Brief Answer:
First rule out Rhinitis Medicamentosa.

Detailed Answer:
Hi,

Thank you for your query.

1. From his medical history it appears that he has developed Rhinitis Medicamentosa due to nasal decongestant sprays.

2. He first needs at least a two week trial with an anti-histamine, an anti-leukotriene, a steroid nasal spray, steam inhalation, saline nasal washes and a gradual tapering and weaning off the Otrivin nasal spray.

3. If he improves with this medication, surgery can be avoided by taking a three to six month/ a year of tapering this course.

4. If patients do not respond well, I do recommend a plain CT PNS , but with a new modification. Ideally he should get the plain CT done when the nasal obstruction/congestion and difficulty in breathing is maximum. Then 5-8 drops of Otrivin nasal drops or a spray is used on both sides of the nose. The plain CT PNS scan is repeated (but charged as one scan like in post-contrast CT) after 15 minutes. The images are compared along with his feedback as to any change/improvement.

5. If you can upload CT PNS images here or directly at bit.ly/Dr-Sumit-Bhatti, I will be able to give you an accurate assessment.

6. Many patients like him benefit from RaVoR (Radio-Frequency Volumetric Reduction) of Turbinates, which is a relatively simpler procedure than Septoplasty.

7. FESS will be required only if the sinuses are involved. Balloon Sinuplasty is a newer, less invasive option, if required.

8. It is important to remember that DNS is very common and many people with severe DNS have absolutely no issues. On the other hand, many people with a perfectly straight nasal septum have nasal obstruction. This is due to nasal inflammation, hypertrophied nasal turbinates and sinusitis.

9. The appearance of the interior of the nose is also important. Video endoscopic images of the nose, nasal smear examination and blood tests will help look for non-allergic rhinitis, intrinsic rhinitis and NARES (Non-allergic Rhinitis with Eosiniophilia Syndrome) and so on. This is because surgery will correct the bony structure, not function of the linings of the nose.

10. Since he snores, check his BMI (Body Mass Index). The nasopharynx must be evaluated. He may benefit from a Septoplasty if the DNS is identified as the sole airway obstruction. Here again Radiofrequency or coblation of the nasal turbinates may help avoid septal surgery.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.

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Brief Answer:
Control RM, Stop smoking, AEC, BSP/RF/Coblation.

Detailed Answer:
Hi,

Thank you for writing back.

1. His severe congestion and cold like symptoms may be due to Rhinitis Medicamentosa due to over use of nasal decongestant sprays.

2. The raised RBC count and Hematocrit in the blood test reports is consistent with smoking. Ask him to stop smoking as advised. Smoking also affects the muco-ciliary clearance of the respiratory system.

3. He has eosinophilia which is under treatment, Repeat an AEC (Absolute Eosinophil Count).

4. As mentioned in point 10 of the previous answer, his BMI is 23.6 which is within normal limits. His nasopharynx does show adenoid hypertrophy. Hence the DNS is not the sole cause of nasal obstruction. Coblation is a better tool for adenoid resection.

5. I am based in XXXXXXX hence a direct consultation may be difficult. I would suggest that you consult Dr. XXXXXXX Levine MD regarding Balloon Sinuplasty (BSP) at the XXXXXXX Nasal Sinus & Sleep Center and the XXXXXXX Clinic Foundation’s Head and Neck Institute. This should be a 6 hour drive or an hour's flight from your location. You may also consult Dr. XXXXXXX F. Castellanos at UAB Medical West, Alabama. This would be a day's travel.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.

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