United Airways. Asthma of the nose. Hay fever and chronic rhinitis not caused by allergy.
The airways start at the tip of the nose, continue through the nose, throat, larynx, windpipe, bronchi until the alveoli. In principle these structures can be understood as one organ. In consequence these structures would react in the same way, as a unit. We divide them in upper airways (above larynx, i.e. nose and sinuses) and lower airways (beneath larynx, i.e. bronchi resp. lung).
We find patients suffering only from hay fever. The bronchi are not affected. Indeed, in this case only the upper airways react. And we know other patients only suffering from asthma without symptoms above the larynx. Only the lower airways react. But in many cases it is merely a matter of time before the disease spreads. The disease starts, for example, as hay fever with an allergy against poll in the upper airways. Years later the disease develops further and an asthma, for example caused by an allergy against house dust mites, occurs. Than we speak of a “shift” from the upper to the lower airways. We should rather speak of an “addition” then of a “shift”. The disease is spreading. Both levels are affected and need diagnosis and treatment.
With hay fever and an allergic asthma these connections are commonly known and accepted. Concerning asthma not caused by allergy the situation is more difficult. The freedom from allergies can hardly be proofed. We do not find allergies and so we conclude there are none. We can not be sure. We see an asthma not caused by an allergy and the upper airways can be affected in the same way. We find an asthma and chronic rhinitis, however, both not caused by allergies. In most cases the eyes react less. We speak of a “sin bronchial syndrome which is not allergic”, which is debatable. With this kind of disease we hardly see any obvious findings. That is found in both levels of airways. Incorrectly these patients are often considered as hypochondriacs, functionally or mentally ill.
ENT-doctors do not find obvious results. The mucoid layers may be swollen or inflamed a little. Sometimes worse results are found, like chronic sinusitis. In the throat mucus runs down. That’s why the term “Post-nasal-drip-syndrome” is used. But this term is quiet wrong because it describes not a disease or a syndrome but only a symptom. In the same way cough is not an illness or a syndrome but a symptom.
It would be even more wrong to assume that the mechanism of running mucus is the problem, and that it affects the windpipe and lungs. Many patients suffer from cough and even shortness of breath. However, the mucus does not enter into the windpipe or bronchi. The mucus running down from nose into the throat causes swallowing and runs down further into the oesophagus and stomach. There it is disinfected and digested. This way is not harmful. The lung is bypassed without reaction. Postnasal drip is not harmful and only shows a symptom. Hidden behind it is an illness of the airways. This illness is the problem.
The underlying illness is an inflammation of the airways. In the bronchi it mainly causes phlegm, cough and shortness of breath. The nose is mainly blocked through swollen mucoid skin and through secretion, mainly thin and clear like water and not tinged. This phlegm is cleared to the front when the nose is blown or it runs back through the throat and is swallowed.
Patients are examined by the ENT-doctor. If he does not see the running phlegm behind he will only see a little inflammation and nothing else, however, sometimes not even that. The nasal septum is rarely extremly in the middle. In consequence it is assumed to be the cause and will even be rectified by operation. In more than 50 % afterwards the condition is not better than before. That is well known. I think the cause is the wrong interpretation of the processes in the nose. Like so many times before in medicine (especially of the airways) “I don´t see anything” does not mean “There is nothing”. This conclusion is wrong but is often drawn.
Here we need to change our minds, first in the way we draw conclusions and second in the way we understand the process of the disease. This kind of illness belongs to the group of diseases of the airways with inflammation and obstruction, sometimes but not always caused by allergies.
The COPD of the nose – The chronic rhinitis in chronic bronchitis. (6/2016)
Hayfever is mainly a condition in young people. As these patients become older, symptoms often subside gradually. A new developed hayfever in the elderly is rarely. The non allergic type can be seen more frequently in the elderly.
Chronic bronchitis is a condition of the second half of life. It starts slowly and the progress is gradually. Smokers are affected earlier and stronger. In simple cases and in phases without infection pathologic results are rarely found by the pathologist. Based on samples of tissue he describes „chronic bronchitis“ as it is found in many old people.
The COPD-associated illness of the nose is similar. It rarely shows acute symptoms. During an infection the reaction may be seen with severe rhinitis, coloured discharge and sometimes nosebleeding.
During phases without infection the complaints are few, nasal discharge like water mostly occurs in the morning. Often it is felt at breakfast when the coffee steams or the hot cup of tea stands in front of the patient and bread is toasted. The mouth waters. The nose reacts also. The nose runs like water and the water runs like a spate. The handkerchief urgently is needed. Suddenly a drop may fall at the table or even on the plate. How embarrassing.
After the meal salivary glands calm down. The nose calms down too. The way to work leads through humide and cold air. One is in a hurry. Time is short. Breathing accelerates. But to avoid symptoms in the throat we breathe correctly through the nose. Suddenly and unexpectedly liquid drops from the nose again. Quickly a handkerchief. After some time the nose calms down. But quiet often lasts it until the reach of the workplace or even half an hour longer.
At lunch: The same symptoms as at breakfast. At five o’clock-tea again and at dinner too. Even after retreating into your warm and cosy bed the symptoms recur. Throughout the night the nose is calm.
Some people tend to suffer from frequent airway infections or sinusitis, others do not.
What do physicians see? A slightly inflamed mucoid layer that seems dry, rarely with a little phlegm, a little swollen mucoid skin. In short: Nothing. Tissue samples for the pathologist are rarely taken. Probably they would show only mild signs of chronic inflamation, nothing unusually in elder people. The changed function of the glands we do not see with the bare eyes nor through the microscope. What are the reasons for this changed function? Is it a kind of erosion or degeneration or due to age?
The not allergically caused rhinitis in the asthmatics and the chronic rhinitis in chronic bronchitis today can hardly be distinguished. We lack the reliable test methods. In asthma the main process will be inflamation. In chronic bronchitis mainly the function of the glands will be altered. Maybe, the differences are only gradual.
To call this disease „post-nasal-drip-syndrome“ or better „sinbronchial syndrome“ has the same effects as in asthma (see above). Allergies do not play any role in chronic rhinitis in patients suffering from chronic bronchitis.
The larynx as hub of the transport routes in the throat. (1/2017)
Seen from the front on the throat the larynx is located where we see an up and down moving swell. The larynx is the entrance to the windpipe. In the entrance on the right and on the left are strechted the two vocal cords, more precise vocal folds, because they are no cords but sails with a cord-like thickening on the edge. With these vocal folds we sing and speak. They widen when we breathe and they close when we cough.
In the throat the windpipe with the larynx as entrance lies in front of the esophagus carrying the nutrition to our stomach. But the mouth is at the front and beneath the nose, through which we normally breathe, which is up and behind. So food and air in the pharynx have to pass the same way before going into different directions. However, gravitation would lead everything into the windpipe and into the lungs.
In order for the air to flow into the windpipe and for food and liquids not slip into the windpipe but into the gullet we have the larynx at the entrance with the epiglottis. The epiglottis blocks the entrance when swallowing anything. Afterwards, and when breathing too, it opens the entrance. The transport routes of air and nutrition cross in humans. Does the larynx belong to the gastrointestinal tract or to the airways? In anatomy it marks the entrance to the lower airways. It belongs to them. But we can also reflect it as a part of the gastrointestinal tract.
Many people suffering from diseases of the lung feel a lump in the area of the larynx. Probably they feel a little pain. People often become hoarse, because of a mild swelling of the vocal cords and a change in the frequency of swinging. Furthermore clearing of the throat and even a mild cough may occur. In several cases also some mucus may be expectorated. That is the reason why people think that the lump in their throat is a little mucus that has to be expectorated. Often only very little phlegm comes up. We have to use an expectorant. We get it at the doctor or at the pharmacy. However, the effect on the mucus is negligible. The main effect is the one at two purses, one gets lighter and one gets heavier. A lot of patients suffer from these symptoms chronically for many years and decades. They themselves get used to it but parents, spouses and friends feel irritated by it.
When seeing the ENT-Doctor he often finds unobtrusive results only or a little spot of redness at the posterior edge of the larynx. Because this spot lies next to the entrance of the gullet in many cases the conclusion is drawn that the redness is caused by gastric acid resp. reflux. The gastric acid is thought to flow through the not entirely closed entrance of the stomach into the esophagus when lying and causes inflammation. This disease is found fairly often. It should be treated. But if we took the gastric acid to be the reason for the lump in the throat the gastric acid would have to flow along the hole esophagus and in the pharynx it would have to flow against gravitation up to the larynx and cause the inflammation there. In severe cases the mechanism may occur but in most cases, i.e. the mild and moderate cases we can’t believe this explanation. One can try to treat with a blocker of gastric acid. If there is no relieve within 4 weeks the treatment can be stopped.
Lets remember the larynx is the entrance into the windpipe. At its lower end it splits into two main-bronchi and further down branches out like a tree. So in fact the space in the windpipe and in the bronchi is one space. Inflammation caused by allergies or other reasons will affect the entire space. The different parts may be effected in different ways but the combining issue is a slight inflammation spread over the entire airway space. Most noticeable is the inflammation in the small bronchi by a swollen mucoid layer, perhaps by production of a little phlegm or a constriction of the muscles in the wall of the bronchi. As a result the bronchi are often constricted.
A second structure are the very finely built vocal cords. Even a little swelling causes a change in their swinging followed by hoarseness. In many cases these complaints belong to the airways and not to the esophagus.
However, we may ask why these complaints are not felt in the breast or lung. This fact has to do with the anatomy of the lung. The inner organs like liver, kidney, lung, splen and others are not nerved. The painnerves are located in the skin of the organs, for example the pleura, the tunic of kidney etc. A tumor in the lung big as a fist may not cause any pain, neither in the liver. Does the growing tumor reach the cover or does it expand the organ so that the capsula becomes dilated severe pain is felt. In the tissue in the organ we hardly feel anything.
Back to the lung: The painnerves begin next to the larynx. That is the reason why complaints are felt there. More into the lung tissue we hardly feel anything because the sensors are missing as mentioned above. We feel the problem at the larynx though the complaints are caused in the lung. To simply connect feeling to reality is often misleading.
In addition we have the fact that the patient often thinks of the feeling as a foreign body, often as phlegm. A little phlegm is got rid of but the feeling hardly changes. In consequence he coughs intentionally to get out all phlegm. And so, we irritate the mucoidlayer even more causing new inflammation, phlegm and sensation of a foreign body. The opposite of the intended affect is achieved.
Others interpret the sensation at the larynx as dryness in the airways.
Again the question rises: Do we interprete this sensation in the right way? How do we feel an inflamed mucoid membrane? Many times I have asked my patients. Why indeed should the patient know this?
Right. After many years of explorative work with patients suffering from lung diseases I conclude that this feeling at the larynx is caused by the inflamed mucoid membrane. And it is sessile. By coughing we bring up a little phlegm. That is it. To cough more than that does not help. However, the irritation of coughing will increase the tickle in one’s throat. It will not change anything.
Wrong! I am able to change this sensation by drinking often or sucking a sweet. In both cases one has to swallow more often. Many people think that mucoid layer is too dry. Even many ENT-physicians tell that to their patients. I have looked into the mouth of almost all of my patients. Only very few of them have a dry mucosa. In most cases the mucoid layer is wet and reflective. Not the lack of humidity is the cause. We can compare the sensation with a feeling of itchiness elsewhere on the skin. When we stroke the itching skin we change the feeling, maybe even eliminate the itch. But we have not changed the cause and soon the itch will be there again. The essential is not what we swallow, but that we swallow. When swallowing the mucosa touches on both sides in the whole throat. So the itchiness disappears. But we have not relieved anything fundamentally. Drinking or sucking are able to change the feeling, but they do not change anything really. We don’t get a final solution.
Finally I like to come back to the issue of expectorants, which many patients suffering from lung diseases think about. I have never understood why expectoration is so important. It is important but even more important whould be to reduce the production of mucus. To this end we have to reduce the inflammation and activity of the mucoid glands. Obviously phlegm that is not produced does not have to be dissolved. That is why fighting against inflammation and reducing activity of mucoid glands is so essential.
Let us sum up: Our sensation and the processes occuring in our body cannot be explained or interpreted simply. We need deep knowledge about the background. The sensation of phlegm is not necessarily caused by phlegm. Many patients suffering from lung diseases feel something next to the larynx. They suffer from hoarseness and dry cough. The stomach is rarely the cause of these sensations. It is the lung. Sucking and drinking relieve the irritation at the larynx. But in fact they do not eliminate the cause.