Expert: Marc Rubin, RPh Asthma Educator - 1/10/2011

Question
Dear Marc Rubin

i am suffering from allergic rhinitis and post nasal drip from four years. from few months i feel mucus in my chest when wake up in morning. i am taking cetirizine 10 mg, montelukast 10 mg and azelastine nasal spray on regular basis from four years. pls guide me is post nasal drip go down into chest in sleeping or it is another disease. is mucus in chest normal or creat other disease? and other question is mucus produce in my lungs or it is result of post nasal drip and allergies. i visited a chest physian who said all is ok.

Regards
Zafar Iqbal

Answer
Hi Zafar,

Right now I have two concerns: 1)inability to remove allergen/irritant triggers from your environment, and 2) the doctor should rule out a condition called CSF rhinorrhea.

1) Allergy/asthma medication have limited benefit if you are constantly exposed to triggers in the environment. Identifying allergens and using a HEPA filer in your home and if possible, workplace, can significantly reduce theses levels. Irritants, like ozone, industrial pollution, smoke from cigarettes, fireplaces, particulate discharge from truck exhausts, may be more difficult.

2)To help differentiate the allergic issue from a membrane abnormality that allows cerebral spinal fluid to leak into the sinuses, the following list helps:

Watery discharge from the nose can occur in cases of CSF rhinorrhea and allergic rhinitis (also in other causes of increased mucus secretion in nose). It is important to differentiate between them so that appropriate treatment can be given.

   * History
         o CSF rhinorrhea – head injury, surgical procedures, intracranial tumors
         o Allergic rhinitis – sneezing, head cold, itching, tearing eyes
   * When the discharge occurs
         o CSF rhinorrhea – when straining or bending forward
         o Allergic rhinitis – no relation to straining or bending forward, continuous flow
   * Whether discharge can be sniffed back
         o CSF rhinorrhea – cannot be sniffed back
         o Allergic rhinitis – can be sniffed back
   * Character of discharge
         o CSF rhinorrhea – clear, thin, watery
         o Allergic rhinitis – slimy (mucus), watery (tears)
   * Taste
         o CSF rhinorrhea – sweet
         o Allergic rhinitis – salty
   * Glucose levels
         o CSF rhinorrhea – more than 30mg/dl. Should be compared to the levels in CSF obtained after lumbar puncture as glucose levels decrease in intracranial infections)
         o Allergic rhinitis – less than 10mg/dl
   * Specific test – Beta 2 transferrin
         o CSF rhinorrhea – invariably present
         o Allergic rhinitis – absent

Review this with your doctor, then get back to me for us to move forward.

Sincerely,

Marc