(Disclaimer: This article is for general use only, and the information in the following content has been processed to protect patient privacy)
Abstract: The patient in this case is a young male who developed nasal discomfort 1 year ago, but was not diagnosed and treated at that time, and his symptoms did not improve after taking medication on his own, and only came to our hospital 1 week ago when his discomfort worsened.
Basic information】Male, 17 years old
Type of disease】Allergic rhinitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】April 2022
Treatment Plan】Oral medication (Cetirizine Hydrochloride Tablets) + Topical medication (Serozoline Hydrochloride Nasal Spray)
Treatment period】Treatment with medication for 2 weeks, long-term follow-up
Treatment effect】The condition was controlled and the nasal discomfort disappeared.
I. Initial consultation
The patient, male, 17 years old, reported that one year ago, without any obvious cause, he felt that his nasal cavity was not well ventilated and runny bilaterally, but his sense of smell was normal, and he had no headache, dizziness, nausea, vomiting, etc. He mistook it for a cold and applied anti-inflammatory drugs (the exact name and dosage of the drugs are not known) at home, but the effect was not good. He was examined by nasal endoscopy and saw bilateral nasal mucosa congestion and edema, a small amount of mucopurulent secretion in the middle nasal passages bilaterally, bilateral inferior turbinates hypertrophy with mulberry-like changes on the surface, insensitivity to 1% methocarbamol astringency, no pressure pain in the bilateral sinus areas, no obvious abnormality in the pharynx; no obvious abnormality in the laryngeal dynamic microscopy. Based on the above findings and combined with the patient’s symptoms, a preliminary diagnosis of allergic rhinitis was made.
II. Treatment history
In order to further clarify the diagnosis, the patient was admitted to the hospital and underwent serum specific IgE test and cytological examination of nasal secretion smear. The test results were positive for serum specific IgE and more eosinophils were detected in the nasal secretion, suggesting that the patient was in a sensitized state and had recently been exposed to allergens, which could confirm the diagnosis of allergic rhinitis. To determine the allergen, a nasal mucosal excitation test was performed, and the patient was initially detected to be allergic to willow wool and pollen, but the presence of other allergens that were not detected could not be excluded. After confirming the diagnosis and allergens, we communicated with the patient and his family about his condition and decided to give medication, including oral cetirizine hydrochloride tablets and topical spray of celozoline hydrochloride nasal spray for treatment.
III. Treatment effect
After 2 days of hospitalization, the patient’s condition improved, and the uncomfortable symptoms such as nasal hyperventilation and runny nose gradually decreased. The patient came to the follow-up clinic 2 weeks after discharge and reported that the discomfort symptoms had basically disappeared. The re-examination indicated that the nasal mucosal congestion and edema had completely disappeared, indicating that the treatment plan was effective and the patient’s allergic rhinitis was controlled this time.
IV. Notes
After 2 days of hospitalization, the patient’s condition improved and her discomfort gradually decreased. At the same time, I also reminded the patient that after discharge, he should avoid contact with and inhalation of allergens such as willow wool and pollen, and wear a mask when going out to avoid re-irritation of the nasal mucosa and aggravation of allergic reactions; he should also keep indoor air circulation and appropriate temperature and humidity, suggesting that he should open windows at home regularly and use a humidifier in spring and other dry times; finally, he was advised to improve his bad habits and avoid blowing his nose hard and digging with his fingers. Finally, it is recommended that patients should improve their bad habits and avoid blowing nose hard and digging nostrils with fingers to reduce the stimulation of external factors on nasal mucosa.
V. Personal insight
Allergic rhinitis is mostly characterized by itchy nose, runny nose, nasal congestion, sneezing and other symptoms, and some patients easily confuse it with cold, like the patient in this paper, who mistook it for a cold in the early stage, resulting in intermittent attacks of allergic rhinitis for a year before getting systematic treatment. The most important point in the treatment of allergic rhinitis is to stay away from allergens and to avoid contact with them again after the cure, so as to effectively prevent recurrence.