Postnasal Discharge Research Articles

Analysis of intractable cough in 128 children

To disclose the etiological factors and to investigate the therapeutical effect on nasal disorders in 128 children with intractable cough. One hundred and twenty-eight children with intractable cough were consulted by ENT doctors using electronic nasopharyngoscope, for those children with nasal diseases, relevant treatment was given. Among 128 children, one hundred and sixteen had nasal disorders. Upper airway cough syndrome (UACS) was diagnosed in 92 cases (71.9%), nasal disorders without UACS was diagnosed in 24 cases (18.7%), no nasal disorders were found in 12 cases (9.4%). Among children with UACS, allergic rhinitis was diagnosed in 76 cases, rhino-sinusitis in 39 cases, adenoid hypertrophy in 54 cases, and chronic rhinitis in 8 cases. However, for those children without UACS, 10 cases had chronic rhinitis and 14 cases had allergic rhinitis. Clinical symptoms, signs and the findings of electronic nasopharyngoscope were analyzed in 92 children with UACS. The results showed that regular cough occurred in 62 cases, nasal disease in 65 cases, subjective feeling of postnasal discharge in 18 cases, mouth breathing or snoring in 32 cases, purulent secretion in nasal meatus in 61 cases, retropharyngeal folliculosis in 58 cases, purulent secretion in pharynges detected from pharynx in 41 cases, and purulent or viscosity secretion were found in 91 cases by first electronic nasopharyngoscopy. After 14 days of treatment, the children with UACS (90/92) had significant higher remission rate (chi² = 32.21, P = 0.000) in cough than those who had nasal disorders but without UACS (13/24). The nasal disorders, especially for UACS, were common in children with intractable cough. The therapy to nasal disorders could release the chronic cough symptoms in children with intractable cough.

Rhinitis in subjects with work-exacerbated asthma

This study aimed at characterizing the nature, severity, and timing of nasal and ocular symptoms in subjects with work-exacerbated asthma (WEA). Among the 363 subjects referred to a tertiary-care hospital for the investigation of work-related asthma symptoms, 105 subjects who demonstrated non-specific bronchial hyperresponsiveness to histamine, but a negative response to a specific inhalation challenge with the suspected occupational agent(s) were considered as having WEA. Their characteristics were compared with those of 172 subjects with occupational asthma (OA), ascertained by a positive response to a specific inhalation challenge. A high proportion of subjects with WEA (83%) and OA (90%) reported at least one nasal symptom at work. Sneezing/itching and rhinorrhea were more frequent in subjects with OA (78% and 70%, respectively) than in those with WEA (61%, p = 0.004 and 57%, p = 0.038, respectively), while post-nasal discharge was more common in WEA (30%) than in OA (18%, p = 0.019). Nasal symptoms were less severe in WEA (median [25th-75th percentiles] global severity score: 4 [2-6]) as compared to OA (5 [4-7], p < 0.001). Nasal symptoms preceded less frequently those of asthma in subjects with WEA (17%) than in subjects with OA (43%, p = 0.001). Nasal symptoms are highly prevalent in subjects with WEA, although their clinical pattern differs from that found in OA. Further investigations of the health and socio-economic impacts of upper airways symptoms in WEA are required to improve the understanding and management of this common condition.

Diagnosis and Management of Chronic Rhinosinusitis in Adults

Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.

Evolution of Sinonasal Symptoms Following Transnasal Endoscopic Skull Base Surgery Using a Pedicled Nasoseptal Mucosal Flap

Transnasal endoscopic surgery of the anterior skull base has been increasingly used by skull base surgeons in recent years. A dual-surgeon approach, with an otolaryngologist and neurosurgeon operating together, provides excellent visualization and operative maneuverability. To counter cerebrospinal fluid (CSF) leaks, pedicled nasoseptal mucosal flaps (PNSMFs) have been proposed to augment the closure. Sinonasal complaints are expected sequelae of this technique. We describe the evolution of sinonasal symptoms in a series of patients who have undergone this type of surgery, as documented by the Sinonasal Outcomes Test (SNOT-20), a widely used disease-specific, health-related quality-of-life measure for rhinosinusitis. From January 2008 through May 2009, 85 adult patients underwent transnasal endoscopic surgery using a PNSMF for a variety of diseases. The most common diagnosis was pituitary tumor, but others included Rathke's cleft cyst, meningiomas, chordomas, and hypothalamic lesions. Postoperative complications were rare. Six patients (7%) had CSF leaks requiring reoperation. Significant postoperative nasal bleeding occurred in one patient, and this was successfully managed in the emergency room with cautery and packing. All patients performed daily nasal saline irrigations at home and returned at regular intervals for debridement of their sinus cavities. They filled out the SNOT-20 at regular intervals after surgery, describing their postoperative nasal symptoms. The vast majority did not have significant sinus disease preoperatively. Sinonasal complaints were universal during the first month and included crusting, congestion, rhinorrhea, and sinus pressure, but they gradually diminished over the ensuing months. Scores for the symptoms of sneezing, postnasal discharge, runny nose, and thick nasal discharge showed significant improvement over time. Scores for most other sinonasal symptoms showed improvement over time, but did not reach statistical significance. All patients had a temporary loss of smell, but this returned to near normal levels within 3–6 months.

Infección rinosinusal por Scedosporium apiospermum en un hospedero inmunocompetente

Scedosporium species can cause colonization, superficial and deep localized infection or systemic disease, especially in immunocompromised hosts. We report a case of localized infection due to Scedosporium apiospermum in a 47 year old woman, with previous nasal surgery. She consulted for recurrent mucopurulent post-nasal discharge not responding to antibiotics. Computed tomography showed opacification of right maxillary sinus. Surgery was performed to removed abnormal tissue from sinus; biopsy revealed chronic sinusitis with aggregate of tightly packed hyphae suggestive of filamentous fungi. The microbiology fungal culture reported Scedosporium apiospermum.

An Easy Guide for Voice Evaluation in the Clinic

An Easy Guide for Voice Evaluation in the Clinic

An Easy Guide for Voice Evaluation in the Clinic

An Easy Guide for Voice Evaluation in the Clinic

Polyp Inside the Concha Bullosa: Unusual Manifestation of Chronic Rhinosinusitis

Chronic rhinosinusitis has complex pathophysiological features. The role of anatomic variations in the development of sinusitis remains unclear. We describe a rare manifestation of this disease, a polyp inside the pneumatized concha polyposa. A 23-year-old male patient had been suffering from headache, nasal obstruction, loss of the sense of smell, and postnasal discharge. Computed tomographic scans of the sinuses showed bilateral conchae bullosae, with a polyp inside the left one. Therapy included endoscopic nasal surgery and postoperative topical corticosteroid and macrolide treatment. We discuss the influence of sinusitis on the phenomenon of "sinus headache." We also comment on the use of topical corticosteroids and macrolides in preoperative and postoperative treatment of chronic rhinosinusitis with nasal polyposis.

Sinusitis in children and adolescents with chronic or recurrent headache: a case–control study

The aim of this study was to determine the frequency of misdiagnosis of sinus headache in migraine and other primary headache types in the children and adolescents with chronic or recurrent headaches. Children with chronic or recurrent headaches (n = 310) were prospectively evaluated. Data collection for each patient included history of previously diagnosed sinusitis due to headache, and additional sinusitis complaints (such as fever, cough, nasal discharge, postnasal discharge) at the time of sinusitis diagnosis, and improvement of the headache following treatment of sinusitis. If sinus radiographs existed they were recorded. The study included 214 patients with complete data. One hundred and sixteen (54.2%) patients have been diagnosed as sinusitis previously and 25% of them had at least one additional complaint, while 75% of them had none. Sinusitis treatment had no effect on the headaches in 60.3% of the patients. Sinus graphy had been performed in 52.8%, and 50.4% of them were normal. The prevalence of sinus headache concomitant with primary headache, and only sinus headache was detected in 7 and 1%, respectively, in our study. Approximately 40% of the patients with migraine and 60% of the patients with tension-type headache had been misdiagnosed as “sinus headache”. Children with chronic or recurrent headaches are frequently misdiagnosed as sinus headache and receive unnecessary sinusitis treatment and sinus graphy.

Symptom Outcomes in Endoscopic Sinus Surgery: A Systematic Review of Measurement Methods

To determine the type and prevalence of measurement methods used to analyze symptom outcomes after endoscopic sinus surgery (ESS). Data were derived from PubMed, MEDLINE, EMBASE, Web of Science, Cochrane databases, Google Scholar, and manual searches. All English-language studies consisting of more than 10 adult patients from January 1980 to December 2006 reporting ESS symptom outcome results were reviewed. Studies of radical surgery and studies involving patients with significant comorbidities were excluded. The ESS symptom outcome results of 29,333 patients were reported in 204 studies. Symptom outcome was determined by survey instruments in 47 (23.0%) studies and individual symptom scoring in 63 (31%) studies. Of 18 validated instruments used, almost two thirds of studies that reported results by survey measures used the following three instruments: Chronic Sinusitis Survey (12 studies), Sinonasal Outcome Test-20 (11 studies), and Medical Outcomes study 36-Item Short-Form Health Survey (10 studies). The percentages of studies that reported specific results of the 1997 American Academy of Otolaryngology-Head Neck Surgery Rhinosinusitis Task Force (RSTF) chronic rhinosinusitis symptom criteria varied as follows: facial pain/pressure, 35%; facial congestion/fullness, 10%; nasal obstruction/blockage, 42%; nasal discharge/purulence/discolored postnasal discharge, 47%; hyposmia/anosmia, 35%; fever, 2%; halitosis, 4%; fatigue, 11%; dental pain, 3%; cough, 10%; and ear pain/pressure/fullness, 6%. ESS symptom outcome is assessed inconsistently by numerous measures. Individual report- ing of all RSTF chronic rhinosinusitis symptom criteria, as recommended by the RSTF and by subsequent consensus conferences, is rarely noted. Many RSTF symptom criteria are seldom studied.

Onset of symptom resolution in adults with acute bacterial rhinosinusitis treated with a single dose of azithromycin extended release compared with 10 days of levofloxacin: A retrospective analysis of a randomized, double-blind, double-dummy trial

Background: A previous study found that a single 2-g dose of azithromycin extended release (AZ-ER) was as efficacious as 10 days of levofloxacin (LFX) 500 mg QD in adults with acute bacterial rhinosinusitis (ABRS). The speed with which patients experience resolution of ABRS symptoms has not been reported. Objective: The purpose of this study was to evaluate the resolution of ABRS symptoms after a single 2-g dose of AZ-ER compared with 10 days of LFX. Methods: This was a retrospective analysis of data from a published international, randomized, double-blind, double-dummy clinical trial conducted between January 21, 2003, and February 20, 2004, that included 534 adult (age ≥18 years) outpatients with ABRS. All patients entering the study were required to have purulent nasal discharge, purulent drainage in the posterior pharynx, or purulent discharge from the maxillary sinus orifice and at least 1 of 3 other protocol-defined cardinal symptoms of ABRS (sinus pain, pressure, or tenderness) for ≥7 days. In addition, they were required to have at least 2 of the following 6 noncardinal symptoms at baseline: cough, fever, headache, nasal congestion, postnasal discharge, and leukocytosis. All patients who received medication were assessed for the occurrence of adverse events at study visits during and after therapy. At the ontreatment visit (between days 3 and 5), baseline symptoms were reassessed as resolved, improved, same, new, or worse. Resolution of symptoms was calculated as the proportion of patients with 3 or 4 cardinal symptoms either resolved (if present at baseline) or not new (if absent at baseline). Concomitant medications other than antibiotics were allowed as needed for symptomatic treatment. Results: Demographic characteristics were similar at baseline between the AZ-ER and LFX treatment arms (mean age, 38.4 and 39.5 years, respectively), although more women were randomized to receive LFX (62.9%) than AZ-ER (53.3%) ( P = 0.025). More than 90% of patients in both arms had ≥3 ABRS symptoms at baseline. At the on-treatment visit, resolution of ≥3 ABRS symptoms was achieved in 88 of 270 AZ-ER patients (32.6%) and 61 of 261 LFX patients (23.4%) ( P = 0.018). Resolution of individual symptoms in the AZ-ER and LFX groups at 3 to 5 days was as follows: sinus pain (92/253[36.4%] and 77/251 [30.7%]; P = NS), sinus pressure (97/243 [39.9%] and 68/244 [27.9%]; P = 0.005), sinus tenderness (83/218 [38.1%] and 73/214 [34.1%]; P = NS), and nasal discharge (57/270 [21.0%] and 49/264 [18.6%]; P = NS). Treatment-related adverse events were reported by 63 of 270 AZ-ER patients (23.3%) and 41 of 268 LFX patients (15.3%). Gastrointestinal disturbances were the most common adverse events, including nausea (4.4% and 3.4%) and abdominal pain (2.6% and 0.4%).

Functional Endoscopic Sinus Surgery: Review Of 266 Patients

Introduction: Functional Endoscopic Sinus Surgery is a method used with success in the treatment of chronic or recurrent sinusitis & nasal polyps. Objective: This study was conducted to assess the treatment results in patients undergoing Functional Endoscopic Sinus Surgery for chronic sinusitis, with evaluation of prognostic indicators of success and failure. Method: This study includes 266 patients who underwent Endoscopic Sinus Surgery for chronic sinusitis over a period of 7 years (from Feb.1995 to Feb.2002). The diagnosis of chronic sinusitis was based on ongoing symptomatology for greater than 3 months and the presence of mucosal disease on radiological examination. A retrospective analysis was done looking at patient data, presenting symptoms, CT findings, operative details and outcome at 6 and 12 months follow up. Results: The most common presenting complaints were olfactory disturbance followed by nasal obstruction and postnasal discharge. There was a positive history of asthma in 25.4 %, allergies in 13% and ASA triad in 3.3 % patients. 41.7% patients had previous nasal surgeries in the past. Positive outcome was obtained in 81.9% at 3 months and 84.7% at 6 months. Revision operations were required in 7.9% patients. Minor complications were seen in 10.5% and major complications in 0.75%. These results are comparable to those in the literature. Factors affecting outcome included asthma, polyposis & pansinusitis. Complications: Functional Endoscopic Sinus Surgery has good results and little morbidity. Extent of diseases as reflected by polyposis and pan sinusitis are the most important determinants of the outcome. Study conducted at: Staffordshire General Hospital, Stafford, UK Paper presented at: Section of Rhinology, Royal Society of Medicine, May 2004

Rinossinusite crônica em pacientes infectados pelo vírus da imunodeficiência humana: avaliação clínica e radiológica

O advento dos inibidores de protease, aumentando a sobrevida dos pacientes infectados com HIV aumentou a procura destes pacientes por médicos otorrinolaringologistas, já que 40% a 70% deles podem apresentar alguma alteração otorrinolaringológica. OBJETIVIVOS: Objetivamos, nesse estudo, comparar os achados radiológicos e sintomatologia nasossinusal entre pacientes infectados com HIV e pacientes com AIDS, com rinossinusite crônica. A literatura sobre o assunto é revisada e discutida. FORMA DE ESTUDO: clínico prospectivo com coorte transversal. CASUÍSTICA E MÉTODOS: Prospectivamente, 39 pacientes em uso de drogas antiretrovirais foram divididos em 2 grupos: pacientes com diagnóstico de AIDS (grupo I) e aqueles apenas infectados pelo HIV (grupo II). Estes grupos foram comparados clinicamente, quanto à contagem de células CD4+ e avaliação tomográfica dos seios paranasais. RESULTADOS: Os pacientes dos grupos I e II apresentaram média de células CD4+ de 118 cél/10-9l e 377 cél/10-9l, respectivamente. Na comparação dos achados tomográficos pelo sistema de Lund e Mackay, o grupo I apresentou escore médio de 12 e o grupo II apresentou média de escore de 5,63 (p&lt;0,001), sendo a febre e a secreção pós-nasal mais prevalente no grupo I (p&lt;0,001). CONCLUSÃO: A prevalência da sinusite crônica nos pacientes infectados pelo HIV foi de 12%. Os sintomas da rinossinusite foram similares nos pacientes sem AIDS e com AIDS, com exceção da presença de febre. Os pacientes com AIDS apresentaram alterações radiológicas mais extensas do que os pacientes HIV positivos.

Chronic rhinosinusitis in HIV-infected patients: radiological and clinical evaluation

The advent of protease inhibitors, which enhances the survival rate of HIV-infected individuals, leads patients to search for otorhinolaryngologists, as 40-70% of them may present some sort of otorhinolaryngological disorder. We aimed at comparing the CT scan findings and the nasosinusal complaints of HIV-infected and AIDS patients with clinical diagnosis of chronic rhinosinusitis. The literature on the subject is revised and discussed. Clinical prospective with transversal cohort. Prospectively, 39 patients with chronic rhinosinusitis, in use of antiretroviral therapy, were included in the present study and divided into two groups: patients with diagnosis of AIDS (group I) and those infected by HIV (group II). Clinical and laboratorial assessments, with CD4+ cell count and CT evaluation, were performed and compared among groups I and II. Group I and II presented mean CD4+ cell count of 118 cells/10-9l and 377 cells/10-9l, respectively. Comparison of the tomographic findings by the Lund-Mackay staging system presented a score of 12 for group I and 5.63 (pd" 0.001) for group II. Fever and postnasal discharge were more prevalent in group I (pd" 0.001). In our Service, prevalence of chronic rhinosinusitis in HIV-infected patients was 12%. AIDS patients had a higher incidence of fever and postnasal discharge than those of group II. Moreover, extensive radiological findings were prevalent in patients with AIDS (group I) than in HIV-infected individuals (group II).

Role of Leukotriene Inhibitors in the Postoperative Management of Nasal Polyps

This was a prospective double blind comparative study on 40 patients. It compared the effects of the leukotriene receptor antagonist montelukast and beclomethasone nasal spray on the post-operative course of patients with sinonasal polyps. All patients underwent endoscopic sphenoethmoidectomy and were randomized post-operatively into two groups. Group I: 20 patients (9 females and 11 males) age 17 to 67 (32.4 ± 9.5 years), receiving 10 mg montelukast orally daily and Group II: 20 patients (6 females and 14 males) age 17 years to 57 years (33.5 ± 11.9 years), receiving 400 ug beclomethasone local sprays daily. All patients were followed up for 1 year and a symptom score was recorded throughout this period. There was a significant reduction in symptom scores in both groups throughout the study period. In the montelukast group improvement was more marked in itching, post-nasal discharge and headache. The control of sneezing and rhinorrhea was comparable in both groups with a marginal advantage of montelukast. Steroids had a more marked effect on smell disturbances and obstruction. There was no difference in the recurrence rate or in the need for rescue medications between both groups. Both drugs seem to have a complementary action and further studies are needed to determine which patients should receive which treatment.

Chronic intractable cough and silent sinusitis: role of functional endoscopic sinus surgery

Intractable chronic cough is common and challenging, but treatable. This paper presents a prospective study of adult patients who were referred for ENT diagnosis and management of chronic cough. In 61 patients a nasal cause was responsible for the cough. All patients were evaluated clinically, had nasal endoscopy, allergy skin tests, postnasal discharge culture and sensitivity and CT Scans. In 43 patients the cough was attributed to silent sinusitis (diagnosed on CT findings with minimal symptoms). The spectrum and frequency of causes found; postviral (20%), infective rhino sinusitis (18%), allergic rhino sinusitis (15%), nonallergic rhino sinusitis (9%), nasal polyps (8%) and more than one nasal diagnosis (30%).All patients received medical treatment initially; of these 12 patients with medically recalcitrant chronic sinusitis had functional endoscopic sinus surgery (FESS).The cough was attributed to postnasal drip and/or irritation of cough receptors in the sinuses. CT sinuses were crucial in diagnosis.Treatment outcome was obtained 3–6 months later; subjective outcome in patients undergoing FESS was better as compared to nonsurgical group.

Perforation de la cloison nasale et maladies systémiques

Introduction. – Nasal septal perforations are mainly due to trauma. Our review highlights systemic diseases leading to this disorder. Current knowledge and key points. – Various systemic diseases may be responsible of nasal septal perforation: Wegener's granulomatosis, systemic lupus erythematosus, antiphospholipid syndrome, sarcoidosis, cryoglobulinaemia. But, very few data are available about the frequency of septum nasal perforation in each disease. Clinical manifestations are numerous and not specific: obstruction, epistaxis, postnasal discharge, whistling, crusting. Asymptomatic forms are frequent. Biopsy of nasal septum is poorly useful for the diagnosis except when granuloma or vasculitis is found. Pathophysiologic mechanisms of nasal septal perforation are ischemic, infectious or inflammatory. Future prospects and projects. – Systemic disease may be suspected in unclear nasal septal perforation. More, in systemic disease, even when symptoms are absent, intranasal examination is required.

内視鏡下鼻内手術の術後成績

Functional endoscopic sinus surgery (FESS) is the surgical treatment of choice in chronic sinusitis for many physicians.We evaluated subjective and objective improvement in patients undergoing first-time FESS over a 5-year period. Eighty-seven patients were followed for mean of 11 months (range 3 months to 45 months). A retrospective analysis was performed using the patient's medical records. Outcomes analyzed included pre- and postoperative clinical symptoms (nasal obstruction, nasal discharge, postnasal discharge, headache, olfactory disturbance), preoperative computed tomographic (CT) findings and postoperative endoscopic findings of maxillary and ethmoid sinuses.The most common presenting complaint was nasal obstruction, followed by nasal discharge and olfactory disturbance. Clinical symptoms improved in 94% of the patients subjectively. However, the cure rate of olfactory disturbance and postnasal discharge was below 70%. In the objective endoscopic findings, 87% of patients obtained a good outcome. Residual or recurrent polyposis was noted in 12 (13%) of the 87 patients. Four patients with persistent symptoms underwent revision FESS. The extent of disease on CT was classified into four groups according to Kennedy's staging system. Patients with severe disease (stage III-IV) had a worse outcome than patients with mild/moderate disease (stage I-II) but this difference was not significant. Seventeen patients with allergic rhinitis and/or asthma had a worse objective outcome than patients without allergic rhinitis and asthma but this difference was not significant. There was no significant difference in subjective outcome between patients with and without allergic rhinitis and/or asthma. The finding in this study suggest that factors affecting outcome after FESS included the CT stage of disease, allergic rhinitis and asthma, but that FESS improved in terms of subjective symptoms in patients with severe disease and with allergic rhinitis and asthma.

External root resorption of a primary molar: “Incidental” histopathologic finding of clinical significance

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:4-8)

EVALUATION AND MANAGEMENT OF ALLERGIC RHINITIS

Allergic rhinitis is a problematic disorder that is common. The practicing physician recognizes the majority of the overt clinical symptoms of sneezing, nasal itching, postnasal discharge, and eye symptoms but may not be attuned to the more subtle symptoms of lethargy, headache, and loss of productivity they create. Food sensitivities may complicate the evaluation and treatment of the sensitive patient, and frequently the idea of foods causing problems with rhinitis is ignored. For most patients, practical medications are beneficial in reducing symptoms without producing the side effects of sedation. The newer topical nasal steroids are becoming the first line of therapy, and nonsedating antihistamines are still useful because they have few side effects. Immunotherapy is recommended for treatment failures in the appropriate patient. Specialty referral then should be considered.