Why is my nose blocked or runny all of the time? Could my problem be cluster headaches?

I have had a sinus problem for two years. A consultant has told me there is no infection or polyps in the nose, but every day I cough or sneeze and have a blocked or runny nose, leading to pains around my left eye. A natural sinus rinse does help. Could my problem be cluster headaches? I’m in my 80s.

Trevor Collins, by email.

Chronic perennial rhinitis is responsible for long-lasting swelling and mucus production in your nasal passages

To me, it seems clear that you have a form of chronic perennial rhinitis — long-lasting swelling and mucus production in your nasal passages.

The question is: what is causing it, and what can be done to treat you? 

My thinking on this subject is influenced by my work at a nose clinic at the Royal Brompton Hospital, where I was an assistant for many years.

Most patients referred to our team had symptoms of nasal blockage, mucus production, or cough; some had problems with their sense of smell, recurrent sore throats or persistent sinus infections. 

 

In 90 per cent of cases, these patients’ problems were the result of allergy — to house dust or pollen, for example.

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The remaining 10 per cent, who were not allergic, had a variety of different diagnoses. 

But the majority were classed as having chronic perennial non-allergic rhinitis. 

This is where the inflammation has no obvious cause and may, in fact, be a mixture of problems. It sounds as if you fall into this category.

Your symptoms have been evaluated by an ENT specialist, and structural problems such as polyps (swellings in the nasal lining) have been excluded.

I expect you have had a CT scan, as well as screening tests for allergy. And in your longer letter you tell me you failed to respond to azelastine, a potent antihistamine nasal spray, which also suggests that your rhinitis is non-allergic.

In cluster headaches there are attacks of pain on one side of the head, usually around the eye. But this pain is short lived and nasal symptoms are secondary

Your question about cluster headaches is valid, but your symptoms don’t appear to fit the diagnosis.

In cluster headaches (also known as migrainous neuralgia) there are attacks of pain on one side of the head, usually around the eye, often accompanied by feelings of restlessness and agitation. 

The attacks last between 15 and 20 minutes, and there may be five or ten a day.

The eye on that side may be red and watery, and the nose may be blocked or streaming. 

However, the dominant symptom is shortby lived pain and the nasal symptoms are secondary. In your case, the rhinitis is the main complaint.

I would suggest the pain around your eye is related to thickening of the nasal and sinus lining, due to inflammation. 

This can interfere with the ventilation of the frontal sinuses (air-filled cavities behind the eyes), causing pain.

A good test as to whether this is causing your pain is to bend forwards with the head lowered. This can make it worse.

My advice is that you continue to use a sinus rinse regularly. In the nose clinic we would recommend several snorts, twice a day, of alkaline nasal douche.

Mixing a scoop of table salt with the same quantity of sodium bicarbonate to a pint of boiled cooled water can be effective as a sinus rinse

You can make this by adding a salt-spoon size scoop of table salt and the same quantity of sodium bicarbonate (baking powder) to a pint of boiled cooled water.

You could also try using betamethasone nasal drops (a corticosteroid) twice daily in each nostril. These have a potent antiinflammatory effect, and will need to be prescribed by your GP.

To use these, you have to be in the ‘head down and forwards’ position. 

If you can, kneel down, forehead touching the floor, and drip the medication into the nostrils, waiting for 60 seconds for it to penetrate the sinus channels.

This may take some practice, but this approach will be more effective than using a steroid nasal spray, which is less concentrated and finely atomised. 

But these can be used as a maintenance treatment after trying a course (for one or two months) of the drops. Please discuss this with your GP.

I have recently been diagnosed with phimosis. I have tried a couple of creams (clotrimazole and Canesten) and antibiotics, none of which worked. A urological consultant has recommended a circumcision, but I am not keen. Are there any alternatives? I am 62.

Name and address supplied.

Phimosis is defined as the inability to retract the foreskin. But by the age of 12, it is believed that three out of four boys are able to

Phimosis is defined as the inability to retract the foreskin. Boys are born with foreskins fully attached to the underlying glans (the sensitive tip of the penis). 

But the age of 12, three out of four can retract it. By age 18, only 2 per cent of men are unable to do so. It is unusual to have this problem at 62, and I assume it has been developing for some time.

When phimosis is mild, repeated stretching (when washing, say) may cause small tears in the delicate skin, which lead to inflammation and scarring that can make the problem worse.

Because of the hygiene issues it poses, severe phimosis can lead to infection, which can cause further scarring. 

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To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email [email protected] – including contact details.

Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries. 

In rare cases, chronic inflammation and prolonged infection can result in cancer (specifically, squamous cell carcinoma, a form of skin cancer).

If you have had symptoms for some time, this may be why your urologist has recommended circumcision — though I am sympathetic to your reluctance.

You have tried Canesten (the generic name is clotrimazole), an anti-fungal cream, often prescribed for the yeast infection thrush (another possible complication of phimosis). However, it does not relieve the phimosis itself.

A better treatment is a steroid cream or ointment, typically betamethasone (0.05 per cent), which helps by softening the scarred skin and some patients find that it resolves the phimosis completely. 

Your doctor may agree to you trialling this, twice a day for four weeks.

However, the studies confirming that this is an effective treatment were conducted in much younger patients than you. 

If it does not help in your case, then an operation is the only option.

This does not have to be full circumcision. There is the procedure called a dorsal slit, which involves a small incision from the tip of the foreskin to the corona (the edge) of the glans. 

No skin is removed, and the cut is stitched to stop it narrowing as it heals.

Once healed it can look rather untidy, but it does make the foreskin retractable, enables good hygiene, and does not interfere with intercourse.