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Nasal Dysfunction Clinic Terence M. Davidson, M.D. Appointments
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CONTENTS
The acquisition and processing of oxygen and its byproducts is the primary mission of any air-breathing vertebrate. Chewing, walking, reproducing, thinking are all fine, but first one has to breathe. - J.T. Laitman (1996) Proc. Natl. Acad. Sci. 93:10543-10545
The Nasal Dysfunction Clinic is a place where individuals suffering from a variety of nasal diseases can come to have their problems evaluated and treated. The clinic is intended for individuals with nasal disease that has not been successfully or satisfactorily evaluated and treated by the individual´s own physician. Generally speaking, if you have a problem with your nose you should bring it to the attention of your family doctor. If your family doctor is unable to solve the problem, it should be evaluated by a head and neck surgery (ENT) specialist. Only then, if the problem has continued, should you come to the Nasal Dysfunction Clinic. At the Nasal Dysfunction Clinic you will be completely evaluated and then informed about your nasal problem and about what treatments, if any, should be considered. The results of this evaluation can be sent to your own doctor to initiate treatment, or you may choose to have your treatment provided at the Nasal Dysfunction Clinic. This booklet is divided into sections to help you better understand the Nasal Dysfunction Clinic, the normal anatomy and physiology of your nose, a little about some of the more common nasal dysfunction conditions, the tests used to measure nasal function, and the treatments available. The most important chemical sense is olfaction. It is currently estimated that 1–2 percent of the American population suffer from the loss of the sense of smell. For these 2 1/2 to 5 million individuals the world has lost some of its excitement. The most obvious and primary complaint is that food no longer has a taste, for indeed 95 percent of the sensory input received from food (and that which allows us to distinguish a good steak from a bad steak, a good cheese from a bad cheese) is the sense of smell. But smell means a great deal more than just the ability to taste and enjoy food. First and foremost it´s a warning sign. Smoke is an early warning of fire. Most gasolines are odorized and a gas leak is detected by its noxious mercaptan smell. Spoiled food smells horrible but those without a sense of smell will never know that their food was spoiled. Smell is a major pleasure sense and when one smells the fragrance of cut grass, of flowers, of the forest, of autumn, of spring, one derives not only information but pleasure. We all know the smell of our loved ones, the smell of their skin, the smell of their perfumes and even the smell of their body odors. The sense of smell plays an important role in sexual excitement and while we as Americans have done a great deal to camouflage body odor and sexual smells they are still perceived and remain important. The sense of smell is necessary for body hygiene. How would one know when to take a shower without the sense of smell. The nose is the entrance to the respiratory tract. We use it to breathe. When one or both sides are obstructed, one can not breathe and most people perceive this as an uncomfortable inconvenience. Inflammation such as allergy will cause the mucosa to swell, and your nose to feel congested. In this case neither side will breathe well. If your anatomy is crooked, such as found with a deviated nasal septum, one side will be obstructed relative to the other. This impairs your nasal functioning. Your body likes to have both sides symmetric, and when the airway is out of balance, one side to the other, you perceive an asymmetry, and for many this is an unpleasant condition. With the increasing concentrations of pollutants in the air we breathe, and with the chemicals that we are exposed to in homes and at work, nasal irritation is becoming an increasingly common and important problem. We are just beginning to learn the importance of nasal irritation, and are at the very beginnings of our ability to observe and measure the nose´s response to chemical irritants. Sitting to either side of the nose are the sinuses, more properly termed the paranasal sinuses. Their normal function requires open communication with the nose. When this communication is impaired, secretions accumulate and infection ensues, a condition we all know as sinusitis. This can be acute, or it can be chronic. It can be an inconvenience or it can be disabling. We now have the tools to diagnose and treat sinusitis. Sinusitis is one of the most common causes for patients to seek medical care. Nasal disease collectively has single-handedly supported the pharmaceutical industry. We all wish we had a penny for every time someone in the United States used a kleenex, or someone purchased yet another over-the-counter nasal medication. It is these kinds of illnesses, and many, many more that we at the UCSD Nasal Dysfunction Clinic spend our lives understanding, diagnosing and treating.
Dr. Davidson is a member of the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Otolaryngology-Head and Neck Surgery and is a Fellow of the American College of Surgeons. Dr. Davidson has written 145 books and scientific articles. He has produced over 100 hours of videotapes in head and neck and facial plastic and reconstructive surgery. Dr. Davidson is an active member of the American Academy of Facial Plastic and Reconstructive Surgery, and has played a major role in producing a series of videotapes called "The San Diego Classics in Soft Tissue and Reconstructive Surgery." These videotapes are distributed by the American Academy of Facial Plastic and Reconstructive Surgery throughout the world. They are a major contribution to all residency programs in soft tissue and facial plastic surgery. Dr. Davidson´s interest in television and education has resulted in his appointment as associate dean for Continuing Medical Education at the UCSD Medical School, a position he has held since 1982. Nasal dysfunction is a primary interest for Dr. Davidson. He has been actively involved with the nose and its problems since the beginning of his training in 1972. He has been involved with the clinic since its inception, and is the physician responsible for medical evaluation, diagnosis, and treatment. Dr. Davidson's interests outside of medicine lie primarily in outdoor activities and when not on-call, he is most likely to be found hiking through the mountains, four-wheeling through the desert, gardening or fishing.
Since February of 1983, Dr. Murphy has been involved in clinical assessment of smell and taste function at University Hospital. She has been an active and vital member of the team originally brought together to establish the Nasal Dysfunction Clinic at the UCSD Medical Center.
Anatomy The nose can be thought of as a tunnel with an opening on the face and an opening at the top of the throat. The tunnel is called the nasal cavity. The nasal cavity is divided into a right and a left side by a bony and cartilaginous divider called the nasal septum. Towards the front of the nose the septum is constructed primarily of cartilage but in its back is primarily bone. The top of the nasal cavity is divided from the anterior cranial cavity by a bone called the cribiform plate. The lateral walls abut on either side with the maxillary bones also known as the cheek bones. The floor of the nasal cavity is separated from the top of the mouth by the palatal bones.
Please accept our apologies for the complexity, but this is the simplest we could make it.
The nose has several physiologic functions. One of these is to serve as a conduit for inspired and expired air. As the air is inspired through the nose it is humidified and warmed by passing over the moist and warm nasal mucosa. This function is greatly enhanced by the turbinates for they increase the surface area available for humidification and warming. The nose is an energy-conscious organ in that expired air is cooled and some of the moisture is recaptured. The functions of warming and humidification require a tremendous blood flow to the nasal mucosa and also place substantial stress on the nasal mucosa. The nose has what is known as a nasal cycle. To allow the mucosa time to rest from these functions, the nose has periods in which one side of the nose becomes swollen, which we call congestion. During the same period the other side of the nose remains patent or decongested. The normal nasal cycle lasts from three to six hours, and during this time first one side of the nose will be congested and the other side will be patent; then the second side becomes congested as the first side becomes patent. In some individuals it is exaggerated and may even cause complete nasal obstruction on one side or the other. It is also normal for the nose to be congested when an individual lies down. Particularly if you lie on your side you may notice that the downside of your nose becomes congested. This will be relieved rapidly if one rolls over to the other side or sits up. This, too, is normal. Another function of the nose is olfaction. Olfaction is the medical word for smell. Smell is one of the six human senses and for some individuals is a very important sense; for others it seems to be less important. The olfactory centers, as described under the anatomy section, reside very high along the roof of the nose. In order for these centers to be stimulated, the odors have to be inspired into the nose and carried up to the roof of the nose. It is for this reason that one often smells better when breathing or sniffing deeply. If the odor does not reach the roof of the nose due to a variety of conditions, the odor will not be perceived. The nose is capable of distinguishing a large number of different odors. Our understanding of precisely how this occurs is limited, but increasing. Taste is a sense very different from olfaction. It is another of the human senses and is perceived primarily on the tongue. There are four recognized tastes and these are sweet, salty, sour, and bitter. They occupy geographically separate areas on the tongue and are perceived in cells clustered together in taste buds. The flavor of food is a combination of its temperature, its texture (that means how it feels inside the mouth), its appearance, its taste (meaning salty, bitter, sour, or sweet) and its aroma as perceived by the sense of smell. The sense of smell plays a major role in the flavor of foods and it is common for individuals who lose their sense of smell to report that food loses its taste. This is of course incorrect; the food has only lost its aroma, and taste (sweet, salty, sour, bitter) remains intact..
To fully understand the smell disorders you ought to know the vocabulary.
 Any
impairment of breathing (which is called nasal obstruction) will
prevent air from circulating over the olfactory epithelium. In these cases
the odors are not available to the olfactory epithelium and hence are not
detected. The most common cause of anosmia secondary to nasal obstruction
is nasal polyps associated with allergic rhinitis. Both allergy and infection
in the nasal cavity can impair one´s ability to smell. Whether this
occurs because of swelling along the roof of the nose and therefore impairment
of air flow across the epithelium or whether this is some sort of local
chemical effect is unknown. Inflammatory anosmia is caused by infection
and/or allergy. A variety of psychiatric conditions can also adversely
affect one´s smell perceptions. The most common conditions are depression,
hysteric conversion reactions, and schizophrenia.
Nasal obstruction can occur either for structural or inflammatory reasons. Structural causes include such entities as a deviated nasal septum or a crooked nose. In these situations there is an anatomical change that physically impedes air flow through the nose. Tumors may also affect the flow of air and these tumors may be benign, such as nasal polyps, or may be malignant, such as an epidermoid carcinoma. Inflammatory conditions such as allergy and infection cause the nasal
mucosa, that is the lining to the nasal cavity, to swell. When the mucosa
swells, the area available through which air can pass is diminished, and
therefore one experiences a sense of nasal obstruction. Allergy is the
most common inflammatory cause of nasal obstruction, but infection, either
by viruses such as the common cold or bacteria as often found in sinusitis,
may cause nasal obstruction.
Rhinitis means an inflammation of the nose but is used by most of us to connote a runny nose. The discharge from the nose can come through the front of the nose or it can drain through the back of the nose, a condition which we call post-nasal drip. The discharge may be clear or it may be colored, most commonly yellow or green. Allergy frequently produces a runny nose. In these cases the discharge will be clear or occasionally white. Infection also causes nasal discharge, and this will be a purulent discharge most commonly colored yellow or green. Irritation to the nose can also cause discharge. This discharge is most commonly clear or white and it is experienced by many people when exposed to nasal irritants. Many individuals exposed to cold air or to smoke will have nasal discharge and this is an irritative rhinitis. A posterior nasal obstruction either from a tumor, a foreign body or a badly deviated septum will inhibit the normal flow of secretions from the front of the nose to the back. These secretions are normally carried out the back of the nose and swallowed down the back of the throat. If there is a physical obstruction to the flow of secretions through the nose such as one might expect with a tumor, then the secretions must drain anteriorly and flow out the front of the nose. A very common cause of a runny nose is a condition called vasomotor rhinitis. In this condition, the nose responds to stress with a tremendous production of nasal secretions. Stress can cause many different physical complaints. Migraine headaches are caused by stress as are many cases of hypertension, peptic ulcer disease, diarrhea, constipation, and the list goes on and on. The nose can also be affected by stress. This often presents as sinus headaches and/or as a runny nose and the condition is called vasomotor rhinitis. Chronic Sinusitis Chronic sinusitis is a condition in which the sinuses become inflamed, which means the mucosa has swollen and the mucociliary transport system is impaired. As a result, bacteria within the sinus grow continuously. People suffer from facial pains, pressure, nasal congestion, nasal discharge, post nasal drip, cough, fatigue, and just generally not feeling well. Normally, sinusitis is treated with antibiotics. Some add a course of nasal steroids. I am opposed to a course of systemic steroids. If the treatment corrects the problem, wonderful, but all too often it does not. The reason that it does not is that the small drainage ports (the sinus ostia) are too small to keep the sinus aerated and the sinus fluids properly drained. Once you realize that medical treatment is not going to improve or relieve the chronic sinusitis, it is our practice to perform a complete nasal workup looking for anatomic deviations, allergies, irritations, tumors, foreign bodies left in the nose, or anything else which might predispose to the sinus disease. Any illness identified is then treated. If illness is not identified or if medical treatment does not correct the chronic sinus condition, surgery is indicated. The surgery performed today is called endoscopic sinus surgery (ESS). It can be performed under local but most prefer general anesthesia. The surgery is performed using little endoscopes and working through your nostrils. No external incisions are made. The surgery normally takes about an hour to perform. The surgery involves removing the inflamed ethmoid sinuses and then opening the natural sinus ostia to the maxillary and frontal sinuses. The surgery is normally performed as an outpatient, meaning you go home the same day of the surgery. You normally have an uncomfortable stuffy nose for one or, at the most, two days. We recommend that patients take a week off work, not so much that they really need the week, but if you rest, relax, and take care of yourself, you will heal better. This surgery has been extremely effective and relieves or cures the chronic sinusitis in as many as 90 percent of patients. True taste disorders are uncommon. A taste disorder may present as a loss of taste, that is the loss of the ability to detect salt, sweet, sour, and bitter or it may present as an abnormal taste in the mouth such as a bitter taste, an unpleasant taste, or even an electrical sensation. Loss of taste is most commonly caused by an interruption of the nerve to the tongue. This can happen as a result of surgery, tumors, or even dental injections. Abnormal tastes may be caused by injury to the taste buds, injury to the nerves responsible for taste, or to a variety of other conditions which occur within the mouth. Occasionally dental work will set up a small electric charge in the mouth just as an electric charge is created in a dry cell battery. This may be perceived as an abnormal taste or as a stinging, electrical kind of feeling. These conditions vary so much that it is difficult to classify them in a meaningful fashion..
The Nasal Dysfunction Clinic is unique in that it has available a variety of sophisticated tests to evaluate nasal dysfunction. The standard smell test is conducted in two different ways. The first is a threshold test which measures an individual´s ability to detect various concentrations of a single odor. This is similar to a hearing test or to an eye test in that it measures that organ´s ability to perform correctly. The second part of the smell test is an odor identification test. The patient will be presented ten different odors and asked to identify them. Based on one´s performance on the threshold tests and the odor identification tests, a score is calculated. A separate score is calculated for the right and left sides of the nose. A perfect score would be 100. A score from 0–10 is considered anosmia; from 10–40 severely hyposmic; 40–60 moderately hyposmic; 60–90 mildly hyposmic; 90–100 is considered normal. A simple smell test called the alcohol sniff test (AST) is often used for olfactory screening and can be used at home. Another smell test is the University of Pennsylvania Smell Identification Test. This is referred to as the UPSIT. The sense of taste can also be tested. First, the patient is asked to identify a series of four different concentrations of salty, sweet, sour, and bitter tastes which we call stimuli. Next, the patient is asked to estimate the strength of the taste stimuli by assigning numbers. In order to compare the estimates given by one individual to those of others, a second sense (hearing) is used. Five levels of loudness of a single tone are interspersed with the taste stimuli, and intensity estimates are also assigned to the sounds. The patient then compares the intensity of the taste to the intensity of the sound. If a patient rates the tastes as much weaker than the sounds where other people would rate them as equally strong, then the test demonstrates a diminished sense of taste in that patient. The next test is rhinomanometry. Rhinomanometry
measures an individual´s ability to breathe through the nose. This
is done by placing a sealed system in the right and left nostril independently
and asking the individual to breathe in and then to breathe out. The volume
and rate of airflow and the pressure required to generate this airflow
is measured. The result is calculated as a resistance to air flow. Resistance
then is a measure of the degree of nasal obstruction; the higher the resistance,
the greater the obstruction. Generally speaking, results of five or less
are considered normal and above five are abnormal. The rhinomanometry is
performed first with the nose in its normal state and then after the mucosa
is decongested with a medicine called Neosynephrine. After the Neosynephrine
has taken effect, the rhinomanometry is repeated. The resistance in the
decongested state should be an indicator of the degree of structural or
anatomical obstruction.
Nasal cytology is an extremely effective tool for differentiating several conditions within the nose. A sample of nasal mucus is placed on a glass slide, stained, and examined under the microscope. In allergic rhinitis, one generally sees eosinophils and basophils; in infectious disorders, one sees bacteria and polymorphonuclear white cells, and in cancer one will often see the malignant cells. Ciliary motility. The nose cleans itself by transporting trapped particles and mucous to the back of your nose. The tissue in your nose responsible for moving the mucous blanket are the cilia. Ciliary motility is measured by placing a small tablet of saccharin on a mucous membrane in the front of your nose. This is normally transported to the back of your nose in a period of fifteen to twenty minutes. You know it reaches the back of your nose when it drains down the back of your throat, at which time you detect the saccharin as a sweet taste. The time it takes for the saccharin to first be tasted is a measure of ciliary motility. Cilia ultrastructure and function examines
the architecture and performance of nasal respiratory cilia. Cilia are
the small (microscopic) hairs lining the superficial nasal mucosa, and
are necessary for cleaning the nasal cavity. This test is not done routinely;
however, under certain specified conditions it may be required.
Nasal endoscopy. The nose can be examined with a light and a nasal speculum but this only gives the physician a view of the front part of the nose. If one wishes to study the nose carefully, one needs to examine more deeply and this is done by inserting a steel-coated glass rod through the front of the nose and looking directly at the normal nasal structures. Nasal endoscopy is the only means of examining the olfactory epithelium and can be extremely useful in differentiating congenital and traumatic anosmia from viral anosmia and from other conditions. It is often useful for identifying nasal tumors, particularly polyps arising high within the nasal cavity. The x-ray examination is important for looking at the paranasal sinuses, for looking for intranasal tumors, and for looking for brain tumors. The traditional x-ray has been a sinus series; however, this is a very gross test and often inaccurate. A much more sensitive examination is achieved with a computerized tomographic scan, most commonly abbreviated CT or CAT scan. Finances permitting, this will be requested for most individuals and is generally a very useful diagnostic test. A normal CT scan is shown on the following page. Two normal and three abnormal scans are shown at left. Skin Tests. Skin tests are performed by placing small amounts of materials commonly inhaled or eaten on the skin, and then pricking the skin gently with a small needle. After fifteen to twenty minutes a red, raised, itchy spot is present at the site of material which may be causing allergic symptoms. This test must be compared to the seasonal and environmental pattern of nasal dysfunction before conclusions regarding allergy can be made. If the test is positive, avoidance of the material causing the allergy, if possible, is helpful. In addition, desensitization (allergy shots) may also be recommended. Allergy can now be measured with a blood test. The IgE is the immunoglobulin involved with allergy. Measuring the IgE level in the blood is a good indicator of allergic propensity. Immunoglobulin deficiencies, specifically secretory IgA deficiency, can be a part of recurrent or persistent infection. Serum antibody levels are measured from your blood and hence may be requested at the same time as the IgE is being requested. Biopsy. On occasion, a biopsy of the olfactory epithelium will help in the diagnosis of smell deficiency. If it is felt needed, this will be discussed and recommended. Other tests may be ordered and these would include blood tests or consultations with other physicians. These are not routinely requested and are only required when special circumstances dictate..
Treatment of Nasal Dysfunction Medicines Used in the Treatment of Nasal Dysfunction A number of medicines have been found useful for treating nasal dysfunction, and depending upon your specific dysfunction, a selection of medicines will be prescribed. It is important that you take the medicines exactly as prescribed; many of the medicines achieve their effect over a long term and if you use them in a sporadic fashion they will not be effective. The simple drugs used to decongest the nose are called decongestants
and the one most commonly prescribed is Sudafed. This medicine is taken
as a pill. Normally 30 mg are taken every two to four hours. The medicine
should cause some decrease in nasal congestion and discharge. Sudafed causes
little if any drowsiness or other systemic symptoms. It may be taken on
a prn basis; that means you may take it as needed, and do not need to take
it on a regular basis. To the best of our knowledge this medicine has no
long-term deleterious effects, and may be taken for years.
Antihistamine-Decongestants For many situations a simple decongestant is not effective, and the combination of an antihistamine and a decongestant is more potent. There are many antihistamine-decongestant combinations available on the market today. Some of them require a prescription but most are available over the counter. There is variation in an individual´s response to these drugs. It is common for one medicine to work well for one individual and not for another. Each of us has our favorites, and if you identify a preparation which works most effectively for you, bring this to your doctor´s attention as a preferred medicine. Some of the antihistamine-decongestants have a short term effect. Actifed is prescribed three to four times a day. The majority of the antihistamine-decongestants have a long-term, slow-release effect and are prescribed at a maximum of once or twice a day. The antihistamines tend to cause drowsiness, and this side effect is often disconcerting. If one takes the antihistamines on a regular basis, one normally adapts to the drowsy effect and will no longer be bothered by it. The antihistamines do have a long-term effect and are better taken on a regular schedule. Many individuals find that they do well by taking one in the morning and one in the evening. Others find that the drowsy effect interferes with their normal daily function and prefer only taking a pill at bedtime. This is particularly helpful in decongesting the nose during sleep. Another side effect of the antihistamine-decongestants is drying of the nasal mucosa and the throat. While this is a desirable effect in the drippy, runny nose, it is for others an unpleasant side effect. New preparations allegedly have antihistamine effects without the annoying drying effects. Some patients find antihistamine-decongestants to be effective medicines. While many prescribe antihistamines and many use them, I personally rarely prescribe antihistamines. Nasal steroids are more effective. Antihistamines thicken secretions and impair ciliary motility and may be counterproductive in the management of nasal disease.
A new generation antihistamine is now available. These are called Histamine type 1 blockers. They are effective antihistamines with little or no drying effect and little or no effect on sensorium. Terfenadine (Seldane) is taken as needed, twice a day and for some is an effective treatment for mild, episodic allergy. Aztemizole (Hismanal), another H1 blocker, is taken once a day. The problem with Terfenadine and Astemizole is that, when taken with certain antibiotics (such as Erythromycin or Ketoconazole), the drug is not metabolized in the liver and therefore you develop abnormally high serum concentrations. These abnormally high drug levels may affect your heart rhythm. If you use Terfenadine or Astemizole, always check with your doctor before taking an antibiotic. A new H1 blocker called Loratadine (Claritin) is equally as effective as Terfenadine and Astemizole, and allegedly has less potential for cardiac arrhythmia (even when combined with Erythromycins Ketoconazoles). At the time of the writing of this booklet, this is our H1 blocker of choice, not because it is more or less effective than the other H1 blockers, but because we believe there is less risk of adverse reactions. Antibiotics are prescribed when it is felt there is infection in the paranasal sinuses, and only occasionally for infection in the nasal cavity. Acute sinusitis is most commonly treated with Amoxicillin. Chronic infections are best treated with erythromycin or tetracycline. Chronic sinus infections are difficult to treat and are resistant to antibiotic therapy. It is important that the antibiotics be taken for an extended period of time, and this varies from three to twelve weeks. The drugs are best taken one-half hour before eating or two hours after eating. In some individuals this causes gastric discomfort, and for these individuals it is best to take the medicine with some food in the stomach, ideally thirty to sixty minutes after eating, or with a cracker or a snack at bedtime. Antibiotics must be taken on a regular basis. If they are not taken as prescribed they potentially can do more harm than good. There are a number of potential side effects to antibiotics, and if problems occur you should call your pharmacist or physician. Antibiotic resistance is a terrible problem in the United States. All
of the bacteria which cause sinus and ear infections have now been exposed
to our antibiotics for so long that many have developed resistance. Hence,
the pharmaceutical industry has had to develop newer and stronger antibiotics.
While one is tempted to prescribe these for one´s own infections,
you have to realize that every time you take a new antibiotic you now expose
the bacteria to the new antibiotic and slowly but surely induce resistance
to the new antibiotic. Newer antibiotics are 5–15 times more expensive,
and so the cost of medical care slowly rises. My own philosophy is to begin
with the simple time-proven antibiotics. If resistance develops there is
plenty of time to add more potent antibiotics. It is wrong to begin each
new infection with the world´s most potent, most expensive, and probably
most dangerous antibiotic.
Prednisone is a steroid and can be extremely effective in treating smell disorders, specifically those caused by inflammatory disease. While it is not safe to take steroids for a prolonged period as they may reduce the body´s resistance to infection and cancer, it is relatively safe to take prednisone for a week or two. We prescribe it as a diagnostic test. If the smell disorder improves on prednisone, then we know the problem lies in the nose and is theoretically treatable. If there is no change while taking high dose prednisone, it is more likely that the smell disorder is not a nasal inflammatory disease and may not be treatable. New medicines available for the treatment of allergic rhinitis are the nasal steroids. As with the antihistamine-decongestant preparations, there are personal preferences for one or the other. The nasal steroids are one of the medicines that definitely have a long term cumulative effect and must be taken on a regular basis. The usual prescription is Rhinocort AQ, one puff in each nostril once daily. Another medicine found useful in allergy treatment, including allergic
rhinitis, is cromolyn sodium, known as Nasalcrom. This medicine works differently
from the antihistamines, decongestants, or steroids. It tends to have a
short-term effect. Its maximum effect is achieved by taking one sniff in
each nostril four times a day. It can be taken on a symptomatic basis which
means using it when the symptoms are at their worst and not using it when
symptoms are not bad. Some individuals find this a useful medicine and
others find it less useful. It does not seem to have any side effects.
A variety of medicines are available for cleaning the nose. Fingers, cotton swabs, and other mechanical instruments should not be used. The simplest and most commonly used is normal saline. This can be purchased as Nasal Saline Ocean Spray or Ayr, or by mixing one glass of water with a level teaspoon of iodine-free salt. This is administered to the nose either with a dropper or as a spray, and should be sniffed in and then blown back out. This helps clean the nose and in many individuals makes the nose feel more comfortable. For some individuals a different nasal douche will be prescribed. This is called Nasal Lubricant. It contains a variety of drugs including oil of eucalyptus and is effective for cleaning the nose and coating the mucosal lining. Particularly in individuals with a dry crusty nose, this medicine may be extremely useful. It is important that the nasal lubricant not be inhaled into the lungs, for this could cause pulmonary damage. There are a variety of other nasal sprays available through the pharmacy and drugstore. These include Neosynephrine and Afrin. These medicines will cause a marked relief in many nasal symptoms but are unfortunately addictive. If taken for more than two or three days, the individual may become dependent upon them. It is our feeling that no one with nasal dysfunction should ever use these medicines because of their addictive potential. Zinc, Copper, and Other Trace Metals Zinc and other trace metals are used occasionally in the treatment of anosmia and ageusia. The evidence for their efficacy is weak. They are prescribed as harmless medicines and are worth a try. They must be taken in the doses prescribed and taken for six weeks. The standard prescription for zinc is for 100 mg of elemental zinc to be taken three times a day for a minimum of six weeks. If by chance you are reading this material prior to your visit at the Nasal Dysfunction Clinic, it is our preference that you not begin taking zinc or other trace metals until you have had your nasal tests and examinations. If allergic nasal disease is diagnosed and if medicines are either ineffective in controlling the symptoms, or if they cannot be tolerated because of the side effects, or if one wishes to decrease the use of medications, allergy desensitization injections may be useful. These injections consist of dilute solutions of the materials causing the allergy. The materials are injected in gradually increasing amounts to cause the build-up of protective (rather than allergy-causing) antibodies. Generally, 75 percent of people benefit from this therapy. It requires one to three years, initially on a weekly basis but eventually only one injection a month is required. This treatment is provided under the direction of a trained allergist..
Surgeries for the Treatment of Nasal Dysfunction Septoplasty, Endoscopic Sinus Surgery, Rhinoplasty, and Septorhinoplasty Septoplasty is an operation that straightens the nasal septum. It can be performed under local anesthesia or under general anesthesia. Commonly, it is performed as an outpatient procedure, that is, you come in the morning and leave later in the afternoon. At the end of surgery, Vaseline gauze packing is placed inside your nose to hold the septum precisely in the midline. There is relatively little discomfort from this surgery and most individuals rarely take more than Tylenol for their discomfort. Nasal packing is rarely used and for most surgeries involving the septum, silastic splints are placed in each nostril, and then sutured together to hold the septum firmly in the midline. Most people are hardly aware that these are in their nose. Most tolerate their presence without discomfort. If they are uncomfortable they can be removed on the fourth or fifth postoperative day, but in most cases we prefer to leave them until the seventh or eighth postoperative day. Following this, there will be some crusting in the nose which can last anywhere from one to three weeks. Generally one will appreciate an improvement in the nasal airway by two to three weeks, but on occasion it takes up to three months to detect this improvement. The septoplasty is not universally successful, and it may fail because you have other nasal problems such as allergy; in many cases the cartilage has a rebound and a memory, and even though the surgery has been correctly performed, the septum returns to its previously deviated state. If your external nose is crooked, you will require a rhinoplasty to straighten this. Rhinoplasty is easily combined with a septoplasty in which case it is called a septorhinoplasty. If you have ever thought about having the appearance of your nose changed, this is the time to do so and you should discuss it with your surgeon during the preoperative planning stages.
A relatively new important development in paranasal sinus surgery is endoscopic sinus surgery. Using small endoscopes to look inside the nose, the surgery is directed at opening the natural drainage channels for the maxillary, ethmoid, and frontal sinuses. Older operations made new drainage channels which did not function physiologically, and frankly did not perform satisfactorily. The new endoscopic sinus surgery is a more natural procedure, substantially less involved, and is performed under direct vision. This is not to say it is without risk, but the endoscope adds an element of safety. This procedure takes practice to perfect, but in our hands, has become the procedure of choice when sinus surgery is required. It does the least harm, removes the least amount of your own tissues, and in our opinion, most effectively reestablishes the natural outflow of sinus secretions and the inflow of air. Endoscopic sinus surgery can be performed under local or general anesthesia.
Most patients prefer general anesthesia. The surgery is performed as an
outpatient, meaning you go home the same afternoon. The discomfort is minimal,
and far less than with the older more conventional operations. The following
is the information/instruction sheet provided for individuals who are having
endoscopic sinus surgery.
Endoscopic Sinus Surgery Information
Endoscopic sinus surgery is an operation in which the surgeon examines the interior of the nose and the orifices to the paranasal sinuses. Abnormal and obstructive tissues are then removed using state of the art microtelescopes and instruments. In most cases the surgery is performed entirely through the nostrils, leaving no external scars, little swelling, and only mild discomfort. Whereas, in the past attention has often been directed towards the removal of all sinus mucosa from the major sinuses, the endoscopic approach relies on the principle that sinus disease is reversible if the underlying cause can be identified and corrected. A careful diagnostic workup is, therefore, very important and consists of endoscopic examination in the office, CT scans of the sinuses, nasal physiology (rhinomanometry and nasal cytology), and selected blood tests. Surgery is usually recommended only after optimal medical therapy with antibiotics, decongestants/antihistamines, nasal steroids, and allergic management have failed. Potential surgical complications include bleeding, bruising around the eyes, swelling, scarring, and infection. Rare complications include the possibility for intracranial entry and spinal fluid leak. The ethmoid sinus is located under and adjacent to the brain, and the fluid that surrounds it can leak through into the nose. There is then the potential for infection which could result in meningitis. Because the endoscopes used in surgery allow improved visualization of the ethmoid sinuses, this complication is uncommon. Double vision and loss of vision have occasionally been reported after ethmoid surgery. Fortunately, this is a rare complication. No surgery is always successful, and while this is in our opinion the best sinus procedure available today, its success is not 100 percent. The advantage of endoscopic sinus surgery is the philosophical recognition that the surgical goal is to open the natural drainage channels, thereby restoring normal physiologic function. This differs greatly from past procedures which were ablative and destructive. Other advantages over past sinus surgeries are: diminished postoperative discomfort, minimal nasal packing, decreased bleeding, shortened recovery time, and most important, an improved success rate. Instructions Before Endoscopic Sinus Surgery Because of potential bleeding problems, aspirin, Advil and other non-steroidal anti-inflammatory agents are not to be used for ten days preceding and ten days following surgery. A complete history and physical examination including laboratory work and possible chest x-ray and EKG must be completed before surgery. This workup may be done in our offices or by your personal physician. Generally, endoscopic sinus surgery is performed on an outpatient basis. You will need to arrange to have someone drive you home after surgery. Arrangements can be made should you wish to spend the night in the hospital following surgery. Please check with your insurance company regarding hospitalization policies and whether you need a second opinion prior to surgery. Do not eat or drink anything after midnight before surgery.
1. Dressing: Light red to clear drainage from the nose is normal for three to six days following surgery. The outside gauze dressing needs to be changed when soiled or saturated. A 2x2 gauze pad folded in half over the nostrils, held in place with a strip of paper tape is sufficient. 2. Packing: Nasal packing is usually used after surgery. Do not attempt to blow the nose with packing in place. It is normal to have bad breath or smell a foul odor while the packing is in place. 3. Medication: Headache, sinus, or nasal discomfort is common after surgery and you should have pain medication for this. Antibiotics and/or a moisturizing saline spray may be prescribed. 4. Activity: No swimming or strenuous activities should be attempted for at least ten to fourteen days after surgery as this might produce bleeding or dislodge any packing that may be present. 5. Diet: Eat and drink normally. Avoid alcoholic beverages. 6. Follow up: You will need to be seen in the Head and Neck Surgery office for follow-up one to seven days following surgery depending on the presence or type of packing used, or need for post-operative cleaning. Specific instructions will be given to you at the time of discharge. An appointment is necessary and should be made before leaving the hospital. 7. Saline Irrigations: When directed, saline irrigations are recommended to reduce crusting and to keep sinus openings clear. Mix one to two teaspoons salt in one quart warm water. Put this solution into a nasal irrigator bowl. Lean over a sink and irrigate both nasal passages. Irrigate twice a day, morning and evening. See the following section for more complete details. When To Call The Doctor Call the UCSD Medical Center Head and Neck Surgery Clinic at 543-6322, or the Perlman Ambulatory Care Center Head and Neck Surgery Clinic at 657-8590 between 9:00 a.m. and 4:30 p.m., Monday through Friday; or after hours, call the page operator (543-6737) asking for the Head and Neck Surgeon on call if any of the following are noted: a) Excessive, bright red bleeding. 
Instructions for Nasal Irrigation There are three commercially available nasal irrigation systems. The first is produced by Hydromed and is called the Grossan Hydro Pulse Nasal/Sinus Irrigation System. Ethicare also makes a nasal irrigation system. Ethicare and Kenwood Laboratories make nasal irrigators which attach to a Teledyne Water Pik. All three irrigation systems are equally effective. As the Grossan and the Ethicare systems are designed exclusively for nasal irrigation, it may be easier to obtain medical insurance reimbursement. Which system you use is a matter of personal preference. Grossan and Kenwood both provide premade additives. I have found that commercially available table salt is effective and less expensive. Some patients, however, have preferred the pre-mixed solutions. The following instructions are the same for any of the three nasal irrigation systems. Assemble the nasal irrigator as instructed in the materials. Turn the water control to the lowest setting. Select and attach the nasal irrigator. The nose is best washed with diluted salt water. No salt or too much salt will cause irritation or a burning sensation. Most people use 1or 2 level teaspoons of common table salt in 500 milliliters (1 pint) of water. Tap water is generally sterile and is excellent for nasal irrigation. The water temperature is controversial. Some like cold water and some like it hot. 98.6o Fahrenheit, (37o centigrade) is the body temperature ideal for nasal irrigation. The coolest water that should be irrigated through the nose is 72o Fahrenheit and the warmest 102o Fahrenheit. If you select the Grossan or the Ethicare Nasal Irrigation systems, they come with a nasal adaptor. If you select the Teledyne irrigation system, you will require an adjustable model (these come in drug stores). You will need to obtain a special nasal adaptor. Adaptors are available from three sources. 1. The first is Hydromed which
provides the Grossan Nasal irrigator, telephone number (800) 560-9007.
Some of these companies produce their own water delivery system. The pusaltile irrigation is the key to success. Non pulsatile systems are not recommended and are considered less effective. Fill your nasal irrigator with the chosen water temperature and salt concentration. Turn the unit on and lean over the sink. Place the irrigator up to your nose. Let the water run into your nose. It will run out the opposite side or out your mouth. Tilt and twist the irrigator side to side and up and down directing the water flow into all portions of the nasal cavity. When the first nostril feels clean, switch to the opposite side. You can irrigate with one quarter of the bowl, one half of the bowl or the entire bowl. Continue to irrigate until your nose feels clean. This can be repeated once, twice or even 3 times during the day. As you get accustomed to the water cleaning your nose, you can increase the water pressure.
Environmental Control for Allergy If your doctor recommends environmental control for you or someone in your family, the following steps need to be taken. House Dust House dust is partially composed of the breakdown products of natural plant and animal fibers. If these fibers or materials that make up a large part of the home furnishings (rugs, curtains, stuffed furniture, bedding, etc.) are replaced with synthetic materials such as nylon, acetate, polyester, etc., which are nonbiodegradable, much of the source of house dust will be eliminated. Bedroom Since a large part of the time is spent in the bedroom, dust control in this area should be more vigorous.
Special Instructions to Anosmics Persons who are anosmic should observe some simple precautions. A smoke detector in the home is important. As a minimum there should be a smoke detector in the kitchen, in every room that might have a fire such as a room with a fireplace, and in every room in which the patient might sleep, i.e. bedroom, den, etc. Smoke detectors can be battery-operated or connected directly into a 110 volt AC current system and can be obtained at most hardware, lighting, or other building stores. An electric stove is preferable to a gas stove, but a gas stove equipped with an automatic pilot light may also ensure safety. Commercial gas detectors are also available. If the house uses propane or natural gas, there should be an appropriate gas detector at each facility where a gas leak might exist and cause a problem. Propane gas, butane gas, and regular gasoline are all heavier than air, and so detectors for these substances should be placed near the floor. Natural gas is lighter than air and rises, as does smoke. Detectors of these substances should be placed at high points such as the ceiling, top of the stairwell, etc. Propane detectors are available through propane dealers, recreational vehicle dealers, and marine stores. Natural gas detectors, propane detectors, and gasoline detectors are all available through the gas company, recreation vehicle store, or marine electronics stores. Care should be taken in preparing food, particularly left-overs, since spoiled food, undetected, can be hazardous. When in doubt, discard left-overs or have a family member with a normal sense of smell confirm that the food is not spoiled..
Numerous Smell and Taste Clinics are available throughout the U.S.
Director, T. Davidson e-mail: tdavidson@ucsd.edu web site: http://www.drdavidson.ucsd.edu Telephone: (619) 543-3893 or (619) 657-8594 University of California, San Diego 9500 Gilman Drive Mail Code 0957 La Jolla, California 92093-0957 web site: http://www.ucsd.edu/chemo Telephone: (619) 622-5830 Fax: (619) 458-9417 Monell Chemical Senses Center 3500 Market Street Philadelphia, PA 19104-3308 Telephone: (215) 898-6666 State University of New York Health Science Center at Syracuse College of Medicine 766 Irving Ave. Syracuse,NY 13210 Telephone: (315)473-5591 University of Connecticut Health Center Farmington, CT 06032 Telephone: (860) 679-2459 National Institute of Health NIH Bldg 10, Room IN-I 14 Bethesda, MD 20892 Telephone: (301) 496-4261 University of Colorado Health Science Center 4200 E 9th Ave. Denver, CO 80262 Telephone: (303)315-5650 Hospital of the University of Pennsylvania 3400 Spruce St. Philadelphia, PA 19104-4283 Telephone: (215) 662-6580 |
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All
the nasal cavity bony surfaces are lined by tissue called mucosa. This
mucosa contains blood vessels, nerves, and small glands (these glands secrete
fluids into the nasal cavity). The mucosa supports small hair-like projections
called cilia. These cilia carry the mucous blanket from the front of your
nose to the back, and from the sinuses out into the nose, and then into
the back of your nose from whence the mucous is swallowed. This is a very
complex and important function. It is called the mucociliary transport
system, and is the key to a healthy nose. Protruding into the nasal cavity
on either side are three small bones called turbinates and as you will
learn under the section on physiology, these act as air conditioners and
filters for normal respiration. At the very top of the nose the nerves
responsible for conducting information about smell enter into the nasal
cavity through a series of very small holes in the cribiform plate. On
the nasal cavity side of the cribiform plate is a very special mucosal
lining called olfactory epithelium. It is here that the sensory cells for
smell detect the various odors, and it is here that these cells form the
nerves that then course through the cribiform plate to the olfactory centers
within the brain. The nose is also supplied by nerves capable of detecting
pain, temperature and pressure. These are called sensory nerves. The main
sensory nerve supplying the nasal cavity is the trigeminal nerve.
Contained
within the facial bones and surrounding the nasal cavity are a system of
air cells called paranasal sinuses. The paranasal sinuses include the maxillary
sinuses, the ethmoid sinuses, the sphenoid sinus, and the frontal sinuses.
The sinuses are all lined by the same mucosa that lines the nasal cavity.
The paranasal sinuses all communicate with the nasal cavity by a series
of small holes called ostia.
Taste
is a sense different from smell. The sense of taste lies primarily in the
mouth and predominantly on the tongue. The information from the taste buds
is predominantly transmitted to the brain in a nerve called the facial
nerve. The facial nerve is distinct from the olfactory nerve. Some of the
taste information is also transmitted in the glossopharyngeal and the vagal
nerves. Sensory input to the mouth and throat is carried in the trigeminal,
glossopharyngeal, and vagal nerves.
