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Rapid Responses: Rapid Responses published:
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oxymetazoline nasal spray may induces rebound swelling and nasal hyperreactivity.
- Edoardo Cervoni (15 February 2002)
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Don't forget to examine the nose
- Brian J Lipworth (15 February 2002)
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Use of normal saline nasal drops in rhinitis
- Sugeet Baveja (21 February 2002)
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availability of immunotherapy
- Jane E Wilson (22 February 2002)
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What about allergen avoidance?
- Adam Jacobs (23 February 2002)
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An Effecitve Alternative Therapy For Rhinitis
- DR.Praveen kumar Madikonda (23 February 2002)
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Unilateral nasal obstruction in rhinitis
- Andrew W McCombe (27 February 2002)
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Too much importance attached to allergy
- Geoffrey S Barr (5 March 2002)
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10-minute consultation: Rhinitis
- Natalie Brookes, Hesham Saleh, Ian Mackay. (6 March 2002)
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Allergic rhinitis and bronchial asthma
- Dr S K Agarwal (17 March 2002)
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Re: Unilateral nasal obstruction in rhinitis
- zia syed (23 June 2002)
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Allergic rhinitis
- N.P. Viswanathan (3 July 2008)
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Edoardo Cervoni, M.D., Ph.D., ENT Specialist Aerospace Medical Research Unit, McGill University, 3655 Drummond Street, Montreal, PQ, Canada H3G 1
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The worsening of the symptoms in the case reported by Samantha Walker and Aziz Sheikh may be related to the use of oxymetazoline in two different ways. The prolonged use of nasal decongestant could have induced either rhinitis medicamentosa and rebound nasal hyperreactivity. Graf et coll. (1995), in a A randomized double-blind parallel study, showed that four-week use of oxymetazoline nasal spray once daily at night is enough to induce rebound swelling and nasal hyperreactivity. An adequate treatment of these patients consists of a combination of vasoconstrictor withdrawal and a topical corticosteroid to alleviate the withdrawal process. The underlying nasal disorder must then be treated (i.e.: turbinate reduction if chronic hypertrophy causing significant nasal obstruction). Patients with rhinitis medicamentosa who overuse topical decongestants and are able to stop using such drugs should be careful about taking these drugs again, even for a few days. They must be informed about the rapid onset of rebound congestion upon repeated use in order to avoid the return of the vicious circle of nose-drop abuse. |
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Brian J Lipworth, Professor of allergy and pulmonology Ninewells University Hospital,Dundee,DD19SY
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The article of Walker and Sheikh is a nice brief overview of allergic rhinitis for a 10 minute consultation in primary care.However,no mention is made of the importance of clinical examination.Anterior rhinoscopy is simple and quick and provides information on abnormalities in the valve area of the nasal cavity in terms of the septum and inferior turbinates,and will also detect large polpys .Measurement of peak nasal inspiratory flow is also simple,rapid and cheap ,and provides objective information on nasal airflow obstruction and may also be used to objectively assess treatment response at follow up . This is complimentary to taking a good history and allergy testing in making an accurate diagnosis and effecting appropriate treatment.For example, where there is significant mechanical obstruction due to septal deviation or turbinate hypertrophy ,this will impede delivery of topical therapy with corticosteroid or antihistamine sprays into the nasal cavity. In these circumstances, systemic administration [eg antihistamines] by the oral route is more likely to be of benefit, or a referral for turbinate or septal surgery to facilitate intransal delivery. Finally I was amused to see a picture showing how not to use a nasal spray -using the method illustrated in the picture would spray the vestibule rather than the turbinates and be likely to result in treatment failure. |
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Sugeet Baveja, consultant physician kalyani hospital,mehrauli road, gurgaon,india,122001
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I have observed that patients have better control of rhinitis if normal saline nasal drops are used before using a steroid spray.Frequent use of normal saline drops keeps the patient more comfortable and the dose of steroids required is also decreased. |
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Jane E Wilson, veterinary surgeon London
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I understood that the Committe for Safety of Medicine had banned the importation of antigen for immunotherapy. I have (personally) been seeking desensitisation for dog and house dust mite allergens and am prepared to 'go private' for this service - but have now been told it simply cannot be done in UK. A consultant advised taking an opportunity to work in Europe as a route to getting treatment. My GP has now suggested alternative medicine, but as a veterinary surgeon I am reluctant to give up on conventional means! |
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Adam Jacobs, Director Dianthus Medical Limited, SW19 3TZ
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I am surprised that Walker and Sheikh do not mention allergen avoidance as part of their advice on treating rhinitis [1]. This is recommended as an important part of the management of allergic rhinitis not only in the guidelines that they cite [2] but also in American guidelines [3]. It is, of course, important to identify the offending allergen(s) before embarking of a potentially burdensome programme of allergen avoidance, and this is most easily done by skin prick testing. There is no reason why this cannot be offered in a primary care setting [4]. References: 1. Walker S, Sheikh A. 10-minute consultation: Rhinitis. BMJ 2002;324:403 2. van Cauwenberge P, Bachert C, Passalacqua G, et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy 2000;55:116–134 3. Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 1998;81:478–518 4. Sibbald B, Barnes G, Durham SR. Skin prick testing in general practice: a pilot study. J Adv Nurs 1997;26:537-42 |
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DR.Praveen kumar Madikonda, Senior Resident Faculty of Ayurveda; Institute of Medical Sciences: Banaras Hindu University; Varanasi, INDIA 221005
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Dear sir I have gone through the article in detail.It was intresting and informative.Being a physician of Ayurveda and keeping in view of my clinical experience on the subject i would like to convey Ayurvedic approach on the clinical entity of rhinitis. Consider my views on the subject irrespective of the status of Alternative system in {UK} general and Ayurveda in perticular. IT IS ONLY AN EFFORT TO BRING AYURVEDIC ALTERNATIVE APPROACH TO THE MAIN FOCUS AND NOT TO CONSIDER AS PERSONAL REMARKS. In India the incidence of chronic rhinitis has been steadily increasing.Most of the patient population miserably fail to perform their daily routine owing to the great inconvenience caused by this chronic illness. All most all patients who visit Ayurvedic clinics have a long treatment history at allopathic hospitals. The antihistemics and steroids haven't yielded the desired results. In ayurveda we treat this condition on terms of "Kapha" disorder and perform an elimination therapy{Panchakarma}. A systematically carried emesis{Vaman Therapy} has produced improvement in more than 90% of the subjects in only one sitting.Life style correction and diet also plays a major role in its management. Why cannot such an effective medical system has been overlooked by the western world? I often feel hurted to know that the valuable information of Ayurveda is prevented in reaching the western world in the name of scientific studies and clinical research.Ayurveda is a time tested medicine.People need to come to india to see its clinical efficacy where it is still a living medical system. We are not againt to the clinical research.But that will only delay its implementation for another century. YOURS SINCERLY DR.Praveen |
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Andrew W McCombe, Consultant ENT Surgeon Frimley Park Hospital, GU10 4LT
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I am not sure how valuable a piece the 10-minute consulatation on Rhinitis by Samantha Walker and Aziz Sheikh might be but I do know that their comment that unilateral nasal obstruction and blood-stained discharge as an "alarm symptom" of nasopharyngeal carcinoma is NOT. Unilateral nasal obstruction and nose bleeds are extremely common nasal symptoms presenting either seperately or together, and usually due to a deviation of the nasal septum. The occaisions on which they might be due to serious pathology are vanishingly small. Furthermore these are not symptoms of nasopharyngeal carcinoma; it tends to present as a unilateral serous otitis media. In over 7 years as a consultant head and neck surgeon, I have seen only 2 cases of sino-nasal malignancy. In both, although nasal obstruction was present, it was not the presenting symptom; that was pain and facial swelling. Neither case had any bleeding. The statement that patients with such symptoms warrant an urgent specialist opinion, without reference to the relative frequencies of the causative pathology, is therefore unhelpful and inappropriate. Yours faithfully Andrew McCombe
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Geoffrey S Barr, ENT Consultant Gwynedd Hospital, LL57 2PW
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EDITOR - The primary care article on rhinitis by Walker and Sheikh probably attaches too much significance to allergy. Treatment of nasal mucosal disease is generally the same whether allergy is present or not. Topical nasal steroid sprays are the treatment of choice, but when patients fail to respond we advise them to ignore the manufacturer’s instruction leaflet and instead spray the nose whilst holding their breath. Instruction leaflets telling patients to breathe in when spraying makes most of the atomised spray disappear into the lower respiratory tract. Persistence of symptoms suggests irreversible mucosal swelling, which can be treated by diathermy or electrocautery, or there is a structural abnormality in the nose for which an ENT opinion should be sought. Geoffrey Barr
1. Walker S, Sheikh A. Rhinitis. BMJ 2002; 324: 403 |
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Natalie Brookes, Specialist Registrar Charing Cross and Royal Brompton Hospitals, Hesham Saleh, Ian Mackay.
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We read with interest this helpful article regarding the management of rhinitis in primary care1. Whilst serving as a useful guide for treatment of this common condition, we feel that certain points merit clarification. We would certainly agree that unilateral nasal blockage and bleeding warrant prompt referral since these symptoms may be indicative of an underlying malignancy. Contrary to the authors' suggestion, however, this is a very uncommon presentation of nasopharyngeal carcinoma, which is more frequently associated with unilateral glue ear or cervical lymphadenopathy. It should be emphasised that examination of the nose by an experienced clinician using adequate illumination is essential to exclude other diagnoses such as septal deflection, turbinate enlargement or nasal polyposis. We are also surprised that there is no mention of the diagnostic value of allergy testing which has been shown to be a feasible investigation in primary care2. 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 demonstrated incidence of rebound oedema and rhinitis medicamentosa3. We also disagree with the assertion that steroid drops should not be used in treatment of chronic allergic rhinitis since they increase systemic absorption. Betamethasone nasal drops do cause significant systemic bioavailability and in protracted regimes have been associated with undesirable side effects. This is not the case, however, with fluticasone drops (Nasules) which have been shown to have negligible absorption, (0.06%), less even than Flixonase spray (0.51%)4. They, along with Rhinocort Aqua (budesonide), do not contain benzalkonium chloride preservative found in most other topical preparations and to which some patients are sensitive5. These preparations are therefore of particular use in patients developing nasal discomfort with more commonly prescribed sprays. Certainly, either Betnesol or Flixonase Nasules are preferable therapeutic options to the course of 20mg oral prednisolone, suggested by the authors, a treatment rarely administered for allergic rhinitis even by specialists. Equally, the authors are unwise to suggest referral for immunotherapy as a realistic option in a primary care setting since this controversial technique is used in very few centres. We entirely agree that many patients with allergic rhinitis can be treated successfully in primary care, but feel 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,
Hesham Saleh, Consultant Surgeon, Ian Mackay, Consultant Surgeon. Department of Otorhinolaryngology, Charing Cross Hospital, Fulham Palace Road, London W6 & Royal Brompton Hospital Sydney Street, London SW3 1. Walker S, Sheikh A. Rhinitis. BMJ 2002;324:403. 2. Sibbald B, Barnes G, Durham SR. Skin prick testing in general practice: a pilot study. J Adv Nurs 1998;27:442-4. 3. Graf P, Hallen H, Juto JE. Four-week use of oxymetazoline nasal spray (Nezeril) once daily at night induces rebound swelling and nasal hypersensitivity. Acta Otolaryngol 1995;115(1):71-5. 4. Daley-Yates PT, Baker RC. Systemic bioavailability of fluticasone propionate administered as nasal drops and aqueous nasal spray formulations. Br J Clin Pharmacol 2001;51:103-5. 5. Hallen H, Graf P. Benzalkonium chloride in nasal decongestive sprays has a long-lasting adverse effect on nasal mucosa of healthy volunteers. Clin Exp Allergy 1995;25(5):401-5. Competing interests: None declared |
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Dr S K Agarwal, Head, Department of Chest Diseases, Institute of Medical Sciences, BHU, Varanasi
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As many as 88% of patients with asthma exhibit the symptoms of rhinitis, and half of the rhinitic patients have asthma. Rhinitis often precedes asthma; hence successful treatment of rhinitis may well prevent asthma. In patients with rhinitis and coexistent asthma, the treatment of rhinitis has a beneficial effect on asthma. It is estimated that allergic rhinitis affects between 10% to 30% of the population of the United States and its prevalence seems to be increasing. It’s quite common to see patients of allergic rhinitis taking intranasal steroid on demand basis rather than on regular basis thereby defeating the whole purpose for which it is indicated |
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zia syed, ent specialist Liaqat National hospital.karachi.pakistan74800
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I have to agree with my respected colleague ,that the usual presentation of nasopharyngeal carcinoma is unilateral serous otitis media but it does also presents with nasal bleeding and nasal obstruction,besides, the symptom of unilateral nasal obstruction and nasal bleeding is also a predominant presentation of nasopharyngeal angiofibroma,which is common in this part of the world. |
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N.P. Viswanathan, Family Physician S.V.clinic,Gm palya,Bangalore-560075,India
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Sir, Seasonal allergic rhinitis is a common problem in Bangalore. Regarding intranasal steroids, How long it can be used without side effects?Now leucotrine inhibitors are used in the treatment of allegic rhinitis.when to initiate leucotrine inhibitors?Please comment on intranasalantihistaminics. Thank you N.P.viswanathan Competing interests: None declared |
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