Interesting Case Studies

How to stop nasal allergies – the long game

History:
A 29 year old lady complained of “sinus” symptoms since she was in her teens. Her main symptoms were nasal obstruction, sneezing and runny nose. She was already on treatment with nasal sprays (intranasal steroids) and antihistamines. Her runny nose and sneezing were better but there was minimal improvement in her nasal obstruction.

What we did:
Evaluation with Nasendoscopy showed inferior turbinate hypertrophy (swelling). Skin prick allergy testing showed strong positive allergic reaction to 2 types of house dust mites (D. farinae, B. tropicalis), oil palm and casuarina. 

To treat her nose block, she underwent surgery to reduce the size of the inferior turbinates  (inferior turbinate reduction -see figures below). 


Fig 3a. Left nasal passage


Fig 3b. Left nasal passage – Inferior turbinate after surgery (shaded yellow) with wide, unobstructed nasal airway (shaded purple).

As she did not want to rely on medications indefinitely, she also opted to have immunotherapy to treat her allergy. At 12 months of treatment, her nose does not get blocked and she rarely has runny nose symptoms. Follow-up allergy testing also shows the effectiveness of the immunotherapy.

Allergy Grade
Pre-treatment At 12 months
D. farinae 4+ 0
B. tropicalis 4+ 0
Oil palm 4+ 2+
Casuarina 3+ 0

She will need to continue the immunotherapy for another 2 years for long term remission (“cure”) of her allergic rhinitis.

Diagnosis:
1. Allergic rhinitis
2. Inferior turbinate hypertrophy

Discussion:
Allergic rhinitis may cause the nasal turbinates to become permanently enlarged if the allergy is severe and left untreated for too long. A surgical procedure to reduce the size of the turbinates may be the only option to relieve nasal obstruction. While this can solve the problem of the block nose, the patient is likely to continue suffering from runny nose if the allergy is not controlled. Furthermore, there is a chance that the turbinate may increase in size over a few years.

Some patients prefer not to be reliant on intranasal steroids as this could be for months, years or longer. Immunotherapy may be the closest to a cure. Treatment involves applying drops under the tongue (typically less than 1 minute per day) for 3-4 years and clinical studies consistently report high success rates for the form of treatment. 


Contributed by: Dr David Chin Chao-Wu