Troubles in the nasal area

Question

Dear expert team,

Our 3-year-old daughter has had strong infections of the upper and lower airways from October 2011 (when child care started) until January 2012. All infections were treated with antibiotics. At the beginning of December 2011 (permanent) grommets were inserted. We were told that the removed secretion did not look different from those of other children. No information about bacterial colonisation was given.
At the beginning of 2012 her condition was improving and she did not need antibiotics anymore but now the appearance of yellow/green mucus in the nose is increasing. Two days ago we went to the Otolaryngologist (ENT specialist) for the follow-up examination of the grommets. The physician diagnosed increased production of mucus; she did not see purulent nasal discharge or growth though. We asked what kind of preventing or alleviating measures we could take but she only said we should go to a medical supply store and ask there. The next follow-up visit is supposed to take place in 14 days.

With regard to the airways the current therapy is as follows:

In the morning:
Pari Junior Boy® baby mask or mouthpiece, 4ml NaCl 3% + 3 drops Salbutamol; 2,5ml Ambroxol

In the afternoon:
e-Flow mouthpiece, 5ml NaCl 0,9% + 3 drops Salbutamol; 2,5ml Ambroxol

In the evening:
Nebula RhinoWash (we bought and tried it on our own initiative) with 10ml NaCl 0,9%; Pari Junior Boy® baby mask or mouthpiece, 4ml NaCl 3% + 3 drops Salbutamol; 2,5ml Ambroxol

At night:
As required

Our question:
What can we do to finally stop the infection in the upper airways?

Would it be recommended to have a nasal mucus test (swab) done to find out more about the bacterial colonisation?
Are there particular measures that can support specifically the elimination of germs in the nasal area?
From which age is it recommended to use Cortisol and/or Pari Sinus?

We are concerned that an ongoing infection will have negative effects on the lungs again and we would like to avoid this.

Many thanks in advance.
Best regards

Answer

Dear family,

An increased number of infections is typical for most children when they start going to the kindergarten. Mostly, viral infections are the reason for it and these frequently cause long-term troubles of the airways with mucous rhinitis and cough (oftentimes in this order). Other children get rid of the virus infection without drugs after 3-7 days; in CF, however, the virus infection also leads to an increase of bacteria in the airways where the bacteria can survive in the viscous mucus caused by the disordered self-cleaning mechism. Therefore, a frequent use of antibiotics is necessary in cystic fibrosis in order to avoid scarring in the lungs. In this context, the generous and long-term use of antibiotics has contributed considerably to the dramatic improvement of prognosis in CF so that you do not have to be afraid of the use of antibiotics. Generally, the benefits in CF are much higher than a possible risk.

In CF patients, inflammations of the middle ear are not expected to happen more frequently than in other individuals.
In the congenital PCD (Primary ciliary dyskinesia) which is like CF characterised by a disordered self-cleaning mechanism of the airways, it is different: In PCD the involvement of the ears is a main symptom.

Pseudomonas can also colonise the ear area (also in isolation), not only in CF and PCD. Therefore, if the drumhead is open - here because of the grummets - repeated swabs with targeted long-term microbiological cultivation should be made by the microbiological department.

You ask for therapy options.

For persons who are having secretion troubles of the upper airways it makes sense to mobilise secretion by nasal rinsing. Preschool children and individuals who are having problems using a standard nasal douche/wash (125ml per nostril) can use a nasal nebuliser. Rhinowash (by Truma), that you bought, as well as Rhinoclear (by Flores) can be combined with an usual (e.g. Pari) nebuliser and transports a higher amount of saline (0,9 - approx. 2% NaCl solution) rapidly to the upper airways (see instructions in the internet).
We recommend this compressor aided nasal wash for children having secretion problems from age one (!).

If the nose is congested time and time again, a nasal spray with a very low dose of cortisone might also be an option for a long-term therapy (e.g. Avamys, Nasonex, Budenasal,… some of them are [in Germany] only approved for children from age 6, nevertheless it is also justifiable to use it in children under 6).

Generally, inhalation with Pari Sinus can only be done successfully from school age (see instruction in the internet).

Maybe the grommets will not be needed anymore soon. Whether grommets are useful in CF or PCD or not is discussed controversially - maybe one day this will be tested in studies.

It is important to keep in mind that our highest aim is not to avoid antibiotics but to avoid irreparable lung damages. The director of a CF centre in Kiel [Germany city] used to tell the parents: "Antibiotics are a friend of your child" and if we consider the dramatic improvement of the course of the disease under generous use of antibiotics, it seems that he was right.

With all these tools at hand and given that your child's immune system will become progressively stronger, this period can be managed so that not every virus will become a long-term problem.

Best regards,
Jochen Mainz

24.04.2012