What to expect from your initial consultation

The initial appointment will last 1 hour and will involve a comprehensive assessment of the presenting problem, relevant examination and directed investigations. The focus would be to obtain an exact diagnosis and discuss treatment options to suit individual needs. Training to self-manage the problem with a written management plan and best medicine delivery technique will be provided.

Please come 10 minutes early to provide your details and complete any relevant symptom scoring sheets and questionnaires.

Stop all antihistamine medication for at least 2 days before your appointment if possible. Continue all other medication including asthma inhalers.

Following the consultation, a full medical report and management plan will be sent to you by post. Only with your permission, will a copy be sent to your GP.

Follow-up consultation

This will last 30 minutes and is a review to assess treatment response, any outstanding management issues and review any outstanding investigations.

Payment terms

Please contact the practice team for further information. Dr. Kariyawasam is recognized by all major insurers and practices within insurance guideline fees. It is important to have all planned consultations authorized beforehand if seeking payment through an insurance company and provide the authorization code on the day of consultation.

Please read the following detailed guidance note for further information

Download 'An Explanation about Medical Fees in the Private Sector'.

Does the nose and sinus system have a function?

The nose and sinuses serve several essential functions acting as an air conditioner; filtering, warming and humidifying over 10,000 litres of air daily before it progresses to the lungs. The nasal passages and sinuses face environmental insults being the first site of allergen, microbial and particle entry into the body. This demands that the upper airway location must have a well developed and advanced immune system to confer protection from the environment.

What does the immune system do in the upper airway to protect us?

The immune system is primarily responsible for fighting infection. An important lymphoid tissue mass (tonsils and adenoids) collectively termed Waldeyer’s ring (prominent in childhood) is an important immunological organ surrounding the throat. It is important for the development and maturation of the immune system. When the immune system is defective or slow, recurrent nose or sinus infection can occur a long time before involving the lungs or other organs. The upper airway surface (called epithelium) can rapidly generate immune factors in response to nose and sinus injury, allergen or infection contact that starts and then sustains inflammation. The airway tissue is rich in cells that can sample the environment, decide on whether the material is harmful to the body and then activate an immune response via induction of immune cell function and antibody production. An over excessive or poorly controlled immune response can lead to problems such as allergy, sinusitis and other diseases that can bother the nose and sinus system.

Do I need mucus?

Another very important system is the ciliary (ultra-fine hair-like structures) and mucus secretion system. The cilia beat in a very efficient and coordinated manner to move a fine layer of mucus that has trapped environmental particles or debris to the back of the nose so that it can be swallowed. When mucociliary clearance is impaired it can lead to recurrent sinus and nose infection, as shown in diseases such as primary ciliary dyskinesia (PCD) and cystic fibrosis. Sinus disease is almost universal in these patients.

Normal sinus function needs

  • Open sinus drainage pathways
  • Normal cilia and mucus function
  • Normal and regulated immune system

The aim of evaluating someone with problems in the nose and sinus system is to carefully evaluate the above 3 factors which lead to disease. We do this by evaluating the anatomy via inspection through an endoscope and often a CT scan of the nose and sinuses. We can evaluate cilia function and sinus inflammation using specific rhinology tools. The immune system is evaluated using skin allergy tests and other detailed blood testing.

What is sinusitis?

Sinusitis is an umbrella term for any condition that leads to inflammation of the sinuses. Given that inflammation of the nose (rhino) and sinuses occur together, the term rhinosinusitis is more appropriate. Rhinosinusitis often presents with two or more symptoms, one of which should be nasal obstruction (blockage, congestion) or nasal discharge (front of nose/back of throat) together with either facial pressure/pain or diminished or loss of smell. On the basis of a scoring system called a visual analogue scale (VAS), symptoms can be divided into mild, moderate or severe. The degree of severity tells the doctor what level of treatment is needed. Often medical treatment is important and one of the important reasons for seeing a Rhinologist is to make the correct diagnosis, find the cause of the symptoms and therefore treat accordingly. The most up to date evidence base for using treatments is summarised in the European Position Paper on Rhinosinusitis and Nasal Polyps 2012 (called EPOS12 for short).

Acute rhinosinusitis

Acute rhinosinusitis is diagnosed when the symptoms have lasted less than 12 weeks and complete recovery is often expected. Anyone who has had a bad cold will have experienced this condition. Often viral infection is the cause, but bacterial infection can occur (sometimes following a viral cold). The symptoms can be the same whatever the cause, and if severe or troublesome symptoms such as facial pain occur, treatment is recommended. Based on treatment guidelines, once the correct diagnosis has been made, a nasal steroid often helps. If things are very severe, a nasal steroid with an antibiotic is needed. These recommendations are on the basis of systematic review and meta-analysis, the strongest type of evidence we have. For severe symptoms and particularly facial pain, steroid tablets may be indicated, but need to be taken early on to have the best effect and speed of recovery. Anyone with a swollen or red eye, high fever or facial swelling should attend accident and emergency as this may indicate a complication from the rhinosinusitis.

Chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is diagnosed when two or more symptoms, one of which should be nasal obstruction (blockage, congestion) or nasal discharge (front of nose/back of throat) together with either facial pressure/pain or diminished or loss of smell persist beyond 12 weeks. CRS is another umbrella term for a group of several different disorders with distinct causes and disease mechanisms, but can have overlapping abnormalities in the immune system. CRS is sub-classified into that without nasal polyps or with nasal polyps. This is still too simplistic view of a complex problem but at present allows us to broadly divide CRS into two major groups each with distinct causes. CRS is consistently associated with increasing severity of asthma.

What are nasal polyps?

This disorder manifests in the nose with symptoms of a severe cold which fails to resolve. Loss of smell and taste can be most troublesome with profound effects on quality of life. Nasal polyps (fluid filled sacs of inflammation) block the nose and sinus drainage pathways, and asthma and aspirin sensitivity can develop over the following few years. This condition needs an exact diagnosis and careful treatment, as very rarely a condition called Churg-Strauss syndrome can develop. Specialist long term treatment is usually required.

Are my nasal steroid sprays safe?

There are several nasal steroid formulations available and all are effective at treating inflammation in the nose and to some extent the sinuses. Studies have shown that the structure of the nose lining actually improves as inflammation decreases. Any medicine should only be used if the benefits outweigh the risks from the drug. If the absorption of the drug from the nose/sinuses is minimal then only negligible amounts enter the bloodstream and cannot therefore lead to distribution to the rest of the body. In addition, if the drug is broken down to inactive compounds by the body (usually via the liver), then the little amount of active drug that maybe absorbed from the gut is rapidly destroyed. This leads to what is termed ‘low bioavailability’ of the drug. The bioavailability of the commonly used steroids are so low that detection requires careful blood analysis. We therefore feel that such nasal steroids confer more long term benefits than harm to patients. Not all nasal steroids have low bioavailability so if you are uncertain always ask your pharmacist or doctor to check.

How do I take my intranasal spray?

Intranasal spray

The correct method of taking an intranasal spray-hitting the target is essential-is illustrated.

  1. Shake the bottle or device to ensure the drug is not sitting at the bottom of the spray.
  2. Remind yourself of the structure of the nose

The middle of the nose is the septum. This must be avoided.
The sides of the nose are where the structures of the nose called the turbinates are found.
The sinuses drain to the side of the nose. Thus we aim the nozzle of the spray gently towards the sides of the nose.

  1. Using your right hand hold the spray and aim towards the side of the left nostril.
  2. Using your left hand hold the spray and aim towards the left nostril
  3. Do NOT sniff after the spray as this will push the medicine down your throat away from the nasal lining. Instead bend you head down for 10 seconds and breathe through your mouth.

Cat and Dog Allergy-can it be prevented?

Most people love pets and this is very much the case in the UK. Around 7% of school children are sensitised to cats and around 5% sensitised to dogs. Such sensitisation is a risk factor for developing asthma at a later date and worryingly can increase the risk of an asthma attack leading to hospital admission. We are not sure if keeping a cat increases the risk of sensitisation or if in fact it is protective. Some studies even show no effect either way from keeping cats. With dogs, studies show having a dog, especially 2 or more dogs, may prevent sensitisation to the animal. There is no strong data that having a dog leads to increased risk of dog allergy. However, the birth cohort studies show that when children reach mid-school age, dog allergy will occur in children predisposed to dog allergy regardless of whether they had a dog at home or not. Currently it is very difficult to tell parents how to stop their children from becoming allergic to cats and dogs. Unfortunately there is no such creature as a hypoallergenic dog.

Asthma and Pet Ownership

General advice is that if a person is allergic to the pet and has asthma then pet removal is required. When the pet is removed the amount of asthma medication use decreases and asthma symptoms improve. Unfortunately, it is not possible to fully avoid cat and dog allergen. The major and most potent cat allergen (called Fel d 1) is distributed throughout the environment with a 100 fold increase in levels in homes with cat. The allergen is sticky and is therefore transported by owners on their clothes and hair into schools, public transport and cinemas for example. Strict allergen avoidance is therefore impossible. Dog allergen (Can f 1) has a similar distribution.

How do I avoid house dust mite allergen?

This is tricky as house dust mites are present nearly everywhere including buses and trains, offices and shops, not just obviously dusty environments. Carpets and bedding are rich house dust mite reservoirs. It is your bedroom that you can attempt to control dust mite levels. I give the following generic advice, although allergen avoidance is considered the most difficult and therefore probably the most ineffective intervention for allergic rhinitis (hence level of recommendation is Grade D in treatment guidelines)

Action Effect
Live carpet free Helps to decrease the mite reservoir levels
Take out dusty things-toys, curtains, books Deceases mite build up and airborne levels
Use allergen proof covers for pillows and mattresses This helps to reduce mite reservoir levels in bedding, and breathing mites in when asleep.
Wash all bedding weekly at >60℃ Kills house dust mites and removes allergen
Wash all fluffy toys at a hot cycle Kills house dust mites and removes allergen
Use air conditioning in summer and central heating in winter to lower indoor humidity Discourages house dust mite growth
Vacuum carpets and upholstery Decreases the allergen levels of dust mites

When is the Pollen Season in the UK?

Pollen Season in the UK

As you can see from the above chart, the tree pollens can start to appear as early on as January although the peak season is often around March when spring arrives. The grasses pollens are highest often around June. Weather and geographical factors will determine the exact timing and severity of the pollen season each year. Real time data is available from the National Pollen & Aerobiology unit at http://www.pollenuk.co.uk/ and is a helpful exact guide.

Occasionally, in late summer and autumn, weeds such as nettles and dock as well as mugwort and plantain can trigger hay fever, and should be suspected if symptoms start at the end of the grass season.

How do I approach the hay-fever season?

Four-step management undertaken by GPs

  1. Identify the pollens that may be causing allergic rhinitis.
  2. Take advice on allergen avoidance measures.
  3. Start medical therapy with an intranasal steroid (INS) at least 2-4 weeks before onset of symptoms. In individuals with moderate to severe symptoms or when nasal congestion is significant starting an intranasal steroid spray prevents immune system priming.
  4. Consider immunotherapy (allergy desensitisation) if symptoms do not respond to standard medical intervention the year after via referral to an Allergist trained to undertake this treatment approach.