The blocked nose 137
to positional and climatic factors, such as a sudden
change in temperature. Similarly, some patients seem
to have symptoms triggered by alcohol or emotional
changes.
Thankfully, we do not need to concern ourselves
further, since the treatment for this condition is
similar to that for true allergic rhinitis, i.e. avoidance
of any known precipitating factors and nasal steroid
preparations. In patients whose primary complaint
is of watery rhinorrhoea, the anticholinergic iprat-
ropium bromide, delivered as a nasal spray, is often
effective. In resistant cases with turbinate hypertro-
phy (see below), surgery may indicated.
Rhinitis medicamentosa
This is an acquired sensitivity of the nasal lining
in response to the prolonged use of topical nasal
decongestant substances. The root of the problem
lies in the fact that, once the effect of a nasal
decongestant has worn off, there is a rebound
vasodilation. This leads to further nasal congestion,
and the patient feels the need for relief and so uses
the decongestant again. The whole process rapidly
becomes self-perpetuating and results in turbinate
hypertrophy with chronic, unresponsive nasal
obstruction. Many over-the-counter preparations
contain nasal decongestants, and these must be
enquired about directly when taking the history,
since patients will rarely offer this information
spontaneously.
Prevention by education of patients is important.
Treatment involves cessation of the decongestants,
with instigation of topical nasal steroids. Where
turbinate hypertrophy is a major feature, turbinate
resection may be required.
Atrophic rhinitis
This condition was much more frequent in the past
and is seen more often in developing countries. It
would seem therefore that socioeconomic factors
have some role to play in the development of this
condition.
Nowadays, in developed countries atrophic
rhinitis is associated with an abnormal patency
of the nostril, usually as a result of nasal surgery,
particularly turbinate resection, and in patients who
have undergone radiotherapy for cancers involving
the nasal cavity. The nasal lining loses its cilia and
atrophies. Thick secretions are formed, which
quickly dry and lead to large crusts with a char-
acteristic unpleasant sweet odour. Bleeding is fre-
quent. Nasal toilet is required regularly, and the
patient is encouraged to use steam inhalations
and glucose-in-glycerin nose drops in an attempt
to soften the crusts. The most effective treatment
is surgically to close off the nostril. However,
this is often poorly tolerated by the patient. With
the cessation of airflow, the nasal lining returns
to normal, but when the airway is reopened the
problem returns.
Other types of rhinitis
Other types of rhinitis have been described in
response to a wide variety of factors. They include
the following:
Rhinitis of pregnancy: this occurs in response to the
hormonal changes associated with childbearing.
The condition resolves after parturition.
Senile rhinitis or dewdrop nose: this describes
the watery anterior rhinorrhoea that occurs
particularly in old men.
Honeymoon rhinitis: this refers to nasal symptoms
that occur as a result of sexual excitation.
Rhinitis sicca: this occurs as a result of exposure to
extremely hot dry conditions, such as in foundry
workers or in the desert.
Turbinate surgery
This is performed in cases of permanent turbinate
hypertrophy. Turbinates may be excised (totally
or partially), or scarring of the vascular turbinate
tissue can be induced, with resulting shrinkage.
Many different scarring techniques are employed,
largely depending on the surgeon’s personal
preference. Hot wire, cryotherapy and laser cautery
are all used to scar the surface of the turbinate.
Submucous diathermy (SMD) and filleting of
the turbinate bone are used to cause subepithelial
scarring (Figure 10.16). The immediate risk is of
bleeding. This can be impressive and potentially
life-threatening at times. Later atrophic rhinitis can
develop, usually after radical turbinate excision.
Even minor intervention/surgery to the nose can