeries if the problem of nose persists or recurs, that means there is again a growth of the same bone or mass. Actually in these cases, the allergy and vasomotor phenomenon remains incompletely and improperly treated which leads to recurrence of symptom. It happen due to lack of education of patient pertaining to follow up treatment on part of surgeon or it may happen due to overreaction of patient to tend to keep poor follow up to boost its immunity. Follow up courses, reasons booster treatment and courses of preventive treatment at regular intervals help to improve immunity of the patient. Improvement of immunity helps to prevent attack of allergy. Most of these patients take decision to undergo surgery very late. Presence of disease for few years (which may vary from 2 years to 20 Years or even more) habituates the patient for persistence of symptoms. After surgery, to improve resistance power of the patient and to develop immunity, it takes few months to few years depending on type of allergy, duration of the disease and severity of the disease. In spite of known long history of past sickness, patient expects dramatic and permanent relief of all symptoms. Such over expectation cannot be fulfilled by the practitioner due to limitations of nature. So patient should have optimum expectation and should avoid extra expectation.


As mentioned above, after surgery, medical line of treatment is necessary, especially when there are associated problems of allergy, vasomotor instability, exposure to allergen, long history of the disease etc. Such medical treatment taken continuously for certain period of time and then repeated intermittently as a booster course. This preventive therapy helps to prevent recurrence of the disease and maintains local and general resistance power. Need to keep follow up for preventive medical treatment must be realised and accepted by the patient so that the family doctor gets chance to break the cycle of established disease process in the body. Such need of adjuvant medical line of treatment should not be taken by the patient as failed surgical line of treatment or incompetency of doctor who advises the long term follow up. Such follow-up and preventive treatment is very effective in the patients who have persistent low immunity, low resistance power and long duration of the disease.

PERENNIAL NON-EOSINOPHILIC NON-ALLERGIC INTRINSIC RHINITIS OR RHINORRHEA SYNDROME: -


In this condition due to parasympathetic over activity, there is an episodic watery rhinorrhea with nasal obstruction without any specific cause.

Predisposing factors: -

Routine sedentary work, lack of active physical exercise, psychological stress, change in climate, exposure to cold-dry air, strong odours, chemicals, pregnancy, contraceptive pills, beta blocker drugs, spicy foods predispose this disease.

This condition is most likely to develop for the first time in adult between 3rd and 4th decade of life. In contrast, rhinitis presenting in childhood is most likely to be of allergic etiology. These patients do not give history of seasonal or diurinal variation, family history, itching in nose, sneezing, asthma, conjunctivitis and allergies in childhood. Eosinophils are not present in nasal secretions. There is no H/o family sickness.

Clinical features: -

In these cases, patient has excess nasal watery discharge. Nasal obstruction is mild and less dominant symptom. Sneezing and itching in nose are less frequent. So these cases may be present as ‘Rhinorrhea syndrome’. Hyposmia may be present. There is no itching in nose. Some patients have facial aches due to high-pressure sinus headache. It is due to blockage of sinus ostea. Inferior turbinate is not enlarged. Mucosa is inflamed, mildly swollen and pink or congested. It is less oedematous as compared to that in allergic rhinitis. No signs of infection are present.


In some cases of allergic rhinitis, there might be simultaneous presence of element of intrinsic (vasomotor) rhinitis or vice versa. So before planning the treatment assess for any possibility of overlapping picture should always be considered. Allergic rhinitis and chronic intrinsic rhinitis are likely to be associated with sinusitis. Some times in chronic cases concurrent presence of allergic rhinitis with intrinsic rhinitis with sinusitis and /or deviated nasal septum or other obstructing pathology (e.g. enlarged turbinate, narrow nose, weak alae of nose, Crooked nose, deviated nose, drooping of nasal tip, saddle nose etc.) may be observed. All these possibilities must be considered.


Treatment: -

It is really challenging to treat these cases effectively and completely because of uncertainty about response, unavoidable possibility of recurrence inspite of sufficient course of treatment and high drop out rate of patients. Incomplete treatment and use of self medication may modify presentation of symptoms and increase chance of recurrence. So, medical treatment is advised for a long period.


1. Follow all precautions mentioned in treatment of common cold and allergic rhinitis.

2. Advise the patient to do enough physical exercise, aerobics, pranayam, Sudarshan Kriya, yogasana, relaxation sessions etc.

3. Assess problems of personality elements, life style of the patient and environment. Suggest him about necessary steps to be taken to become stable psychologically and emotionally. These patients are reluctant to go to psychologist and psychiatrist for such advice. They say, " We have nose problem. Why should we go for counselling to psychologist and psychotherapist? Nothing is wrong in our mind." Due to ignorance they do not realise relationship of mind with body and vasomotor phenomenon. So, our role-playing as an adviser should also be like trainer, friend, philosopher, motivator, educator, counsellor etc.

4. Advise first generation oral antihistaminic with systemic decongestants. Topical steroids are helpful. Antianxiety drugs are advised. Patient with rhinorrhea syndrome respond better to topical anticholinergics like Iprotropium spray, hoscine (orally or patch), systemic anticholinergics and sympathomimetics (like chlorpheniramine).
In patients of intrinsic rhinitis, if nasal obstruction is not relieved with medical treatment for sufficient period then surgery is considered along with medical line of treatment. The later should be continued even after surgical treatment. In patients with excess rhinorrhea, vidian nerve cautery or neurectomy may be advised.

Differential diagnosis of Rhinitis: -


1) Acute rhinitis (Common cold): -

a) Patient initially feels burning and irritation in nose for some time. He experiences raw feeling in throat. Along with these symptoms, sneezing and watering are dominating symptoms. Patient feels fever, headache, and malaise. Nasal blockage develops later on.

2) Chronic rhinitis:

Recurrent running of nose and blockage are dominant symptoms for more than ten to twelve weeks. Mucosa is congested. Thick and viscid mucopus is present in nasal cavity.

3) Seasonal rhinitis: -

This disease develops after exposure to allergen at onset of the change of season. Symptoms develop rapidly. Sneezing develops suddenly and it is predominant symptom as compared to that in perennial allergic rhinitis. Watery discharge is present. Patient develops swollen and congested conjunctiva, itching and weeping is present in eyes, post nasal drip, coughing etc. may also be present. In late phase, nasal obstruction may be felt.

4) Perennial allergic rhinitis: -

It may be present as chronic, non-remitting disease, or periodic episode of disease, which coincide with intermittent exposure to allergen. Symptoms are similar to seasonal allergic rhinitis. But nasal blockage is somewhat more predominant symptom and sneezing is not very prominent and sneezing as compared to blockage in seasonal allergic rhinitis. Eosinophilia is observed in nasal secretion.

5) Perennial occupational rhinitis: -

Symptoms of the nose aggravate at work place. These patients have work related nasal symptoms with improvement during period away from the work suggest occupational rhinitis. e.g. working in flourmills, paint factory, spray painting, resin factory, pharmaceutical factory, wood dust, road dust,

6) Perennial infective rhinitis: -

Along with usual clinical features of chronic rhinitis, they may have infection due to fungi, tuberculosis, host defence deficiency (e.g. Panhypogammaglobinemia, IgA deficiency, AIOS), local problem, (primary ciliary dyskinesia).

7) Perennial non-infective non-allergic rhinitis: -

These conditions are poorly understood. It is more difficult to identify specific cause, and provoking factors in a particular case.

a) Perennial idiopathic rhinitis- Patients show hyper response to non-specific triggers such as strong smells (perfumes, bleach, solvents), smoke, smoking, vehicle smoke, changes in environmental temperature and humidity.


b) Perennial non-allergic intrinsic rhinitis without eosinophilia or rhinorrhea syndrome- Watery rhinorrhea is more troublesome and nasal blockage is less troublesome. Patients may not have sneezing or may have occasional sneezing due to exposure to irritants. Symptoms are aggravated by disturbed psychological activity or stress. Mucosa is somewhat pink and less oedematous as compared to that in allergic rhinitis.


c) Perennial non-allergic intrinsic rhinitis with eosinophilia syndrome (NARES) or Obstruction syndrome: -Nasal blockage is more dominant symptom as compared to other symptoms. Hyposmia is present. Mild rhinorrhea may be present. Mucosa is markedly swollen and inferior turbinate is hypertrophied. Nasal polyp may be present. Nasal eosinophilia is observed. Skin prick tests are negative and IgE concentration is normal.

d) Hormonal rhinitis: - This type of rhinitis is seen in puberty, pregnancy, hypothyroidism, acromegaly, post menopausal period. Elderly men sometimes develop watery rhinorrhea (old man's drip). The symptoms are like chronic rhinitis, which may not respond to routine treatment satisfactorily. In hypothyroidism, hypoactivity of sympathetic system and hyperactivity of parasympathetic activity causes nasal stuffiness. Advise thyroid hormone investigation.

e) Drug induced rhinitis:-

Blockage of nose is more dominant complain. Patients taking beta blockers, chlorpromazine, anti-inflammatory agents, angiotensin converting enzyme inhibitors may develop drug induced rhinitis after certain period. Nasal drops and nasal spray may cause same type of rhinitis. Stop these drugs to improve the condition.

f) Food induced rhinitis: -

It is gustatory rhinorrhea because it is observed during consumption of hot-spicy food. Food colouring, may cause nasal symptoms. Food preservative containing sulphates, benzoates, and tartrazine may cause allergy. Cheese, poorly preserved fish, certain wines contain histamine and so they cause pseudo allergy. Alcohol, citrus fruits, certain fish, milk, egg may cause allergy. These patients are atopic with sensitivity to common air allergen and to certain food. Along with nasal symptom, they may have symptom in other organs like mouth, tongue, skin and digestive tract (oral and gastrointestinal symptoms).

g) Irritant induced rhinitis- Exposure to irritating factor in atmosphere cause such type of rhinitis. The symptoms stop after going away from that exposure.


h) Emotional factors induced rhinitis:

We respond to several emotional stimuli like tension, anxiety, resentment, hostility, humiliation, grief etc. Emotional stress, sexual arousal cause autonomic stimulation and precipitate the attack of rhinitis. In these patients, sneezing is absent. They live sedentary life. Their routine life is irregular. They respond to antidepressant and anticholinergic drug like imipramine.

i) Non air flow rhinitis: when nose is not used for respiratory turbinates become swollen. Due to lack of air flow, discharge stagnates in nasal cavity. So, rhinitis develops. It happens in patients having adenoid hyperplasia, choanal atresia, larynectomy and tracheostomy.

8) Atrophic rhinitis: - excess nasal crust causing nasal blockage, unpleasant smell, (ozoena), and anosmia are the features.

EFFECTS OF RHINITIS AND RHINO-SINUSITIS ON THE PATIENT

Often rhinitis and sinusitis are non-painful diseases. Initially, these diseases are mild and tolerable. Patient considers it as just a common cold. At conscious level, he often does not consider it as a disease and often try to manage his problem with over the counter medicines. Patient approaches to family physician casually. So, patient does not take treatment or takes incomplete course or medicine or he takes treatment sincerely very late i.e. when problem becomes intolerable. He is tempted to take self-medication by referring earlier prescription. When he realises that he is getting only temporary relief after the treatment he may temporarily take sincere treatment but may not keep long term follow up till the complete eradication of the disease and resumption of healthy immunity status. Some patients tend to change doctors or pathy. They may feel that doctor is not able to diagnose the disease or he is hiding the facts. Doubts in mind makes the individual worse as a patient and he loses the advantage of faith. He is keen to know what exactly has happened in his case or what is exact diagnosis but he is not so much keen to understand disease process, disease behaviour and management plan and long term follow up with the same expert in spite of recurrence. Persistent or recurrent rhinitis and sinusitis causes various types of effects on the person and his life. So, quality of life of the individual is affected. Due to ignorance and emotional disturbance, patient does not realise the gravity of secondary effects of chronic rhinitis and sinusitis. Many of them are habituated for such complaints and may consider as normal for them. They do not even think of undergoing investigations as they consider it as simple common cold. So mentally, they are not ready to spend money, time and energy on complete investigations and complete preventive treatment.

Effects of persistent rhinitis and rhinosinusitis

1. Physical effect 4. Social effect
2. Mental effect 5. General health perception effect
3. Emotional effect 6. Vitality effects

1) Effects of the body: -

Physical functioning is disturbed. The capacity of physical function of the body reduces to variable extent. Work performance and school performance remains disturbed. Congestion of nose leads to heavy breathing. Because of mouth breathing, the individual will likely to suffer from tonsillitis, pharyngitis, laryngitis, and lower respiratory tract infection. In social life, offices, public places, patient feels awkward to spit out infected postnasal secretion. So he/ she compells oneself to deglute it. It may cause disturbances in gastrointestinal tract. Concentration on physical work and quality of skill gets reduced. Sleep remains disturbed. So on the next day, life and activities are affected. Some patients have feeling of headache, body ache and weakness. He may put off his work or daily earning. Absentism may increase.

2) Effects on the mind: -

Patient's mind remains disturbed. Concentration capacity and intellectual capacity may get reduced or it is not used fully. As far as problem pertaining to health are concerned, his attitude becomes negative. Due to doubts about results of treatment, he often does not keep follow up and does not undergo surgery at right time. Many of them undergo surgery very late but expect complete and permanent relief of all symptoms. If symptoms recur they feel frustrated or tense, such effects lead to mismanagement in follow-up treatment and lack of follow up. His professional or business work may be affected.

3) Effects on the emotions: -

Emotional irritation and instability of mind may increase and may in turn provoke the problem and affect health. Changes in mood and appearance develop. Negative impact develops in life style.

4) Effects on social life: -

Person doesn't like to be with handkerchief, which he frequently uses for nasal cleaning and clearing. He feels odd. Due to embarrassment in social life, he avoids social appointments, social programmes and social involvement. Social cost can be high to some persons.

5) Effects on general health perception: -

More often rhinitis and sinusitis cause mild to moderate symptoms. Individual learns to live with them and tolerate those disturbances. He knows home remedies and common medicines, which he takes and keeps the disturbances in body to minimal extent and within easily tolerable limits. In other words, he unknowingly learns to manage his chronic or recurrent problem himself and with self-medication. Such management of one's own problem is rather mismanagement because indirectly it helps for persistence or recurrence of the disease. Person starts neglecting effects of rhinitis and also other mild problems. Disturbed sleep and mind affects general health. He develops tendency to overlook persistent or recurrent mild problem, which later on may likely to aggravate. These patients more often take time-being treatment, which they consider as enough course of treatment. Due to failure of satisfactory response to such treatment and early recurrence of the same symptoms, they feel that their problem is incurable and even expert will not be able to cure their nose disease. Although, nose expert are able to effectively treat him with proper follow up. They may be in mood to keep follow up and report the expert from time to time in spite of recurrence of certain interval. Although, such recurrence is unavoidable for few months or years in spite of complete treatment. The severity reduces gradually and disease does not disturb physically and mentally.

6) Effects on vitality: - Vitality gets reduced, so patient feels fatigue easily.
Considering various direct and indirect effects caused by the disease in terms of economical losses in the routine life, cost effectiveness of treatment and cost of follow up for preventive treatment is very beneficial. Once patient takes enough treatment for long period of time, from nose specialist, he feels that he should have done it 2-3 years ago. He improves not only in primary nasal symptoms but also in secondary symptoms like sleep disturbance, snoring, disruption of concentrating ability, fatigue, disturbed work performance, reduced confidence and negativity of the attitude.

Almost all of them never report for preventive line of treatment at certain intervals to boost their resistance power and immunity. Such incompletely taken treatment and lack of preventive treatment later on provoke attack. These patients do not bother for such less severe attacks because earlier they had faced more severe symptoms. They consider that such less severe symptoms are common for them and those symptoms can be managed with some medicines which they have taken during earlier course of treatment. They neglect to consult for proper follow up treatment. Nature of disease perception and negligence in the treatment on part of the patient’s also depends on their socio-economic status, culture, speed at which symptoms occur and whether they can accommodate these symptoms or adjust with the symptoms.

In spite of long-term presence of nasal problem, patients have a tendency to expect that they should get relief with one or two consultations. Most of these patients know advertised medications or prescribed antihistaminics. These drugs control symptoms instantly but temporarily. So they develop over expectation from prescribed treatment of doctor. If attack recurs, their frustrated mind considers that treatment had failed or the doctor could not do exact diagnosis. But they do not consider that it is due to insufficient management on their part and their reduced resistance power. They do not think of increasing their resistance power or immunity. Most of them, do not report, for further follow up treatment, once they feel relief. Sometimes, complete relief of symptoms does not mean that disease is cured. As patients do not realize the proper trick of treatment management, they have tendency to take short cuts in the treatment. Short cut becomes long cut due to self-medication, improper doses, negligence in management and negligence in avoiding precipitating factors in routine life. These patients may have concept that they are not able to follow precautions and complete treatment due to their life style, profession, social life and pollution in environment. They may straight way deny to follow precautions and treatment plan due to rigid mental outlook. Some of Such patients do not keep flexibility in routine life so that they follow the preventive instructions and treatment.

Lack of understanding the disease, its nature, ways of effective treatment leads to wrong expectations and negative thoughts. e.g. After treatment "rhinitis should not recur and if it recurs means doctor has failed or doctor's treatment is not good." "Rhinitis is mild problem, I can manage life with it." "It is not harmful. So treatment can be taken later on." "Once symptoms disappear, why to take treatment for a long time and waste money." "Cold is non-curable. It will last for a week. Then it will reduce by natural process. So why to waste time and money and efforts in taking follow-up treatment."

Thus, most of these chronic patients have lost their good way of proper approach to manage their recurrent nasal and sinus problem. We find more and more patients suffering from recurrent nose problem. They have developed the negative hopes, negative attitudes, wrong concepts etc. in relation to faith, follow-up treatment, investigation and surgery. So, many of them become victim of misconcept that they have non-curable nasal problem. They do not actively try to know exact nature of the disease, its course and management. Such ignorance lead to insufficient understanding and misunderstanding of their nasal problem.

ACUTE SINUSITIS / RHINOSINUSITIS

Acute Rhino-sinusitis is an inflammation of the sinuses with symptom complex like purulent rhinorrhea, purulent pharyngeal draining and cough lasting less than 8 weeks in adults and less than 12 weeks in children. Rhino-sinusitis has become one of the most common diseases of the world. In India, more than crore of people suffer from it. Billions of rupees are spent on over the counter medications; in an effort to relieve symptoms. Despite of its prevalence, sinusitis remains one of its most overlooked and misunderstood problems in clinical practice. It is commonly considered as common cold and not sinusitis.

CLINICAL FEATURES: -

Headache aggravates on bending forward, Pain is localized over the affected sinus. Patient may have pyrexia, malaise, bodyache and chills, fatigue etc. post nasal drip is present. Purulent rhinorrhea and cough are common complaints: Purulent pharyngeal draining is present. Discomfort is felt in post nasal space, loss of vocal resonance and sense of smell may be seen. Nasal blockage increases. Patient feels unpleasant taste due to post nasal discharge.

Localized tenderness on the sinus is present; oedema and abundant secretions are present in nose. Red shiny swollen mucous membrane is seen near ostium. Mucopurulent rhinorrhoea is seen in middle meatus. Dry nose or normal findings in nose does not rule out the diagnosis.

Treatment: - It is aimed to break the cycle of development and blockage of ostia, oedema of mucosa in sinuses. So we have to think of: - 1) Reopening of sinus ostium, 2) Adequate course of antibiotic to control infection: - Generally, it should be started after pus is collected for culture and sensitivity. 3) Correction of underlying conditions and arresting inflammatory process.

(1) For reopening ostia-

a) Oral antihistaminic and systemic decongestant. These drugs are advised orally for 3-4 weeks to reduce congestion and oedema near the opening of the sinuses. Antihistaminics control and prevent allergy. It is said that antihistaminics may actually interfere with treatment of acute sinusitis by causing excessive drying and thickening of mucus secretions. Antihistaminics prevent histamine release and thus help in decongestion of allergic oedema. Sufficient treatment over prolonged period should be given. Afterwards preventive treatment must be adopted for a long period. Oral decongestants like pesudoephedrine, ephedrine, phenyl epinephrine, phenyl propanolamine should be used to reduce congestion. Combination of antihistaminics and decongestants are used orally.

b) Decongestant nasal drops & sprays: -

Xylometazoline, oxymetazoline nasal drops can be used for short of 4-5 days with due precautions. To reduce or control oedema caused by allergy, steroid spray for 10-30 days can be advised. The duration of the use of medicine depends on duration of the problem. Put nasal drops or spray, wait for 10-15 minutes so that nasal passage and meatuses open. Then, again put nasal drops or nasal sprays after gap of 10-20 minutes so that deeper non-approachable areas are also decongested. Such complete decongestion in nose during initial phase of treatment helps in fast recovery. Hypertonic saline drops and sprays can also be used. These hypertonic saline drops should be preferred if you find problem of rhinitis medicamentosa and resistant cases that need to maintain decongestion. Once satisfactory decongestion is achieved, isotonic saline drops may be advised to maintain decongestion for a longer period of time.

c) Nasal wash:

Wash the nose with plain 0.9 % saline or with mixture of decongestant drops may be advised in severe and resistant cases. Nasal wash with slightly hypertonic saline during initial phase of 2-3 days helps to decongest drainage area of paranasal sinuses. Later on patient should continue isotonic saline nasal wash with 20 ml syringe or with special 'Neti' pot two times in a day for a few weeks. In resistant cases, one may continue for few months.

d) Steam inhalation: -

It is very helpful. If patient feels discomfort on taking medicated steam inhalation, he may use plain water steam inhalation. Advise steam inhalation twice in a day for 10-20 days.
Advise enough bed rest in well ventillised room. Local heat is applied. Take plenty of fluids and vitamins with nourishing diet. Pain killers are advised to relief pain. Nose should be blown frequently. One nostril should be blown at a time and mouth should be kept open while blowing. Broad spectrum antibiotics are advised for a week.

Advise to keep long term follow up and advise preventive measures at intervals. One should aim to reduce oedema in middle meatus completely, so that the ventilation of the sinus recovers, pus is easily drained out and infection can be controlled easily. Advise steam inhalation, local decongestant drops, and systemic decongestant for at least 2-3 weeks. Course of antihistaminics and decongestant oral drugs should be repeated at the gap of 1-3 months.

(2) For control of infection: Antibiotics: -

Antibiotics must be given in sufficient doses over enough period of 2-3 weeks. Antibiotics acting on gram-positive organism are more effective. e.g. Ampicillin, Amoxycillin, Erythromycin, Roxithromycin, Azithromycin, Cephalexin. If one suspects gram-negative bacterial infection, use suitable antibiotics.

(3) For control of precipitating factors, and to correct underlying conditions-

These factors and underlying conditions are vasomotor phenomenon, allergy, environmental factors, poor resistance power of the patient, deviation of septum, hypertrophy of turbinate, diabetes etc. To manage these factors, refer the various chapters on common cold, allergy, intrinsic rhinitis, deviated nasal septum and advise the patient accordingly. Make the patient conscious of these contributing causes and provoking factors. In case of acute on chronic sinusitis and recurrent acute sinusitis, patient should be told to take full course of treatment for at least 3 weeks. They should be advised to keep follow up with family physician till these factors are fully controlled. For complete relief, one should assess all possible precipitating factors and underlying conditions in each and every case. Try to know doubts of the patient and give proper explanation. Then prescribe the plan of treatment to patient. One should take care to explain why various points of treatment are prescribed and how important it is to follow the treatment plan completely. Warn the patient about possible recurrence and resistance development to the treatment in case of negligence on the part of the patient or not keeping regular follow up at certain intervals for assessing any need to advise preventive treatment. In all resistant and recurrent cases, preventive courses of medication may be advised as boosting treatment at certain period of interval, which may vary from 1 months to three months.

Recurrent cold and cough in children: -

Many parent do not consider common cold as disease. They think that in children common cold is bound to happen and it does not need any special care and treatment. So, common cold and chronic simple rhinitis is often neglected or self treated or incompletely treated. So, chances of its recurrence and its spread to nasopharynx, tonsils, larynx, lungs increases. Parent worry more about cough rather than associated rhinitis. So, complete treatment course of rhinitis is not taken.

Lowered resistance of child due to poor nourishment, unhygienic environment, allergy aggravates spread of infection to lower respiratory tract. So, with symptoms of chronic simple rhinitis, throat and lower respiratory tract infections develop. E.g. recurrent cough, fever etc.

Investigate the case completely for haemogram, radiograph etc. Give full course of antihistaminic, antibiotic. In refractory cases, surgical treatment for sinusitis, adenoiditis, tonsillitis may be advised.

Good ventilation, proper humidity, sunshine helps. Local head application of ten minutes three times in a day relieves pain and promotes drainage. Amoxycillin or any broad spectrum antibiotic should be used for two weeks. Decongestant nasal drops are useful to re-establish drainage. Steam inhalation helps a lot. Analgesics are used to relieve pain. In case of no response, sinus drainage operation is done.

Advise nutritious diet, improve hygiene. Advise to keep proper follow up and preventive treatment.

CHRONIC RHINO SINUSITIS:-

Long-standing infection of the sinus for more than 3 months or if there are more than 4 episodes of acute sinusitis in a year, it is called as chronic rhino-sinusitis. Generally, acute episode of rhinitis and sinusitis initiates infection and inflammatory oedema. Onset may be insiduous. Continuation of oedema due to infection may in turn cause more obstruction of sinus ostium. Blockage of sinus ostium affects aeration and mucus drainage of sinuses which results in persistent sinus infection. Recurrent blockage of ostia of sinus may lead to recurrent negative pressure in the sinus and irreversible infection. Negative pressure in sinus sucks the infected secretions of nose through the meatus of sinuses. Thus, infection tends to spread from nasal cavity into sinus.

Causes: -

Adenoid hypertrophy, deviated nasal septum, polyp, enlarged turbinates, lateralization of middle turbinate, upper teeth root infection, foreign body are surgical causes. Allergic rhinitis, intrinsic rhinitis, rhinitis medica mentosa, wrong use of topical decongestant, recurrent viral upper respiratory tract infection, and immunodeficiency are medical causes. Pollution, smoking, frequent change of weather, lack of rest, overwork aggravate mild problems. Incomplete treatment, negligence in taking treatment at proper time, lack of follow up on the part of the patient provokes the sinus problem at intervals.

DEVIATED NASAL SEPTUM: -

Nasal septum divides nasal cavity in two nostrils. In clinical examination if nasal endoscope is not used one is not able to see more than 1/3rd to ½ part of the septum. Often due to deviation and enlarged nasal turbinate one may not be able to see more than anterior one third part of the septum. So, in most of the cases, one may not be able to examine major part of nasal septum unless one uses nasal endoscope for clinical examination. 85% of population has some deviation of nasal septum. Out of them, about 60% do not have any problem of nose in spite of deviation of septum. Out of remaining population, some have blockage of nose on same side of deviation, some have of nose blockage on the other side of the deviation and others have blockage on both sides. The blockage on opposite side of deviation is due to compensated hypertrophy of turbinates, which may block osteomeatal complex in middle meatus and cause blockage in drainage of the sinus. So, it causes sinus problem. In such cases, complaints are more on the side of non-deviation of septum. Deviation of the septum causes nasal obstruction unilaterally or bilaterally. It may be associated with snoring, mouth breathing, headache and symptoms of sinusitis. Headache may be due to sinusitis. In some cases, neuralgic headache occurs due to deviated nasal septum (DNS) touching lateral wall of the nose or pressure on the turbinate. Blockage of sinus ostium may lead to absorption of the air by the mucosa of the sinus which results in vacuum headache. All these factors lead to recurrent cold.

There are many misconcepts about septum and its position not only among laypersons but also among the medical practitioners. It is most ill understood structure by them. Many family physicians and laypersons wrongly consider deviated nasal septum as cause of any symptom of the disease in nose including allergy, intrinsic phenomenon, sinusitis etc. As explained earlier, no two cases of nose have similar problem and structural abnormalities. We have to assess each case separately by taking into account of detail history, examination and response to follow up treatment. One should be much familiar with normal structural variations and variety of pathological changes in nose in relation to the diagnosis.

More often deviation of septum is wrongly considered as new growth of bone. Some have misconcept that such growth of bone is incurable or it grows again even after good surgery. All these misconcepts are due to lack of enough and proper communication between ear nose and throat specialist or family physicians with patients. Most of these patients do not keep proper follow up for sufficient period and they frequently change expert. Frequent change of doctor may be due to urge for early relief, search for better and better doctor and lack of faith. These changes are also provoked by frustration in the patient. This frustration is due to absence of satisfactory response to the treatment, lack of patience on the part of the patient, expectation of prompt and persistent response in spite of chronic existence of the disease. Over expectation and wrong expectation always leads to frustration, reduction in faith and tendency of insufficient course of treatment. Patient is not aware about his frustration. He takes this mental state as normal. Even if somebody brought to his notice about such changes, he may say, “ Why I should not think and behave like that? I did not get relief. My time and money is wasted. So, to feel irritation and frustration is my normal reaction. I am not at fault.”

All cases of DNS do not need septal surgery. If deviated part of septum blocks the nasal airway in spite of enough medical line of treatment and follow up course of medicine, then, septoplasty is advised. As mentioned above, all cases of DNS must be given enough treatment with medication for at least 4-6 weeks. In spite of enough medical treatment, if blockage of nose and/or sinusitis persists, then, septum is corrected.

Just correcting the septum deviation, will not be enough to give satisfactory results in every case. If patient has associated hypertrophy of turbinate and diseased osteomeatal complex that should also be corrected by partial turbinectomy or turbinoplasty and functional endoscopic surgery in the same sitting. For re-establishing sinus drainage, sinus wash, partial middle turbinectomy, clearance of osteomeatal complex, fracture of middle turbinate, removal of polyp from sinuses etc. may advised. Choice of procedure depends upon associated findings. Abnormal shape of nose like crooked nose, depressed nasal tip, extra-elevated nasal tip, narrow nose, weak lateral walls of nose and narrow nasal valve also play role in blockage of nose. These conditions should also be corrected simultaneously by rhinoplasty.

Most of these patients have persistent problem for few months to few years preoperatively. So they always need post-operative treatment adequately over long period. In these cases, surgery is not the only treatment but it is one part of treatment. Even after such surgery, patient needs to keep follow-up to accelerate healing process of local wound, re-established ventilation of sinus, to control allergy, to improve immunity status, to control intrinsic factors, to reduce effect of environmental factors and general factors (like DM, reduced immuno deficiency). Patient should continue medical line of treatment to suppress allergy and to improve local nasal flora. This patient should be adequately treated for above-mentioned medical factors over sufficient duration. If patient has recurrence of nasal complaints, they must be adequately treated and should be advised to keep follow up at certain intervals to boost immunity. Such interval varies from case to case which may range from 3 weeks to 3 months. Duration, frequency and severity should also be considered while prescribing the course of treatment.

During postoperative period patients do not have any pain or significant discomfort. So many patients wrongly think that "now they do not need much treatment. Surgery has removed all problems." So they do not take any more treatment. When these patients have recurrence of symptoms, they may feel depressed or frustrated. Some of them may think that their operation has failed or surgeon could not performed successful or skilful operation. Such doubts keep him away from reporting to same surgeon from time to time and right time follow up. Some of them may think that the bone in nose has grown again. Such wrong and negative thinking creates frustration and emotional upset in patients. The feeling of repenting leads to mismanagement of precipitating factors and improper follow up, which may in turn, aggravates the problem after certain duration. They may wander from one surgeon to another with the hope of certain wonderful guaranteed results in one or two visits. False hope or over expectation makes him frustrated or anxious. Such mentally disturbed patients does not realise that his frustration compels him to commit more mistakes in managing his health problem. So he may likely to become a victim of self-medication, early drop out and medical shopping. He even doubts about advice of proper follow up treatment. To prevent such problem, for each and every case of nasal disease, enough time should be spent for proper counselling. Discussion should be done on what is his problem, what is his health status, what are environmental problem in which he reside and work etc. while advising medical line of treatment, tell your treatment plan and extent of relief he should expect. If one advises surgical treatment, explain him how much surgical treatment will be helpful and why he will need post operative medical treatment or follow up treatment for certain period and at certain interval. The duration of this ‘certain treatment’ and frequency of this ‘certain period’ depends on duration of disease, stage of disease and effects of disease on the body in spite of good surgery. The duration of this 'certain period' and frequency of this 'certain interval' depends on duration of disease, stage of disease and effects of disease on the body. Explain him why his allergy or vasomotor element may recur due to problem in his environment, habits and life style. Ask him what he expects from treatment and how much relief he expects from treatment and surgery. Assess him further and find out his motivating factors which brought him for the treatment. Assess his faith, find out his motivating factors which brought him for the treatment. Assess whether his expectations are over expectations or right expectations. Counsel on what he should expect after treatment. Proper counselling motivates him to understand his disease, immunity status and health status; faith and motivating in follow up. It saves the patient from early drops out, medical shopping. It prevents development of frustrating attitude, thoughts and behaviour.

As in most of these patients, disease is always of longer duration; he is partially anxious, depressed. He or she may have doubt about effectivity of treatment and follow-up management. So he or she may not keep adequate follow for long term to assess response to previous surgery, to boost immunity, to suppress allergy and to maintain sinus drainage. Sufficient counselling effectively convinces to keep proper follow-up treatment. They should be advised probable follow-up schedule of their case preferably in writing. Such written schedule reminds the patient for follow-up at right time. Such period of postoperative follow-up treatment varies from few months to few years. This period depends upon duration and severity of preoperative problems, response of patient and precautions taken by patient. As patient responds satisfactorily, the follow-up visit interval increases. Patient should also advise to avoid precipitating factors. Initially, follow up may be advised every two months. Then after one year, he may be advised follow-up after every 3 to 5 months depending upon response to follow up treatment. The family physician plays a great role in motivating the patient to keep follow up and in assessing response to treatment. He is important link in giving feedback and counselling with the surgeon.

Counselling of the patient preoperatively plays great role in understanding ones problem, avoiding postoperative drop out and improves success rate of treatment plan. Patient may be explained as follows:

"Every body in this world is likely to suffer from common cold and other nasal problem. Three to four attacks of common cold are normal in healthy person. These attacks of common cold are generally controlled by nature and more often these attacks are unnoticeable and non-troublesome. So one feels that he/she may not need active treatment. As you have suffered for so much duration and severe nose complaints like running of nose, nasal blockage, sneezing etc. the natural resistance power of your own body to face these problems has been reduced. This persistence of reduced level of resistance power for long period made you more susceptible or easily susceptible for attack of common clod or nose infection. Let us not only control your disease in nose but also improve your resistance power and immunity. It takes its own time to build up your resistance power and immunity."

"Everybody has natural resistance power and adjustment capacity against changes in environment, routine life, exposure to unnatural atmosphere, and exposure to pollution like dust, smoke, fumes etc. It is not same in all. It may vary widely. One must keep in mind about awareness that everybody has to maintain one's resistance power and immunity against all these factors."

"All those who are exposed to such factors do not suffer from common cold and other nasal problem. Only 10-15% persons suffer. These sufferers say that because they are exposed to such changes, they have suffered. But it is not true. Why all others who have been also exposed simultaneously have not suffered? It is because others have good resistance power. So fault lies not in environment or treatment but it lies in that individual's resistance power and immunity status. Often one fails to understand such mechanism. Many of us do not like to accept our faults, deficiencies and disorders. When these are in mild to moderate extent we straight way deny them. Even when we accept these problems, we do not take active step to get relief from them. We do not consult specialist at right time. Those who consult may not keep proper follow up. Some of us, feel that "I have done enough efforts, now, let me not do any more efforts and wait for automatic cure of my problem". Perhaps these efforts are not upto sufficient extent for treatment of his severe or long standing allergy. Duration of treatment is often short even early stage of problem often one takes 1-2 tablets and if one feels improved then medicine is not continued. When one is relieved of symptoms, one does not bother to improve one's resistance power. So indirectly, we remain susceptible to disease. or increase our susceptibility. We often take treatment for cure of disease but we do not bother to take treatment to improve our health status and resistance power against disease. This results in recurrence of disease or persistence of disease."

"We study only when examination is near future. But we do not study at other times in academic year. Then, how can our intellectual capacities will increase? In the same way, we take treatment when we feel symptoms, once symptoms disappear, we do not take treatment for improving our resistance power and immunity status. So indirectly our resistance power remains low and it results in easy susceptibility to the diseases. "

"Let us manage your problem with medicine and following precautions. If in spite of full course of therapy, or if attack recurs then, we may think of any surgical treatment or specialised treatment like subcutaneous immune therapy. As your problem is chronic, you need to undergo certain investigations like X-ray of paranasal sinuses or CT scan. This helps to assess extension of disease. Such information helps in planning the treatment."

NASAL POLYP:

Nasal polyp is not a disease, but it is a symptom of underlying nasal and sinus disorder. It is due to intrinsic rhinitis. Nasal Polyps are more common in non-atopic asthma and rhinitis as compared to their allergic counter part. Nasal polyposis is an indication of underlying systemic disorder. Aspirin intolerance, sinusitis and asthma are a group of patients having hyperplastic rhinitis and polyp. Patient of cystic fibrosis, allergic fungal sinusitis. Kartagener’s syndrome, Young’s syndrome, Churg-Stranuss syndrome, nasal mastocytosis may develop polyp. Persistent and recurrent nasal inflammation cause inflammatory changes in mucosa due to infection and allergy. Histologically, they contain degranulated mast cells. Local IgE is low.

Definition:

Nasal polyp is a prolapsed pedunculated part of the non-neoplastic oedematus mucosa of the nose or paranasal sinuses. It is inflammatory in origin.

CLINICAL FEATURES: -

Polyp may remain asymptomatic till it grows to sufficient size so as to cause nasal blockage and other symptoms. Usually it arises from middle meatus.

Polyp leads to nasal obstruction. It is relieved by decongestants during initial phase of the disease but as disease increases, obstruction is not relieved with decongestant. Nasal blockage is the most common symptom. So patient may feel breathless. Some of them may be wrongly treated for the chest problem (e.g. asthma) rather than nose problem by general practitioner for complaint of difficulty in breathing. Patient develops mouth breathing and snoring due to nasal obstruction. After increased obstruction, patient develops hypo-nasal voice.
Nasal discharge is mucopurulent. Nasal discharge may be bilateral in ethmoid polyp and unilateral in antrochoanal polyp Postnasal drip may be present.

Sneezing and watering is present in 50% cases, and partial or total anosmia is in 75% cases. In some cases, associated problem of asthma may be present. Headache is due to sinusitis.

Polyp is round; smooth, soft, mobile translucent, yellow or pale or pearly white, glistening and non-sensitive structure attached to nasal or sinus mucosa with relatively narrow stalk. If it is punctured with needle, blood does not come out of it. If pressed hard over it with a probe, it appears softer and no hard bone is felt in it. It is non-tender. It can be moved forward or backward when it is palpated by probe. Probe can be passed all around most of its' part. When polyps last for longer duration, nasal bridge may widen. The later may also be due to cystic fibrosis, aspirin hypersensitivity and colic diseases. {ASA triad: Asthma, intolerance to acetyl salicylic acid and nasal polyps are called as ASA triad.}

Antrochoanal polyp: -

This type of polyp is less common and arises from lining of maxillary sinus due to infective pathology. The mucosal lining becomes oedematous. It is more common in adolescence. Usually it is unilateral and so it causes unilateral nasal blockage. Blockage is more on expiration due to ball valve effect of polyp blocking posterior choana. It is thin stalked. Initially, blockage is unilateral. As it enlarges and reaches nasopharynx, it may cause bilateral nasal blockage. It grows backward as a single, unilateral, trifoliate (Dumbbell like) structure. Its protruded portion may undergo metaplastic changes and may become ulcerated. It may be missed during clinical examination like anterior rhinoscopy because it grows posteriorly.
Ethmoid polyps: - These are mostly seen in adults. Ethmoid polyps are always multiple and bilateral, grow anteriorly like a bunch of grapes. These may become pink after some period due to vascular changes. Anosmia often present.



    Copyright 2006. Vent Hospital. All Right Reserved