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ALLERGIC RHINITIS
AND THE ENT PRACTICE
RL Friedman | MBBCh, FCS(SA) ORL
M Hockman | MBBCh, FCS(SA) ORL
ENT Surgeons, Mediclinic Sandton, Johannesburg
Email | friedmanr@surgeon.co.za
ABSTRACT
The term allergic rhinitis implies nasal inflammation with a specific allergic cause. Despite excellent clinical guide-
lines for the management of this condition, therapy is often unsatisfactory in many patients. A number of reasons
for this phenomenon are possible, including the presence of local disease, ongoing and unrecognised allergic
triggers, but also comorbid or unrelated pathologies in the nose and sinuses. Careful nasal and facial examination
is mandatory in patients, but especially those who fail first line therapy for allergic rhinitis.
A B C
Figure 3: Lip retraction and tongue thrust with nasal obstruction and ob- A. Inverted V deformity
structed nasal airway in a deviated nose B. Nasal valve collapse
C. Nasal ptosis
itch, sneeze, rhinorrhoea and nasal obstruction in clinical Figure 4: Important signs in nasal obstruction
A narrow or pinched middle third of the nose may suggest with gentle diaphragmatic breathing as well as with a deep
middle third of the nose cartilage collapse, sometimes ex- sniff. Sometimes these lateral walls may only collapse on
hibiting the inverted V sign. Similarly, over prominent nasal deep inspiration. These patients may complain of nasal
dimples are suggestive of nasal inlet obstruction, (nasal obstruction with exercise.
valve area). This area is responsible for 50% of total airway
resistance. In health it is the rate limiting step of airflow to The Cottle sign, gently drawing the sidewall of the nose
the lungs. These nasal valves may only collapse on inspira- away from the midline, will give information relating to the
tion and may be unilateral. Narrowing here increases airway nasal inlet internal nasal valve area.
resistance according to Poiseuilles Law; The effective resis-
tance in a tube is inversely proportional to the fourth power of In patients with nasal obstruction, a good nonspecific
the radius change. Halving the radius of the tube effectively examination, such as the above, is quick and within the
increases the resistance by a factor of 16. capabilities of all physicians and might alert the physi-
cian prior to AR treatment failure or if after treatment
A deviated external nose may be suggestive of a deviated failure, prevent unnecessary additional medication and
nasal septum which may be complex and obstructive. A investigation.
nasal ptosis (overhanging tip) often accompanies this with
a caudal nasal septal deformity or shortening. Caudal 2. Specific examination
nasal septal deformities are especially important as they Should the above red-flag a patient prior to or after
effect the nasal valve areas. More importantly they are treatment failure, then referral for a more thorough nasal
easily seen without any special instrumentation. examination including nasal endoscopy and CT scan
evaluation is indicated. Basic geographic and personal
When examining airway competence the physician should specific allergy testing at primary care and specialist level
place a finger below each nostril delicately on alternate is mandatory. Total IgE testing value is limited.
sides, so as not to distort the nose and assess the airway
Figure 6: Illustrative example: 32 yr. old male. Sinus diagnosis for years, in reality actual relevant symptom was a persistent blocked nose. Post nasal
discharge, asthmatic. Family history of proven allergy. Total IgE 250 Ku/l. Phadiotop positive. Multiple skin prick test positive. Repeated poor response to
all medicines and sprays, multiple combination of medicines including asthma medicines and oral steroids. Multiple over-the-counter (OTC)
medications.
Note: Severe nasal septal deformity + severe and complex aeration of left lateral nasal wall structures + chronic rhinosinusitis. No previous trauma.
RED FLAG: Complex deviation of the external nose should be very suggestive of internal nasal structure problems.
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