Allergic rhinitis

Allergic rhinitis seems to be the buzz word now in Hong Kong, and in most urban cities in China nowadays. With the ever increasing Air Pollution index (API) being daily monitored, most Hong Kongers are not only aware of allergic rhinitis but are probably most likely sufferers of this condition.

Rhinitis is the medical term for inflammation of the nose (rhino-itis) and when the cause is an allergen that causes an allergic response, we call it allergic rhinitis. What is the related impact of this condition? Looking at this condition globally, it is estimated that 20% of everyone on Planet Earth is affected by rhinitis; that is to say one in every five persons. In the United States, an estimated 58 million Americans suffer from allergic rhinitis due to some allergens, whilst another 19 million have non-allergic rhinitis. This accounts for almost 30% of clinic attendances seen by the average Ear, Nose and Throat Specialist.

Most allergic rhinitis sufferers are usually allergic to things like house dust mite extracts (not house dust), pollen, cockroach extracts, molds and fungi. The fur or dander of pets like cats and dogs can also stimulate an allergy. So what happens when this occur?

       

Our nose is a very fine and sensitive organ. It regulates the temperature and humidity of the air entry in order to protect our lung, as well as to cleanse the entering air of particulate matter that would otherwise damage our lungs.

In the presence of house dust mite extract or molds, the blood flow to the nose will increase and cause the tissues in our nose (the turbinates) to swell.  This blocks air entry in to the nose; so we suffer from blocked nose. The nose starts to secrete copious amounts of mucus to irrigate away these allergens; we then suffer with a running nose, usually with a postnasal drip. And finally the chemical mediators released in an allergic reaction in the nose causes us to sneeze; this removes the allergens from our nose with a violent blow.

       

Allergic rhinitis, although considered as a disease, is best viewed as our body’s natural and protective response to contaminated air entering our body. There is no fever as there are no viruses or bacterial infection. It can occur everyday unlike e.g. viral infections that runs a course 2-3 times a year. And as the nasal passages get swollen, the sufferer often encounters other associated conditions like:

•  Sinusitis and sinus headaches becomes more likely as the sinus openings are blocked

• Mouth breathing to compensate for the blocked nose often ensues. This results in dry mouth, bad breath, recurrent sore throats and tonsillitis, recurrent mouth ulcers and poor sleep quality

•  Recurrent tonsillitis will result in enlarged tonsils. This is a cause of snoring and obstructive sleep apnea, with a poorer sleep quality.

•  A poorer sleep quality over time can affect one’s ability to function well cognitively with memory loss, irritability and frustration as well as maintaining a normal blood pressure for one’s age.

•  Bronchial hyperactivity with dry cough and exacerbation of asthma is a common sequelae of poorly controlled allergic rhinitis. The simple reason for this is that the nose, mouth and lung airway share the same mucosal lining. So when the nose is no longer able to prevent soiling of the lung by the poor air e.g. because of mouth breathing, dry cough with asthmatic episodes increase.

•  As the eyes have a similar lining that is equally reactive and similarly innervated by the nose, allergic rhinitis causes the eyes to stream tears, be itchy and cause blur vision and difficulty with wearing contact lenses comfortably.

So how can we treat allergic rhinitis? Whatever we do, we need to do regularly as most individuals are allergic to the ubiquitous house dust, which is everywhere. We need to remove the allergens. Simply avoiding would help but it is not always practical. Keeping our home and work environment dust free will help by wiping with a moist cloth, cleaning air-conditioning filters regularly, washing bed linen in water >63 degree Celsius to kill the house dust mites, avoid carpets if possible or at least keep them clean regularly.

The simplest way is to use a low pressure, high volume nasal saline douching system for the nose. These are available from the local chemists. They irrigate the nose, keeping the allergen load at a minimum and should be a part of one’s daily hygiene regime to maximize the benefit.

Whilst the above would work for the mild sufferers, often medication is required. The commonest prescribed medication is a topical nasal steroid, which are anti-inflammatory.

They are very effective in reducing inflammation of the nasal lining topically at the target site of the condition, improving the nasal airway and reducing the secretions and itchiness. Unlike the dreaded injected or orally taken steroids, topical nasal steroids have been shown to be very safe to use in children as young as 3 years. Antihistamines oral medications are also used and they are especially effective in reducing the sneezing and runny nose.

So what about surgery for allergic rhinitis? In patients whose main problem with their rhinitis is a blocked nose with sinus related headaches and mouth breathing; surgery helps to unblock the nose. Enlarged turbinates can be reduced, deviated septum can be realigned and sinuses can be re-ventilated as necessary. As surgery does not remove the nasal lining completely, there may be residual allergic symptoms of sneezing and runny nose. However with a more patent nose, saline douching and/or topical nasal steroids will be more effective in reaching their target, and to minimize inflammation of this lining.

Allergic rhinitis is a condition that can affect the quality of life of the sufferer. With the sinusitis, poor sleep, reduced cognition, recurrent throat infections, obstructive sleep apnea and asthma that can be associated with it, it adds to the “unseen” economic loss for employers and the Hong Kong community as a whole. Simple measures and medication do help, but just sometimes surgery is required to better control the condition.

Case study

A 39 year old executive presented with a blocked nose, dry mouth, snoring, with poor sleep and morning headaches. His turbinates were swollen and they blocked the nose. When the turbinates were decongested for a full nasal examination, a deviated bony septum was seen and an enlarged postnasal adenoid was seen. With the blocked nose and daily mouth breathing, the tonsils and pharynx were inflamed and enlarged. The tonsils added to the snoring, which when he reached the deeper stages of sleep, together with a relaxed tongue, caused an airway obstruction during sleep. Hence good deep sleep was not always possibly attained. In spite of medication, the condition did not improve, and surgery was offered.

Surgery, to straighten the nasal septum, reduce the inferior turbinates, remove the tonsils and trim the elongated uvula, was performed. The improvement in the airway was significant and resulted in a better sleep, minimal snoring and an overall improved quality of life and work. Regular nasal saline douching daily was still required to maintain good nasal hygiene.

More information: http://www.entific.com.hk/

The Chinese version of this article was published in Hong Kong Economic Journal  on February 14 & 28, 2013.

I cannot hear in one of my ears!

Single sided hearing deafness (SSD) is not uncommon. There are all kind of reasons including accidents & trauma, medication, surgery, strokes, brain tumours, etc. However, usually the reason is never known (idiopathic) as in patients who experience sudden hearing loss of unknown cause. It has been suggested that overall, single sided hearing loss may be as common in our population as 12 in every 100,000 persons.

What problems do these SSD sufferers have?

SSD patients cannot hear clearly from one side, and therefore do not have stereoscopic sound i.e. they are unable to localize the source of a noise. Also in noisy environments, their only hearing ear is challenged by the useless “noise” that masks the useful “sounds” that they want to hear e.g. speech of a friend in an interesting conversation over cocktails in a crowded party. 

SSD patients also automatically modify their lifestyles to better suit their condition. For example, they will always walk and talk with family and friends standing, sitting and walking on their better hearing side. They will arrive at meetings earliest, not because they are the keenest, but so that they can sit strategically with their good ear to the meeting attendees.

What is the solution?

The state of the art evidenced based solution that is better than others on the market, is the  Cochlear™ baha® ( bone anchored hearing aid ) hearing system. The Cochlear™ baha® hearing system was FDA-approved for the treatment of single sided deafness in 2003, and has been successfully used to treat specific hearing conditions in Hong Kong since 1996. The technology translates sounds from an hearing processor, through a titanium implant, to the cochlea or inner ear. The vibrations received are perceived as sounds, and the patient “hears”.

How does the baha help with single sided deafness?

The Cochlear™ baha® hearing system is applied to the deaf side of the head. Sounds that it “hears” are conducted though the implant to the other good and normally functioning inner ear on the opposite side of the head. The good ear interpretes the sound as coming from the deaf side, and the brain does the rest.

Is the hearing normal then?

The hearing is not normal as there is only one inner ear that is functioning and translating sound from both sides. However the brain is able to understand the difference. For the patient, they can now hear sounds from their deaf side.

How do I know if the baha will help me?

The Cochlear™ baha® hearing system comes with a Softband™ for trial in a clinic setting. You will be assessed with the Softband™ and advised if the Cochlear™ baha® solution is the right one for you. If you are a potential candidate, you can try the Cochlear™ baha® processor in your different sound situations specific to your lifestyle….and then choose for yourself.

Dr. Gordon Soo, MD

The information aims to provide educational purpose only.  Anyone who is reading it should consult ENT Specialists before considering treatmenst and should not rely on the information above. 

The Cochlear™ baha® hearing system

The Cochlear™ baha® ( bone anchored hearing aid ) sound processor system has been successfully used to treat specific hearing conditions in Hong Kong since 1996. The technology translates sounds from a hearing processor, through a titanium implant, to the cochlea or inner ear. The vibrations received are perceived as sounds, and the patient “hears”.

Today, for the surgeon and the baha client, this simply translates to a direct bone conduction hearing system that is:

• surgically simpler with the Hong Kong incision, 

• faster with single stage surgery, 

• earlier for baha use with improved implant coating     technology and design, and 

• higher in fidelity hearing performance with the latest series   of digitally programmable hearing processing systems.

                      

Currently the indications by clinical condition for the baha hearing system include any of the following:

1. Conductive hearing losses e.g. congenital aural atresia,     mastoidectomies

2. Mixed hearing losses e.g. post-irradiated nasopharyngeal cancer patients with hearing difficulties

3. One-sided total hearing losses ( or medically, single sided deafness, SSD)

How do we know if a patient will benefit from the baha processor?  Simply we let them try it with a softband. If they like it, they are potential candidates for….

...the only hearing implant system that “you can try before you buy”.

The Cochlear™ baha®  hearing system…..now, how much easier can it be!

Dr Gordon Soo, MD

















The information aims to provide educational purpose only.  Anyonew who is reading it should consult ENT Specialists before considering treatment and should not rely on the information above. 

Nose bleeds in children

Children commonly experience nose bleeds. This occurs for all sorts of reasons but generally children have thinner nasal linings that can break.

For children, it is because their nasal lining is thinner and they may have an underlying nasal allergy that :

• makes them sneeze
• makes them rub their nose
• blocks the nose so there is more turbulence and drying

One, or all of the above, causes the fine blood vessels of the Little’s area to rupture and bleed.

Treating nose bleeds in children is relatively simple. If the cause is nasal allergy, that should be adequately treated. Thereafter persisting nose bleeds would require a more comprehensive examination to exclude less commoner causes. Sometimes a troublesome engorged vessel/s may require sealing. 

The information aims to provide educational purpose only. Anyone who is reading it should consult ENT Specialists before considering treatment and should not rely on the information above. 

Blocked nose (nasal obstruction) – Part Two

Q: Why does my head feel heavy, and sometimes I experience pain between, above and/or behind the eyes, when I am blocked and sneezing?

A: The sinus openings and linings inside the nose, are the same as the nose itself. Hence a rhinitis (inflammation of the nasal lining) is indistinguishable from sinusitis. In fact ENT physicians usually called it by its proper condition i.e. rhinosinusitis.

When the sinus openings are blocked by the inflammation, and they themselves are inflamed, the sinus pressure drops. This negative sinus pressure results in pain and heaviness around and behind the eyes, because the sinuses are all surrounding our eyes. Sinus pressure pain is characteristically worst especially if we put our heads between our knees or bend down to pick something up

Q: I feel tired in the morning and unrefreshed, even though I have had a good 8 hours of sleep? 

A: Quantity sleep is not the same as quality sleep. If your nose is blocked due to enlarged turbinates, the turbinates are going to even more engorged when lying flat. When one’s nose is blocked, we then have to breathe through our mouth.  Although the mouth is a much larger airway than the nose technically, it can obstruct if the tongue is drawn back during deep sleep, or the tonsils are enlarged. Hence our oxygenation drops intermittently and disrupts our sleep pattern, depriving us of quality sleep.

Q: And my mouth always feels dry in the morning?

A: With a blocked nose, we have to open our mouth to breathe. It will inevitably be dry in the morning.

Mouth-breathing, especially if persistent, predisposes to recurrent sore throat, recurrent mouth ulcers, bad breath and increased dental caries and gum disease.

Q: My spouse / partner tells me I snore heavily. I notice this especially when my nose is blocked. Why?

A: Air passing from the nose to the lung, needs to navigate a gauntlet of structures. In the nose, the structures are relatively fixed, and it is either open or blocked. Nothing vibrates.

But below the nose, the air flows and  passes through

•    behind the soft palate and uvula,
•    between the tonsils,
•    behind the tongue and then
•    behind the epiglottis.

All these structures are relatively mobile. They can, and do vibrate according to the airway pressure changes when we breathe in, and especially when the nose is blocked during sleep. When each of these structures vibrate, they emit their own resonant sound like “ a flag furling in the wind “. These different vibrating structures create their own “symphony” of the snore, and the music of the night!

Q: I just feel tired all the time and forgetful, with the blocked nose!

A: This is again related to the poor quality of the sleep.

You should speak to your ENT Physician to assess the underlying blocked nose, and to further assess if there is significant obstructive sleep apnea that requires further management.

The information aims to provide educational purpose only. Anyone who is reading it should consult ENT Specialists before considering treatment and should not rely on the information above. 

Blocked nose (nasal obstruction) – Part One

A blocked nose is the commonest symptom described. It can either be intermittent or persistent.

Causes are many and varied. They include allergy, viral infection, injury to the nose, a bent septum and nose,...,etc.

The function of our nose is to clean, filter, humidify and warm the environmental air before it reaches our delicate lungs. This function is suitably served by the turbinates in the nose and especially the inferior turbinates. 

If the environmental air is polluted or carries allergens to which a person is sensitive, the nose responds immediately by increasing blood flow to the turbinates. The effects are predictable, and actually physiological i.e. normal responses of the body  :

1. The turbinates swell to prevent the polluted air from entering the nose and lungs ("Doctor, my nose is blocked")

2. The improved blood flow increases nasal secretions, that attempts to cleanse the nose (" I have a running nose and it drips down the back of my throat ")

3. The nasal sensations are heightened, causing the nose to expel out the pollutants/ allergens forcibly ( "I sneeze a lot")

If the condition is an acute viral inflammation, other signs of viral infections are apparent e.g. fever, muscle aches, headaches, tiredness. Viral infections however last only a few days, and usually the average person contracts this 1-2 times a year, usually during the Winter season.

However allergic, vasomotor or pollution-related type rhinitis (inflammation of the nose) happens every day, or predominantly throughout the year, without fever or aches, are more common.  This is the nose reacting to the constant presence of pollutants, allergens, etc.

The treatment for the nose condition depends entirely on the most likely cause, and is best discussed with your physician. It includes conservative treatment as well as surgery to improve the nasal airway diameter.

The information aims to provide educational purpose only. Anyone who is  reading it should consult ENT Specialists before considering treatment and should not rely on the information above.

Epistaxis (or nose bleeds)

Nose bleeds are quite common. The majority of nose bleeds are idiopathic; that is to say we do not know the cause. But that is alright as long as the cause has been sought for, and important causes excluded.

The majority of nose bleeds occur in the front of the nose called the septum and turbinates. There are a variety of reasons for nose bleeds:

Nose picking habit

Nasal allergy that increases the inflammation of the nose

Distorted nasal anatomy like a deviated nasal septum 

Surgery or major trauma to the nose

Tumors and growths (these do not generally cause frank nose bleeds but rather blood-stained nasal  discharge)

Blood thinning medication usually taken for stroke prevention and hypertension.

Nose bleeds are more common in extreme weather conditions and during rapid weather changes especially when the air gets both colder and drier quickly. 

Trivia: Why does cold and drier air makes the nose to bleed more?

How to stop a nose bleed?

Lean forward, open the mouth to breathe and apply firm pressure to the soft lower third of the nose (essentially squeeze the bottom half of the nose together so you cannot breathe through the nose at all).  By doing this, you are applying firm pressure to Little’s area (the area where the little finger can touch inside the nose and where Keisselbach’s plexus of blood vessels confluence) and where the majority of nose bleeds occur. 

Trivia: Why is Little’s area named as such?

By tipping your head forward and down by at least 20 degrees, blood will not run back down to the throat and make you cough and splutter. Also you will be fully aware of any continuing bleeding and the amount of blood loss.

Trivia: What anatomical reason requires us to tip the head forward by 20 degrees? Why not just sit straight

Hold this for 20 minutes (normal blood will coagulate after 5 minutes and holding longer gives it a margin of security). If available, suck an ice cube as well. 

Trivia: How does sucking ice help?

If you are taking blood-thinning drugs like Warfarin, Aspirin, Plavix, Pradaxa, etc., you will need to continue pressing for longer.

If the bleeding persists, especially down the back of the throat, then the bleeding area is most likely at the back of the nose. In this case, an Ear, Nose & Throat Specialist or hospital care should be sought immediately, as the bleeding is less likely to be controlled by your own applied pressure in the front, and may recur later. Bleeding from the back of the nose also tends to be more profuse as the bleeding points are nearer the feeding arteries with a higher pressure.

After the bleeding has been arrested, an endoscopic nasal inspection would be advised especially if this has been a recurrent event.

The information aims to provide educational purpose only. Anyone who is reading it should consult ENT Specialists before considering treatment and should not rely on the information above.