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Dr. Miller: Allergies, colds or something else? How do you tell and how do you treat them? That's next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Jeremiah Alt. He is an ENT surgeon. That's an ear, nose and throat surgeon. He's a member of the Department of Surgery here at the University of Utah. Jeremiah, how does one tell the difference between an allergic symptoms of nasal discharge versus a common cold or sinusitis? Is there a way to sort of know if you have one or the other?

Dr. Alt: Yeah. That's very difficult. Even very difficult for the physician to figure that out in many cases and requires a thorough history with the patient to figure some of these things out. In general, allergic rhinitis if it's seasonal will occur during the season, where if you have hay fever, you'll get itchy eyes and a runny nose.

Dr. Miller: I always think of hay fever as being itchy.

Dr. Alt: Right.

Dr. Miller: Right? So people are scratching the corners of their eyes and they're blowing and sneezing.

Dr. Alt: Right.

Dr. Miller: The back of the throat is kind of scratchy. Sometimes when I think of the common cold or sinusitis that doesn't feel very itchy. That's [inaudible 00:01:15].

Dr. Alt: Right. So the common cold will have some of the similar symptoms, as there's definitely overlap where you can have increased congestion and nasal blockage. You'd probably be more likely, though, to have some facial pain and pressure. We commonly talk about the loss of smell occurring with sinusitis. But this can also occur with allergies as the inner lining inside your nose is swollen and angry, and inflamed and it can block off some of the ability to smell.

One of the big differences though, is we commonly think of discharge. So if the discharge is yellow or green, this is more signs that this is more severe than just an allergic reaction.

Dr. Miller: More inflammation, more at that issue of infection in the sinus.

Dr. Alt: Correct.

Dr. Miller: So one goes to the store to self-remedy what they would consider to be a fairly short course of this problem. If they have rhinitis, that is the itchy symptoms, what should they be using to treat that problem with? I think most of the medications now are purchased or can be purchased over the counter.

Dr. Alt: Correct. The oral antihistamines are a great option, and they've been used for many years. The second generation are non-sedating, like the Benadryls were that can make people very tired. Although, the second generations can make some people tired.

Dr. Miller: I've taken Benadryl and it works as an antihistamine. But man, does it knock me out. I think it does the same with some people and some people, they don't seem to have that fatigue that I get or that a number of people will get.

Dr. Alt: Correct.

Dr. Miller: Now, I've heard with Claritin, which is an example that comes generic as loratadine, that it's not sedating. But do you think it works as well as something like Benadryl or diphenhydramine?

Dr. Alt: Well, partly it's also what we're targeting. The itchiness, I think, works great. Another great antihistamine is Zyrtec. So if the patient has the itchiness with the runny, drippy nose, what we call clear rhinorrhea, or clear, drippy nose, the Zyrtec is actually quite more drying than let's say the Claritin. So we would push the patient more towards the Zyrtec, which is a more drying medication.

Dr. Miller: This is also listed as a non-sedating antihistamine.

Dr. Alt: Correct. One thing to consider is even if the second generations make you drowsy or feel a little fatigued, you can also take them at night which is an option.

Dr. Miller: So sleep a little better and maybe get a little bit better coverage for the allergic symptoms.

Dr. Alt: Yeah. A third option that's more recent is a topical spray antihistamine. This is not taken by the mouth and you can spray it in the nose. This type of antihistamine, I've never seen it cause drowsiness or fatigue in patients, and you can use it on contact. So if you know you're going outside you can quick spray it in your nose to reduce the antihistamine response that you have for your allergies.

Dr. Miller: So Jeremiah, does that require a prescription or is that available over the counter?

Dr. Alt: That one is still a prescription medication. So you really need to get that from you allergist or your ENT, or your primary care doctor.

Dr. Miller: Now, there's another class of medication used to treat allergic rhinitis as well, and that would be the nasal steroids.

Dr. Alt: Yeah. So the nasal steroids actually have great evidence to be used both for allergic rhinitis and for many of the diseases that we talked about in some of the other podcasts, including chronic rhinosinusitis or reoccurring acute rhinosinusitis, where there's just an overall inflammation inside the sinonasal cavity. This just calms the inside of the nose down. It's a topical steroid. It's sprayed within the nose, usually dosed once or twice a day. What I like to think of it, it addresses the root of the problem.

Dr. Miller: The inflammation.

Dr. Alt: The inflammation, correct. So it really reduces the overall amount of goblet cells in the nose, the inflammatory, or those mediators in the nose and the immune system that are really creating the immune system to start with to create this inflammation.

Dr. Miller: Now, do you think that a patient with allergic rhinitis could also take the antihistamine orally, antihistamine nasal spray, and a topical steroid nasal spray, or should they use them separately? What's your thought on that?

Dr. Alt: It really depends on the patient's response and the overall diagnosis that you've come up with your doctor and your treatment plan. However, commonly we like to use both and we feel like patients get a good response by both blocking with an antihistamine and using a topical nasal steroid like Flonase or Nasonex.

Dr. Miller: Both of which they could get over the counter.

Dr. Alt: Correct.

Dr. Miller: It's possible that they could start their own treatment and then if things weren't going well they could end up seeing their physician.

Dr. Alt: There is a new medication, Dymista, that has actually combined the two together. So you can get it in a single spray, which patients are noting that they've really enjoyed using just one medication instead of two separate.

Dr. Miller: Now, let's say they have the common cold or sinusitis. Do the same medications work?

Dr. Alt: Yes. In general, though, we don't typically use antihistamines for chronic sinusitis unless they have a comorbidity or that's one other disease process that they also have on top of the chronic sinusitis that we want to help control symptomology. So if they have allergies and we want to help control some of that drippy nose, postnasal drip symptoms, we can add on an antihistamine. But, yeah, the steroids are great, as we talked about. It's really disease of inflammation, so that topical nasal steroid is ideal for helping.

Dr. Miller: Would you recommend using an oral, what we call, sympathomimetic, like pseudoephedrine or Sudafed for someone who has the common cold or sinusitis?

Dr. Alt: Those are really two different diseases and two different applications for that. For an acute onset cold or viral rhinosinusitis or bacterial, this can help make the patient feel better. I don't think it really helps get you over the illness quicker. But it can help improve your overall well-being. Now, in sinusitis it can also improve your overall feel of increasing your ability to breathe through your nose.

But this doesn't get at the root of the cause of the disease itself, and we commonly don't like to think of using these long-term in a disease like chronic rhinosinusitis, which is a chronic condition. You'd have to use this over potentially months and years, which we're concerned about the possibility of hypertension.

Dr. Miller: Now, you could also use the same medication as the nasal spray for a few days, I understand.

Dr. Alt: Afrin or over-the-counter oxymetazoline is a great sympathomimetic, which really reduces the overall swelling inside the nose. We commonly like to really counsel the patient that these are great short-term. So these are two to three-day treatment options, and then they really need to consider trying to come off of them.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: February 19, 2019
originally published: December 1, 2015

Dr. Miller: So you have a deviated septum. Does that need to be fixed and what symptoms does a deviated symptom cause? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ear, nose and throat physician. He's also a professor here at the University of Utah and a member of the department of surgery. Jeremiah, what's the story of the deviated septum? What is a deviated septum and, if you have one, do you always need to have it fixed?

Dr. Alt: We commonly have patients who come in with complaints of just simple nasal obstruction. Commonly, we have to go through the differential diagnosis of what that is.

Dr. Miller: You mean they can't breathe out of one side or both sides of their nostrils, is that right?

Dr. Alt: Yeah, correct. As a rhinologist, I commonly see patients with sinus disease and congestion and allergies. It also commonly comes up that they just have what's called septal deviation and the septum itself separates basically the right and left side of the nose.

Dr. Miller: So it's your nose bone?

Dr. Alt: Yeah. It's made up of both cartilage bone. The septal deviation can occur just from normal development as everything is not perfectly symmetric as we develop. So it can be deviated to one side or the other. It can also occur from trauma.

Dr. Miller: Getting boxed in the nose.

Dr. Alt: Getting boxed, vehicle accidents, getting bumped in the nose. So after the trauma, this is an acute event, someone would come and say, "I can't breathe out of the right side of the nose," after getting bumped or something that's been there their whole lives and they've just noticed that they're having increased trouble breathing, they can't sleep as well.

Dr. Miller: I'm curious, is deviated septum mostly due to trauma or are people born with it?

Dr. Miller: I think the majority is they're born with it or we have a known etiology of why it's deviated.

Dr. Miller: Okay. So the come to you and they complain that they have difficulty breathing out of one side of the nose or the other or maybe both. At what point do you say, "Well, look, maybe we can repair this surgically if you need to have it repaired"?

Dr. Alt: A lot goes into talking about the deviated septum. In many instances, it's found incidentally, which means we look in their nose and they have a deviated septum but they don't describe nasal obstruction.

Dr. Miller: And under those circumstances, you probably wouldn't recommend surgery?

Dr. Alt: Correct. In those situations, I don't even like to bring it up because then it's something that patients start to worry about. But if it's significantly deviated and we look at it and we assess the patient and it's significantly closing off one side of the airway, we can discuss different surgical options and how to correct that.

Dr. Miller: I have a question. How often do people come to you to looking for cosmetic reconstruction of that bone?

Dr. Alt: That bone itself is usually not cosmetic. It's functional. It doesn't correlate into how the nose looks.

Dr. Miller: So that's a whole different type of surgery.

Dr. Alt: Correct.

Dr. Miller: Not to be confused with the symptoms that a deviated septum would cause.

Dr. Alt: So that's really talking about what we usually term open septorhinoplasty is where were able to change the look of the outside of the nose or [Inaudible 00:03:12] and changed inside the nose for functional breathing, which sometimes we do in combination if the nose is broken or twisted on the outside, we also have to fix the outside in addition to the inside.

Dr. Miller: So how often do you find the patients with need to have surgical correction for a deviated septum?

Dr. Alt: It's actually quite common. It's one of the most common procedures we perform. Not only is it bothersome in the sense that they can't breathe but it substantially affects patients quality of life, which has been shown over and over again by improving the way we breathe through our nose substantially affects how we feel in our day-to-day activities. And this is most likely partially contributing to the way we sleep and the way we get good night's sleep. If we can't breathe through the nose, it forces us to breathe through the mouth and we may have more obstructive events and it can also potentially lead to what we call obstructive sleep apnea.

Dr. Miller: So how do you do the surgery?

Dr. Alt: So there are several options to do surgery and one that we're doing more and more that gets great results is doing endoscopic septoplasties. So it's using angled and straight, rigid endoscopes with that special high-definition camera. And we're able to make very specific and delicate incisions within the septum to take out those crooked parts and so there are no external incisions on the nose. It's all done on the inside of the nose and we feel that patients get great functional responses and, at the same time, have quicker healing.

Dr. Miller: Now, do you tell your patients that they are going under general anesthesia? Do you put them to sleep when you do these or is it a local sort of anesthetic you use?

Dr. Alt: Yeah. I would not recommend local and patients probably wouldn't like me very at the end of the procedure. So we really counsel the patients that these should be done under general anesthesia where they're totally asleep, they're not moving. We have the ability to take our time and do the job correctly.

Dr. Miller: What's the recovery like?

Dr. Alt: Really, the recovery's not too bad. We normally tell the patients they'll probably have to take pain medications for two to three days. Commonly, these type of procedures used to be packed with nasal packing. We no longer pack the nose. We moved into placing splints on the inside of the nose like flexible plastics splints, but even now we're even moving away from that. So many times, we can get away with doing the what we called endoscopic septoplasty without putting any packing in the nose and so this helps patients feels better and recover quicker too, as they're not obstructed with something in their nose we don't have to take out in a week. Usually, at a week, at that point, the patient feels great, usually back to light activity. At two weeks, you're completely healed.

Dr. Miller: Now, for a patient who is going to primary care physician, is a primary care physician usually able to tell if they have a deviated septum or do they usually refer them to make that diagnosis?

Dr. Alt: I think in general, you can determine what we call a caudal septal deviation. It's more towards the front of the nose because you can just look at it with the simple measure of using the nasal speculum looking at the front of the nose and you can tell if it's deviated. Interesting enough, those septums that are more deviated or caudally towards the front of the nose actually usually need a more significant type of surgery, which we'll discuss with the patient, but that usually actually leads to what we call an open septorhinoplasty.

Many times, the posterior septal deviations are easier to fix endoscopically and those are actually harder to diagnose because you need to see further into the nose. So seeing someone like an ENT or rhinology person like myself, we're able to use scopes to look at the septum more posteriorly in the nose to diagnose it.

Dr. Miller: So in conclusion, what three things might you told the patient that would lead them to your doorstep to where you would make a diagnosis of a deviated septum?

Dr. Alt: I think the first thing is if they're having trouble breathing through their nose. Typically, it's unilateral, but it can be both sides, bilateral. The next thing is if this is causing significant changes in how they feel and how they function during the day, if the obstruction's bad enough where they feel like they need some improvement. And third, which we didn't mention, but I think should be mentioned here conclusion, is that many times, medical management can improve nasal obstruction even with septal deviation. So commonly of pretrial of medical management needs to be done before you start discussing . . .

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: January 23, 2019
originally published: November 11, 2015

Dr. Miller: When does short-term sinusitis become long-term or chronic sinusitis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ENT surgeon, Ear, Nose and Throat Physician. He is in the Department of Surgery here at the University of Utah. Jeremiah, all of us, or most of us, I would think, have had acute or sudden onset sinusitis and most of that is due to viruses that last a few days to a week or so and then goes away. When does that become chronic sinusitis? What is chronic sinusitis?

Dr. Alt: Something we commonly see in my practice as a rhinologist, we commonly describe acute sinusitis is either viral or bacterial. And these are really short-term. These consider viral up to seven days and if they're lasting over seven days, then you can start considering this to be potentially a bacterial rhinosinusitis. And, commonly, that's when your provider is going to prescribe an antibiotic. It's normal to have two to three episodes of these either viral or bacterial rhinosinusitis a year in general amongst the population. The concern becomes when these occur more than four times a year. When they occur more than four times a year, we start to come into a category of sinusitis that needs a little bit more specialty care and this is called recurrent acute rhinosinusitis.

Dr. Miller: Now, this is different than what people would experience during an allergy season. It's not just runny nose or itchy nose and sneezing. I mean, you've got pain, discomfort and post-nasal drip and basically during sinus inflammation you don't feel very good.

Dr. Alt: Yeah, that's correct. We commonly really describe this with four big symptoms that I like to talk about and one is nasal obstruction or congestion. Another is a loss of the smell. Third is facial pain and pressure that the patient has during these episodes.

Dr. Miller: Is there any particular place that they'll have the pain?

Dr. Alt: That's some of the studies that we're doing that we quite don't particularly understand, which is a misconception that pain in pressure behind the eyes or underneath eyes correlates well to a sinus infection. That's just not true per se, although . . .

Dr. Miller: I suspect that's also true with headaches. I know there's been this association and I'm not sure that's clear association.

Dr. Alt: Correct. And so commonly we need to do further imaging or testing and to determine if their facial pain and pressure are really due to a sinus infection. And the difference really between acute and chronic then is really about the time course. So acute, we're talking about seven to 10 days. And chronic is really what we describe the something that occurs over 12 weeks. So this is a long, drawn-out infection that they continue to have congestion/obstruction, loss of the smell, facial pain and pressure. And it's not cleared by medical management, which what I mean by that is antibiotics or oral steroids or rinses for the nose or decongestants. And they continue to have a substantially reduced quality of life during this time.

Dr. Miller: How do you deal with if they've had several courses of antibiotics or course of steroids and they're still plugged up, so to speak? What the next step there?

Dr. Alt: Well, part of the issue is, what is the etiology of chronic sinusitis. And the etiology of chronic sinusitis isn't completely known. Many different things can be contributing. This probably has to due to an array of different competing factors, such as allergy or environmental exposure of the poor air quality, could be due to a non-immune issue. So what I'm getting at is the underlying cause of chronic rhinosinusitis is not the bacteria itself or the infection, it's really a disease of inflammation that we're just beginning to understand.

Dr. Miller: When they make it to your doorstep, you end up treating them again medically to see if that works? I know sometimes the duration of the antibiotic course is not necessarily long enough. Sometimes it might help to do both antibiotics and steroids to reduce the inflammation as you speak about. But it sounds like maybe you . . . do you give them another chance of medical therapy before you start talking about surgical correction?

Dr. Alt: Yeah. We normally like to discuss what we consider maximum medical management for patients with this disease. And that really entails four big things that most of the rhinologists across the United States agree with. Recent surveys in 2007 and 2013 looking at all the rhinologists across the United States, they really kind of agree on four big things. And those four big things are was the patient treated with an oral antibiotic. Yes or no? If no, they need to be on it. The next is basically topical corticosteroids. These are drugs you probably heard in the news with Nasonex or . . .

Dr. Miller: Are now over the counter, as I recall.

Dr. Alt: That's correct. Now they're over the counter. So this is a second thing that patients really need to be on. The third is actually some type of high-volume irrigation in their nose. So they're irrigating their nose out with some type a sailing solution. And the fourth would be oral steroids, particularly in those patients where we diagnose as chronic sinusitis with nasal polyps.

Dr. Miller: What about the use of topical sympathomimetics like Afrin that you could buy over the counter? I think some people find initially that that works pretty well. Is there a problem with long-term use of that?

Dr. Alt: Yeah. So short-term use, I think these can be very beneficial to the patient with improving the nasal obstruction and congestion that they feel. And it may also open up the sinuses some to help deliver medication. However, we commonly discourage long-term use of these because they can be somewhat addictive to your nose where your nose can become more inflamed and release more mucus, causing overall longer term deficits with that medication.

Dr. Miller: So let's say that you take with position through the four steps that you've outlined and they don't respond to therapy. What would be the next step?

Dr. Alt: So the next step is an honest discussion of how this is really affecting their overall quality of life. Because the next step we commonly think of is surgery. And surgery isn't a cure for chronic sinusitis, but it does help improve the medical treatment of chronic sinusitis. So I like to really discuss that this is overall an elective procedure. If their chronic sinus disease is affecting them enough, which we know it is just as severe or more severe than those on kidney dialysis or diabetes or hip replacement, so we know it really affects a patient's quality of life. So surgery gives them the opportunity to basically, what I like to term, hit the reset button to help open up the sinuses to help us deliver better medical care.

Dr. Miller: What percentage of patients with chronic sinusitis does end up with surgery as a potential treatment?

Dr. Alt: I think it depends on the surgeon and who you're talking with. I would say here at the University of Utah, we normally deal with more complex cases. Patients many times have already had one or two surgeries and they've been treated with multiple rounds of different types of medical therapies. So in my practice, I would say the majority end up needing some type of surgical management to get to hold off the problem. In the community, it just depends. You can have great response with a thoughtful program and medical treatment for your chronic sinusitis. It doesn't always need to have surgery.

Dr. Miller: So in conclusion, what would you tell a patient who is seeing one of the primary care physician, in terms of when might it be time for them to head on over and seek your expertise?

Dr. Alt: Yeah, as we talked about in the beginning, I think it is . . . really need to consider how many times a year you're getting sinus infections. Is it four or more? How long do you have the sinus problem in general? Is it seven to 10 days or do they really stretch out between one month, three months? And definitely if the disease is stretching onto that two or three months, you probably need to see a specialist.

Dr. Miller: I'd like to put a final plug in and I'll see if you agree with me that if you have acute sinusitis, sudden onset sinusitis that lasts only a week, you shouldn't necessarily be asking for antibiotics.

Dr. Alt: Yeah, that's a great point, the common misperception of that. I think we overprescribe antibiotics and patients commonly feel they have a sinusitis. But with a good medical physical exam, many times it's viral and you can wait. Now, you have to be cautious and every patient's different. Many times, you can have complications from a viral sinusitis. So it's depending on the patient, but overall, in general, you're right.

Dr. Miller: Generally up to seven days.

Dr. Alt: Yep. If it clears in seven days you do not need an antibiotic.

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