#blockage
 
Post-Nasal Drainage and Cough, Asthma and Gerd

Post-nasal drainage is commonly caused by rhinitis or sinusitis. Abnormal swelling of the nasal and sinus membranes causes them to produce thick abnormal mucus. This thick mucus can drain into the back of your throat and cause cough, sore throat, nasal blockage, and so forth.

Thick post-nasal drip is a common cause of bad breath. This thick mucus can be white, yellow or even green. If you have sinusitis, it is stagnant in your sinuses and becomes foul-smelling. Then it drips back into your throat to give you bad breath. No mouthwash will take this bad breath away! You need to see a sinus specialist.

Besides post-nasal drip, another common cause of cough is acid reflux. If you have a chronic cough, and especially if you smoke, it is critical that a specialist examine your larynx. You might also need a chest x-ray. Treatment of the cause -- post nasal drainage, acid reflux, or both -- should improve it or resolve your cough.

The backflow of stomach juices, including acids and occasionally ingested foods, constitutes gastroesophageal reflux disease or GERD. Common esophageal symptoms of GERD include repeated bouts of heartburn, difficulty swallowing, hoarseness, lump-in-the-throat sensation, chronic cough and throat clearing, and mucus build-up in the throat. People can suffer from one or more of these symptoms.

Sometimes, the symptoms of GERD can mimic some of the symptoms of sinusitis. The sensation of post-nasal drainage and the need to clear your throat constantly may be due to post-nasal drainage -- but may also be due to GERD. The sinus specialist may therefore examine you in the office to see if there is physical evidence of GERD.

Acid reflux can sometimes actually contribute to sinusitis! That is to say, the acid can travel all the way up to your nose and sinuses (for instance, while you are lying down asleep), and this acid can inflame the nose and sinus linings. This problem is more common in children -- but it may also be seen in adults. At The Nose and Sinus Center, Dr Becker can do a fiberoptic evaluation of your nose and sinuses to pinpoint the problem, and he can show you the specific problem on a video screen. Then he will discuss treatment options. Recent technology has made these treatments more effective, safer, and more comfortable than ever before.

For more information regarding technology, Click here.
To download our book chapter on "Symptoms of sinus disease - taking a closer look", Click here
To download our book chapter on "Reflux and sinus disease", Click here
To download our book chapter on "Asthma and sinus disease", Click here

QUESTIONS AND ANSWERS

Question: What can I do about postnasal drainage?
Answer: Postnasal drainage is a symptom that can be a result of rhinitis or sinusitis: Abnormal swelling of the nasal and sinus membranes causes them to produce thick abnormal mucus. This thick mucus can drain into the back of your throat and cause cough, sore throat, nasal blockage, and so forth.

Question: What can I do about cough?
Answer: Two of the most common causes of cough are post-nasal drip and acid reflux. If you have a chronic cough, and especially if you smoke, it is critical that a specialist examine your larynx. You might also need a chest x-ray. Treatment of the cause -- postnasal drainage, acid reflux, or both -- should improve it or resolve your cough. Question: What if my cough persists despite treatment? Answer: Sometimes a cough can persist even after the cause has been treated. This might be a cough reflex. Often, the cough cycle must be broken by a cough suppressant prescribed by your doctor.

Also, re-examination for other causes is important when a cough persists.

Treatment of postnasal drainage can include treating the cause of the postnasal drainage.

Question: What can I do about bad breath?
Answer: A common cause of bad breath is thick postnasal drip. This thick mucus can be white, yellow or even green. If you have sinusitis, it is stagnant in your sinuses and becomes foul-smelling, then it drips back into your throat to give you bad breath. No mouthwash will take this bad breath away! You need to see a sinus specialist.

On Asthma and Sinusitis

Question: What is the unified airway?
Answer:
The close relationship between the upper (nose and sinuses) and lower (lungs) airways has been widely noted for decades. Patients with asthma and other lung diseases have been observed to also be afflicted with disorders of the nose and sinuses. We know that patients with asthma are much more likely to have chronic sinusitis than those without asthma. We also know that patients with sinusitis are much more likely to have asthma than those without sinusitis. More recently, scientific researchers have begun to uncover the details of this inter-relationship on a molecular level. This interrelationship of airways has been termed the "Unified Airway."

Question: When should I suspect that I might have asthma?
Answer:
Asthma is characterized by hyper-responsiveness of the lower airway. Patients with asthma typically complain of some combination of coughing, wheezing, chest tightness, dyspnea (difficult or painful breathing), and increased mucous production. Typically these signs and symptoms of airway obstruction are reversible. Patients can experience asthma on a wide ranging continuum. For some, asthma "attacks" are infrequent and mild. For others, symptoms can seem continuous and may land patients in and out of the hospital on a regular basis.

In many patients, cough may be the only symptom of asthma. This may make diagnosis particularly challenging, since cough may be a manifestation of a panoply of airway problems ranging from the common cold, acid reflux, and asthma to pneumonia, aspiration, and tuberculosis. Wheezing is perhaps the most "specific" symptom of an adult patient in the general population with asthma. This means that most adult patients who wheeze have asthma. Dyspnea, or shortness of breath, is often described as chest-tightness or a breathless sensation. Ironically, it is very difficult to correlate a patient's subjective sensation of shortness of breath with an objective measurement of airway obstruction. What seems to impact this sensation most is the percentage change in a patient's airway function rather than the absolute value of lung function. While it does remain difficult to qualify, the sensation of dyspnea is common among patients with asthma, and should not be ignored.

Question: What are some commonalities between asthma and sinusitis?
Answer:
Mucous hyper-secretion is perhaps one of the areas of greatest overlap between patients with sinusitis and asthma. A sensation of "too much mucous" is shared by patients with asthma, rhinosinusits (post-nasal drainage), and laryngopharyngeal acid reflux. In many asthmatics, attacks are characterized by overwhelming quantities of mucous. In fact, some asthmatics seem to have significant increases in the number of mucous-producing (goblet) cells, and the characteristics of their mucous is much thicker and difficult to manage. As with many of the other symptoms of patients with asthma, careful evaluation must be performed to rule out other causes of thick, profuse mucous including cystic fibrosis, immotile cilia syndromes, and other mechanical deformities.

Question: How is asthma diagnosed?
Answer:
Patients suspected of having asthma should have a thorough evaluation by a pulmonologist (lung specialist). In addition to taking a thorough history and performing a complete physical examination, pulmonologists have many adjunctive tools at their disposal for the diagnosis of asthma. Pulmonary function testing is an invaluable tool in the characterization of a patient's lung function. While several methods exist for evaluating pulmonary function, spirometry is one of the most widely available. With simple inhalation and exhalation into a hand-held device, measurements can be obtained which characterize a patient's lung function is detail.

Forced expiratory volume1 (FEV1) is the volume of air that a patient can expire in 1 second of maximal effort. Forced vital capacity (FVC) is the total volume of air that can be expired after a complete inhalation. In patients with normal lung function, FEV1 is approximately 80% of the FVC. In patients with asthma (and other obstructive airway diseases) there is a decrease in the FEV1/FVC ratio. These measurements can also be used to qualify a patient's asthma. For instance, an FEV1 70-85% of the predicted value (based on normative values) characterizes mild asthma. An FEV1 60-69% of the predicted value characterizes moderate asthma, and so on. It is notable that this severity system for asthma allows for regular monitoring of the progression of a patient�s disease, as well as his or her responsiveness to medical regimens.

Asthma is notable for its reversibility. Increase in FEV1 by 12% or more after administration of a bronchodilator supports a diagnosis of asthma. Similarly, airway obstruction can be stimulated in patients with asthma with the administration of provocative agents such as Methacholine. This "bronchial challenge" may also be used to confirm a diagnosis suspected by a positive response to a short acting bronchodilator.

There are many other tools that a pulmonologist has to diagnose and evaluate patients suspected of asthma. Clinical judgment will often direct a pulmonologist toward one test or another in his or her quest for an appropriate diagnosis.

Question: How is asthma treated?
Answer:
Asthma management requires individualized treatment plans, as every patient's asthma impacts their lives in different ways. Moreover, the severity of symptoms may vary based on season, allergies, work environment, stress, and other factors. It is for this reason that patients must have a working relationship with the physician helping them to manage their asthma.

Patients with asthma should be very proactive in exerting control over their environment where possible. Environmental irritants, cigarette smoke, viral infections, molds, and dust-mites can all exacerbate asthma and lower the threshold for asthma attacks. Overlapping illnesses -- acid reflux, sinusitis, inhalant allergies, allergic rhinitis -- should also be tightly controlled if possible.

There are several medications available for the management of asthma. Deciding on a specific regimen should be performed in careful consultation with a patient's physician.

Question: Would you tell me more about the relationship between asthma and sinusitis?
Answer:
For several years now, practitioners have noted a link between patients who have asthma and those who have sinusitis. As noted above, patients with asthma are more likely to have sinusitis than other members of the general population, and patients with sinusitis are more likely to have asthma than other members of the general population. Specifically, the prevalence of asthma in patients with sinusitis is 20% compared to around 6% in the general population. The prevalence of nasal and sinus symptoms in patients with asthma is as high as 85 to 90%.

This clinical and epidemiological observation is now supported on a molecular and a histological level. The "unified airway" concept has demonstrated how the upper and lower airways are inextricably linked. Inflammation in the upper airway (nose and sinuses) may lower the threshold for inflammation in the lower airway (lungs and bronchial tree), and vice-versa. Some have suggested the presence of a "nasobronchial reflex" and a "pharyngobronchial reflex" as a physiological link between the upper and lower airways. In this "�nasobronchial reflex," when the nerves of the nasal and sinus passages are irritated, a reflex mechanism activates the parasympathetic nervous system and leads to bronchoconstriction. In the "pharyngobronchial reflex," mucous that drains from the sinus and irritates the pharynx (back of the throat) stimulates a reflex mechanism that activates an inflammatory pathway in the bronchial tree. While these mechanisms are no longer as widely believed to be the definitive link between the upper and lower airways, they do provide an intellectual framework in which to begin to understand how these 2 seemingly distinct systems can interact.

It is now believed that the upper and lower airways are connected by systemic inflammatory mediators. Stimulation of the nasal passage, for instance, may lead to an inflammatory reaction both in the nose and sinuses, as well as the lungs. Researchers have begun to unlock the complex web of molecular pathways that link these 2 systems. It has been discovered that the inflammatory cells and mediators that are most prevalent in the nose and sinuses of patients with sinusitis are also quite evident in the lungs of patients with asthma. This is supported by similarities in the lining of these distinct organ systems and helps to explain similarities in inflammatory function.

Question: How does treating my sinusitis affect my asthma?
Answer:
If asthma and sinusitis are related entities it follows that improved management of one disease might lead to improvements in the other disease. There is, in fact, a fairly abundant amount of data to support this idea. Several studies have demonstrated that improvement in patients' sinus disease may lead to improvement in the lung function of patients with asthma. Other studies have shown that sinus surgery in patients with asthma and sinusitis, and whose sinus disease has not improved with medical management, often leads to improvement in lung function of these patients. These patients with asthma who have undergone sinus surgery have, in several studies, been documented to require decreased amounts of medication to control their asthma.

On Reflux (GERD) and Sinusitis

Question: What is GERD?
Answer:
The backflow of stomach juices, including acids and occasionally ingested foods, constitutes gastroesophageal reflux disease or GERD.

Question: What are the symptoms of GERD?
Answer:
Common esophageal symptoms of GERD include repeated bouts of heartburn, difficulty swallowing, hoarseness, lump-in-the-throat sensation, chronic cough and throat clearing, and mucus build-up in the throat. People can suffer from one or more of these symptoms.

Question: What is the the relationship between GERD and sinusitis?
Answer:
Sometimes, the symptoms of GERD can mimic some of the symptoms of sinusitis. The sensation of post-nasal draining and the need to clear your throat constantly may be due to post-nasal drainage -- but may also be due to GERD. The sinus specialist may therefore examine you in the office to see if there is physical evidence of GERD.

Acid reflux can sometimes actually contribute to sinusitis! That is to say, the acid can travel all the way up to your nose and sinuses (for instance, while you are lying down asleep), and this acid can inflame the nose and sinus linings. This problem is more common in children -- but it may also be seen in adults.

Question: What causes GERD?
Answer:
There is a one-way valve near the top of the stomach. Stomach acid can escape through a weakened valve and travel up the esophagus -- even up to the voice box and throat -- and produce the symptoms listed above.

Question: How do you diagnose GERD?
Answer:
Heartburn is easily recognized by the family doctor. However, some of the symptoms relating to the throat and voice box should be evaluated by a specialist. The specialist will then perform a complete examination including taking a look at the voice box with a small endoscope placed through the nose. If you have GERD, your sinus specialist may ask you to also see a gastroenterologist.

Question: Are there any diagnostic tests?
Answer:
A gastroenterologist may decide to order some additional tests to evaluate your GERD. A Barium swallow is a series of x-ray films that monitor dye as it travels through the stomach. A PH monitoring test is a 24-hour test to record the back flow of acid from the stomach into the esophagus and even the throat. A small flexible tube is placed in the stomach through the nose and is connected to a small computer to record 24-hour acid reflux. Endoscopy is sometimes performed to evaluate the esophagus for damage from acid burns and to examine the stomach for irritation and ulceration.

Question: How is GERD managed?
Answer:
With lifestyle and dietary changes, with medical treatment, and at times surgical treatment.

Question: Tell me about life style and dietary changes.
Answer:
Don't drink alcohol, and don't smoke. Both nicotine and alcohol irritate the stomach and increase acid production. Also,

  • Avoid clothing that is tight around the waist -- corsets, belts.
  • Avoid bending over.
  • Lose weight.
  • Raise your head when lying down. This is best achieved NOT with pillows, but by raising the head of the bed by 6 to 8 inches. This can be done by sliding blocks under the legs at the head of the bed or a wedge under the head of the mattress.

Question: Tell me about dietary modifications.
Answer:
You may wish to avoid coffee and tea, carbonated beverages, alcohol, fatty fried foods, spicy food, citrus fruits and juices, tomato juice, orange juice, and grapefruit juice, tomatoes, onions, peppermint, spearmint, chocolate, cheeses, and eggs.

Avoid large meals, especially in the evenings. Do not lie down right after eating. Allow three to four hours after supper and lying down. Make the mid day meal the heavier meal of the day and eat small, well-balanced meals.

Question: Tell me about medical treatment.
Answer:
Medical treatment is based on neutralizing stomach acid, reducing or eliminating stomach acid and improving gastric emptying. Neutralizing stomach acid can be achieved by using over-the-counter antacids in liquid or tablet form such as Sucralfate suspension, Maalox, and Ryopan. Reducing or eliminating stomach acids can be achieved with H-2 blockers, which are drugs that depress acid production, such as Cimetadine (Tagamet), Ranitidine (Zantac), or Famotidine (Pepcid). These are also now available over-the-counter at lower dosage.

Antacids and H-2 blockers should be taken one hour apart as antacids may reduce the other drugs' effectiveness. New drugs like Omeprazole (Prilosec) and Nexium completely stop stomach acid production. These drugs are generally prescribed for short-term use.

Improving gastric emptying can be undertaken by Cisapride, Metoclopromide, Bethanachol, and other drugs. These drugs increase the squeezing action of the esophagus and tighten the esophageal sphincter, in addition to making the stomach empty faster.

Question: Tell me about surgical treatment of GERD.
Answer:
Surgical treatment is undertaken as a last resort. If the dietary and medical treatments do not bring relief, or if the patient finds them hard to comply with, they may be candidates for surgery. One procedure is called "fundoplication." It involves wrapping the top of the stomach around the top of the esophagus in order to strengthen support and prevent reflux. If possible, it is preferable to control GERD with medical treatment!

 
 
 
 
 
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