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Managing rhinitis

GP Dr Alex Watson and ENT surgeon Mr Peter Robb give advice on how to manage patients who complain of a blocked nose

GP Dr Alex Watson and ENT surgeon Mr Peter Robb give advice on how to manage patients who complain of a blocked nose

Many individuals who perceive their nose to be stuffy are suffering from modern living. Air-conditioning, central heating and pollution contribute to poor nasal mucociliary function.

Red flags requiring referral are summarised in the box at the end of this article.

Allergic and non-allergic rhinitis

• Allergen avoidance and reduction of allergen load (such as synthetic bedding) are helpful.
• Sunglasses in the grass pollen season reduce pollen contact with the eyes.
• Medical treatment is aimed at controlling nasal block and irritant symptoms. Obstructive symptoms respond to nasal steroids, but these may take a number of weeks to be effective. Symptoms such as itching, rhinorrhoea and sneezing respond to oral non-sedating antihistamines. Some need a combination of both.
• For long-term use, consider a nasal steroid with minimal systemic absorption (such as mometasone) and an antihistamine without the problem of tolerance (tachyphylaxis) – for example, fexofenadine.
• Cromoglycate sprays require frequent use and compliance is often poor.
• Adjunct antihistamine eye drops may also be helpful.

Atrophic rhinitis

• The difficulty in managing this condition is that the senile nasal mucosa is histologically different, producing a more watery nasal secretion. The nose drips but feels dry and stuffy. Parasympathetic stimulation (such as eating) may make the drip worse, causing embarrassment.
• Drying the nose with an anti-cholinergic spray (for example, ipratropium bromide) may reduce the drip, but make the mucosa dry, crusty and superficially infected.
• Antihistamines and vasoconstrictor sprays are generally not helpful.
• A combination of regular sterile seawater spray with ipratropium reduces the drip and keeps the mucosa moist.
• It is often difficult to achieve symptom control to the patient's satisfaction.

Nasal polyps

• Specialist diagnosis and nasal endoscopy is recommended.
• Initial medical management with nasal steroid drops or oral steroids is recommended. The disadvantages of oral steroids are the potential adverse effects, even with a shorter course, and the frequent rebound effect that occurs after completing the course.
• Nasal drops for six to eight weeks are often effective in reducing the polyps significantly. Long-term nasal steroid sprays may control the polyps for long periods after this.
• Surgery is considered for failed medical treatment, and this may include simple nasal polypectomy or endoscopic sinus surgery.

This article is an extract from ENT in Primary Care by consultant ENT surgeon Mr Peter Robb and Surrey GP Dr Alex Watson, published by Rila – to order go to www.rila.co.uk or call 020 7637 3544

Refer if...

• Unilateral nasal obstruction with or without bloodstained discharge
• Progressive or sudden loss of sense of smell and taste
• Structural abnormalities requiring a surgical opinion
• Failure of medical treatment for rhinitis

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