Children’s Ear, Nose and Throat Problems

Children commonly have issues with their ears, nose and throat. This is partly because of the natural physiological process of development which can make them prone to viral infections and allergies to name a few. While the common cold and ‘flu’ affect children and adults alike, the complications of these often ‘minor’ ailments can lead to more serious problems. An example would be tonsillitis which in the past when untreated could cause problems with the heart valves!

Thankfully this is very rare now. Nasal congestion and ‘sinus’ issues may spread to the eye (potentially causing blindness) through the thin bone that separates it from the nose. Commonly, children can have a blocked or painful ear which may affect their hearing, reducing their attention span, affecting speech and language and causing behavioural problems too. Allergy to dust mite, pets and different plant pollen is very common.

Sneezing, itching of the eyes and nose as well as a runny or blocked nose are typical symptoms. Referral to an ear, nose and throat (ENT) surgeon for an allergy test as well as treatment for their symptoms is highly recommended. Currently, treatment using a tablet placed daily under the tongue can help cure patients with some of these allergies and in many cases it helps avoid other conditions such as asthma later on in life.

Some pointers you can use to check on your child:
1. Does your child snore?
2. Does your child have recurring colds that progress into a sinus infection?
3. Does your child always complain of headache, and/or giddiness?
4. Does you child have a short attention span?
5. Does your child sneeze?
6. Does your child always feel tired and sleepy?

Ear, Nose & Throat Cancer
There are several types of cancers that an ENT and head and neck surgeon manages. They tend to affect adults and generally men who smoke and drink although this is not always the case. Cancers of the back of the nose (Nasopharyngeal cancer, NPC) tend to affect non-smokers and drinkers of Chinese ethnicity more than other populations. These cancers can be screened for in high risk groups. They present without much warning – with pain or bleeding being uncommon symptoms. A lump in the neck, blocked nose and blocked ears with some hearing loss may be the initial complaint. Quick referral to an ENT surgeon is strongly advised to assess the back of the nose with a special video telescope known as a nasendoscope.

Biopsies and scans may be necessary thereafter. Other cancers such as tonsillar (oropharyngeal) cancer are becoming more common partly due to a viral driven pathway – the human papilloma virus (HPV). Patients may present with an enlarged tonsil, swallowing issues or a neck lump. They tend to be younger and the condition is not caused by smoking and alcohol. Thyroid cancers are commoner amongst younger women and have a good prognosis usually. Surgery is the main treatment and in some cases it is done in combination with radio-iodine treatment.

Salivary tumours are rare. They are also treated surgically as the main management option. These tumours can affect the ‘major’ glands but are more aggressive in the minor ones that are dotted all over our oral cavity and throat. Any lump that is new within the mouth or neck should therefore be investigated if it does not regress or disappear after a fortnight or so.

Hearing Loss
Hearing loss affects the young and old. Childhood hearing loss can be due to genetic causes or birth issues. Certain drugs can also cause hearing loss. The commonest causes in children tend to be less serious and usually improve and disappear as the child develops. Often, the cause is a developing Eustachian tube which is short and less angled compared to an adult. Blockage or failure to clear mucus in the middle ear results in hearing loss which can also cause ear infections. Large adenoids (lymphoid structures similar to tonsils) can act as physical barriers to the opening of the Eustachian tubes and be a nidus for infection too. Surgery can help treat these conditions and is commonly performed in recalcitrant cases.

Age-related hearing loss is becoming a global concern as research continues to demonstrate its link with dementia. Many elderly patients become socially isolated and are not provided with the right recommendation for treatment – be it hearing aids or even cochlear implants. As the hearing begins to weaken, other functions take over the hearing centre in the brain creating a situation where the hearing areas of the brain do not ever recover from. Early referral to an audiologist and ENT surgeon is recommended.

Childhood Hearing Loss – Often Avoidable, Preventable and Treatable

Childhood Hearing Loss – Often Avoidable, Preventable and Treatable

Hearing loss affects over 350 million people worldwide with over 30 million being children. The World Health Organisation (WHO) has issued a paper in line with the principles of the Convention on the Rights of People with Disabilities focusing on ‘improving hearing and access to communication to facilitate education and employment and fostering social inclusion and psychological well-being in people with hearing loss’. A three-prong approach comprising Prevention, Identification and Intervention has been established1. Paediatric hearing loss affects children the world over with 60% of cases being preventable. A greater number of children are affected from low-resource settings (low and middle-income groups).

This article provides several cases of children with hearing loss and aims to highlight the importance of early diagnosis and treatment that is appropriate for the stage of life, degree of hearing loss and economic factors that impact families with these children.

Case 1


A 4-year girl presented with repeated right ear discharge and hearing loss. She is known to snore and mouth breathes. She has a family history of asthma. She has been seen by her primary care practitioner thrice in the last year with similar complaints and treated with oral antibiotics and eardrops. Her teachers have mentioned that she is easily distracted and can be disruptive.

Diagnosis and management

Glue ear (Otitis Media with Effusion with possible perforation of the ear drum). Cases of ear discharge and hearing loss in pre-school children are very common. The vast majority of children in this age group have or will have issues pertaining to their middle ear simply due to the incomplete development of their mid-face and structures associated with it. The tube that connects the back of the nose to the middle ear (Eustachian or pharyngotympanic tube) is shorter, more horizontal and less sturdy in a young child. Lymphoid tissue similar to the tonsils at the back of the throat known as the adenoids also swell up (contributing to nasal blockage and resulting in snoring) with infections of the upper respiratory tract and increase the infective load and /or physically block the opening.

Most often, this condition if left alone for a few months or treated symptomatically resolves as the child develops. In instances where the condition recurs regularly and is affecting the speech development of the child, a specialist opinion for surgical treatment of the adenoids (adenoidectomy) and glue ear or, for hearing aids – may be necessary. Insertion of small tubes – some of which are akin to a yo-yo / dumb bell (called grommets) are inserted using a microscope by an ENT specialist to help equalize pressure across the ear drum and improve hearing and speech and in so doing, concentration and possibly other behavioural issues.

Case 2


A thirty-five year-old mother of two children is pregnant with her third child. She develops a rash and is unwell for a week during her first trimester of pregnancy. Her son is born slightly before term and is found to have hearing loss on the newborn hearing screen. She notices that he doesn’t respond at all to sounds.

Diagnosis and management

Congenital rubella infection. One in every 1000 children is born deaf. Infective causes of deafness are the most common causes of preventable deafness despite immunization programs worldwide. Rubella is a highly contagious viral infection which can be transmitted from mother to fetus. Other congenital infections such measles, mumps, cytomegalovirus (CMV), toxoplasmosis and herpes can cause profound deafness. There have been spikes in measles cases in Singapore and worldwide with deaths from the disease mainly due to lack of vaccination for a variety of reasons.

Congenital rubella syndrome is often picked up when the child has had its newborn hearing screening and later if it does not display the normal reactions to sounds. Infected children should be managed in a multi-disciplinary setting with specialist eye, heart and ENT care. Cataracts, congenital heart defects and sensorineural hearing loss are amongst the more common conditions associated with in utero transmission to the child. Prompt specialist audiological and ENT input with the need to provide hearing aids or other devices (cochlear implants – Figure 1) may be advised.

Case 3


After a protracted bout of the ‘flu’ Millie, who was only 8 years old, developed viral meningitis. She was admitted to the intensive care unit and made a slow recovery. Her hearing in both ears was badly affected. She could barely hear loud noises and only felt them as vibrations.

Diagnosis and management

Profound sensorineural hearing loss secondary to viral meningitis. She was referred to the ENT and audiology department for specialist input. A trial of hearing aids failed and she was offered cochlear implantation. Given the urgency in performing the procedure before calcification of the cochlea (similar to hardening) occurred, an operation was performed within a few weeks to help restore her hearing.

Cochlear implants have revolutionised hearing rehabilitation in both the young and old. Indications vary accordingly but age at implantation, at either extreme, is becoming less rigid. Results in children who are born congenitally deaf are very good in most cases when implantation is performed before the child should have started to verbalise (becomes lingual). In certain instances (cultural or due to financial constraints), sign language is the preferred modality of communicating. The Deaf community has its own well-established practices for signing and there are schools, libraries and other social institutions for the Deaf to engage in (i.e. Deaf Culture).

Case 4


John was born with multiple defects affecting the development of his eyes, ears, facial bones and teeth. His ears were badly misshapen and very small. He could barely hear and testing his hearing was difficult.

Diagnosis and management

Treacher Collins Syndrome.  This syndrome is a genetic disorder which affects approximately 1:50,000 people. Children born with this condition require hearing rehabilitation and surgery depending on the severity of the condition. In general, the external and middle ear are affected. This means that the shape and size of the outer ear, ear canal and the three small bones (malleus, incus and stapes aka hammer, anvil and stirrup) of the ear are abnormal. Reconstruction of the external can be done in stages using the patient’s own rib cartilage and shaping it into an external ear. Another option is the use of a prosthetic ear which can be designed bespoke and can be inserted using titanium screws attached to the side of the head (Figure 2). Hearing aids that attach to the side of the head onto the skull are also very helpful (Figure 3. Bone-Anchored Hearing Aids, BAHA). They transmit sound waves by vibrating the skull and thereafter transmitting the energy to the inner ear.


Paediatric hearing loss manifests in many ways. It can be mild, moderate, severe or profound. The causes vary and treatment options depend on the degree of hearing loss, the age at presentation, what structural defects are present, the resources available to the patient and potential for rehabilitation. Modern surgical techniques such as cochlear implantation have transformed hearing restoration. Better hearing aids with the capacity to filter sound, be programmed to suit the needs of the individual and provide other modern conveniences (e.g. Bluetooth) are available too. Early prevention, identification and intervention are essential in making in-roads in the treatment and rehabilitation of children with this disability.

Vyas M.N Prasad
Consultant, Ear, Nose & Throat (ENT) – Head & Neck Surgery
Singapore Medical Specialists Centre

Specialties / Sub-specialties
Otorhinolaryngology / ENT
Specialty Interests
Voice & Swallowing Disorders, Head & Neck Surgery

The Business Times, Sunday, 11 April 2019

Helping Senior find their voice

The Aging Voice

Voice disorders are fairly common and in the vast majority of cases – self-limiting. They are seen in all age groups and caused by a variety of factors including overuse / abuse, infection, laryngopharyngeal reflux (LPR) and cancer. There is however an increasing trend in the first world of age-related voice deterioration which is becoming more prevalent given the increased life expectancy. The aim of this review is to provide the reader with an understanding of the physiological changes that occur with aging to the voice box, the effects this has on the quality of life of the patient vis-à-vis phonation (voicing) primarily and the medical management of the aging voice (presbyphonia).


Our voice box (larynx) consists of a rigid framework (thyroid and cricoid cartilages) housing a set of muscles and ligaments and these are supplied by nerves and blood vessels. These structures change with time in varying ways and rates. The cartilages can become harder with calcium deposition (ossification) but this however does not change the voice. It is the aging process physiologically that does so.

Physiological changes

As we age, our bodies tend to lose muscle bulk partly due to reduced need and also due to reduced hormonal / neurological stimuli. In the aging male, testosterone levels begin to taper around the fifties /sixties with reduced muscle bulk in the voice box more so than in women where the hormone is less prevalent. Consequently, the male voice begins to rise in pitch and may become more feeble. The female voice generally remains the same or very slightly lowers its pitch due to reduced tone of the vocal folds (cords) and relaxation creates a deeper voice with greater difficulty to ‘stretch’ the vocal folds. The ensuing processes can result in ‘bowing’ of the vocal folds which can appear as a breathy voice. The mucous glands that moisten the vocal folds begin to reduce in number and size (atrophy) leaving the vocal folds drier. The vibratory surface from which air escapes becomes less supple creating a less efficient sound. Laryngopharyngeal reflux (LPR) also affects this age group and the stomach acid irritates the lining of the larynx. Finally, the most important part of the vibrating fold, its ‘cover’ is a very delicate structure composed of flattened cells over a jelly like layer called the superficial lamina propria (SLP). This gelatinous layer has elastic fibres, collagen and water. The density of this SLP becomes higher with aging and less pliable with time causing it to stiffen up affecting our aging voice.

Aging also affects cardiorespiratory function. The elderly can be prone to conditions such as heart failure, chronic bronchitis (in smokers) and pneumonia. A weaker lung results in reduced air expulsion and weakening of the voice. Chronic cough and throat clearance can also affect the voice.

Other medical conditions

Neurological diseases such as Parkinson’s disease and stroke affect the voice. These conditions are more prevalent in the elderly. Subtle voice changes may be a harbinger for early forms of these conditions. Similarly so, tumours affecting the brain, neck or lungs can also affect the voice box. Hoarseness can be the first manifestation of the primary cause and in such cases, a referral to an ENT surgeon is recommended.

Smoking and alcohol

Elderly patients who smoke or have smoked and drink alcohol are also prone to voice problems due to the irritating effects of these substances. Chronic irritation and inflammation in women smokers can result in swelling of the SLP and concomitant hoarseness to an extent that the pitch can resemble a males. Changes to the surface cells which are due to the effects of these substances increases the formation of a protein – keratin. As a result, there is a resultant stiffening of the vibration. Chronic smoking with or without alcohol consumption can potentially cause the cells to transform into cancerous cells with patients having a 38-fold increased risk. Hoarseness in the elderly who have or continue to smoke and drink heavily is a serious symptom and should be seen urgently by an ENT surgeon.

Management of the Aging Voice

Elderly patients do not always complain of voice deterioration. Sudden deterioration is more alarming and requires investigation if the patient does not improve within a fortnight. Gradual deterioration is less likely to worry but may require investigation if the symptoms begin to worsen – e.g. hoarseness, breathiness, vocal fatigue, pitch breaks and/or weakness.

A thorough history including the patient’s drug history (inhalers, diuretics blood pressure tablets), previous surgery (thyroid, neck, chest) and medical history (low thyroid level, neurological conditions, chest disease) should be sought and documented.

Examination of the ears, nose and throat followed by a special examination using rigid or flexible laryngoscopes help evaluate the voice box in detail. Hearing tests can be helpful in many cases as deafness is common and often associated with voice abuse . Nasal conditions such as allergy and chronic rhinosinusitis can increase the backflow of mucus irritating the throat and resulting in a chronic tendency to clear the throat and/or cough. Other conditions in the throat can affect the voice including infections, cancer and rarer pathologies in the upper gullet (oesophagus) such as pharyngeal pouches (Zenker’s diverticulum).

The ‘gold’ standard for voice evaluation using endoscopes is a videolaryngostroboscopy (VLS). This examination is performed usually without any need for anaesthesia, takes a few minutes at most and allows for visualization of the movement of the vocal folds and their mucosal wave. Current technology has improved to an extent that the digital camera is a t the tip of the flexible scope with high definition image capture, recording and data storage facilities included in the console. A further refinement where a microscope is incorporated into the scope tip is also available.

Multi-disciplinary Clinic

Patients who have voice disorders (dysphonia) benefit from a multi-disciplinary voice clinic. This includes an ENT surgeon who has a special interest in voice (laryngologist) and a speech and language therapist (SALT). Together, they provide a holistic assessment and appraisal of the voice disorder with complementary roles in diagnosing and treating patients with dysphonia. The vast majority of patients with age-related voice disorders benefit from optimization of their voice using voice exercises and also changes to their lifestyle which may be contributing to their problem. Issues with diet (oily, spicy, coffee, tea and irregular eating times) physical exercise (cardiovascular function), hearing loss and medical disorders (hypothyroidism etc.) are jointly dealt with. Where there is only a need to help with conversational voice, SALT is often adequate. There are however patients who seek help especially when they are still working and use their voice professionally. Amateur singing in choirs, bands and other such activities which are hobbies dear to some patients can be affected too. Social isolation as a result of this is becoming an increasingly important problem. Together with deafness, many patients with presbyphonia may develop depression and even dementia.

Voice Therapy

Speech therapists provide a range of rehabilitative exercises for patients seeking an improvement to their aging voice. These exercises combine evidence-based therapies with achievable outcome measures that are tailored individually to each patient. Subjective and objective voice assessment tools with or without acoustic analysis of patient’s voices are utilised in the voice laboratory. Typically, patients benefit from 6-12 sessions each lasting a30-60minutes depending on the individual.

Surgical Treatment

Surgical intervention for the aging voice is rarely recommended in isolation. Most patients benefit from SALT before and after surgery. The aim of surgery in the aging larynx, assuming that there are no other vocal fold pathologies (nodule, polyps, cysts etc.) is to provide a better bulk to the atrophy of the folds. This involves injecting bio-compatible materials either in the office setting with the patient awake or in the operating theatre under a general anaesthetic (Images 1 and 2). These materials can be temporary or permanent and the choice of material is dependent on the individual’s needs and general health. Other procedures which include external operations on the voice box are rarer but can help in selected cases to close the ‘gap’ between the two vocal folds that develops over time (Images 3 and 4).  Surgery does not however restore the loss of the SLP and the pliability of the folds does not improve. It does however help improve voice quality and amplification.


Presbyphonia is a problem which is increasingly seen. It affects between 12% to 47% of the population. Its impact on the quality of life of our elderly is high but early identification and intervention has been shown to be helpful in reversing what is viewed as a ‘normal’ part of life. As clinicians, it is imperative that we view aging as natural but provide our elderly with a quality of life that allows them to enjoy their golden era to the fullest.

Vyas M.N Prasad
Consultant, Ear, Nose & Throat (ENT) – Head & Neck Surgery
Singapore Medical Specialists Centre

Specialties / Sub-specialties
Otorhinolaryngology / ENT
Specialty Interests
Voice & Swallowing Disorders, Head & Neck Surgery

The Business Times, Sunday, 2 December 2018

Nasal allergy: a review of a common, chronic problem affecting the upper airway

Nasal allergy: a review of a common, chronic problem affecting the upper airway.


Nasal allergy (Allergic Rhinitis, AR) is a common condition affecting both the young and the old. It is the commonest immunological disease affecting mankind. Despite this, the condition remains poorly understood, diagnosed and treated worldwide. AR has a profound impact on the quality of life (QOL) of sufferers – it affects schooling in children, reduction in attendances, reduced concentration and similarly so, has a profound effect on the working adult population with a considerable financial impact. The prevalence of allergic rhinitis in the first world ranges from approximately 10% in the USA to 40% in Singapore. These figures have increased over the last few decades and several factors are thought to play a part in this rise. These include genetics, environmental factors and possibly economic and industrial development with a corresponding change in lifestyle, social activities, smaller family sizes, urban environments and reduced exposure to infectious diseases.

Rhinitis, by definition, is an inflammation of the lining of the nasal passage (mucosa) and presents typically with nasal discharge (runny nose), itching, sneezing and nasal blockage or congestion. Rhinitis can be caused by a variety of factors, allergy being one. It can also be non-allergic, infective and also from a combination of factors i.e. mixed.

Allergic Rhinitis, Asthma and Other Medical Conditions

Allergic rhinitis is a risk factor for asthma and affects the control of asthma too. Consequently, a combination of the two conditions increases the cost of managing both. AR in early childhood is a risk factor for future development of asthma in adult life. Approximately 80% of patients with asthma report symptoms of rhinitis and vice-versa. The World Health Organization (WHO) published guidelines on Allergic Rhinitis and its Impact on Asthma (ARIA) classification (Figure 1) based on the frequency and severity of symptoms. AR is associated with other ‘allergy’ states (i.e. atopy) such as eczema and food allergy. AR also affects the eyes (conjunctivitis), reduces the sense of smell (hyposmia), affects the middle ear and potentially reduces hearing, irritates the throat and can affect the voice box. Middle ear inflammation and swelling of the adenoids (lymphoid tissue found at the back of the nose) may be associated with AR too. There is also some evidence to suggest its effects on sleep, mood and concentration. Occupational rhinitis i.e. rhinitis caused by airborne substances in the work environment affecting the nasal lining can affect the individuals primarily or affect predisposing asthma and potentially even cause it.

Common allergens

Most allergens affecting the nose are airborne and are called aeroallergens. The common aeroallergens are house-dust mite, grass, pollen, cockroach, dog and cat dander-although this list is by no means exhaustive. House-dust mite and house-dust (fecal matter of the house-dust mite) is the most common cause of aero-allergenic AR in Singapore. The two most common species of dust mite are Dermatophagoides pteronyssinus and Blomia tropicalis (Figure 2). They are found in mattresses, pillows, bed linen and carpets. They are invisible to the naked eye. In temperate climates, there is a seasonal variation of AR involving a variety of pollen etc. that are released throughout the year.


History and Examination

Referrals for allergic rhinitis are usually made to ENT surgeons, paediatricians with an interest in allergy and immunologists/ allergy specialists. A thorough history is taken with an emphasis on the chronology and frequency of symptoms (e.g. sneezing, itching of the nose, eyes and palate) environmental factors, seasonality (if present) and the effects on the QOL of the subject.  Other medical issues such as asthma and symptoms such as cough and wheeze should be explored. Sleep problems, voice change and snoring should also be ascertained. The family history as well as social considerations such as pets, hobbies etc. are important in developing a holistic understanding of the patient’s issues.

Medication such as beta-blockers (e.g. for high blood pressure) and anti-histamines, aspirin and non-steroidal anti-inflammatory drugs worsen symptoms of AR. Likewise, the oral contraceptive pill is known to worsen nasal congestion.

Examination of the ear, nose and throat looking for signs of AR is performed routinely. This includes looking for an ‘allergic salute’ – a horizontal nasal crease across the front of the nose above the tip and dark circle around the eyes due to pooling of blood around the eyes (i.e. shiners). Inspection of the front of the nasal passages (anterior rhinoscopy) looking at the health of the nasal lining, any swelling of the side walls of the nose (turbinates) and deviation in the nasal partition (septum) is documented. Nasal endoscopy is performed in specialist centres by ENT surgeons. This examination allows for visualization of the back of the nose and throat. Other conditions that may affect the nose such as infections, polyps and adenoidal swellings are easily picked up on nasendocopy.


The mainstay of diagnostic testing in subjects with AR are tests that assess a type of immunoglobulin in the skin or blood serum. These molecules (i.e. immunoglobulins) are effectively antibodies that are produced by a specific type of cell as part of the bodies immune system.  The allergen-specific immunoglobulin is called IgE. Skin prick tests (SPT) are a routine part of the allergy work-up and involve the pricking /scratching of the skin while inserting a purified sample of the known allergen (e.g. house-dust mite, dog dander etc.). A positive SPT does not always mean that the individual is allergic to a particular allergen with up to 15% of individuals who do not exhibit any AR. Serum (blood) tests are more specific and are performed when SPT is not available or when the SPT result is unhelpful. Serum specific IgE can be tailored according to the profile and possible exposure of the patient. Finally, where there is a suspicion of concomitant asthma, patients can be referred to a specialist for lung function measurements.


Allergic rhinitis in Singapore is predominantly due to house dust mite allergy. While seasonal allergens are more easily avoided and do not affect the patient throughout the year, the house dust mite allergy sufferer has a greater challenge facing him or her given the practical challenges of reducing exposure. Patients are advised to take simple measures such as removing unnecessary carpeting, washing their bed linen at higher temperatures, using anti-allergenic mattresses etc. Saline washes have been shown to help some individuals and possibly reduce the need for medication although not completely substituting them.



Given the difficulties in allergen avoidance, many AR patients are prescribed a variety of medication. A stepwise therapeutic approach is recommended with combination therapies being prescribed as severity increases. Antihistamines are drugs that stop the release of histamine which is secreted by cells found in the nose, throat and eye. These drugs can be administered orally, as nasal sprays or eye drops. The older generation antihistamines caused more ‘central’ effects such as drowsiness. The newer ‘2nd’ generation antihistamines are longer acting and have a less sedating effect.  By and large, antihistamines are the first line treatment for mild to moderate symptoms of AR. The topical intranasal compounds have been shown to help with faster onset of action.


This class of drugs is the cornerstone of the anti-inflammatory treatment in AR and are administered intranasally as sprays. They are suitable in children and adults depending on the preparation and manufacturer’s recommendations. They reduce nasal congestion and have a much better effect in comparison to other therapeutic groups such as the antihistamines. Intranasal steroids (INS) can take several hours to take effect and clinical improvement can take a few days with even a fortnight for maximal effect. Unlike their oral counterparts, the newer INS have much lower to negligible absorption into the bloodstream thus reducing systemic side effects (low bioavailability). As such, they are also used in children. Besides some nasal irritation, the INS can cause mild insomnia and can raise the intraocular pressure in glaucoma patients. They are ideal in patients with moderate to severe symptoms and can be used in conjunction with antihistamines. Combination treatments where a topical antihistamine and INS are mixed together have been shown to help all nasal symptoms of AR in addition to ocular complaints.

Other Medical Treatments

Nasal decongestants help in the short term to reduce the swelling of the nasal lining. They work much faster than INS and may be tempting to use in the long term given their immediate effect. They are however NOT recommended for long term use given the rebound nasal congestion after. A three-to five-day course (maximum) is recommended. Another class of drugs known as the anti-leukotrienes have been used with some success in asthma and AR sufferers. They are well tolerated but do not have the same effect in managing inflammation as the INS. Another class of drugs which may help in watery discharge, the anti-cholinergics (e.g. ipratropium bromide) can be used in combination with INS when necessary. Finally, cromoglycates, a class of drugs that aim to prevent histamine release from sensitized cells can help in mild AR and used as eyedrops for ocular symptoms.


This form of therapy aims to re-educate and ‘calm-down’ the immune response by habituation and development of ‘tolerance’ to a particular allergen. Subcutaneous immunotherapy (SCIT) involves the incremental injections of purified allergen under the skin over a period of time in a controlled manner and setting. This process can take up 3-5 years with 4-6 weekly injection. Access to emergency resuscitation facilities are imperative however given the risks of anaphylaxis (severe life threatening allergic reaction). Sublingual Immunotherapy (SLIT) as the name implies involves placing a tablet or drops of purified allergen under the tongue. It is generally well tolerated and has been effective for grass pollen and house dust mite. Besides side-effects such as oral irritation and mouth swelling, it is safe and can be administered by the patient at home. In summary, immunotherapy is the only treatment that has the capability to modify the immunological course of AR and has been to shown to improve the QOL by reducing or obviating the need for INS and other treatments.


Given that AR is primarily an immune mediated condition, the role of surgery is limited to dealing with anatomical issues such as a deviated septum, inferior turbinate hypertrophy, concomitant chronic rhinosinusitis and in so doing help with more efficient drug delivery.


Allergic rhinitis is a common but chronic and complex condition. It is poorly understood and often under treated. The ramifications of AR include the development of asthma, worsening of daily performance and quality of life in both children and adults. Treatment options are available and a stepwise evidence-based approach to its management is essential in order to provide a sustained improvement or even cure to affected individuals.

Vyas M.N Prasad
Consultant, Ear, Nose & Throat (ENT) – Head & Neck Surgery
Singapore Medical Specialists Centre

Specialties / Sub-specialties
Otorhinolaryngology / ENT
Specialty Interests
Voice & Swallowing Disorders, Head & Neck Surgery

The Business Times, Sunday, 29 December 2018