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I once lived next door to a woman with terrible hay fever. From May onwards every morning started the same way. “AaaaaaaaaAAAAAAH…” she would begin. Our shared wall would judder like a drum skin. “TISHYOOOO!” Further sneezes followed, each more gigantic than the last. The first time I met her, I had my gaze pitched at the wrong height. I was expecting an Amazon. She was tiny.
It is difficult to sneeze to order, which means people don’t try to reproduce the symptom when they come to the doctor (unlike a cough). This aside, I sometimes find consultations about allergic rhinitis a bit unsatisfactory.
Allergic rhinitis causes a congested, itchy, runny nose as your body reacts to allergens: pollen, in the case of hay fever. Unfortunately you can have seasonal allergic rhinitis even outside the grass pollen peak of May to July. If you’re sensitive to tree pollen, you might be sneezing from February to June, whereas mould spores are most prolific in the autumn. If you’re allergic to something indoors, such as cat dander or house mites, you’ll have perennial allergic rhinitis, which is symptomatic all year round.
A quick look helps to rule out other pathology. Asking someone “Do you mind if I just look up your nose?” isn’t the most dignified moment in medicine. Neither is the examination, which involves squashing the nose back so as to peer up the nostril. You may see benign outgrowths, or polyps, that can block the free flow of air; or a deviated septum. But most likely all you’ll see is red, inflamed nasal mucosa.
At this point I usually suggest a nasal spray and the patient proposes some “hay fever pills” instead. Steroid nasal sprays lack glamour. (“Can’t I just use a rolled tenner ha ha?” a patient once asked.) Because they’re widely misunderstood, they also illustrate the first rule of successful prescribing: tell the patient what to expect.
As with steroid inhalers for asthma, steroid nasal sprays take time to work. They’re not decongestants – anyone expecting a minty buzz and a sudden sensation of airiness will be disappointed. Unless you want a consultation that starts with your patient dumping an unused bottle on your desk (“This doesn’t work!”), you need to let him know this.
The patient also needs to use steroid sprays regularly; it’s no good having a sniff only when feeling itchy. We don’t actually know how topical steroids work in allergic rhinitis – “in lots of ways,” our lecturer used to say – but we know they calm down the inflammatory processes in the nose, shrinking the swollen lining, reducing the flow of mucus and alleviating the itch and the sneezing.
Steroid nasal sprays have one major advantage: they deliver the medicine exactly where it’s needed and nowhere else. The amount absorbed into the rest of the body is minimal, sparing the user from potential steroid side effects. But as well as using the spray regularly, you need to use it with good technique.
You shouldn’t point it at the back of your nose or snort when inhaling. Both methods will deliver most of the drug to the back of your throat, where few suffer from allergic rhinitis (and anyway most nasal sprays taste disgusting). For the same reason, you should lean forwards rather than backwards – counter-intuitive advice that’s also true in nosebleeds. And try to avoid the septum, a vulnerable area – as any cocaine-user who’s ended up with a single nostril will testify. “That doesn’t really leave me anywhere to put it, does it?” said my patient. “Straight up,” I said.
Sophie Harrison is a hospital doctor in South Yorkshire. This column appears fortnightly