Disease: Chronic Rhinitis and Post-Nasal Drip

    Chronic rhinitis and post-nasal drip facts

    • The nose functions to warm, clean, and humidify air as well as playing a role in the sensations of smell and taste.
    • Rhinitis (inflammation of the nose) may or may not be caused by allergies.
    • Certain conditions alter the production, character, and clearance of nasal secretions.
    • Treatment of chronic rhinitis and post-nasal drip depends on the underlying cause.

    What is the purpose of the nose?

    The purpose of the nose is to warm, clean, and humidify the air you breathe, help you to smell, and for taste enhancement. A normal person will produce about two quarts of fluid each day (mucus), which aids in keeping the respiratory tract clean and moist. Tiny microscopic hairs (cilia) line the surfaces of the nasal cavity, helping to brush away particles. Eventually the mucus blanket is moved to the back of the throat where it is unconsciously swallowed. This entire process is closely regulated by several body systems.

    The nose is separated into two passageways (left and right nostrils) by a structure called the septum. Protruding into each breathing passage are bony projections, called turbinates, which help to increase the surface area of the inside of the nose. There are three turbinates on each side of the nose (inferior or lower turbinates, middle turbinates, superior or upper turbinates). The sinuses are two pairs of air-filled chambers which empty into the nasal cavity. Their purpose is not really known, but may help to reduce the weight of the skull, enhance lung function by producing nitric oxide, and contribute to voice character.

    Picture of the SinusesDetailed Picture of the Sinuses

    What are rhinitis and post-nasal drip?

    Rhinitis is a very common condition and has many different causes. Basically, rhinitis may be defined as inflammation of the inner lining of the nose. More specifically speaking, it may be defined by the presence of one or more of the following symptoms:

    • Rhinorrhea (runny nose)
    • Nasal itching
    • Nasal congestion
    • Sneezing

    A significant association exists between rhinitis (allergic), asthma, and chronic sinusitis (inflammation of the sinuses for >12 weeks) in some individuals. Some evidence suggests that 1 to 3 of every 5 patients has multiple conditions.

    Post-nasal drip is mucus accumulation in the back of the nose and throat leading to, or giving the sensation of, mucus dripping downward from the back of the nose. One of the most common characteristics of chronic rhinitis is post-nasal drip. Post-nasal drip may lead to chronic sore throat, chronic cough, or throat clearing. Post-nasal drip can be caused by excessive or thick secretions, or impairment in the normal clearance of mucus from the nose and throat.

    What causes rhinitis?

    Rhinitis has many possible causes. Rhinitis can be either acute orchronic, and is categorized into three areas: allergic rhinitis, non-allergic rhinitis, and mixed rhinitis, which is a combination of the previous two.

    Allergic rhinitis is the most common cause of rhinitis. It is caused by environmental allergies and is characterized by an itchy/runny nose, sneezing, and nasal congestion. Other allergic symptoms include:

    • itchy ears and throat,
    • Eustachian tube problems (the tube connecting the inner ear to the back of the throat),
    • red/watery eyes,
    • cough,
    • fatigue/loss of concentration/lack of energy from loss of sleep, and
    • headaches or facial tenderness (not typical).

    People with allergic rhinitis also have a higher incidence of asthma and eczema, which are also mainly allergic in origin.

    Seasonal allergic rhinitis (hay fever) is usually caused by pollen in the air, and sensitive patients have symptoms during peak times during the year.

    Perennial allergic rhinitis, a type of chronic rhinitis is a year-round problem, and is often caused by indoor allergens (particles that cause allergies), such as dust and animal dander in addition to pollens that may exist at the time. Symptoms tend to occur regardless of the time of the year.

    Is rhinitis always related to allergies?

    No, rhinitis may have many causes other than allergies. Some of these other types of rhinitis are listed below.

    Non-allergic rhinitis occurs in those patients in whom an allergic or other causes of rhinitis cannot be identified. Forms of non-allergic rhinitis include:

    1. idiopathic rhinitis
    2. vasomotor rhinitis,
    3. gustatory rhinitis,
    4. rhinitis of pregnancy,
    5. atrophic rhinitis, and
    6. non-allergic rhinitis with nasal eosinophilia syndrome (NARES).

    These conditions may not have the other allergic manifestations such as, itchy and runny eyes and are also more persistent and less seasonal.

    • Idiopathic rhinitis often does not have a specific cause identified, but commonly includes upper respiratory infections.
    • Vasomotor rhinitis is thought to occur because of abnormal regulation of nasal blood flow and may be induced by temperature fluctuations in the environment such as, cold or dry air, or irritants such as:
      • air pollution,
      • smog,
      • tobacco smoke,
      • car exhaust, or
      • strong odors such as, detergents or fragrances.
    • Gustatory rhinitis may present predominantly as runny nose (rhinorrhea) related to consumption of hot or spicy food.
    • Rhinitis of pregnancy or, generally speaking, hormonal alterations as seen with pregnancy, menopause, and some thyroid changes have been linked to rhinitis.
    • Atrophic rhinitis following extensive sinus surgery or from a rare nasal bacterial infection.
    • Non-allergic rhinitis with nasal eosinophilia syndrome (NARES) is characterized by a clear nasal discharge. The nasal discharge is found to have eosinophils (allergic cell type), although the patient may not have any other evidence of allergy by skin testing or history or symptoms.

    Occupational rhinitis may arise from exposure to irritants at a person's workplace with improvement of symptoms after the person leaves the workplace.

    Other causes of rhinitis may be related to:

    • certain medications (oral contraceptives, some blood pressure medications, some anxiety medications, some erectile dysfunction medications, and some anti-inflammatory medications), or
    • some nasal structural abnormalities (deviated septum, perforated septum, tumors, nasal polyps, or foreign bodies).

    Infections, mostly viral, are a common cause of rhinitis. Viral rhinitisis usually not chronic and may resolve by itself.

    Sometimes rhinitis may be related to other generalized medical conditions such as:

    • acid reflux disease (GERD),
    • Wegener's granulomatosis,
    • sarcoidosis,
    • cystic fibrosis, and
    • other less common conditions.

    What conditions cause an abnormal production of nasal secretions?

    The following conditions are often associated with increased nasal drainage. Also, it would not be unusual to have more than one factor involved in a particular individual.

    The following may cause an increase in thin secretions:

    • viruses
    • allergies
    • cold temperatures
    • certain foods or spices
    • pregnancy or hormonal changes
    • drug side-effects (particularly certain high blood pressure medications)
    • structural problems (deviated septum, large turbinates)
    • vasomotor rhinitis (an abnormal regulatory problem with the nose)

    Decreasing the fluid content of the mucus usually thickens the secretions leading to the impression of increased mucus. The following may cause thickened secretions:

    • low humidity
    • sinus or nasal infections
    • foreign bodies (especially if the drainage is from one side)
    • environmental irritants (tobacco smoke, smog)
    • structural problems (deviated septum, enlarged turbinates, enlarged adenoids)
    • advanced age - mucus membrane lining the nose can shrink with age leading to a reduced volume of secretions that are thicker
    • hormonal problems
    • drug side-effects (antihistamines)

    What conditions cause an impaired clearance of nasal secretions?

    The primary reason for impaired clearance of nasal secretions within the nasal cavities is from smoking. Smoking impairs the movement of the cilia (microscopic hairs) and their ability to push the secretions out of the nasal cavity to be swallowed.Other conditions that can impact clearance of secretions in the nose include allergies and some genetic disorders.

    Swallowing problems can make it difficult to clear normal secretions from the back of the throat. This may result in the accumulation of material in the throat, which can spill into the voice box, causing hoarseness, throat clearing, or cough. The following factors can contribute to swallowing problems:

    • Advancing age: This will lead to decreased strength and coordination in swallowing.
    • Stress: Stress leads to muscle spasm or "lump in throat." Also a nervous habit of frequent throat clearing will make the situation worse.
    • Narrowing of the throat due to tumors or other conditions: This will impair the passage of food.
    • Gastroesophageal reflux (GERD)
    • Nerve or muscle disorders: (stroke, and muscle diseases, etc.)

    How can chronic rhinitis and post-nasal drip be treated?

    The treatment is generally directed towards the underlying cause.

    Identifying and avoiding allergens

    An allergy is an exaggerated "normal body" inflammatory response to an outside substance. These substances that cause allergies are called allergens, and typically include:

    • pollen,
    • mold,
    • animal dander (cats and dogs),
    • house dust,
    • dust mites and cockroaches, and
    • some foods.

    The best treatment is avoidance of these allergens, but in many cases this may be very difficult if not impossible. Some helpful suggestions include:

    • Use a pollen mask when mowing the grass or cleaning the house.
    • Install an air purifier or at least change the air filters monthly in heating and air conditioning systems.
    • Use cotton or synthetic materials such as Dacron in pillows and bedding.
    • Enclose mattress in plastic.
    • Select pillow covers.
    • Consider using a humidifier.
    • Keep windows closed during high pollen times.
    • Eliminate house plants, and bathe pets frequently or give away dander-producing pets.

    Avoidance of nasal irritants: Nasal irritants usually do not lead to the typical immune response seen with classical allergies, but nevertheless they can mimic or make allergies worse, as in vasomotor rhinitis. Examples of these irritants include cigarette smoke, perfume, aerosol sprays, smoke, smog and car exhaust.

    Identifying the possible allergens may be just as hard as avoiding them. In some, this may be identified by a very careful history taken by their physician. Details of the patient's possible exposure to allergens or irritant at home or the workplace may give some clues. In others, even a very detailed history may not reveal a possible trigger. Therefore, a consultation with an allergy specialist (allergy and immunologist) may be prudent. The allergy doctor may perform some simple skin tests to try to identify common environmental allergies.

    What medications can be used to treat rhinitis and post-nasal drip?

    In addition to measures noted above, medications may also be used for the treatment of rhinitis and post-nasal drip.

    For allergic rhinitis and post-nasal drip many medications are used.

    Steroid nasal sprays

    The experts recommend using intra-nasal glucocorticoids (steroid sprays applied directly into the nose) as the first line of treatment. Steroids are known to be potent anti-inflammatory and anti-allergic agents and they are known to relieve most of the associated symptoms of runny and itchy nose, nasal congestion, sneezing, and post-nasal drip.

    Their use must be monitored and tapered by the prescribing physician as long-term use may have significant side effects. Examples of the nasal steroids include:

    • beclomethasone (Beconase),
    • flunisolide (Nasarel),
    • budesonide (Rhinocort),
    • fluticasone propionate (Flonase),
    • mometasone furoate (Nasonex), and
    • fluticasone furoate (Veramyst).

    Learn more about: Beconase | Flonase | Nasonex | Veramyst

    These are generally used once or twice daily. It is recommended to tilt the head forward during the administration to avoid from spraying the back of the throat instead of the nose.

    Oral steroids

    These drugs [prednisone, methylprednisolone (Medrol), hydrocortisone (Hydrocortone, Cortef)] are highly effective in allergic patients. A patient can experience potential serious side effects when using these medications for extended periods, however. They are best used for the short-term management of allergic problems, and a physician must always monitor their use. These are reserved only for very severe cases that do not respond to the usual treatment with nasal steroids and antihistamines.

    Learn more about: Medrol | Cortef

    Antihistamines

    Allergy medications, such as antihistamines, are also frequently used to allergic rhinitis and post-nasal drip. These are generally used as the second line of treatment after the nasal steroids or in combination with them. Histamines are naturally occurring chemicals released in response to an exposure to an allergen, which are responsible for the congestion, sneezing, and runny nose typical of an allergic reaction. Antihistamines are drugs that block the histamine reaction. These medications work best when given prior to exposure.

    Antihistamines can be divided into two groups:

    1. Sedating, or first generation [diphenhydramine (Benadryl),chlorpheniramine (Chlor-Trimeton), clemastine (Tavist)]. Sedating antihistamines should be avoided in those patients who need to drive or use dangerous equipment.
    2. Non-sedating or second generation [loratadine (Claritin), cetirizine (Zyrtec),fexofenadine (Allegra)]. Non-sedating antihistamines can have serious drug interactions. Most of these are found over the counter.

    There is also a nasal antihistamine preparation that has been shown to be very effective in treating allergic rhinitis, called azelastine nasal (Astelin).

    Learn more about: Astelin

    Decongestant sprays

    Examples of decongestant sprays include:

    • oxymetazoline (Afrin), and
    • phenylephrine (Neo-Synephrine)

    Learn more about: Neo-Synephrine

    Decongestant sprays quickly reduce swelling of nasal tissues by shrinking the blood vessels. They improve breathing and drainage over the short-term. Unfortunately, if they are used for more than a few days they can become highly addictive (rhinitis medicamentosa). Long-term use can lead to serious damage. Therefore, their use should limited to only 3 to 5 days.

    Oral decongestants

    Oral decongestants temporarily reduce swelling of sinus and nasal tissues leading to an improvement of breathing and a decrease in obstruction. They may also stimulate the heart and raise the blood pressure and should be avoided by patients who have high blood pressure, heart irregularities, glaucoma, thyroid problems, or difficulty in urination. The most common decongestant is pseudoephedrine (Sudafed).

    Learn more about: Sudafed

    Cromolyn sodium (Nasalcrom)

    Learn more about: Nasalcrom

    Cromolyn sodium (Nasalcrom) is a spray helps to stabilize allergy cells (mast cells) by preventing release of allergy mediators, like histamine. They are most effective if used before the start of allergy season or prior to exposure to a known allergen.

    Montelukast (Singulair)

    Learn more about: Singulair

    Montelukast (Singulair) is an agent that acts similar to antihistamine, although it is involved in another pathway in allergic response. It has been shown to be less beneficial than the steroid nasal sprays, but equally as effective as some of the antihistamines. It may be useful in patients who do not wish to use nasal sprays or those who have co-existing asthma.

    Ipratropium (Atrovent nasal)

    Ipratropium (Atrovent nasal) is used as a nasal spray and helps to control nasal drainage mediated by neural pathways. It will not treat an allergy, but it does decrease nasal drainage.

    Mucus thinning agents

    Mucus thinning agents are utilized to make secretions thinner and less sticky. They help to prevent pooling of secretions in the back of the nose and throat where they often cause choking. The thinner secretions pass more easily. Guaifenesin (Humibid, Fenesin, Organidin) is a commonly used formulation. If a rash develops or there is swelling of the salivary glands, they should be discontinued. Inadequate fluid intake will also thicken secretions. Increasing the amount of water consumed, and eliminating caffeine from the diet and the use of diuretics are also helpful.

    Immunotherapy

    Immunoptherapy treatment has a goal of reducing a person's response to an allergen. After identification of an allergen, small amounts are given back to the sensitive patient. Over time, the patient will develop blocking antibodies to the allergen and they become less sensitive and less reactive to the substance causing allergic symptoms. The allergens are given in the form of allergy shots or by delivery of the allergen under the tongue (sub-lingual therapy). Sublingual therapy has been more common in Europe. In either method, the goal is to interfere with the allergic response to specific allergens to which the patient is sensitive

    Combinations

    These drugs are made up of one or more anti-allergy medications. They are usually a combination of an antihistamine and a decongestant. Other common combinations include mucus thinning agents, anti-cough agents, aspirin, ibuprofen (Advil), or acetaminophen (Tylenol). They help to simplify dosing and often will work either together for even more benefit or have counteracting side effects that eliminate or reduce total side effects.

    Learn more about: Tylenol

    There are some combination nasal preparations available as well to target the tissue of the nose. The combination of azelastine and fluticasone (Dymista) combines a nasal anti-histamine and steroid to help provide relief of seasonal allergic rhinitis symptoms.

    What can be used to treat non-allergic rhinitis?

    Treatment of non-allergic rhinitis is similar to the treatment of allergic rhinitis.

    Steroid nasal sprays and nasal antihistamines [azelastine (Astelin)] as described in more detail in the previous section, are the main stray of therapy for non-allergic rhinitis. Combination therapy using steroid nasal spray and nasal antihistamine has been shown to be more beneficial.

    The other therapies, such as ipratropium (Atrovent) and decongestants, may also be used in patients who continue to have symptoms despite proper therapy with nasal steroids and nasal antihistamines.

    Does salt water have any role in the treatment of rhinitis and post-nasal drip?

    Irrigating the nose with salt water is very useful therapy for non-allergic rhinitis and especially beneficial for treating post-nasal drip.

    Nasal irrigation utilizing a buffered isotonic saline solution (salt water) helps to reduce swollen and congested nasal and sinus tissues. In addition, it washes out thickened nasal secretions, irritants (smog, pollens, etc.), bacteria, and crusts from the nose and sinuses. Non-prescription nasal sprays (Ocean spray, Ayr, Nasal) can be used frequently, and are very convenient to use.

    Learn more about: hypertonic saline

    • Nasal irrigation can be done several times per day.
    • Nasal irrigation is frequently performed with a syringe or a Water Pik device (the attachment is purchased separately).
    • The irrigating solution can be made by adding two to three heaping teaspoons of non-iodized (does not sting) salt to one pint of room-temperature distilled water. It is best to use Morton Coarse Kosher Salt or Springfield plain salt because table salt may have unwanted additives. To this solution, add one teaspoon of baking soda.
    • Store at room temperature, and always mix the solution before each use.
    • If the solution stings, use less salt.
    • In the beginning, or for children, it is best to start with a weaker salt mixture. It is not unusual to initially have a mild burning sensation the first few times you irrigate.
    • While irrigating the nose, it is best to stand over the sink and irrigate each side of your nose separately. Aim the stream toward the back of your head, not at the top of your head.
    • For young children, the salt water can be put into a small spray container, which can be squirted many times into each side of the nose.

    What are other options for the treatment of rhinitis and post-nasal drip?

    Treatment can also be directed towards specific causes of rhinitis and post-nasal drip as outlined below.

    Treatment of infection

    The most common nasal infection is a viral infection known as "the common cold." The virus causes swelling of the nasal membranes and production of thick clear mucus. Symptoms usually last several days. If "a cold" goes on for many days and is associated with yellow or green drainage, it may have become secondarily infected by bacteria. Very few patients with a common cold from a virus will go on to have acute bacterial rinosinusitis from sinus blockage and impaired sinus function. Sinus blockage can lead to acute sinusitis (less than 4 weeks in duration) or chronic sinusitis (lasting 12 weeks with continuous symptoms), which can be characterized by nasal congestion, thick mucus, and facial or dental pain. From 4 to 12 weeks, the symptoms are classified as subacute sinusitis or recurrent acute sinusitis. Prompt and aggressive treatment of infection by your physician, only occasionally with antibiotics, along with supplemental medications. In some cases surgery, will help to re-establish the normal drainage pathways.

    Symptomatic treatment often involves pain relief, decongestants, mucous thinning medications, saline rinses, and anti-histamine therapy.

    Reflux Medications

    For rhinitis that is thought to be related to acid reflux disease, antacids (Maalox, Mylanta) can help to neutralize acid contents, whereas other medications [cimetidine (Tagamet), famotidine (Pepcid), omeprazole (Prilosec), esomeprazole (Nexium)] can decrease stomach acid production. Non-pharmacological treatments include avoiding late evening meals and snacks and the elimination of alcohol and caffeine. Elevating the head of the bed may help to decrease reflux during sleep.

    Surgery

    Structural problems with the nose and sinuses may ultimately require surgical correction. Obviously, this should be done only after more conservative measures have been tried and failed. Surgery is not a replacement for good allergy control and treatment. Septal deviation, septal spurs, septal perforation, enlargement of the turbinates, and nasal/sinus polyps can lead to pooling of or overproduction of secretions, blockage of the normal pathways leading to chronic sinusitis, and chronic irritation. The surgery is performed by an ear-nose-throat doctor (otolaryngologist). Surgery can also enhance the delivery of nasal medications and rinses into the nasal cavities.

    What are rhinitis and post-nasal drip?

    Rhinitis is a very common condition and has many different causes. Basically, rhinitis may be defined as inflammation of the inner lining of the nose. More specifically speaking, it may be defined by the presence of one or more of the following symptoms:

    • Rhinorrhea (runny nose)
    • Nasal itching
    • Nasal congestion
    • Sneezing

    A significant association exists between rhinitis (allergic), asthma, and chronic sinusitis (inflammation of the sinuses for >12 weeks) in some individuals. Some evidence suggests that 1 to 3 of every 5 patients has multiple conditions.

    Post-nasal drip is mucus accumulation in the back of the nose and throat leading to, or giving the sensation of, mucus dripping downward from the back of the nose. One of the most common characteristics of chronic rhinitis is post-nasal drip. Post-nasal drip may lead to chronic sore throat, chronic cough, or throat clearing. Post-nasal drip can be caused by excessive or thick secretions, or impairment in the normal clearance of mucus from the nose and throat.

    What causes rhinitis?

    Rhinitis has many possible causes. Rhinitis can be either acute orchronic, and is categorized into three areas: allergic rhinitis, non-allergic rhinitis, and mixed rhinitis, which is a combination of the previous two.

    Allergic rhinitis is the most common cause of rhinitis. It is caused by environmental allergies and is characterized by an itchy/runny nose, sneezing, and nasal congestion. Other allergic symptoms include:

    • itchy ears and throat,
    • Eustachian tube problems (the tube connecting the inner ear to the back of the throat),
    • red/watery eyes,
    • cough,
    • fatigue/loss of concentration/lack of energy from loss of sleep, and
    • headaches or facial tenderness (not typical).

    People with allergic rhinitis also have a higher incidence of asthma and eczema, which are also mainly allergic in origin.

    Seasonal allergic rhinitis (hay fever) is usually caused by pollen in the air, and sensitive patients have symptoms during peak times during the year.

    Perennial allergic rhinitis, a type of chronic rhinitis is a year-round problem, and is often caused by indoor allergens (particles that cause allergies), such as dust and animal dander in addition to pollens that may exist at the time. Symptoms tend to occur regardless of the time of the year.

    Is rhinitis always related to allergies?

    No, rhinitis may have many causes other than allergies. Some of these other types of rhinitis are listed below.

    Non-allergic rhinitis occurs in those patients in whom an allergic or other causes of rhinitis cannot be identified. Forms of non-allergic rhinitis include:

    1. idiopathic rhinitis
    2. vasomotor rhinitis,
    3. gustatory rhinitis,
    4. rhinitis of pregnancy,
    5. atrophic rhinitis, and
    6. non-allergic rhinitis with nasal eosinophilia syndrome (NARES).

    These conditions may not have the other allergic manifestations such as, itchy and runny eyes and are also more persistent and less seasonal.

    • Idiopathic rhinitis often does not have a specific cause identified, but commonly includes upper respiratory infections.
    • Vasomotor rhinitis is thought to occur because of abnormal regulation of nasal blood flow and may be induced by temperature fluctuations in the environment such as, cold or dry air, or irritants such as:
      • air pollution,
      • smog,
      • tobacco smoke,
      • car exhaust, or
      • strong odors such as, detergents or fragrances.
    • Gustatory rhinitis may present predominantly as runny nose (rhinorrhea) related to consumption of hot or spicy food.
    • Rhinitis of pregnancy or, generally speaking, hormonal alterations as seen with pregnancy, menopause, and some thyroid changes have been linked to rhinitis.
    • Atrophic rhinitis following extensive sinus surgery or from a rare nasal bacterial infection.
    • Non-allergic rhinitis with nasal eosinophilia syndrome (NARES) is characterized by a clear nasal discharge. The nasal discharge is found to have eosinophils (allergic cell type), although the patient may not have any other evidence of allergy by skin testing or history or symptoms.

    Occupational rhinitis may arise from exposure to irritants at a person's workplace with improvement of symptoms after the person leaves the workplace.

    Other causes of rhinitis may be related to:

    • certain medications (oral contraceptives, some blood pressure medications, some anxiety medications, some erectile dysfunction medications, and some anti-inflammatory medications), or
    • some nasal structural abnormalities (deviated septum, perforated septum, tumors, nasal polyps, or foreign bodies).

    Infections, mostly viral, are a common cause of rhinitis. Viral rhinitisis usually not chronic and may resolve by itself.

    Sometimes rhinitis may be related to other generalized medical conditions such as:

    • acid reflux disease (GERD),
    • Wegener's granulomatosis,
    • sarcoidosis,
    • cystic fibrosis, and
    • other less common conditions.

    What conditions cause an abnormal production of nasal secretions?

    The following conditions are often associated with increased nasal drainage. Also, it would not be unusual to have more than one factor involved in a particular individual.

    The following may cause an increase in thin secretions:

    • viruses
    • allergies
    • cold temperatures
    • certain foods or spices
    • pregnancy or hormonal changes
    • drug side-effects (particularly certain high blood pressure medications)
    • structural problems (deviated septum, large turbinates)
    • vasomotor rhinitis (an abnormal regulatory problem with the nose)

    Decreasing the fluid content of the mucus usually thickens the secretions leading to the impression of increased mucus. The following may cause thickened secretions:

    • low humidity
    • sinus or nasal infections
    • foreign bodies (especially if the drainage is from one side)
    • environmental irritants (tobacco smoke, smog)
    • structural problems (deviated septum, enlarged turbinates, enlarged adenoids)
    • advanced age - mucus membrane lining the nose can shrink with age leading to a reduced volume of secretions that are thicker
    • hormonal problems
    • drug side-effects (antihistamines)

    What conditions cause an impaired clearance of nasal secretions?

    The primary reason for impaired clearance of nasal secretions within the nasal cavities is from smoking. Smoking impairs the movement of the cilia (microscopic hairs) and their ability to push the secretions out of the nasal cavity to be swallowed.Other conditions that can impact clearance of secretions in the nose include allergies and some genetic disorders.

    Swallowing problems can make it difficult to clear normal secretions from the back of the throat. This may result in the accumulation of material in the throat, which can spill into the voice box, causing hoarseness, throat clearing, or cough. The following factors can contribute to swallowing problems:

    • Advancing age: This will lead to decreased strength and coordination in swallowing.
    • Stress: Stress leads to muscle spasm or "lump in throat." Also a nervous habit of frequent throat clearing will make the situation worse.
    • Narrowing of the throat due to tumors or other conditions: This will impair the passage of food.
    • Gastroesophageal reflux (GERD)
    • Nerve or muscle disorders: (stroke, and muscle diseases, etc.)

    How can chronic rhinitis and post-nasal drip be treated?

    The treatment is generally directed towards the underlying cause.

    Identifying and avoiding allergens

    An allergy is an exaggerated "normal body" inflammatory response to an outside substance. These substances that cause allergies are called allergens, and typically include:

    • pollen,
    • mold,
    • animal dander (cats and dogs),
    • house dust,
    • dust mites and cockroaches, and
    • some foods.

    The best treatment is avoidance of these allergens, but in many cases this may be very difficult if not impossible. Some helpful suggestions include:

    • Use a pollen mask when mowing the grass or cleaning the house.
    • Install an air purifier or at least change the air filters monthly in heating and air conditioning systems.
    • Use cotton or synthetic materials such as Dacron in pillows and bedding.
    • Enclose mattress in plastic.
    • Select pillow covers.
    • Consider using a humidifier.
    • Keep windows closed during high pollen times.
    • Eliminate house plants, and bathe pets frequently or give away dander-producing pets.

    Avoidance of nasal irritants: Nasal irritants usually do not lead to the typical immune response seen with classical allergies, but nevertheless they can mimic or make allergies worse, as in vasomotor rhinitis. Examples of these irritants include cigarette smoke, perfume, aerosol sprays, smoke, smog and car exhaust.

    Identifying the possible allergens may be just as hard as avoiding them. In some, this may be identified by a very careful history taken by their physician. Details of the patient's possible exposure to allergens or irritant at home or the workplace may give some clues. In others, even a very detailed history may not reveal a possible trigger. Therefore, a consultation with an allergy specialist (allergy and immunologist) may be prudent. The allergy doctor may perform some simple skin tests to try to identify common environmental allergies.

    What medications can be used to treat rhinitis and post-nasal drip?

    In addition to measures noted above, medications may also be used for the treatment of rhinitis and post-nasal drip.

    For allergic rhinitis and post-nasal drip many medications are used.

    Steroid nasal sprays

    The experts recommend using intra-nasal glucocorticoids (steroid sprays applied directly into the nose) as the first line of treatment. Steroids are known to be potent anti-inflammatory and anti-allergic agents and they are known to relieve most of the associated symptoms of runny and itchy nose, nasal congestion, sneezing, and post-nasal drip.

    Their use must be monitored and tapered by the prescribing physician as long-term use may have significant side effects. Examples of the nasal steroids include:

    • beclomethasone (Beconase),
    • flunisolide (Nasarel),
    • budesonide (Rhinocort),
    • fluticasone propionate (Flonase),
    • mometasone furoate (Nasonex), and
    • fluticasone furoate (Veramyst).

    Learn more about: Beconase | Flonase | Nasonex | Veramyst

    These are generally used once or twice daily. It is recommended to tilt the head forward during the administration to avoid from spraying the back of the throat instead of the nose.

    Oral steroids

    These drugs [prednisone, methylprednisolone (Medrol), hydrocortisone (Hydrocortone, Cortef)] are highly effective in allergic patients. A patient can experience potential serious side effects when using these medications for extended periods, however. They are best used for the short-term management of allergic problems, and a physician must always monitor their use. These are reserved only for very severe cases that do not respond to the usual treatment with nasal steroids and antihistamines.

    Learn more about: Medrol | Cortef

    Antihistamines

    Allergy medications, such as antihistamines, are also frequently used to allergic rhinitis and post-nasal drip. These are generally used as the second line of treatment after the nasal steroids or in combination with them. Histamines are naturally occurring chemicals released in response to an exposure to an allergen, which are responsible for the congestion, sneezing, and runny nose typical of an allergic reaction. Antihistamines are drugs that block the histamine reaction. These medications work best when given prior to exposure.

    Antihistamines can be divided into two groups:

    1. Sedating, or first generation [diphenhydramine (Benadryl),chlorpheniramine (Chlor-Trimeton), clemastine (Tavist)]. Sedating antihistamines should be avoided in those patients who need to drive or use dangerous equipment.
    2. Non-sedating or second generation [loratadine (Claritin), cetirizine (Zyrtec),fexofenadine (Allegra)]. Non-sedating antihistamines can have serious drug interactions. Most of these are found over the counter.

    There is also a nasal antihistamine preparation that has been shown to be very effective in treating allergic rhinitis, called azelastine nasal (Astelin).

    Learn more about: Astelin

    Decongestant sprays

    Examples of decongestant sprays include:

    • oxymetazoline (Afrin), and
    • phenylephrine (Neo-Synephrine)

    Learn more about: Neo-Synephrine

    Decongestant sprays quickly reduce swelling of nasal tissues by shrinking the blood vessels. They improve breathing and drainage over the short-term. Unfortunately, if they are used for more than a few days they can become highly addictive (rhinitis medicamentosa). Long-term use can lead to serious damage. Therefore, their use should limited to only 3 to 5 days.

    Oral decongestants

    Oral decongestants temporarily reduce swelling of sinus and nasal tissues leading to an improvement of breathing and a decrease in obstruction. They may also stimulate the heart and raise the blood pressure and should be avoided by patients who have high blood pressure, heart irregularities, glaucoma, thyroid problems, or difficulty in urination. The most common decongestant is pseudoephedrine (Sudafed).

    Learn more about: Sudafed

    Cromolyn sodium (Nasalcrom)

    Learn more about: Nasalcrom

    Cromolyn sodium (Nasalcrom) is a spray helps to stabilize allergy cells (mast cells) by preventing release of allergy mediators, like histamine. They are most effective if used before the start of allergy season or prior to exposure to a known allergen.

    Montelukast (Singulair)

    Learn more about: Singulair

    Montelukast (Singulair) is an agent that acts similar to antihistamine, although it is involved in another pathway in allergic response. It has been shown to be less beneficial than the steroid nasal sprays, but equally as effective as some of the antihistamines. It may be useful in patients who do not wish to use nasal sprays or those who have co-existing asthma.

    Ipratropium (Atrovent nasal)

    Ipratropium (Atrovent nasal) is used as a nasal spray and helps to control nasal drainage mediated by neural pathways. It will not treat an allergy, but it does decrease nasal drainage.

    Mucus thinning agents

    Mucus thinning agents are utilized to make secretions thinner and less sticky. They help to prevent pooling of secretions in the back of the nose and throat where they often cause choking. The thinner secretions pass more easily. Guaifenesin (Humibid, Fenesin, Organidin) is a commonly used formulation. If a rash develops or there is swelling of the salivary glands, they should be discontinued. Inadequate fluid intake will also thicken secretions. Increasing the amount of water consumed, and eliminating caffeine from the diet and the use of diuretics are also helpful.

    Immunotherapy

    Immunoptherapy treatment has a goal of reducing a person's response to an allergen. After identification of an allergen, small amounts are given back to the sensitive patient. Over time, the patient will develop blocking antibodies to the allergen and they become less sensitive and less reactive to the substance causing allergic symptoms. The allergens are given in the form of allergy shots or by delivery of the allergen under the tongue (sub-lingual therapy). Sublingual therapy has been more common in Europe. In either method, the goal is to interfere with the allergic response to specific allergens to which the patient is sensitive

    Combinations

    These drugs are made up of one or more anti-allergy medications. They are usually a combination of an antihistamine and a decongestant. Other common combinations include mucus thinning agents, anti-cough agents, aspirin, ibuprofen (Advil), or acetaminophen (Tylenol). They help to simplify dosing and often will work either together for even more benefit or have counteracting side effects that eliminate or reduce total side effects.

    Learn more about: Tylenol

    There are some combination nasal preparations available as well to target the tissue of the nose. The combination of azelastine and fluticasone (Dymista) combines a nasal anti-histamine and steroid to help provide relief of seasonal allergic rhinitis symptoms.

    What can be used to treat non-allergic rhinitis?

    Treatment of non-allergic rhinitis is similar to the treatment of allergic rhinitis.

    Steroid nasal sprays and nasal antihistamines [azelastine (Astelin)] as described in more detail in the previous section, are the main stray of therapy for non-allergic rhinitis. Combination therapy using steroid nasal spray and nasal antihistamine has been shown to be more beneficial.

    The other therapies, such as ipratropium (Atrovent) and decongestants, may also be used in patients who continue to have symptoms despite proper therapy with nasal steroids and nasal antihistamines.

    Does salt water have any role in the treatment of rhinitis and post-nasal drip?

    Irrigating the nose with salt water is very useful therapy for non-allergic rhinitis and especially beneficial for treating post-nasal drip.

    Nasal irrigation utilizing a buffered isotonic saline solution (salt water) helps to reduce swollen and congested nasal and sinus tissues. In addition, it washes out thickened nasal secretions, irritants (smog, pollens, etc.), bacteria, and crusts from the nose and sinuses. Non-prescription nasal sprays (Ocean spray, Ayr, Nasal) can be used frequently, and are very convenient to use.

    Learn more about: hypertonic saline

    • Nasal irrigation can be done several times per day.
    • Nasal irrigation is frequently performed with a syringe or a Water Pik device (the attachment is purchased separately).
    • The irrigating solution can be made by adding two to three heaping teaspoons of non-iodized (does not sting) salt to one pint of room-temperature distilled water. It is best to use Morton Coarse Kosher Salt or Springfield plain salt because table salt may have unwanted additives. To this solution, add one teaspoon of baking soda.
    • Store at room temperature, and always mix the solution before each use.
    • If the solution stings, use less salt.
    • In the beginning, or for children, it is best to start with a weaker salt mixture. It is not unusual to initially have a mild burning sensation the first few times you irrigate.
    • While irrigating the nose, it is best to stand over the sink and irrigate each side of your nose separately. Aim the stream toward the back of your head, not at the top of your head.
    • For young children, the salt water can be put into a small spray container, which can be squirted many times into each side of the nose.

    What are other options for the treatment of rhinitis and post-nasal drip?

    Treatment can also be directed towards specific causes of rhinitis and post-nasal drip as outlined below.

    Treatment of infection

    The most common nasal infection is a viral infection known as "the common cold." The virus causes swelling of the nasal membranes and production of thick clear mucus. Symptoms usually last several days. If "a cold" goes on for many days and is associated with yellow or green drainage, it may have become secondarily infected by bacteria. Very few patients with a common cold from a virus will go on to have acute bacterial rinosinusitis from sinus blockage and impaired sinus function. Sinus blockage can lead to acute sinusitis (less than 4 weeks in duration) or chronic sinusitis (lasting 12 weeks with continuous symptoms), which can be characterized by nasal congestion, thick mucus, and facial or dental pain. From 4 to 12 weeks, the symptoms are classified as subacute sinusitis or recurrent acute sinusitis. Prompt and aggressive treatment of infection by your physician, only occasionally with antibiotics, along with supplemental medications. In some cases surgery, will help to re-establish the normal drainage pathways.

    Symptomatic treatment often involves pain relief, decongestants, mucous thinning medications, saline rinses, and anti-histamine therapy.

    Reflux Medications

    For rhinitis that is thought to be related to acid reflux disease, antacids (Maalox, Mylanta) can help to neutralize acid contents, whereas other medications [cimetidine (Tagamet), famotidine (Pepcid), omeprazole (Prilosec), esomeprazole (Nexium)] can decrease stomach acid production. Non-pharmacological treatments include avoiding late evening meals and snacks and the elimination of alcohol and caffeine. Elevating the head of the bed may help to decrease reflux during sleep.

    Surgery

    Structural problems with the nose and sinuses may ultimately require surgical correction. Obviously, this should be done only after more conservative measures have been tried and failed. Surgery is not a replacement for good allergy control and treatment. Septal deviation, septal spurs, septal perforation, enlargement of the turbinates, and nasal/sinus polyps can lead to pooling of or overproduction of secretions, blockage of the normal pathways leading to chronic sinusitis, and chronic irritation. The surgery is performed by an ear-nose-throat doctor (otolaryngologist). Surgery can also enhance the delivery of nasal medications and rinses into the nasal cavities.

    Source: http://www.rxlist.com

    The treatment is generally directed towards the underlying cause.

    Source: http://www.rxlist.com

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