Letters

10-minute consultation: Rhinitis

Referral to specialist otolaryngologist may be advisable

Article is unhelpful

Referral to specialist otolaryngologist may be advisable

EDITORAlthough the 10-minute consultation on rhinitis serves as a useful guide for treatment of this common condition, certain points merit clarification.¹

We agree that unilateral nasal blockage and bleeding warrant prompt referral since these symptoms may indicate an underlying malignancy. Contrary to the authors' suggestion, however, this is an uncommon presentation of nasopharyngeal carcinoma, which is more frequently associated with unilateral glue ear or cervical lymphadenopathy. Examination of the nose by an experienced doctor using adequate illumination is essential to exclude other diagnoses, such as septal deflection, turbinate enlargement, and nasal polyposis. We are also surprised that no mention is made of the diagnostic value of allergy testing, which has been shown to be feasible in primary care.²

With regard to treatment, the authors do not emphasise that topical nasal decongestants such as oxymetazoline should be avoided in prolonged courses owing to the incidence of rebound oedema and rhinitis medicamentosa.³ We disagree with the assertion that steroid drops should not be used in chronic allergic rhinitis since they increase systemic absorption.

Betamethasone nasal drops do cause appreciable systemic bioavailability and in protracted regimens have been associated with undesirable side effects. This is not the case, however, with fluticasone nasal drops, which have negligible absorption (0.06%), less even than fluticasone spray (0.51%).⁴ Along with budesonide, they do not contain benzalkonium chloride preservative, which is found in most other topical preparations and to which some patients are sensitive.⁵ These preparations are therefore of particular use in patients developing nasal discomfort with more commonly prescribed sprays.

Either betamethasone or fluticasone nasal drops are preferable to the course of 20 mg oral prednisolone suggested by the authorsa treatment rarely given for allergic rhinitis even by specialists. Equally, the authors are unwise to suggest referral for immunotherapy as a realistic option in primary care, since this controversial technique is used in only a few centres.

We agree that many patients with allergic rhinitis can be treated successfully in primary care but believe that more emphasis should be placed on adequate initial examination of the patient and particularly on referral to a specialist otolaryngologist or allergist should initial treatment fail.

Natalie Brookes, specialist registrar. 
Nataliebrookes{at}aol.com

Hesham Saleh, consultant surgeon. 
Ian Mackay, consultant surgeon. 
Department of Otorhinolaryngology, Charing Cross Hospital, London W6 8RF

Article is unhelpful

EDITORThe comment in the 10-minute consultation on rhinitis that unilateral nasal obstruction and bloodstained discharge is an alarm symptom of nasopharyngeal carcinoma is untrue.¹ Unilateral nasal obstruction and nose bleeds are extremely common nasal symptoms, presenting either separately or together, and are usually due to a deviation of the nasal septum. The occasions on which they might be due to serious disease are vanishingly small. Furthermore, they are not symptoms of nasopharyngeal carcinoma: it tends to present as a unilateral serous otitis media.

In over seven years as a consultant head and neck surgeon, I have seen only two cases of sinonasal malignancy. In both, although nasal obstruction was present, it was not the presenting symptom: that was pain and facial swelling. There was no bleeding in either case.

The statement that patients with such symptoms warrant an urgent specialist opinion, without reference to the relative frequencies of the causative disease, is unhelpful and inappropriate.

Andrew McCombe, consultant ear, nose, and throat and head and neck surgeon. 
Frimley Park Hospital, Camberley, Surrey GU16 5UJ AMcco79794{at}aol.com