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Handbook of Nasal Disease by
Terence M. Davidson, M.D., F.A.C.S. Appointments: (619) 543-6631 |
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The nose is certainly a
prominent organ for it sits right smack in the middle of your face. Not only
does it contribute to the beauty of your face, not only does it support your
glasses, but it plays an important role in your overall well-being and health.
The most obvious function of the nose is breathing. Air enters your body
through your nose and it is warmed, humidified and filtered. That same heat
and humidity are recaptured each time you exhale. When your nose is ill
it is often blocked and you are forced to breathe through your mouth. Most
consider this to be a very disconcerting annoying inconvenience. Diseases can
enter your body through your nose. A common cold is the best known example
and when this happens your nose and sinuses become blocked and filled with
secretion and even the toughest of us are reduced to constantly blowing,
sniffing/snorting and not feeling well. The nose also houses
the receptors responsible for your sense of smell. Without smell, food would
lose all of its flavor. The environment, your loved ones and perfumes turn
flat. While we all take our ability to smell for granted, the two to four
million Americans who have lost their sense of smell will tell you this is a
major disruption to their well-being. Many consider it a handicap and a
disability. The nose is an
important part of one's appearance. We all have expectations of what our
noses should look like and if your nose looks different because it is bigger,
smaller or crooked, this changes your self image. Nasal and sinus complaints
are one of the most common causes for people to consult physicians. Many of
these problems can be easily diagnosed by yourself. Many are best treated
with some of the simple remedies suggested in this handbook. These same
treatments also complement traditional medical therapy.
I like to think of the
nose as a bony tunnel in the middle of one's face. Air passes in and out of
this tunnel. The back of the tunnel connects with the top of one's throat.
The tunnel is divided in half by a piece of bone and cartilage. This is your
nasal septum. In a few people it is straight, but in most of us it is
crooked; so it is only a matter of degree as to how crooked or deviated. The
septum divides the nose into two halves. Protruding down into
each nasal passage are three small mucosal covered bones. These are called
turbinates. They increase the filtering, warming surface of each nasal
cavity. Residing to the side of the nose, underneath your eyes and up into
your forehead are large air pockets in the facial bones. These connect with
the nasal cavity. They are called sinuses or more correctly paranasal
sinuses. They are named the maxillary, ethmoid, frontal and sphenoid sinuses.
The nose and the paranasal sinuses are lined with tissue which is called
mucosa. The mucosa has little hairs called cilia and floating over these
hairs is a layer of fluid. On top of the fluid layer floats a layer of mucus.
The cilia beat back and forth in the fluid layer and they move or propel the
mucus blanket along, out of your sinuses into your nose. The mucus blanket is
then transported to the back of your throat. Under normal circumstances the
mucus is swallowed. In a normal functioning nose a quart or more of fluid is
generated daily, carried to the back of the nose and swallowed. This whole
system is called the mucociliary transport system and it is the key to nasal
health. Particulate materials such as dust, or bacteria become trapped in the
mucus blanket and the cilia carry these to the back of your nose where they
are swallowed and killed or digested when they reach your stomach. If the
mucociliary system becomes impaired, then nasal and sinus secretions
stagnate. They become infected by the bacteria which are always present
within your nose and infection develops, be it in your nose or your sinuses. The smell receptors, or
olfactory receptors as they are properly called, reside in the very uppermost
portions of your nose. The nose must be reasonably open for odors to be
carried to the roof. Here the odors are perceived and if the system is intact
and functioning, you are able to smell roses, food and all the other smells
of life.
There are two
commercially available nasal irrigation systems. The first is produced by Hydromed and is called the Grossan Hydro Pulse Nasal/Sinus
Irrigation System. The second is the SinuPulse. Ethicare makes nasal irrigators which attach
to a Teledyne Water Pik. All pulsatile irrigation systems are equally
effective, albeit there are personal preferences. As the Grossan, SinuPulse
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. Several companies make premade additives.
I have found that commercially available table salt is effective and less
expensive. Some patients, however, prefer the pre-mixed solutions. I prefer
tap water to sterile water and I do not recommend adding baking soda unless
you experience burning with the tap water. The tap water contains chemicals
to clean the drinking water and it is acidic. This kills nasal bacteria. If you cannot afford or
do not like the pulsatile irrigators, there are numerous laminar flow
irrigators. The Neti pot is one, but your drug store probably carries
several. The following
instructions are the same for any of the 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. Ten
percent of patients say the standard salt solution causes burning. For
these individuals, one quarter to one half teaspoon of baking soda changes
the acidity (pH) and will ameliorate the burning problems. A slightly acidic
solution is preferred so baking soda should only be used if necessary for
comfort. If you select the
Grossan or the Ethicare Nasal Irrigation systems, they come with a nasal
adaptor. If you select the Teledyne Water Pik 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 two
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.
In some cases, patients
will be advised to irrigate with an antibiotic called Tobramycin. The
Tobramycin bottles will require prescriptions, typically as Tobramycin 80
mg./2cc., dispense 10 vials. Appropriate syringes will be given to you by the
nursing staff. Using a syringe, draw up to 1/2 cc. (20 mg.) of Tobramycin.
This is added to the last 20 or 50 cc. (2 oz.) of fluid in the bowl. Irrigate
the first half of this through your right nostril, and the second half
through your left nostril. Stronger concentrations may cause nasal
irritation. Weaker concentrations may not deliver as much antibiotic as would
be ideal. Tap water is generally
sterile, and so infection has not been a problem. By the same token,
the Tobramycin in the syringes will keep the syringes sterile, so they can be
reused for up to ten treatments. Grossan provides an insurance form. If we don_t give it to you
in the clinic, download the document, fill it out and submit it to your
insurance company.If Tobramycin is not covered by your insurance company or
is not available to you, Gentomycin can be used as an antibiotic. The same
final concentration, namely 20mg in 20-50cc of nasal irrigant is recommended.
Mupirocin can be used
to treat nasal infections either as an ointment or by irrigation. To use as
an ointment, place a little in each nostril 3 or 4 times daily and spread it
around the front of your nose with your little finger, not a Q-tip, your
finger.
The average American
gets at least two common colds each year. Children in day school may get as
many as ten or twelve colds a year. These colds are caused by viruses. They
begin with infection in the back of your nose. This is perceived as a sore
throat. As a sore throat resolves, you become aware of nasal congestion. At
first you have clear secretions and then as they become infected by bacteria,
the secretions turn green or yellow and are blown out the front of your nose
or drip down the back of your nose and throat. Medicine has no
treatment for the common cold and because there are so many different kinds
of viruses, vaccines are not generally available. The cold is transmitted
from person to person, either by direct contact with infected mucus or by
viral practicles breathed out of the sick individual and breathed in by the
soon to be sick individual. Proper hand washing and avoidance of placing
one's fingers in one's eyes, nose and mouth are the best prophylaxis.
Unfortunately, most people with a cold are contagious long before they are
symptomatic. Antibiotics are prescribed for the common cold way too often.
They do nothing to treat the cold. They do reduce the bacterial
supra-infection and they may make you a bit more comfortable particularly at
the tail end of the cold. There are risks to
antibiotics. First and foremost, you may develop a reaction to the
antibiotic, and in some cases these reactions are so severe they will kill
you. You may also develop a less severe allergic reaction and as a result
will not be able to take this or similar antibiotics in the future. When you
and everyone else take antibiotics, the bacteria are continuously exposed to
these antibiotics. Slowly but surely the bacteria develop resistance to the
antibiotics. Soon the antibiotics will no longer be effective for you or
anyone. If you take antibiotics for every cold you may not have an antibiotic
to use when a more serious infection develops. Lastly, antibiotics are
expensive and if we all use them for every cold, we either increase the cost
of medical care or we decrease the availability of medical care for more
serious conditions. There are hundreds of
home remedies; few have been scientifically substantiated. Somewhere there is
a scientific paper that alleges benefit to chicken soup. That only works if
you like chicken soup. There are some suggestions that vitamin C may be
useful. Aspirin and Motrin reduce the symptoms of being sick but may reduce
your own immune system's ability to fight the cold. The best defense system
you have is your own immune system. Your immune system does not work when you
are tired or stressed. In fact, when you have the first signs of a cold you
would be well advised to go home, curl up in bed, drink lots of water and try
to sleep and relax. To whatever degree you are successful, the intensity and
duration of the cold will be reduced. If your nose becomes
horribly stuffed, decongestants such as SudafedR are available. I am opposed
to nose drops such as Afrin and NeosynephrineR, for they are addictive.
Antihistamines are recommended by some. Certainly, if an individual has
allergic rhinitis and that is making the cold even worse, the antihistamines
may be useful. Unfortunately,
antihistamines thicken your secretions and therefore impair the mucociliary
transport system and so they are potentially harmful in treating the common
cold. For those who are not allergic, antihistamines can only thicken
secretions and will probably do little to benefit you. Nasal irrigation is very useful for the
common cold. You can keep the bowl filled and whenever your nose becomes
impossibly congested, irrigate both sides to wash out the thick secretions.
This will provide you relief and improvement for an hour or two. This may
have to be repeated four to ten times a day. You will have to make your own
adjustments for salt concentration, temperature and volume. Please remember
that the common cold is highly contagious and if the irrigator is being
shared for nasal or dental purposes, be careful not to contaminate or use
others' irrigating handles.
Sinusitis is a
bacterial infection of the paranasal sinuses. It occurs when there is so much
swelling in the nose that the drainage hole from the sinus (called an ostium)
is swollen shut. This paralyzes the mucociliary transport system. The sinus
then fills with secretions. These secretions become infected and the
sinusitis develops. You begin with a feeling of nasal stuffiness. Secretion
and postnasal drip may or may not be present. You then develop pressure
within the sinuses. This pressure increases until it becomes painful. You
will generally feel sick and will often have an elevated temperature. While
everyone has some sinus symptoms with most colds, these will be more intense
with bacterial sinusitis. More often than not, they will be present on one or
the other side and not symmetrically, equally present on both sides. Sinusitis is best
treated with antibiotics. Nasal decongestants such as Sudafed can be taken in
the morning. If taken later in the day or the evening they may keep you
awake. While many recommend Afrin(R) and Neosynephrine(R), I prefer not to
recommend these nasal sprays because of their addictive potential. The best
way to keep the nose clean and to wash away the bacteria and thick secretions
is to do nasal irrigation. I
should mention at this point that irrigating is relatively easy, but it tends
to take a little getting used to. While some people pick it up the first time
and become natural irrigators, others find it a little uncomfortable and
awkward for the first couple of days. If you are one of these who use it two
or three times a year for the common cold and for the occasional sinusitis,
it may be difficult or even may be more trouble than it is worth.
Nonetheless, if you find the irrigations useful, they do wash out the
bacteria and thick secretions. Just as with the common cold, the irrigations
can be repeated as often as seems to make you comfortable. I am opposed to
antihistamines for bacterial sinusitis unless there is an underlying allergy.
Steam seems to benefit
many people. Keeping ones room humidified, inhaling steam and remaining
well hydrated all contribute to a rapid improvement. Bacterial infections,
like sinusitis, can be potentially dangerous. These benefit from antibiotic
treatment. You are strongly encouraged to consult your primary care provider
to confirm the diagnosis and obtain the correct prescription.
Chronic sinusitis is a
condition in which the sinuses become inflamed, which means the mucosa is
swollen and the entire 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. If
this corrects the problem, wonderful. All to often this does not
correct the problem, because the small drainage ports (the sinus ostia) are
just too small to keep the sinus aerated and the fluids properly drained.
Once you realize that medical treatment is not going to improve or relieve
the chronic sinusitis, it is my 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 is performed by ear, nose and throat physicians
also called otolaryngology-head and neck surgeons. It can be performed under
local or general anesthesia. The surgery is performed using small endoscopes
(instruments for visual examination) and micro instruments all inserted
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 on you as an outpatient,
meaning that you go home the same day of the surgery. You normally have an
uncomfortable stuffy nose for one, or at the most, two days. I usually
recommend that patients take a week off of 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% of patients. It is interesting that
my familiarity with nasal irrigation began
with endoscopic sinus surgery. When the surgery was first described, it was
the usual practice to see patients back in the office 3 times a week to clean
the crusts from the operated sinuses. This seemed a nuisance both to the
surgeon and the patient. We learned that with nasal irrigation, as prescribed
in this handbook, the patient could flush the crusts and secretions out of
the sinuses. No postoperative endoscopic cleaning was then necessary. For more information,
please review the sinusitis
consultation . In some cases of chronic rhinosinusitis,
Amphotericin, an antifungal agent, is recommended.
Allergies affect 40% of
Americans. The symptoms can be seasonal, in which case the condition is
called seasonal allergic rhinitis or it can be a continual year round problem
in which case it is called perennial allergic rhinitis. The symptoms are
nasal congestion, clear or white nasal discharge, sneezing, itchy nose,
sometimes an itchy palate and very often itchy eyes. The allergens are small
proteins carried in the air. These cause an inflammatory reaction in one's
nose, which results in mucosal swelling, and ultimately increased secretions
and nasal drippings. Allergies can be quite bothersome. The simplest treatment
for allergic rhinitis is to take over-the-counter antihistamines. If these
are effective, they are the best and most appropriate treatment. However, if
the allergies become more serious, one needs to determine to what one is
allergic. Sometimes one can do this by just paying attention to when one gets
the symptoms and what one is then breathing. Sometimes it is best diagnosed
by having skin tests performed in your doctor's office. Once you know to what
you are allergic, the very best treatment is what we call environmental control. This involves protecting you
and your nose from the allergens. If these are seasonal pollens, you may need
to be careful about going out, gardening and mowing the lawn during the
allergic seasons. If they are specific allergens such as cats and dogs, you
either need to live in a pet free environment or you need to keep the pet out
of your bedroom and have the pet washed on a weekly basis to reduce the
allergic load. The most common
perennial allergens are dust and molds. Actually, the dust is not the
allergen, but it is the mites which live in the dust which are the culprits.
As disgusting as it might seem, the real allergens are the broken down
decayed proteins from the dead dust mites and their feces. The average wool
jacket is home for as many as 35,000 mites. The average bed has 100,000 or
more dust mites. There are many recommendations for environmental control.
These need to be tailored for each person, in each household. The general
instructions used at the UCSD Nasal Dysfunction Clinic are listed at the end
of this booklet under environmental control for allergy. There are also a number
of specific equipment pieces to help with environmental
control. These are specific for dust mites, molds or cat danders and so
again, one has to know to what one is allergic. There are superior vacuum
cleaners and allergy-free vacuum cleaner bags. There are masks which will
filter allergens and these are very useful for those whose lives require
exposure. The standard painter's mask is of little benefit. Once one has
instituted environmental control and found that the normal antihistamines are
not effective, the other medical treatments begin with the use of nasal steroids. These
are very weak concentrations of steroids which are sprayed into the nose.
They do not adversely effect the rest of your body and they do very
effectively suppress the allergic inflammatory reaction within the nose. The
next line of treatment are the leukotriene inhibitors. Singular is the best
known. 10 milligrams is taken as a pill before bedtime. Some get remarkable
relief, others do not. If this does not control the allergic rhinitis, the
next step is called desensitization. This is a treatment in which the
individual is tested to determine to what they are allergic. The allergens
are injected into the skin two to three times a week in increasing dosages.
This desensitizes the individual to the allergen. Unfortunately, this
requires injections two to three times a week and this continues for six to
twelve months. Once one becomes desensitized, some level of maintenance
injections is required. The injections are usually given once a week for a
period of two-five years. This is a rather large commitment and should only
be undertaken when simpler forms of treatment have failed. We have found nasal irrigation to be useful for allergic
rhinitis. The allergens are initially deposited in the thick mucus of the
nose. Nasal irrigation washes away the mucus and the allergens. This makes
your nose more comfortable and it reduces the number of allergens reaching
the mucosa and inciting an allergic reaction. For most people, irrigation two
to three irrigations a day is all that is really needed. Some prefer weaker
salt concentrations, some stronger salt concentrations; some prefer cooler
water, some prefer hotter water. These are all things that you have to
determine for yourself. This is the standard
medical approach to allergic rhinitis. Different practitioners, depending
upon their training, may recommend treatments in a slightly different order. The following is how I
treat my own patients. If an individual has a mild allergic problem, if
it arises only occasionally and if it is well-controlled with an
over-the-counter or even prescription antihistamine (and assuming that their
allergy does not predispose them to getting sinusitis everytime they get a
cold) than the over the counter or prescribed antihistamines are the simplest
and easiest treatment. If, however, the allergies are more constant, do not
respond well to antihistamines or predispose to sinusitis, then the first
step I recommend is to identify the allergens and begin environmental
control. Some people know to what they are allergic. If, for example, you
were well and then a pet cat was added to the household and now you has
symptoms of allergic rhinitis, you either need to relocate the cat or take on
a life long treatment for these allergies. You may know that every time a
certain tree blooms, you develop allergic problems. You must then either
eliminate the tree or avoid it during its blooming. But many people do not
know what they are allergic to and for these individuals a skin test is
simple. With a screening battery of 10-15 tests, one can identify 90% of the
major allergens. Once you have identified the allergens that give you
problems, you should begin very aggressive environmental control. Let's assume for a
moment that you are allergic to cats. I will tell you that are also allergic
to dust and mold. First, you take precautions with cats. Either remove the
cat from your household or if the cat remains, keep it out of the bedroom and
shampoo the cat once a week. Have the house professionally cleaned once a
year. In addition, follow the recommendations for general environmental control. To whatever degree you reduce
your exposure to dust, mold and pollens, your nose will be better fit to
withstand the allergic challenge of the cat. With environmental control
instituted, I would add nasal irrigation.
This is harmless, non-invasive, simple and inexpensive. It adds to the
environmental control, reduces the allergic load and makes you feel better by
helping wash out the thick nasal mucus. If this combination is not
sufficiently effective, I will then add a prescription for a nasal steroid. The
usual prescription is Rhinocort AQ, one puff in each nostril, once daily, but
this can vary from physician to physician, person to person and for the
different nasal steroids. This regimen should
control at least 90% of the allergic nasal problems. If, after all this, the
allergic rhinitis persists, it is time to consult a pediatric or an adult
allergist. They will fine-tune the above treatments. They will perform more
extensive skin testing and, where appropriate, institute immunotherapy. I am a surgeon and a
strong proponent of surgery, but for many nasal disorders, surgery does not
play a role in the treatment of allergic diseases. It is common now to
recommend surgery on the turbinates, which can mean fracturing the turbinate,
crushing the turbinate, partially resecting the turbinate, totally resecting
the turbinate, reducing the turbinate with a laser or injuring the turbinate
by freezing or by electro-cautery. Turbinate surgery may improve the airway
for the short run. As you will read in the subsequent section on the aging nose, these surgeries are potentially
harmful. As your nose ages, the mucosa undergoes some shrinkage. When this
occurs on top of the surgically reduced turbinate, you are, in my opinion, at
serious risk to develop atrophic rhinitis. This is a very dry, painful,
infected, crusty nasal disorder. It is probably the most uncomfortable and
disabling of all the nasal diseases is irreversible later in your life. It is
better to manage the allergic rhinitis to the best of your ability and
undergo some suffering rather than to treat the turbinates surgically. Most of what I have
written about turbinates applies to the inferior turbinate. It is not
uncommon while performing sinus surgery to reduce or remove the middle
turbinate. This is often necessary to gain surgical access and to eradicate
the sinus disease. This does not appear to predispose to atrophic problems. I
mention this so that if you are contemplating sinus surgery and your
physician mentions or you read that the middle turbinate was operated on,
this should not concern you. If you have a crooked
septum, this is an anatomic obstruction and it certainly compounds the
allergic rhinitis. As we will discuss later, surgery is appropriate for the
crooked septum.
Bleeding from the nose
is a common problem. If you hit your nose accidently or someone else hits it
not so accidently, it may bleed. Generally, this can be stopped by placing a
gauze in front of your nose to catch the blood and then pinching the nostrils
together. Some like to apply pressure over the upper lip at the base of the
nose. Others like to apply ice to the forehead. Mother Nature controls
bleeding, but it invariably take 3-6 minutes. Whether these ancillary
procedures help or just make you feel better that you are doing something is
a matter of speculation. If the bleeding persists for more than 5 minutes or
if it is truly profuse it is best to go to a medical facility where
specialized equipment and personnel are available. This section focuses
mostly on the recurrent nosebleed; the one that starts bleeding in the middle
of the night or the middle of the day -- the nose that bleeds every day,
every other day, every week or every other week or it always bleeds when you
least expect it. Typically, this bleeding comes from the anterior portion of
the septum and stems from dilated blood vessels. The dilated vessels bleed,
they then crust and every time the crust falls off, the vessel bleeds again,
crusts, bleeds, crusts, bleeds, and on and on. Aspirin, blood thinning
agents and non steroidal anti-inflammatory agents such as AdvilR and MotrinR
decrease your bodies ability to control bleeding, and if you are taking these
medicines you should either decrease them, discontinue them or consult with
your primary care physician. Most anterior
nosebleeds emanate from a crusted, dilated vessell in the anterior portion of
the nose. There are many proposed therapies for this. The one I
have found most effective is to apply vaseline to the nose on a regular
basis. A small portion of vaseline, approximately the same amount as
the amount of toothpaste one places on a toothbrush, is placed on the pinky
finger. This is placed inside the nostril, on both the right and left
side. Next, the pinky finger should be placed inside the nostril and
turned 180 degrees first clockwise, then counterclockwise, so that the
vaseline is spread or smeared along the nasal septum, the roof and the
lateral wall. This should not be done with anything other than the
pinky finger, not a pencil, q-tip, bobby pin or other tool. It is very
important to use the pinky finger as it is gentle and soft. In most
cases, performing this procedure twice daily on a regular basis will prevent
future nosebleeds. During times of recurrent bleeding or during periods
in which one is exposed to very dry air, this can be repeated as often as
three or four times per day. If the above is not
effective, you should appoint with a Head and Neck Surgeon to examine the
nose, diagnose and then treat the underlying problem.
In some conditions, the
nasal mucosa becomes dried. This can happen because of surgical changes, it
can happen because of intrinsic nasal disease or it can happen because of
very dry or difficult environmental air quality. When this happens, the nose
is constantly plagued with unpleasant crusting. In the most extreme cases
infection can built up under the crusts and then one suffers from a constant
foul-smelling odor and discharge. In some cases the nose may be painful. If
bleeding is present in this or any other condition, one most consult with a
physician to exclude a nasal tumor. Assuming no tumor is present, the
condition is easily managed with repeated nasal
irrigation, which washes off the crust. This wets the nasal mucosa and
will wonderfully maintain nasal hygiene. Salt concentration and water
temperature are a matter of personal preference. Normally, a longer
irrigation in which both sides of the nose are very thoroughly irrigated will
be required. The nose does best if all of the crusts are loosened and washed
out daily.
You will occasionally
develop an infection on the skin of the tip of the nose. This presents as a
red, swollen, tender area. It may get better on its own or occasionally will
progress to form a more severe infection and require antibiotics or even
surgery. These infections occur because there are hairs lining the inside of
your nasal tip. If infection develops at the base of one of these hairs (a
condition which is called folliculitis), the Staphylococcus bacteria which
are present in all noses invade the nasal hair shafts and cause a nasal skin
infection. These are potentially dangerous for not only are they
uncomfortable and ugly but, the infection can spread through the nasal veins
into your brain. The infection can then involve a common drainage area called
the cavernous sinus and if this becomes infected, even intravenous
antibiotics may not save your life. My recommendations for
folliculitis diagnosed early are: First, apply an antibiotic ointment such as
mycitracin, or bacitracin to the inside surface of the nose four times daily.
Second, apply a hot pack to the outside of the nose for 5 minutes, 4 times a
day. If the infection appears to progress, consult with your physician and an
appropriate antistaphylococcal antibiotic will be prescribed. For recurrent problems,
a dab of the mycitracin or bacitracin applied once a day or once a week may
provide useful protection.
The nose does not like
cold dry air and it is very common for the nose to protect itself against the
cold by producing copious secretions. This is a normal, albeit troublesome
problem. It is sometimes helped by taking a decongestant. If it is a
continual problem and one is exposed to the cold on a daily basis, nasal steroids may
reduce the nasal response to cold. Prescription nasal sprays with atropine
RutussR or a drug called Ipratropium (AtroventR) may provide some relief. A
scarf or mask covering the nose and therefore helping to preserve nasal
humidity and temperature may also help. Other than these approaches, I can
only suggest a large handkerchief or a generous supply of Kleenex.
You may have heard of
the sick-building syndrome or you yourself may have been exposed to some
chemical that irritates your nose out of proportion to that which one would
expect. Some of the more concentrated cleaning agents are known to do this.
Poorly cared for, closed building air systems cause nasal irritation. Fresh
paint or new or old carpets may cause these same problems. Obnoxious air
pollutants and a variety of organic chemicals have been alleged to cause
irritative rhinitis. At this time, we in medicine, have difficulty
objectively documenting the individual's susceptibility to these chemicals
and so we are obliged to take the patient's word for the degree of
irritation. While there are some individuals who simply do not like where
they work and, therefore, once they get the idea that the air quality is
inadequate, will never be able to work in that environment. There is no
question that some of these people do suffer annoying irritations. The best
treatment would be to correctly diagnose the offending chemical be it at
home, in the air or at work, and then successfully avoid the irritant. This
may not be possible or may not be practical. Nasal steroids will
reduce some of the nasal mucosal reaction to almost anything placed within
the nose, so a course of nasal steroids prescribed by your physician is certainly
worthwhile. Some individuals report some comfort from spraying nasal saline
into the nose. Whether this is done with a little squeeze bottle, with a
little bulb syringe, or with a small washing with nasal
irrigation is a matter of personal choice, but it is always worth trying.
If none of these simple measures are efficacious, you have a difficult
problem. This will require a specialist, and even then it may be difficult or
impossible to attain a cure.
Vasomotor rhinitis is a
nasal disease in which the nerves controlling nasal congestion and secretion
become hyperactive. Whether this is caused by stress, by cold weather, by
trauma, by nasal irritation or by some absolutely unknown factor, the mucosa
of the nose swells and secretes. You, the patient, perceive this as
congestion, a runny nose, and very often concomitant sinus pressure and pain.
As the majority of
vasomotor rhinitis is stress-induced, by far the best advice is to recognize
this and deal with the stress directly. Some find nasal steroids
useful. Very few find relief with antihistamines or with antihistamine
decongestant combinations or with any other treatment. Some have found nasal irrigation useful. If it works, it is
certainly safe, and you are welcome to repeat it as often as you like. If it
does not work, consult with your doctor.
Click here to link to the
Nasal Steroids page.
As your nose ages there
are changes both in the structure and in the mucosa. The mucosa is strongly
supported by your hormones and these change as you age. The changes are often
more dramatic in women than in men, but occur in both sexes. The pregnant
female will have incredible, nasal mucosal swelling and this is recognized by
congestion and secretion. By the same token, as the nose ages and as these
same hormones decrease, the mucosa shrinks and all of a sudden the secretions
become thick and difficult to manage. This is usually perceived as a
tenacious postnasal drip. People will often snort continuously and may
complain of snorting, coughing and even hoarseness. Infection does not play a
role in this illness. For these cases, nasal irrigation is a wonderful cure. Nasal
irrigation can be done once, twice or three times a day. It really does
not matter what salt concentration and what temperature are used. Nasal
irrigation washes away these thick secretions and since they take 4-6 hours
to reaccumulate, the secretions can be repeatedly washed away and the nose
converted from a troubled organ to a normal functioning part of your body. While hormones can be
administered to change the secretions, I would not recommend administering
hormones for the aging nose. If your doctor prescribes hormonal therapy for
other problems such as, osteoporosis or some other medical condition and the
nose benefits, you win. However, the repeated irrigations are so simple and
so harmless that they are often all that will ever be required.
Cystic fibrosis (CF) is
a genetically inherited illness affecting 1 out of 2000 Caucasian children.
It is present in other races but at a significantly lower incidence. While
there are a myriad of problems for people with CF, today's greatest concern
is chronic lung disease. Almost all people with cystic fibrosis also have
nasal and sinus disease, and this occurs because their mucosa is swollen and
their secretions are thick and tenacious. The mucociliary system is not
capable of transporting these secretions. They, therefore, stagnate in the
nose and paranasal sinuses. They become infected and virtually all people
with CF have some degree of chronic sinusitis. The bacteria which grow in the
cystic secretions are then inhaled with every breath into the lungs and then
contribute to the chronic lung disease. Nasal
Irrigation is an excellent tool to help the cystic fibrosis patient
irrigate and get rid of their nasal secretions. To be effective the nose must
be irrigated at least twice a-day. If the sinuses are involved, I strongly
recommend endoscopic sinus surgery, as described in the section on chronic sinusitis. The surgery is designed not
only to open the sinuses, but to facilitate the twice-daily nasal
irrigations. Tobramycin is often added to the nasal irrigant once per
day.
As human
immunodeficiency virus progresses, the nose and paranasal sinuses become
increasingly involved. Once sinus disease begins, the patients benefit from endoscopic
sinus surgery and then nasal irrigation
twice daily. There are a number of
inherited or acquired anatomic nasal problems which are amenable to surgical
repair. The septum is a piece of cartilage and bone which divides the nose
into two symmetric chambers. A crooked septum will cause a persistent
obstruction to breathing. It will also predispose to recurrent nose bleeds,
can contribute to sinusitis and often makes the symptoms of allergic rhinitis
more troublesome than they might have been with a straighter septum. The
septum can be straightened by surgery. This is normally performed on an
outpatient basis. Some surgeons prefer local anesthesia with intravenous
sedation, others prefer general anesthesia. This is ultimately a matter of
personal preference. A half inch incision is made just inside the nose on the
most forward edge of the septum. The mucosa is then carefully lifted off of
the cartilage and bone. Fractures and convolutions are removed surgically.
Concavities and convexities are straightened and then the incision closed.
The septum is held in its new position while it heals. In the old days this
was achieved by packing the nose with 1-2 yards of half inch gauze. Today,
soft gentle packs or silicone plastic splints are placed in the nose. While
there will be crusting and mild discomfort, the postoperative recovery is
mild. Risks and complications do exist, but are fortunately uncommon. The
biggest problem is that the septal cartilage has a memory and sometimes even
though the surgery has been well performed, the cartilage will push its way
back into one or the other sides of the nose and the obstruction will
reoccur. This can happen as often as 10-20% of the time. If the obstructive
symptoms persist and remain troublesome, revision surgery is generally
successful. I should mention that
the normal nose goes through what is called a normal nasal cycle every 4-6
hours. Because the work of the nose is so intense, it cannot continue to
humidify, filter and warm 24 hours a day and so it is normal for one side of
the nose to congest (swell) while the other side decongests (opens up). The
congested side is resting. If your nasal obstruction alternates from side to
side, this is probably not caused by a septal deflection, but is just a
normal nasal cycle. Septal surgery does not interrupt the normal nasal cycle
and therefore will not correct these symptoms. In many, the normal nasal
cycle is somewhat exaggerated, and in some it is much worse at night. When
one lies on one's side, the downside will always congest and obstruct. This
is normal and does not require surgical repair.
XXII. ENDOSCOPIC SINUS SURGERY Endoscopic sinus
surgery is indicated for chronic sinusitis
refractory to medical treatment.
Rhinoplasty is the
operation which changes the appearance and shape of the nose. For some it is
performed to improve breathing. For example, an individual who has suffered a
nasal fracture resulting in a crooked nose may have a significantly impaired
airway, and the only means of restoring the airway is to perform a
rhinoplasty. Many people do not feel that their nose compliments their
overall appearance, and for some this becomes a major focus. The shape of the
nose can be changed and the operation to do this is called a rhinoplasty.
This is performed under local or general anesthesia. The surgery can be
performed through the nostrils or, in many cases today, a very small incision
is made in the columella (that is, the soft tissue at the bottom of the
nose). The remainder of incisions are all made intranasally and so external
scars are not a problem. The cartilages can be thinned and reshaped. The
bones will be rasped smooth and moved to a straighter or more aesthetic
position. For those who desire it and have chosen their surgeon well, the
results are normally wonderful. Surgery does not always go perfectly and some
patients have unrealistic expectations. I can only advise you to discuss all
these matters thoroughly with your surgeon. Make sure that you are happy with
him or her as a caring physician and be sure that you and they are committed
to each other so that should problems occur, the two of you will work on this
together. Some will say that
revision rhinoplasty is necessary in as many as 10% of surgeries. This along
with infection, bleeding and scarring are some of the risks and complications
of rhinoplasty. It is always a tragedy
when the patient goes to the surgeon with a small bump and a slightly larger
than desired tip, with the unrealistic belief that the rhinoplasty will turn
them into a ravishing hollywood model. There is only so much that can be
done. The nose certainly can be reshaped, but that will not change one's
personality. It will not change one into an instant success story. It should
however, provide an improved nasal appearance. The vast majority of people
who undergo rhinoplasty are very pleased with the outcome. For those
interested, it is strongly encouraged that you consult an ear, nose and
throat doctor skilled in rhinoplasty or a plastic surgeon with interest and
ability in nasal surgery.
XXIV. WHEN TO CONSULT A PHYSICIAN If you have a nasal
problem which you cannot diagnose and treat yourself, you are encouraged to
consult a physician. Primary care providers are experts at diagnosing and
treating simple ailments. If your care with your primary care physician is
not successful, insist on a referral to an ear, nose and throat doctor,
(otolaryngology-head and neck surgery), for this is the specialty most
knowledgeable in nasal disorders.
XXV. ENVIRONMENTAL CONTROL FOR ALLERGY The general instructions
used at the UCSD Nasal Dysfunction Clinic are: Bedroom
Special Items
Acute tonsillitis and
recurrent tonsillitis are bacterial infections. They cause sore throat,
fever and the feeling of being sick. Some individuals have a low-grade,
smoldering tonsil infection, often with small white to yellow puss filled
nodules. These are uncomfortable and often cause halitosis.
Tonsillectomy is the conventional treatment. However, many cases can be
managed with topical medication and throat irrigation. The Grossan Hydro-pulse
Nasal/Sinus Irrigation System listed as item #3
in the Handbook of Nasal Disease is the optimal delivery system. If the
irrigation with warm salt water is not sufficient, you can add a diluted
Burrough's solution. This is an astringent and improves the efficacy of
the irrigation system. Burrough’s solution can be purchased over the
counter. It is typically delivered as a tablet which should be diluted
in 2 liters of water. If you were to irrigate with full strength
Burrough’s solution, you would find it extremely bad tasting. However,
if you dilute 1:10 or 1:20, you will find it more tolerable. The 1:10
dilution is made by adding one cup of the Burrough's solution to nine cups of
water. Use this to gargle or irrigate the tonsils. This should be
performed twice daily. Improvement should be achieved within one to two
weeks of treatment. |
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