In an average Ear Nose Throat Surgery practice in Singapore , patients presenting with symptoms of blocked or running nose make up a sizeable percentage of all patients seen. This is expected as several local studies have shown that the prevalence of Chronic Rhinitis range between 10.8% to 32.5%. That is to say that up to 3 out of every 10 persons in Singapore are afflicted with these nasal symptoms. The word "sinus" is an often-quoted term used by non-medical lay persons and not a few non-specialist doctors to encompass a large number of often very different pathologies. This is not correct as not all running or blocked noses are the same. A better term to use would be Rhinitis. 

What is Rhinitis?
The term -itis denotes inflammation; thus Rhi-n-itis implies an inflammation of the inner lining (mucosa) of the nasal fossa. Owing to the continuity of the nasal fossae with that of the sinuses (these are air-filled cavities in the skull), some inflammation is often present in the latter at the same time, constituting a Rhinosinus-itis. When the sinus inflammation is predominant, sometimes the term Sinus-itis is used. Thus when most patients say that they have "Sinus", they could be actually having "sinusitis" but more likely they are having only "rhinitis"(which is commoner).  

Classification of Rhinitis
To better understand Rhinitis, the International Rhinitis Management Working Group, 1994 classified the condition into Allergic rhinitis, Infectious rhinitis and others  

Before definitive treatment can start, it is mandatory that a full medical history be taken as it is often helpful in confirming the diagnosis of rhinitis and excluding other diagnoses. Thorough examination should be carried out to exclude the possibility of underlying physical abnormalities of the nose. 

When is specialist referral indicated?
On the whole, rhinitis is competently managed by general practitioners but the working group agreed that specialist referral is always indicated when patients present with certain symptom complexes such as: 

1.Bilateral chronic nasal congestion with variable sneezing and discharge, but with significant olfactory disturbance ( loss of smell) , suggesting nasal polyposis. 

2.Persistent rebound congestion resulting from the abuse of topical nasal decongestant therapy which suggests rhinitis medicamentosa. 

In Singapore these decongestants are OTC (Off-The Counter) drugs available without a doctor's prescription. The most common brands in Singapore are Iliadin, Otrivin and Afrin. In rhinitis medicamentosa, there is refractory vasodilation of the mucosal vasculature and/or excessive mucosal edema. The nasal tissue having become dependant on decongestant nosedrops, become less and less effective and rebound swelling of the tissues occurs soon after the decongestant effect wears out ie. the patient cannot be weaned off from the medication easily. 

3.Continuous nasal congestion, especially if unilateral and/or with bloodstained discharge, suggests the possibility of a malignancy.  

Nasopharyngeal Carcinoma (NPC)
This is especially important to the South-east Asian countries as Nasopharyngeal Carcinoma (NPC) is common among our local population. It is the fifth most common cancer amongst Singapore males and constituted 15% of all cancers diagnosed in 1988-1992. The incidence of NPC amongst Singapore Chinese males is about 18.6 per 100,000 and 8 per 100,000 in females. It is highest amongst male Cantonese. Recent case-control studies showed significantly increased risks in association with adult consumption of salted soy beans, canned pickled vegetables, "sze chuan chye" and "kiam chye". A protective effect of high vitamin-E intake in adulthood was also observed.  

As with all cancers, the earlier the detection of the disease, the more favourable the result of treatment. 

4. Symptoms occurring particularly on work days suggest occupational rhinitis, which may require specialised investigation. 

Personally other than the above recommendations by the Committee, I feel that a fifth situation for urgent referral is warranted: 

5. When there is a possibility of intra-cranial or intra-orbital complications eg. severe intractable frontal or peri-orbital pains especially with associated with fever, despite adequate treatment with medications.  

Management:
Medications
Once other diagnoses has been excluded, the management of Rhinitis usually consist of:  

1. allergy/irritant avoidance  

2. oral non-sedating antihistamines and/or 

3. topical nasal steroid daily  

4. antibiotics if there is evidence of bacterial infection 

Occasionally, short term systemic steroids and/or decongestants are required. Immunotherapy may be indicated in certain selected patients. 

Allergens in Rhinitis
The most common allergen in Singapore is house dust. In a population-based study involving almost 3000 adults from five housing estates (Yishun, Toa Payoh,Jurong East, Geylang/Eunos and Bukit Merah) , the adults afflicted were allergic to house dust (73%), provocation by birds, cats or dogs (5%), grass or tree pollens (5%) and medicine (5%).  

House dust is a mixture of various waste materials like fabric fibres, human skin particles, animal dander, dust mites, bacteria, parts of cockroaches, mould spores, food particles and other debris. 

Of these, it is the protein (i.e. the fecal pellet) of the house dust mites which is the more common allergen contributing to rhinitis, asthma and atopic dermatitis (eczema). 

Surgery
Although the majority of patients can be treated conservatively , surgery has a role in selected patients with rhinitis, but usually only when there are associated physical abnormalities. 

Dr. Ian Mackay, a world-renowned rhinology surgeon reported that over 50 % of patients whose predominant symptom is chronic nasal obstruction fail to respond fully to medical treatment alone. 

What kind of surgery is needed?
Surgery necessary of course depends upon the nature of underlying structural problem, but may include:  

1. Submucosal resection 

2. Rhinoplasty/septo-rhinoplasty  

3. Turbinate reduction (including Coblation) 

4. Sinus surgery 

5. Polypectomy. 

or combinations of the above. 

Mackay also stressed that medical therapy should usually be used first; and that continued medical therapy is often necessary, both to maintain any improvement gained surgically and to prevent recurrence. 

(The above is adapted from an article written by Dr. Huang Shoou Chyuan which was published in a medical newsletter )