BREATHE RIGHT

BREATHE RIGHT
Azgher M Karjieker FCS(ORL)SA
ENT Surgeon
Chris Barnard Hospital
Constantiaberg Mediclinic
Rondebosch Medical Centre
Normal externally – is relative
Inside it’s ALL THE SAME
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Airway
Smell
Humidification
Heater
Air purifier
Mucus production
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Common error - polyps
Internal Nasal Valve
If he can, so can you
MOST COMMON SYMPTOMS
Most Common symptoms
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Runny
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Blocked
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Bloody
Runny Nose
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Post nasal drip – Water vs tea+coffee intake
NASAL BLOCKAGE
Nasal Congestion
When you turbinate
has an Erection
Engorgement
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Topical irritation
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Sensory receptors
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temperature-sensitive
Cold /Menthol decongests
Heat congests
Autonomic System
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activation of mast cells, basophils, and other leukocytes
histamine & other mediators
Sympathetic: constriction decongestion
Parasympathetic: congestion and edema
Nasal cycle:
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Average 2-6 hours, only 30% of population has this.
Mechanical Blockage
ALLERGIC RHINITIS
Symptoms
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Cardinal symptoms:
 Sneezing
 Nasal
obstruction
 Watery rhinorrhea
 Seasonal
 Perennial
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Look for concurrent – Asthma, Eczema
Asthma and AR – The LINK
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Up to 30% patients with Asthma have A.R.
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AR exacerbates Asthma
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Few patients with AR have Asthma (<2%)
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Rhinitis- bronchial hyper-reactivity association
Asthma and AR – The LINK
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Nasal Steroids – reduce asthma exacerbations
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All patients with Asthma – screen for A.R
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Patient with Poor asthma control 
Consider Chronic Sinusitis
Treatment of allergic rhinitis.
 Avoidance
and environmental controls
 Avoid
cigarette smoke
 Remove carpets
 Good vacuum cleaner – hepa filter
 Mattress /Pillow cover
 Pharmacotherapy
 Immunotherapy
GET SYMPTOMS UNDER
CONTROL - PAED
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Nasal saline spray essential - EARLY
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Dimetap(or equiv) for runny nose
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Paed Iliadin for blocked nose
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No response: Aspelone/ Prelone 1mg/kg
(15mg/5ml) 5 days after breakfast
 Max
3 times per year (all ages)
GET SYMPTOMS UNDER
CONTROL -ADULT
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Nasal Saline spray
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Demazin NS or Equivalent 5 days
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Vibrocil 2 puffs tds 5 days max or equiv
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Mucolytic: ACC 200 or Mucospect/ Mistabron
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No response: Prednisone (F)40-(M)60mg after
breakfast 5 days
KEEP SYMPTOMS UNDER
CONTROL
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Antihistamine : itchy eyes/nose/sneezing
 Allecet
, Deselex or equiv
 AS NEEDED OR CHRONIC
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Nasal Steroid: more nasal symptoms
 AROUND
CHANGE OF SEASON OR CHRONIC
 Alleviates ocular symptoms too
Nasal Steroids
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Beclate
Budesonide (Inflanaze)
Fluticasone (Flomist,Flixonase, Avamys)
Mometasone (Nasonex, Nexomist)
Steroid Absorption negligible
Cost
Chronic Medication Med Aid Cover – limited
unless asthma as well (J45.0 – PMB)
How to use a nasal spray
Steroids
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Decrease infiltration of inflammatory cells
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Diminish hyper reactivity and vascular
permeability of nasal mucosa
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SHORT COURSE
The Big Gun
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Singulair (leukotriene inhibitor)
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Great for nasal Polyps (J33.9)
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Improves asthma control
Immunotherapy/desensitization
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inject increasing strengths of purified extracts of the
substance that causes the reaction
Moderate to severe symptoms –
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involves development of immunoglobulin G-blocking
antibodies & alteration of T cell interactions
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Sublingual route available
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Longterm commitment – 3 years
NASAL POLYPS
What
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Overgrowth of sinus
mucosa prolapsing
thru ostia
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Allergy basis
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Exclude inverting
papilloma
What to do
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Medical
 Oral
Prednisone = 40-60mg daily for 7 days
 Singulair
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10mg daily
Surgery – trim to base then nasal steroid
SNORING AND THE BLOCKED
NOSE
Nasal obstruction and sleep disturbance
In the normal awake state, nasal airway resistance markedly
exceeds that of oral airway resistance
During sleep, the relaxation of the oral and pharyngeal
muscles leads to a reversal of the resistance patterns and oral
airway resistance increases.
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The resistance in the fairly rigid nasal cavity is more
constant during both the awake and asleep states.
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The nose = efficient route of breathing during sleep
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during sleep forced breathing through mouth thus
requires increased effort, leading to greater negative
pressures in the pharynx and a higher risk of collapse.
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SLEEP MRI studies confirm this
Why is the nose a problem?
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Nose congests when lying horizontal
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Any form of rhinitis will aggravate this
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As will mechanical blockage like deviated septum
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Forced to mouthbreathe
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Patients who snore habitually are more likely to wake
up with a very dry mouth
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Medicate/ intervene early
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Counter Mouthbreathing
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Start with Nasal steroid
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Septoplasty early before pharynx bulks up
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Remove large tonsils
Effect on the Larynx
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Dryness
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Hoarseness
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Voice strain
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Poor lubrication
OBSTRUCTIVE SLEEP
APNOEA
OFTEN MISSED
Basic principles
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Open Nose to reverse mouthbreathing
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More floppy tissue in mouth to reverberate
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Prevent progression to OSA
Sleep Apnoea – G47.3
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Affects daytime productivity
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Prevent complications
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Heart Disease
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CVA
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Impotence
RAPID DIAGNOSIS - MY WAY
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Awakes with dry mouth
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Awakes unrefreshed
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Nocturnal micturition
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Research in progress
Conservative Measures
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Start Nasal Steroid early
Weightloss – diet + exercise – review 3
months until goal achieved
Mandibular Advancement splint
Conservative options
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Sleep Study
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CPAP
Surgery for obvious blockages
Surgical options
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Septoplasty
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Tonsillectomy
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Palatal Stiffening
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Less invasive Tongue suspension (NEW)
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Tracheostomy (Last Resort)
Handout page…..
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Algorithm
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Eating Plan
SINUS INFECTIONS:
Why
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Anatomy - swelling in
critical places
Cilia function
Structural
abnormalities
 Deviated
nasal
septum
 Concha Bullosa
 Nasal Polyps
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Degree of symptoms
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Fever, nasal
congestion, facial pain,
nasal discharge, post
nasal drip
Frontal sinus involved
> 10yrs old
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Beware complications
Medical Treatment
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Acute
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Nasal decongestant x 5 days eg Vibrocil
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Antibiotic
 Keep
it simple & cost effective
Antibiotic Choice
(SAMJ Guidelines)
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Amoxil
Amox/Clavulanate
Cefuroxime
Erythromycin
Telithromycin
Azithromycin
Moxiflox
1gr tds
2gr bd
500mg bd
500mg qid
800mg dly
500mg dly
400mg
10 days
10 days
10 days
10 days
5 days
3 days
7 days
Chronic Rx
 Nasal
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Steroid – Nexomist, Nasonex etc
Prednisone 40 – 60 mg daily for 5 days
Failed medical treatment
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Persistent symptoms > 72hrs
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Potential acute complications
 Periorbital
cellulitis/abscess (eye at risk)
 Intracranial spread
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Chronic Rhinosinusitis
>
12 weeks
Surgical Solution
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Imaging – CT rather than Xray
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History
Antral washout(rarely used)
 Inferior antrostomy
 Ext fronto ethmoidectomy
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Endoscopic Sinus Surgery
Gentle Plumbing
 Open blocked drains
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BLOODY NOSE
Epistaxis
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Pinch Correctly
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Vibrocil 2 puffs tds
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Cyclokapron 3tabs stat then 1tab tds
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Cauterise or Pack nose
 Rapid
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Rhino plug – SA Biomedical
Surgery – 1 hour.Endoscopic. 98% Success
TAKE HOME POINTS
Missed Diagnoses
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RhinoSinusitis
Nasal steroid / increase water intake
 poorly controlled asthma
 Chronic cough
 Limited CT sinuses not Xray
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OSA
Poorly controlled BP
 Young male with hpt
 Dry mouth/awakes unrefreshed/Nocturnal micturition
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Research in progress
BREATHE RIGHT
SLEEP TIGHT
0827865333
[email protected]