Chronic Rhinitis and the Sleep Dentist by Warren Schlott
Every sleep dentist has patients who include chronic nasal congestion and/or post nasal drip on their list of complaints. More often than not, the patient suffers from chronic rhinitis. This condition can play a prominent role as a cause of snoring and sleep apnea. It is known that congestion can lead to an increase in intra pharyngeal pressure that leads to open mouth posture and posterior tongue base displacement. This posterior displacement can lead to a partial blockage of the airway resulting in snoring and/or a hypopnea. If the blockage is complete an apnea can occur. At best, an open posture can lead to dry mouth. Hence, rhinitis can cause havoc with CPAP and oral appliance use. An understanding of this condition can be pivotal with treatment of snoring and sleep apnea.
Rhinitis means inflammation of the nose. Signs and symptoms of rhinitis include a blocked or congested nose, runny nose, sneezing, mucus (phlegm) in the throat known as postnasal drip, and cough. Other symptoms can include facial pain, headache, and loss of smell. The most common causes of rhinitis are the common cold and allergies causing hay fever. Chronic or persistent rhinitis doesn’t usually cause itchy nose, eyes or throat.
The most common definition of chronic rhinitis is symptoms lasting for an hour or more on most days of the year. Chronic rhinitis causes can be divided in to two groups: those caused by allergies, and those caused by non-allergic reasons (idiopathic). The most common cause of chronic rhinitis is allergy. The most common allergen is the house dust mite. This tiny insect lives mostly in mattresses, pillows, and carpet. Their feces cause an allergic reaction in many people. House mites live all year long, but their numbers peak in the spring and fall. Another common allergen is pets. Flaking skin, urine, or saliva from dogs, cats, and rodents such as hamsters or guinea pigs can trigger allergic reactions. A small percentage of people are allergic to formaldehyde found in furniture, wood dust, latex, and other chemicals. Regardless of the allergen, histamine and other chemicals are released by the cells lining the nose causing swelling and other symptoms.
Non-allergic rhinitis results when the blood vessels of the nose dilate, filling the nasal lining with blood and fluid. There are several possible reasons this can occur. Some people can have nerve endings that are hyper responsive to a stimulus, in a manner like the way the bronchia react in asthma. Such things as smoke, changes in temperature, humidity, strong odors such as perfumes, and even stress can trigger a reaction. Many drugs can cause rhinitis. These include aspirin, Ibuprofen, oral contraceptives, hormone replacement therapy, anti-anxiety medications (especially alprazolam), sedatives, antidepressants, Viagra and Cialis, and blood pressure medications including beta-blockers and vasodilators. Alcohol can also cause nasal congestion. Another cause of rhinitis is prolonged use of decongestant nasal drops and sprays such as Afrin or Dristan.
Regardless of the cause of rhinitis, rhinitis can be a cause of snoring and obstructive sleep apnea, and it can create problems with treatment for snoring and obstructive sleep apnea. Like sleep apnea treatment, rhinitis is a condition that generally cannot be cured. The condition must be managed. If the cause of rhinitis is allergy, the simplest course of action is to avoid the cause of the allergy. For instance removing a pet from the home may lessen the problem. However, many times removing the cause is impractical. Thus, other steps can be taken.
For mild cases of rhinitis, a nasal wash can be helpful. Neti pots have become popular. They can be purchased online and at most drug stores – NeilMed provides a product for nearly every age and sinus problem. The nasal rinse kit includes a squeezable bottle and packages that contain a salt and baking soda mixture that when combined with water create a saline solution that can be used to rinse the nasal passages. The rinse can remove mucus from the nose and help improve coordination of the cilia (hair-like structures in the nose) to remove allergens.
Antihistamines can be used for seasonal rhinitis. While, they can help with itchy eyes and runny noses, they are not very effective with nasal congestion. Usually, second-generation antihistamines such as Claritin, Zyttec, Allegra, and Xyzal are used because they have fewer side effects (sleepiness) than first generation antihistamines. Second generation antihistamines in a nasal spray may be more effective than the pill form for seasonal allergic rhinitis. However, they may cause sleepiness. Common prescription nasal antihistamine sprays include Astelin, Astepro, Dymista, and Pantanase. It should be noted that nasal antihistamine sprays are not as effective as nasal corticosteroids.
Corticosteroid nasal sprays help prevent and treat inflammation associated with rhinitis, and are considered the most effective drugs for controlling rhinitis. They are often used in conjunction with second generation antihistamines. It takes several days and up to three weeks for a steroid nasal spray to reach maximum effectiveness. However, once symptoms disappear, dosage can be reduced. Commonly used sprays are Nasacort, Nasonex, Flonase, Rhinocort, Nasarel, and Alvesco. Some sprays such as Dymista combine a corticosteroid and an antihistamine. Whereas, oral corticosteroids can have severe side effects, nasal corticosteroids have few. Overt overuse of these sprays can lead to dryness of the nose and/ or headaches
It is prudent to question all new patients, and existing patients with dry mouth from OAT, about nasal congestion
Other possible treatments include sodium cromoglicate nasal spray. This drug is usually used if there is a problem with other treatments. The problem with this spray is that it must be taken 4-5 times per day as compared to once or twice for corticosteroid spray. Leukotriene antagonist drugs such as Accolate and Singulair can be used, but have been associated with mood and behavioral changes and other side effects. They are generally considered less effective than nasal corticosteroid sprays. Over the counter oral decongestants containing pseudoephedrine can be used for congestion but have side effects such as insomnia, irritability, nervousness, heart palpitations, and can raise blood pressure. Sudafed, Claritin-D, Allegra-D, and Zyrtec-D are common names of drugs with pseudoephedrine. Experimentally, the use of capsaicin, an ingredient that makes peppers hot, has been shown to reduce rhinitis for as long as 36 weeks.
If medications fail, immunotherapy is an alternative. More commonly called allergy shots; this therapy hopes to reduce sensitivity to the allergen. The allergen must be first identified, then injected in increasing doses until desensitivity occurs. The injection is usually given twice a week, and then in increasing doses until a maintenance dose is achieved. It can take up to three years to reach a maintenance dose and then this dose may be continued for up to five years. However, symptom relief can begin within three to six months.
Chronic nasal congestion is rampant. Hence, it is prudent to question all new patients about nasal congestion. If your existing patients complain of dry mouth with oral appliance therapy, you probably want to question the patient about nasal congestion. It is unlikely that they will know about chronic rhinitis. Your job is then to educate the patient about rhinitis. You can then suggest over the counter treatments or you may refer the patient to their primary care physician, ENT, or allergist for treatment.
- Massic and Metz: Three Parameters AADSM presentation Minneapolis 2014
- Dykewicz MS, Hamilos DL. Rhinitis and Sinusitis J Allergy Clin Immunol. 2010 Feb; 125(2 Suppl 2): S103-15
- Rabago D, Zgierska A. Saline Nasal Irrigation for Upper Respiratory Conditiions. Am Fam Physician. 2009 Nov 15; 80 (10): 1117-9
- www.acaai.org American College of Allergy, Asthma and Immunology
- Sur DK, Scandale S. Treatment of allergic Rhinitis. Am Fam Physician. 2010 Jun 15; 81 (12): 1440-6
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