Novel Treatment for Non-Allergic Rhinits

Non-allergic rhinitis is an extremely frustrating sino-nasal disorder that is characterized by all the same symptoms of sinusitis and allergies, but NOT due to sinusitis or allergies. Rather, I consider non-allergic rhinitis to be the over-sensitive nose syndrome whereby breathing in air containing particulates (whether smoke, perfume, dust, pollen, etc) PHYSICALLY irritates the nose causing symptoms.

This is in contrast to allergies where the pollen causes an immunologic reaction causing symptoms or sinusitis which is due to an infection.

Non-allergic rhinitis is diagnosed by a negative allergy test (meaning symptoms are not due to allergies) and normal CT sinus scan (meaning symptoms are not due to a sinus infection).

Usually, treatment encompasses avoiding triggers (ie, perfume, smoke, dust, etc), applying a barrier nasal emollient (ie, ponaris), anti-histamine nasal spray (ie, astelin, astepro, patanase), and nasal hygiene using saline flushes which washes away the irritants causing symptoms.

Well, a new study published this month have shown another mode of treatment is quite helpful... ICX72, a proprietary homeopathic preparation of Capsicum annum and Eucalyptol, otherwise known as Sinus Buster!

When used twice daily over two weeks, symptoms were found to be significantly improved when compared to placebo. Furthermore, sinus buster alleviates symptoms attributable to non-allergic rhinitis within 52.6 seconds on average.

Past studies have shown improvement using Sinus Buster, but this is the first controlled study demonstrating efficacy.

Of note, unlike nasal decongestant sprays like Afrin which can result in addiction over time (rhinitis medicamentosa), there does not appear to be any addictive component with this nasal spray.

Read the study abstract here.

Read more about this condition here.



Reference:
A randomized, double-blind, parallel trial comparing capsaicin nasal spray with placebo in subjects with a significant component of nonallergic rhinitis. Annals of Allergy, Asthma & Immunology. Volume 107, Issue 2, Pages 171-178 (August 2011)

Intranasal Capsicum spray in idiopathic rhinitis: a randomized prospective application regimen trial. Acta Otolaryngol. 2009 Apr;129(4):367-71.

Intranasal capsaicin reduces nasal hyperreactivity in idiopathic rhinitis: a double-blind randomized application regimen study. Allergy. 2003 Aug;58(8):754-61.

The long-term effects of capsaicin aqueous spray on the nasal mucosa. Clin Exp Allergy. 1998 Nov;28(11):1351-8.

Beneficial effects of intranasal applications of capsaicin in patients with vasomotor rhinitis. Eur Arch Otorhinolaryngol. 1991;248(4):191-4.

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Nebulizer Treatment for Chronic Sinusitis

Many people are already aware of nebulizer treatments to help with breathing during asthma attacks and other pulmonary conditions.

What many people may not be aware of is that such nebulizer treatments can also potentially be used for chronic sinus infections. One of the best known company offering such treatment is Sinus Dynamics.

Using one of several different nebulizers, compounded liquid medications (antibiotics and/or steroids) selected by the physician are nebulized/atomized which the patient than breathes into the nasal passages. The small size of the particles allow medication to theoretically move through the tiniest of sinus openings directly onto the infected tissue. Treatments are quick generally lasting 3 – 5 minutes (depending on medication and device). Here's a video demonstrating how it is used.



Sinus Dynamics™ specifically is contracted by over 14,000 insurance companies across the nation, which means that most patients are able to receive their treatment for little to no cost out of pocket.

Most ENT doctors are already familiar with this product.

Personally, I prescribe this mode of treatment for the particularly difficult sinus infection that has not responded to oral antibiotics and sinus surgery. The major advantage of such a device is not only the fact that it is topical, but much stronger antibiotics can be prescribed that otherwise would be toxic if given orally. Furthermore, more than one medication can be administered simultaneously (for example, a steroid, tetracycline antibiotic, and ceftazidime antibiotic).

Typically, I require a culture with sensitivities to determine what medication would be optimal for this mode of treatment. Another requirement is prior sinus surgery given studies showing greater effectiveness of the delivery system.

Once cultures are obtained and a determination of the optimal medication to treat, a prescription is faxed to the company who will than take care of the insurance coverage and than ship the device and medication(s) to you. The normal turn-around time is less than 1 week depending on the prescription.

An instructional video is included with the prescription as well as customer service representatives via phone to walk through the first treatment if needed.

Of course, sinus nebulizer treatment is not the only topical treatment than can be provided.

Other topical sinus treatments which may be just as effective if not more include saline flushes containing medications (which can be compounded by any willing pharmacy) as well as application of antibiotic ointments directly into the sinus cavity (which is performed by the ENT under endoscopic guidance).

It is up to your ENT physician to determine what is the best course of treatment based on your history, endoscopic sinus evaluation, culture results, CT scans, and response to prior medical regimens.

It should also be noted that there have been several studies performed suggesting such nebulizer treatment for sinus infections to be ineffective. However, it certainly is worth trying when all else has failed (or insurance has denied other treatment protocols).

References:
Nebulized antibiotics for the treatment of refractory bacterial chronic rhinosinusitis. Ann Pharmacother. 2011 Jun;45(6):798-802. Epub 2011 Jun 7.

Current concepts in topical therapy for chronic sinonasal disease. J Otolaryngol Head Neck Surg. 2010 Jun;39(3):217-31.

A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers. Am J Rhinol. 2008 Jul-Aug;22(4):390-4.

Nebulized bacitracin/colimycin: a treatment option in recalcitrant chronic rhinosinusitis with Staphylococcus aureus? A double-blind, randomized, placebo-controlled, cross-over pilot study. Rhinology. 2008 Jun;46(2):92-8.

Deposition of aerosolized particles in the maxillary sinuses before and after endoscopic sinus surgery. Am J Rhinol. 2007 Mar-Apr;21(2):196-7.

Comparison of topical medication delivery systems after sinus surgery. Laryngoscope. 2004 Feb;114(2):201-4.

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Xylitol (Natural Compound) to Prevent Recurrent Sinus and Ear Infections?

Image by Lauri Andler from Wikipedia

I only recently became aware of a natural sugar compound called "Xylitol" from a colleague's blog, BoogorDoctor, managed by Dr. Russell Faust. I certainly have never heard of it during medical school or surgical training.

This naturally-occurring sugar substitute apparently has all sorts of anti-bacterial as well as anti-fungal properties and has been known to doctors and scientists but hardly marketed or promoted in any fashion.

However, the importance of this compound is that it DOES appear to significantly decrease the incidence of ear infections and sinus infections when used regularly (in essence, xylitol mixed in with salt-water sprayed into the nose several times a day). See references below for links to research papers.

It's cheap, over-the-counter and at least from the studies I've reviewed, does seem to work. However, to be fair, it only works when given regularly even if healthy. If given when sick, it does not work (see this study). Also to be fair, there are some studies that suggest that xylitol does NOT work at all.

However, given there are minimal (if any) side effects and safe for kids, it is certainly something worth trying before surgical consideration, especially in children.

Why is this compound not more well-known?

Probably because it's cheap and therefore not a money-maker... which means not a lot of dollars goes into marketing the product whether directly to patients or doctors.

In any case, you can get it on Amazon.com here (or possibly at a local pharmacy).

I should also mention that Xlear is the only product series that uses the optimal concentration xylitol (others use only the bare minimum concentration to meet ingredient inclusion).




References:
A Story About a Sugar: The X-Factor. Blog by Dr. Faust

Xylitol as a prophylaxis for acute otitis media: systematic review. Int J Audiol. 2010 Oct;49(10):754-61.

A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998 Oct;102(4 Pt 1):879-84.

Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ. 1996 Nov 9;313(7066):1180-4.

Failure of xylitol given three times a day for preventing acute otitis media. Pediatr Infect Dis J. 2007 May;26(5):423-7.

Xylitol administered only during respiratory infections failed to prevent acute otitis media. Pediatrics. 2002 Feb;109(2):E19.

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Steroid and Anti-Histamine All-In-One Nasal Spray!

Meda Pharmaceuticals has announced a new nasal spray "Dymista" that contains both a steroid and an anti-histamine active ingredient. Why is this significant? It's because it's the first and only one to do so. Of course, it's not available yet until the FDA approves it, but at least it has shown effectiveness in Phase 3 clinical trials.

At this time, nasal sprays as it relates to nasal allergies come in two separate flavors:

1) Steroid Nasal Spray (flonase, nasonex, nasacort, rhinocort, veramyst, omnaris, etc, etc)
2) Anti-Histamine Nasal Spray (patanase, astepro, astelin)

This new combo nasal spray "Dymista" contains fluticasone and azelastine. Fluticasone is a steroid that is also found in flonase nasal spray whereas azelastine is an anti-histamine also found in astepro and astelin nasal sprays.

Clinical trials in the past have shown that using a steroid nasal spray and an anti-histamine nasal spray was more effective than using one or the other individually.

Similarly, Dymista has also been found to be better than either nasal spray alone, but with the convenience of using a single nasal spray.

Look for it in the near future! Let's just hope insurance will cover it however.

Read the press release here.

Reference:
Onset of Action of MP29-02 in the Treatment of Seasonal Allergic Rhinitis. J Allergy Clin Immunol 2011; 127; 2; Abstracts 199

MP29-02 in the Treatment of Nasal Symptoms of Seasonal Allergic Rhinitis. J Allergy Clin Immunol 2011; 127; 2; Abstracts 199

Combination therapy with azelastine hydrochloride nasal spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis. Annals of Allergy, Asthma and Immunology, 2008, vol. 100, no. 1, pp. 74 - 81.

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Can Humming Ease Sinus Problems?

Well... according to a recent New York Times article published Dec 20, 2010, the answer is yes...

Apparently, humming can keep air moving through the sinuses and nasal cavity which suggests improved ventilation. Good sinus ventilation means healthy sinuses.

Their conclusion is based on two studies listed under the references below. Unfortunately, the conclusion can't extend to stating humming prevents sinus infections. The only way to evaluate that hypothesis is to do a study comparing two groups of patients with chronic sinus infections and instruct one to hum and the other not to and see if there's any difference in the intervention group over time. Even better would be to do a prospective double-blinded study, but not sure how one can perform a double-blinded study in this case.

Read the NYT article here.

References:
Humming greatly increases nasal nitric oxide. Am J Respir Crit Care Med. 2002 Jul 15;166(2):144-5.

Assessment of nasal and sinus nitric oxide output using single-breath humming exhalations. Eur Respir J. 2003 Aug;22(2):323-9.

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"Sinus Lift" Procedure - The Return of Intra-Oral Sinus Surgery

I saw a patient today who informed me that she underwent a "sinus lift" procedure in the past.

This statement made me realize that though ENTs are generally considered the sinus surgery experts, dentists and oral surgeons perform some sinus surgery as well like the "sinus lift" procedure. As far as I know, there is no ENT surgeon that does that specific sinus operation.

In essence, the "sinus lift" procedure is when the floor of the maxillary (cheek) sinus cavity is raised with bone graft material in order to accommodate a dental implant. Though there are many approaches to accomplish this task, most require entering into the maxillary sinus cavity. See image below:

It is somewhat strange when considering that back in the old days (like a few decades ago), ENTs routinely performed a similar intra-oral approach (Caldwell-Luc) in order to enter into the maxillary sinus cavity when performing sinus surgery for chronic sinus infections. However, with the advent of endoscopic techniques, this approach is now very rarely performed. Indeed, we try to avoid any incisions if at all possible.

So while ENTs have significantly decreased the use of intra-oral approaches for maxillary sinus surgery, the dental world has brought this approach back!

Who knows? Perhaps ENT and oral surgery will join forces at some point in the future in order to perform an endoscopic "sinus lift" procedure in order to avoid making any incisions in the mouth!

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Pediatric ENT Care of Warrenton, Virginia (Fauquier County)

Recently, there has been some confusion regarding whether our office deals with adults only or do we see kids as well... Strangely enough, we also get asked by parents whether our office sees adults when seeing a pediatric patient.

To clear up any confusion, our office does see kids AND adults... starting from birth to the elderly.

Dr. Chang who joined the office in October 2005, was named one of America's Top Physicians by the Consumer's Research Council of America in 2008 as well as a Northern Virginia Top Doctor for 2011 (to be published in February 2011).

Some common problems and procedures for which Dr. Chang sees kids specifically include:

- Tongue Tie Release (starting from ONE DAY OLD!)
- Tonsillectomy
- Adenoidectomy
- Sinus Surgery starting with adolescents
- Ear Tube placement
- Hearing Loss
- Nasal Obstruction
- Nasal Congestion
- Snotty Nose
- Speech Delay
AND many other issues...

Our office has even created videos on a few common pediatric procedures including tonsillectomy, adenoidectomy, earwax removal, ear tubes placement. Watch the video below on tonsillectomy.

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Cocaine As A Medically Approved Medication

Many people are already aware that marijuana is now legal in some states in the US with a medical prescription.

What many people may not realize is that cocaine is also used in medical care, especially in the ENT world.

Cocaine is one of the most potent anesthetic AND vasoconstrictor. These two characteristics make it an ideal medication for use during sinus surgery as well as any nasal procedure where bleeding and pain may be an issue.

Many physicians will use cocaine to help stop nosebleeds (I do not).

Many surgeons use cocaine during sinus surgery to minimize post-operative pain as well as minimize intra-operative bleeding. Use of cocaine also significantly decreases risk of nosebleeds after sinus surgery as well as minimize need for nasal packing.

Cocaine when used for illegal recreational purposes by snorting puts a person at risk for septal perforation due to its vasoconstrictor properties. In essence, the cocaine puts a chemical tourniquet on the blood supply to the septum leading to mucosal necrosis and eventual perforation. Afrin does the same thing, but on a much smaller scale.

Before anybody asks... Cocaine is NEVER prescribed to a patient. It is only ever used in a hospital/office setting and heavily controlled under lock and key. (It is never used in our office.)

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Got Allergies? Maybe It's Actually Non-Allergic Rhinitis

USA Today published a story on Aug 22, 2010 describing a condition called "Non-Allergic Rhinitis" or "Vasomotor Rhinitis" which essentially is having pretty much all the symptoms of classic nasal allergies, but caused NOT by allergies!

Such symptoms include:

- Runny nose
- Nasal congestion
- Post-nasal drainage
- Nasal obstruction
- Sinus pressure
- Sneezing
etc

These individuals also report that their nasal symptoms are triggered not only by pollen and dust, but also perfumes, strong odors, cigarette smoke, chemicals, cold air, high wind, humidity, and certain foods, especially spicy ones.

The way I try to explain this condition from those suffering from it is to consider their nasal lining to be hypersensitive... so hypersensitive that things which ordinarily shouldn't cause any problems, do.

The best way to address this condition is by avoiding known triggers and keeping the nose clean by regular saline washes. The saline washes are quite important in that they clean out the substances which are irritating the nose (much like washing your skin reduces the irritation if you get poison ivy).

Some patients may benefit from medications like anti-histamine and steroid nasal sprays, but such medications do not work as well as for those suffering from classic nasal allergies.

Barrier type of medications like ponaris may also be helpful. Such medications work by creating an oily barrier such that the irritating substances don't actually touch the lining itself when breathed in (much like chapstick on lips).

Some patients with non-allergic rhinitis and large turbinates may benefit from a surgical procedure called turbinate reduction, but rarely cure the problem. At best, there is perhaps a 50% reduction in symptoms.

One should also be aware that you can have BOTH allergic and non-allergic rhinitis.

Read the USA Today article here.

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Intra-Nasal Cooling System Effectively Chills Brain After Cardiac Arrest

In a study in this month's Circulation, a new nasopharyngeal device was used to initiate cerebral cooling during cardiac arrest. This device, called RhinoChill made by BeneChill cools the major vascular structures of the brain thereby improving neurological outcome.

Use of this device was found to increase survival over CPR alone by 27% and a 26% increase in neurologically intact survival.

Reference:
Intra-Arrest Transnasal Evaporative Cooling. A Randomized, Prehospital, Multicenter Study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Published Online on August 2, 2010.

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New Video On Balloon Sinuplasty for Chronic Sinusitis Uploaded

A new video describing balloon sinuplasty has been uploaded on our YouTube channel. Balloon sinuplasty is a relatively new minimally invasive sinus surgery technique to open up diseased sinus cavities without removing mucosa or bone.

In essence, the technique involves threading a tiny guidewire to first identify the sinus opening and than acts as a guide for the balloon catheter. Once the balloon is positioned at the opening of the sinus cavity, it is inflated thereby enlarging the sinus cavity opening.

Watch this sinus surgery technique below or on our YouTube channel here.



Here is an animation of what exactly is going on:

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New Webpage on Rhinitis Medicamentosa (Nasal Decongestant Spray Addiction)

A new webpage has been created and uploaded to our website on rhinitis medicamentosa, a devastating sinus/nasal condition with symptoms of severe chronic obstruction/congestion. This condition occurs when over-the-counter nasal decongestant sprays are used more frequently (every 12 hours) and longer (3-5 days) than directed.

Such nasal decongestant sprays include the common and popular Afrin and Zicam nasal sprays. These sprays contain one of these active ingredients: phenylephrine, neo-synephrine, oxymetazoline, and xylometazoline.

This condition has also been portrayed in the New York Times and the article can be read here.

Check out the webpage here.

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Recurrent Chronic Sinusitis Often Due to Allergies

A 2009 research paper lends credence that allergies may be a VERY important player in patients who suffer from recurrent sinus infections. Such patients will improve with antibiotics only to have their sinus infection symptoms recur shortly after completing the antibiotics.

The research described how allergy exposure to patients resulted in a rapid and radiographically significant response of sinus disease including mucosal thickening and/or opacification. How fast? Within 60 MINUTES!!!

These findings lend support that should patients suffer from recurrent sinus infections that do not clear readily with antibiotics alone should be investigated for allergies. Furthermore, allergy testing and management should be performed in all patients considering sinus surgery. Why? Because if allergies are playing a role, opening up the sinuses via surgery will only exacerbate allergy triggered sinus infections.

What is our office protocol for evaluating patients with chronic sinus infections?

1) History supportive of recurrent sinus infections in spite of antibiotics as well as trial of allergy medications
2) CT Sinus documenting presence of sinus disease for surgical consideration as well as elucidating whether true sinus problems are causing the symptoms
3) Allergy testing (Our office performs immunoCAP blood testing instead of skin prick testing)

If allergy testing is positive, aggressive allergy control is the first step prior to (or at the very least concurrent with) any other intervention including sinus surgery.


Reference:
Diagnostic Value of Nasal Allergen Challenge Combined With Radiography and Ultrasonogrphy in Chronic Maxillary Disease. Arch Otolaryngol Head Neck Surg. 2009 Dec;135(12):1246-55. doi: 10.1001/archoto.2009.189.

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Saline Nasal Sinus Irrigation Systems

I must admit... our office is a big fan of the Neilmed Sinus Rinse bottle for patients who suffer from chronic sinusitis and severe allergies as it is cheap, easy to clean, and it works. However, many patients who are already fans of flushing the nose with saline water end up purchasing saline irrigation systems. There's a bunch of these devices sold on Amazon.com. Check them out below, but I would suggest that you first become adept and able to tolerate saline flushes using the Neilmed sinus rinse bottle first prior to paying almost $100 for these devices.

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