Chronic cough is usually defined as a cough that lasts for 6 to 8 weeks or longer. Most of the time, chronic cough has an underlying cause and needs to be evaluated.
Upper Airway Cough
In general, it is not life-threatening and is more of a quality of life issue. It is typically a dry cough that is most common in elder individuals. This type of cough interferes with sleep, social activities and bladder control (particularly with females). Causes of upper airway cough include: Gastroesophageal Reflux (GERD) or Laryngopharyngeal Reflux (LPR), Postnasal Drip Syndrome from Rhinitis and/or Sinusitis, ACE Inhibitors and Vocal Cord Dysfunction.
Acid Reflux - Gastroesophageal reflux (also known as acid reflux) occurs when acid from the stomach flows back (refluxes) into the esophagus, which is the tube connecting the stomach and the throat. Many people with a cough due to reflux have heartburn or a sour taste in the mouth, however, some patients with GERD have a cough as their only symptom. Substances that increase reflux include high fat foods, chocolate, soft drinks, red wine, acidic juices and excessive alcohol. Avoid eating for two to three hours before lying down. Elevate the head of the bed at least six to eight inches. Lose weight if you are overweight. Quitting smoking may also help reduce acid reflux.
Postnasal Drip Syndrome - Postnasal drip occurs when secretions from the nose drip or flow into the back of the throat from the nose. These secretions can irritate the throat and trigger a cough. Postnasal drip can develop in people with allergies, colds, vasomotor rhinitis and sinusitis. Some people have so-called "silent" postnasal drip, which causes no symptoms other than a cough.
Use of ACE inhibitors - Medications known as angiotensin converting enzyme (ACE) inhibitors, which are commonly used to treat high blood pressure, cause a chronic cough in up to 20% of patients. The cough is usually dry and hacking. Switching to another medication often improves the cough over the course of one to two weeks.
Vocal Cord Dysfunction - This is an abnormal opening and closing of the vocal cords when inhaling and exhaling. Vocal Cord Dysfunction is typically secondary to postnasal drip, mouth breathing or acid reflux. Breathing in through your nose and out through your mouth can help reduce the spasm.
Lower Airway Cough This type of cough is most common in children. Most common causes include: Cough Variant Asthma and Bronchitis. To help manage a lower airway cough, identify the cause through testing which may involve chest x-rays and CT's of the chest and neck. Treatment includes short term cough suppressants.
Asthma/Cough variant asthma - Asthma is the second most frequent cause of chronic cough in adults and is the leading cause in children. In addition to coughing, you may also wheeze or feel short of breath. However, some people have a condition known as cough variant asthma in which cough is the only symptom of asthma. Asthma-related cough may be seasonal, may follow an upper respiratory injection or may get worse with exposure to cold, dry air or certain fumes/fragrances.
Respiratory tract infections/Bronchitis - An upper respiratory infection such as a cold can cause a cough that lasts one to two weeks. This may be due to postnasal drip (as described above) or to irritability in the airways that have developed as a result of the infection. In almost all cases of bacterial tracheobronchitis, patients will have a cough that procures sputum. Sputum can range in color from light yellow to dark green or even brown. If such colored sputum or postnasal drip remains unimproved for more than 10 to 14 days, then antibiotics may be required in order to treat the infection.
Chronic Bronchitis - Chronic bronchitis is a condition in which the airways are irritated causing a cough and sometimes phlegm. Most people with chronic bronchitis are current or past smokers.
Lung Cancer - Although lung cancer can cause coughing, very few people with a chronic cough have lung cancer. Cancer is possible (especially if you are a smoker) when a cough changes suddenly and/or coughing up blood occurs. Cancer is also possible if the cough persists for more than one month after quitting smoking.
Postinfectious Cough - Patients who complain of a persistent cough lasting more than 3 weeks after experiencing acute symptoms of an upper respiratory tract infection may have a postinfectious cough. Such patients are considered to have a subacute cough if the condition lasts for more than 8 weeks. In most patients, a specific etiologic agent will not be identified.
Cough suppression - If the cause of a cough cannot be determined after a thorough evaluation, a medication that suppresses your cough may be recommended.
Eczema Care Instructions
- The key is to moisturize and not let skin become too dry. When skin becomes too dry it leads to itching, which leads to an itch-scratch cycle.
- Good moisturization starts with limited use of soap and using only mild soaps.
- In the bath only use soap on “dirty” areas which include: neck, armpits, groin, feet, and hands.
- Allow the rest of your body to be washed by the running water.
- Soaking in a clean, lukewarm bath daily is hydrating to the skin, but soaps will cause drying.
- Allow your children to play in the tub only until hands become wrinkled. At this time wash with a limited amount of soap and remove from the bath. It is not encouraged to soak in soapy water.
- Do not use any bubbles or other bath products.
- Dove sensitive skin is an excellent soap to use for those with eczema.
- When getting out of the tub or shower pat dry with a towel, leaving some water on the skin. This will stop skin from becoming overly dry as well as evaporation. Be sure to coat the skin with a good moisturizing cream that does not contain alcohol.
- Use your prescribed steroid cream on any active eczema patches before applying moisturizing creams.
- If there are large areas of the skin that are bumpy, it is usually a sign of an eczema flare. Use a nickel to a quarter sized amount of steroid cream mixed with a moisturizing cream to apply to that area.
- These moisturizers are recommended for use by patients with eczema: VaniCream, Cetaphil, CeraVe, Eucerin, Curel, and Aquaphor. These should be creams and not just lotions. Aquaphor also has an ointment that is a greasy product, which is recommended for those with eczema.
- Avoid or limit use of perfume, body sprays, or other scents on the body or clothing.
- Eczema can be very frustrating and requires vigilance even when skin appears to be healthy. This disease waxes and wanes and no treatment will "cure" the problem. The good news for parents is that most children will outgrow the more severe flares and eczema will become easier to control as they get older.
- Because food can sometimes be a trigger for young children, allergy testing and a potential elimination diet may also help control symptoms.
- Allergy testing can also reveal an indoor allergen, in which case removal or avoidance can also help control eczema.
- Patients who are older and still experiencing significant eczema symptoms may benefit from starting allergy injections.
- In some severe cases, especially those who have no found allergy triggers may also need to seek treatment from a dermatologist.
EXERCISE INDUCED ASTHMA
In the United States, it is estimated that as many as 10% of school-age children experience asthma symptoms brought on or worsened by exercise. This is known as exercise induced asthma (EIA).
EIA: Causes, Signs, and Symptoms
Why does exercise cause asthma symptoms? It is thought that the intense breathing that takes place during exertion causes water loss from the lungs, which cools the lungs’ moist lining. The drop in temperature begins a process that results in constriction of the muscles around the airways and inflammation within the airways - the ingredients of an asthma attack.
EIA can be difficult to diagnose. Patients who experience chest tightness, wheezing, shortness of breath or cough after exertion most likely have EIA. (But EIA should be explored whenever any symptoms appear regularly with exercise.) Symptoms usually peak 8 to 15 minutes after exercise ends. These signs and symptoms are then usually followed by a so-called “refractory period” of up to three hours during which normal breathing is restored and difficulty in breathing is unlikely. A late phase of symptoms may occur four to six hours later in some patients.
A diagnosis of EIA can be confirmed with an exercise challenge and spirometry testing. Spirometry is a test performed in the doctor’s office that measures the volume of air that can be forced out of the lungs in one second (called the FEV1). First, the patient takes the spirometry test. Then, he or she uses a treadmill or performs some other type of exercise. After that, FEV1 is measured again. FEV1 that drops more than 10-15 percent after exertion indicates that the patient has EIA. Not all doctors have the equipment to conduct this type of testing. Some patients are asked to measure their peak flow rates before and after exercise. Again, a significant decrease in airflow after exercise suggests EIA. Finally, some doctors diagnose EIA by giving the patient a trial of a bronchodilator medication (which relaxes the smooth muscle around the airways) to treat their symptoms. If the bronchodilator relieves the symptoms and if treatment before exercise prevents symptoms, it is likely that the patient has EIA.
An asthma management plan for someone with EIA would likely include some or all of the following treatments:
- Pre-treat with medication. Short-acting beta agonists (bronchodilators) such as albuterol or levalbuterol, when taken before exercise, can prevent asthma symptoms from occurring and maximize one’s exercise capacity. Bronchodilators may only protect against symptoms during one and a half hours of exercise. Healthcare providers typically advise their patients that they can take another dose after this period, if needed. They may also prescribe a long-acting bronchodilator (LABA), which would prevent symptoms for a longer period of time. (It also needs to be taken further in advance of exercise.) Pre-treatment is usually recommended even if no symptoms are present. (Note: Studies have shown that montelukast sodium, a leukotriene modifier, may reduce the severity of symptoms of EIA and decrease the recovery time for the lungs to achieve their pre-exercise capacity.)
- Take peak flow measurements before and after exercise. If peak flow measurements before exercise indicate that the asthma is not well controlled, they should either not participate in the activity or participate in a less strenuous way (perhaps playing goalie where less running is involved). Decreased activity should only be a temporary solution. If the person is regularly having trouble exercising, it is a sign that his or her asthma is not controlled. The person should visit the healthcare provider so changes can be made to the treatment plan. With proper asthma management, people should be able to exercise comfortably.
- Do warm-up and cool-down exercises before and after exertion. This has been shown to help prevent asthma symptoms. If symptoms develop during the warm-up, a quick-relief medication (bronchodilator) should be taken. Once the symptoms have resolved, the warm-up can be started again.
- Quick-relief medications (bronchodilator) must be available at all times. This means during school (for children) as well as after-school activities. If medications are kept in the nurse’s office, be sure that the office is unlocked and that these are readily available during after-school sports and activities. Medications should also be available to students during field trips or sporting events that are away from the school facility. Students should be taught how and when to use their inhalers and, if school rules permit, they should carry these inhalers with them.
- Avoid cold, dry air that provokes EIA. If this is not possible, the person should wear a scarf over his or her face during the activities outside in cold weather to warm and humidify the air before it reaches the lungs.
With proper asthma management, most people can play any sport. A small percentage may still have some trouble. These people may want to choose sports that are less likely to provoke asthma symptoms. Sports that require a lot of running with little time for breaks, such as soccer or basketball, are more likely to cause symptoms than a sport, such as baseball, that provides periods of rest. Swimming and other water sports, which take place in warm, humid air, are often the best type of exercise for people with EIA.
IF YOU OR YOUR CHILD HAS EIA…
- Work with your healthcare provider to develop an asthma management plan that prevents symptoms and allows maximum exercise capacity.
- Provide copies of the asthma management plan to school staff (including nurses, gym teachers, and coaches).
- Take medication before exercise, even if no symptoms are present.
- Encourage warm-up and cool-down exercise, even if no symptoms are present.
- Teach your child to measure their peak flow before and after exercise.
- Stay positive. Encourage your child to exercise. Good asthma management should allow you to exercise successfully.
- Exercise if asthma is not well-controlled.
- Continue to exercise if symptoms are increasing despite pre-treatment.
- Allow a coach or gym teacher to force your child to continue exercising with asthma symptoms.
- Exercise for at least two hours after receiving allergen immunotherapy.
Did you know that 50% of patients with Allergic Rhinitis also have Exercise Induced Asthma? Controlling nasal symptoms will also help in better controlling EIA symptoms.
NOTE: Avoiding exercise due to uncontrolled asthma should be a temporary situation. If this occurs regularly, see your healthcare provider to review your asthma management plan. With proper asthma management, you should be able to exercise.
Introduction to Asthma
Asthma is an inflammatory disorder (hyperreactivity of the airways) resulting in excessive mucus productions and airway spasm in susceptible people.
Mucus production causes chest congestion and phlegm. Airway spasm causes coughing, chest tightness and wheezing.
The most common triggers for asthma include: Respiratory viral infections, allergies and smoking.
Managing asthma involves avoiding the triggers, treating mucus production (controller) and treating airway spasm (rescue).
Early recognition of asthma symptoms and initiating therapy are key to preventing asthma exacerbation.
Types of AsthmaIntermittent Asthma - Symptoms occur less than two times per week and are usually resolved within two weeks. If not recognized early, then rescue medication is required for short periods of time when asthma flares up. At times, controller medications may be needed for a short period of time (weeks). Lung functions are normal when not experiencing an asthma flare.
Persistent Asthma - Chronic condition involving underlying hyperactivity in the lungs with triggers making it worse. Controller medication is needed all of the time (months or even years). Usually, there are other family members who have the same condition. Rescue medication is required for short periods of time when asthma flares up. Lung functions are normal or abnormal depending on the severity of the asthma. The goals of therapy are to maintain lung functions as close to normal values.
Q: What are Well-controlled Asthma symptoms?
A: Patients are able to exercise and sleep with no coughing, chest congestion and/or wheezing. There should be no limitation of activity.
Q: What are Uncontrolled Asthma symptoms?
A: Patients experience a deep cough, chest congestion and/or wheezing on exertion or at night. Rescue inhaler is being used more than two times per week.
Goals or Therapy
- Asthma is not curable but controllable by avoiding triggers and taking medications.
- Reduce asthma symptoms so they occur less than 2 times per week or not at all.
- No nocturnal awakening caused by asthma.
- Full participation in desired physical activity and sports without asthma.
- Prevent asthma flare-ups/attacks, ER visits and hospitalizations.
- Avoid absences from school or work due to asthma symptoms.
- Maintain normal or near normal lung functions.
- Provide optimal treatment with minimal or no side effects.
- Avoid the need or use of oral steroids.
Asthma Triggers and Control Measures
- Colds and infections: Avoid people with colds or the flu while washing your hands on a frequent basis. Get a flu vaccine every year. If eligible, get pneumonia vaccine. Be sure to rest adequately, eat a balanced diet and exercise regularly.
- Dust mites: If allergic, then encase mattresses, pillows and box spring in dust mite-proof encasements. Wash all linens weekly in a hot water wash (130°F or above). Decrease humidity in the home to less than 50%. Removal of carpet and reduction of clutters such as soft toys can lead to a decrease in dust mite levels. If it is not possible to remove carpet, then regularly use a vacuum with a HEPA filter.
- Animal Dander: If allergic, then the removal of a pet from the home is the best method for reducing allergen exposure. It may take several months after removing a pet from the home to eliminate the allergen in the environment. If it is not possible to remove a pet from the home, then it is best to keep pets away from bedrooms and bathe them regularly. Also, aggressive measures in reducing reservoirs (such as carpet), using air filtration and vacuuming with a HEPA filter will help reduce allergen levels.
- Molds: If allergic, then keep bedrooms, bathrooms and the basement as dry as possible. Run a dehumidifier and keep humidity between 35% to 50%. Keep windows closed and run air conditioning when outdoor mold counts are high. Vent the bathrooms and kitchen. Clean washable surfaces with a 50% bleach solution.
- Cockroach: Take measures to keep cockroaches away by using sprays or roach traps.
- Pollen: If allergic, then keep windows closed and run air conditioning when outdoor pollen counts are high.
- Tobacco Smoke: Do not smoke and avoid all forms of secondhand smoke exposure.
- Smoke from woodstoves/leaves/gasoline: Avoid using wood burning stoves, fireplaces and kerosene heaters.
- Weather Extremes: Cover your mouth and nose with a scarf on windy or cold days. Avoid being outdoors on hot and humid days as well as on ozone action days.
- Strong Odors and Aerosol Sprays: Avoid strong perfumes/fragrances and aerosol sprays. Avoid exposure to paint fumes.
- Exertional Activity: Exercise is healthy but limit it to a tolerable level. Work toward better control of asthma in order to improve exercise tolerance.
- GERD (Gastroesophageal Reflux): Uncontrolled GERD can exacerbate asthma.
- Medications: Beta-Blockers and Aspirin can exacerbate asthma for some people. If that is the case, contact your physician before you stop taking these medications.
Nasal congestion and runny nose is a common problem faced by all of us at one time or another in our life time. Most commonly this is a short duration, caused by respiratory viral infections. At times, this could be a life long problem. The most common cause of constant nasal symptoms is vasomotor rhinitis, where people have nasal sensitivity to irritants. The second most common cause of nasal problems is allergies. Most allergy triggers are from protein based antigens that we commonly inhale like: animal danders, mites, pollens and mold spores. Food allergies can also cause nasal symptoms; however, this is not very common. Injuries, like nasal septal deviations and nasal perforations can cause a problem, too. In other instances people have nasal polyps contributing to their nasal problems. Using nasal decongestant sprays for long periods of time can cause a “rebound effect.” This is where congestion worsens if one tries to stop the nose spray and can cause the need for more and more nose spray to get relief.
Nasal symptoms are nothing to sneeze about!!! If not controlled, in time, it can lead to ear infections (in children), plugged up ears, sinus problems, postnasal drip, mouth breathing, orthodontic problems, watery eyes, and dark circles under the eyes. Collectively, we describe them as upper airway syndrome, starting from the nose compared to the lower airway symptoms like asthma or Bronchitis. Keeping your nasal symptoms controlled all the time, early intervention, avoiding nasal triggers, and finding a long term solution such as allergy shots for allergies is essential for good health.
Types of Rhinitis:
- Allergic Rhinitis – Inflammation of the nasal passages resulting in sneezing, itching, congestion, runny nose, and drainage in the throat. This is the most common cause of nasal blockage (more common in children and young adults). Allergies are less common in older people, unless they have been present throughout their lifetime. Allergists can help identify specific allergies by skin testing and customize treatment options such as desensitization via allergy shots.
- Non-Allergic Rhinitis with Eosinophils – This group of people have similar symptoms as people with allergies; however, their symptoms are present yearlong. They respond well to usage of steroid nasal sprays.
- Vasomotor (non-allergic) Rhinitis – Patients with vasomotor rhinitis basically have very sensitive nasal linings, and any irritants such as: smoke, dust, perfumes, hair sprays, cold air, temperature changes and barometric pressure changes can aggravate their symptoms. They have chronic nasal congestion and constant post-nasal drip. Most of these patients ultimately end up with chronic sinus problems.
- Nasal Polyps – Nasal polyps are growths of extra tissue in the nose, and allergies can aggravate them. Nasal polyps never become cancerous. This group of patients should be on steroid nasal sprays to prevent recurrence.
- Mechanical Blocking Such As: Nasal Septal Deviations, Enlarged Tonsils and Adenoids, can lead to snoring and mouth breathing.
- Rhinitis Medicamentosa – It is caused by excessive use of decongestant nasal sprays. This condition is most common in patients with vasomotor rhinitis.
- Rhinitis due to infection – Rhinitis, secondary to the common cold, usually lasts about 10-14 days and then gets better.
- Antihypertensive medications and oral contraceptives sometimes cause nasal stuffiness.
INSECT BITES OR STING ALLERGIES
Insect stings usually produce only local irritation and discomfort. However, for an unlucky few, about 1% of us injected with insect venom during a sting can have more serious consequences. Reactions can range from a large local reaction to death due to an allergy to the venom.
Some people have symptoms of an allergic reaction to insect bites and insect stings from mosquito’s, horse flies, or deer flies. Usually they do not need any testing or treatment except antihistamines. It is vary rare that someone has a severe allergic reaction with insect bites. However, we do see large local reactions to mosquito bites.
The more severe reactions are due to insect stings. There are five insects in this part of the country that can cause severe reactions including life threatening anaphylaxis. The most common is yellow jacket, and two other insects called hornets. These three belong to the same family. The honey bee belongs to a different family, and usually, when a patient is stung by a honey bee, it leaves a stinger. Wasp is the fifth insect, and there are some cross reactions between the wasp, the yellow jacket and the hornet venoms. The most common reaction with these insects is a local reaction, and we do not recommend any medical treatment. One percent of these patients ultimately may develop severe allergic reactions, but the incidence is no different than the general population.
The second most common reaction is a large, local reaction. Usually the swelling gets worse a few hours later. This is treated with antihistamines and occasionally oral steroids if the swelling is vary large. In general, they do not need allergy testing nor desensitization. About 10% of these patients ultimately may develop systemic reaction if they get stung again.
The third reaction, which is not common but is life threatening, is a systemic reaction with hives, itching all over the body, swelling of the throat, wheezing and hypotension. Adults are at a higher risk than children for fatal reactions. Children with skin reactions only (hives) are not at high risk and do not need testing or treatment; however, adults that have a systemic reaction and children that have systemic symptoms involving respiratory, gastrointestinal or cardiovascular system must be tested and need desensitization. Both children and adults in this category need to carry an epinephrine kit and know how and when to use it.
- Seek immediate medical treatment if you experience itching, hives, dizziness, wheezing, nausea, stomach cramps, or diarrhea.
- All patients who have generalized reactions should keep an EpiPen or an AnaKit to use in case of severe reactions and seek immediate medical treatment.
- All patients who have had a generalized (systemic) reaction, should have skin testing with insect venom.
- Desensitization with insect venom is recommended to those who reacted to skin testing. Studies shown that 95% of patients treated with insect venom injections gained protection. When these patients were re-stung after several months of therapy, only 5% experienced a significant reaction.
As with other types of allergic disease, prevention is the key to staying healthy. Certain precautions can be taken to reduce the risk of an insect sting during the summer months:
- Wear long-sleeved shirts and full-length pants with socks and shoes when outdoors.
- Remove known stinging insect nests from areas around your home. This is best done by a professional exterminator.
- Avoid areas that attract such insects, such as brightly-colored flowers.
- DO NOT wear perfume or cologne.
- DO NOT wear pastel or brightly colored clothing. Wear muted greens, white and khaki.
- Keep lids on garbage cans closed.
- DO NOT drink from opened soda or juice cans where you cannot see what is inside.
- Check your car for insects before you get in. Then, drive with your car windows and sunroofs closed.
Headache is one of the top health complaints of Americans
We’re bombarded with advertisements – and we pay many millions of dollars – for pain relievers. Headache is also one of the most common reasons people see physicians, and it’s not a new problem. Primitive healers may have bored in the skulls of their suffering patients to release trapped spirits thought to be causing the pain. Fortunately, modern medicine offers less drastic treatment for headache sufferers. Some types of headaches have an allergic basis. In these cases, careful evaluation may pinpoint the allergen, or allergy-causing substance, causing your headache.
Everybody gets headaches. How do you know when you should see a doctor about them?
Because each of us is different in how we handle pain, you must decide yourself. However, here are some conditions which may call for a consultation with a physician:
- The recent onset of frequent, moderate to severe headaches, associated with other symptoms such as nausea or vomiting.
- Frequent headaches which occur on a daily or weekly basis.
- Headaches which make it impossible for you to think, do your work, go to school, or enjoy life.
- Headaches which respond only to a great deal of over-the-counter medication such as aspirin and Tylenol-type products.
- Headaches with fever that last more than a day or two.
- Where it is strongest?
- How you obtain relief?
- If other symptoms accompany your headaches?
A physical examination will reveal the causes of some headaches. If necessary, your doctor will order laboratory tests, X-rays, and brain-wave tests. Often these tests are ordered after consultation with a neurologist, a physician who specializes in nerve and brain problems. Most people who come to an allergist for evaluation and treatment of their headaches have been seen by other physicians. If you have not had such a preliminary evaluation, it may be worthwhile to visit your primary care physician first to rule out other causes of your headaches. One hint that allergies may play a role in your headaches is if you have other allergies such as hay fever.What kinds of headaches have been shown to be caused by allergies?
Two types of headaches clearly can be caused by allergies – sinus headaches and migraines. Another unusual headache called cluster headache is possibly related to allergic disease.What are the symptoms of sinus headache?
The four groups of sinus cavities in the head are hollow air spaces, with openings into the nose for the exchange of air and mucus. They’re located inside each cheek-bone, behind the eyes, behind the bridge of the nose and in the forehead. Secretions from the sinus cavities normally drain into the nose. Sinus headaches and pain occur when the sinuses are swollen and their openings into the nasal passages are obstructed, stopping normal drainage and causing pressure to build up. Often the pain is localized over the affected sinus. For example, if the maxillary sinus in the cheeks is obstructed, your cheeks may be tender to the touch and pain may radiate to your jaw and teeth. Sinus pain can be dull to intense, often begins in the morning and becomes less intense after you move from a lying-down to an upright position. Antihistamines/decongestants help relieve the pain. If the area over a sinus becomes tender and you have a fever, the obstructed sinus may be infected. More intensive treatment, including antibiotics, is then required.What about migraines?
Migraine headaches vary from mild to very intense and disabling. Migraines tend to be throbbing, usually one-sided headaches, which often are aggravated by sunlight and are frequently accompanied by nausea. There are two general types of migraine: classic and common (plus many variations). Classic migraine attacks tend to be severe and of long duration. They are preceded by aura, a sensation that signals the start of a headache. The aura may be funny smell, partial vision loss, or a strange sound. Common migraine is more prevalent than classic migraine. Attacks are generally milder and shorter. There is no aura. However, because the attacks may occur more frequently, common migraine also can be quite disabling.What is the role of allergies in these types of headaches?
Sinus headaches develop because of swollen sinus membranes. Allergic reactions to airborne pollens, dust, animal danders, molds, as well as foods can lead to sinus obstruction. Treatment of the underlying allergic cause of sinus pain will result in long-term relief. Medications used to treat allergies include antihistamines, decongestants, intranasal steroids and cromolyn. In some cases, immunotherapy or “allergy shots”, may be recommended. When possible, of course, avoid the allergen if your allergy is caused by an avoidable substance – such as food or an animal. A large number of recent scientific studies have described the importance of food allergies in migraine attacks. Some migraine sufferers will benefit from a careful evaluation of food allergies as a cause of their headaches. Some migraines are provoked by food additives or naturally occurring food chemicals such as monosodium glutamate (often added to Chinese food and packed foods), tyramine (found in many cheeses), phenylethylamine (found in chocolate) or alcohol. The artificial sweetener aspartame and the preservative metabisulfite also may cause migraines. Often, only a few foods trigger migraines and, by limiting or avoiding their use, you can experience complete or marked relief without medication. If you have more questions, your allergist will be happy to answer them.
IMMUNE SYSTEM REACTION
Most of you are familiar with allergy problems; however, very few understand the term “Immunology.” The immune system protects us from the outside environment so we can all lead a healthy life. The immune system consists of many different types of cells, and these cells make antibodies and mediators. The combination of these mediators and antibodies work to keep us healthy. If they do not function, people develop a group of diseases called immunodeficiency diseases. A common example that we all know now is AIDS, which is caused by the HIV virus that attacks the immune cells.
Allergic Diseases as a group develop when part of the immune system reacts excessively and produces an immunoglobulin called IgE antibody. This IgE antibody system is supposed to fight the parasitic infections; however, it reacts to the normal environmental antigens (dust mite, animal dander, pollen, mold spores, insect venom, and food). These diseases include asthma, allergic rhinitis, conjunctivitis, eczema, insect sting allergy, and some forms of hives.
If the immune system reacts to self antigens, people develop a group of diseases called auto-immune diseases. For the immune cells to react they have to recognize which is self and non-self. In most of us, immune cells can perform this function very effectively; however, in some patients who have a genetic tendency they recognize the self antigens as foreign and react to them. There is a constant reaction which goes on between the self antigens and antibodies which create inflammation. Some examples of these diseases are lupus, rheumatoid arthritis, polymyositis, etc...
Immune cells also do surveillance in the body and if they recognize any foreign cell or a tumor cell they will kill these cells. People who do not have enough of these cells are more prone for malignant diseases or cancers. As you can see, the immune system is the key to keeping us healthy. Most of these diseases do have a genetic tendency; however, environmental factors lead to the diseases. Most of the people who have asthma have a genetic tendency; however, they must be exposed to an allergen or a virus to develop an asthma attack.
Even though as allergists and immunologists we do not deal with all these diseases, we have a clear knowledge of how the immune system works and how to diagnose these diseases.
Nose, Sinuses and Ears
We all take for granted that breathing through the nose is normal for everyone. However, there are several million people who do not have the luxury of breathing through their nose. When we breathe through the nose, the air circulates through the sinuses and while passing through the sinuses the air is humidified, filtered, and brought to body temperature. The sinuses also give resonance to our voice.
Anyone with nasal obstruction, either functional or mechanical, has rhinitis. A major symptom of rhinitis in adults can be sinus headaches. These headaches are usually caused by sinus pressure and will not be shown on x-rays or CAT scans. If rhinitis persists the sinus problem can lead to fluid collection in the sinuses and ultimately turn into a sinus infection. Most people who have sinus problems do in fact have nasal obstruction, either partial or complete. Unless the nasal symptoms are cleared, the sinus problems will persist.
The most common complications of rhinitis in children include recurrent fluid collection in the ears and middle-ear infections. In this group of children, hearing loss may be significant which, in turn, can lead to learning problems in early childhood.
Patients who have chronic rhinitis also have constant post-nasal drip and frequent sore throats. Children may have an upset stomach in the morning hours because of the swallowing of mucous and increased gastric acidity.
Nasal obstruction also causes tear-duct obstruction and teary eyes. In extreme cases of nasal obstruction, people experience a loss of smell and taste. Chronic mouth breathing may cause orthodontic problems. The well-known cause of allergic shiners is due to nasal obstruction and venous congestion in the lower eyelids. A crease across the nose can be caused by constant rubbing of the nose.
Cold symptoms that last more than 10 – 14 days, often with green or yellow nasal discharge, may be due to a sinus infection.
Chronic sinusitis can cause a flare-up of asthma and bronchitis. Keeping the upper airways clear is very important in asthmatics.There are several causes for this nasal blockage and some of the most common are described as follows:
- Allergic Rhinitis – this is the most common cause of nasal blockage, more common in children and young adults. Allergies are less common in older people.
- Non-Allergic Rhinitis with Eosinophils – These people have similar symptoms as people with allergies, however, the symptoms are present all year long. They respond well to the usage of steroid nasal sprays.
- Vasomotor (non-allergic) Rhinitis – Patients with vasomotor rhinitis basically have very sensitive nasal linings and any irritants like smoke, dust, perfumes, hair sprays, cold air, temperature changes, and barometric pressure changes can aggravate symptoms. They have chronic nasal congestion and constant postnasal drip. Most of these people ultimately end up with chronic sinus problems
- Nasal Polyps – Nasal polyps are growths of extra tissue in the nose and allergies can aggravate them. Nasal polyps never become cancerous. These patients should be on cortisone nasal sprays to prevent recurrence.
- Mechanical Blocking - such as nasal septal deviation, enlarged adenoids or any foreign bodies.
- Rhinitis Medicamentosa – caused by excessive use of decongestant nasal sprays. This condition is most common in patients with vasomotor rhinitis.
- Rhinitis due to infection – Rhinitis, secondary to the common cold, usually lasts 10 to 14 days and gets better.
- Antihypertensive medications and oral contraceptives sometimes cause nasal stuffiness.
ALL PATIENTS WHO HAVE CHRONIC RHINITIS SHOULD BE EVALUATED FOR ANY OF THE ABOVE CONDITIONS. BY TREATING THE NASAL SYMPTOMS AGGRESSIVELY, WE CAN PREVENT CHRONIC SINUS PROBLEMS.
Treatment of Allergies
Once we find out what a person if allergic to, avoidance is the best measure. Based on the targeted organs, we either treat the nasal symptoms, eye symptoms, or asthma problems. Allergy injections reduce the specific IgE antibody levels, and build up IgG antibody levels.
The most common treatment for nasal symptoms are nasal sprays. There are two major classes of nasal sprays. The first class is “relief” medications which helps within a few minutes. The most common is the non-prescription, over-the-counter decongestant sprays. Long-term use of this is not recommended as it can be habit forming. The other type of relief nasal sprays are antihistamine nasal sprays, i.e.: Astelin, and anticholinergic nasal sprays such i.e.: Atrovent.
The second major class of nasal sprays are “control” medications for nasal symptoms. Most common in this group are the nasal steroids. They do not have any systemic side effects as we use them in minute amounts. The most common side effects are nose bleeds, dryness, and irritation. These nasal sprays must be taken on a regular basis in order to work. There is also a control nasal spray, cromolyn sodium, which is very safe to use; but this nasal spray must be taken at least three to four times a day on a regular basis.
The relief-type medications (antihistamines, decongestants, or a combination) can be taken on an as-needed basis, mostly by mouth.
In the long run, avoiding exposure to allergens, taking medications on a regular basis, and getting allergy injections will prevent nasal symptoms. If nasal symptoms are not well controlled, complications of chronic sinusitis, chronic ear infections, postnasal drip, chronic mouth breathing, and in some instances, lacrimal-duct obstruction and venous congestion in the lower eyelids (dark circles under the eyes), can occur.Asthma, Allergies, and Eczema
Asthma, allergies, and eczema usually runs in the family. If you have all three of these diseases, we will sometimes refer to you as an “atopic individual”. However, all three diseases are different. Approximately one-third of the people who have allergies also have asthma problems, and about one-third of those also have eczema problems.
If you check your family history for two or three generations, some family members may have just had allergies, some of them may have had both allergies and asthma, and some may have had all three. Allergic tendencies run in families. Once a person has a tendency, he must be exposed to potential allergens for a period of time. The greater the exposure, the greater the chance of developing allergies. Once a person has been exposed to a potential allergen long enough, his or her immune system produces a specific IgE antibody to that allergen.
Normally, we all make antibodies which belong to the classes of immunoglobulin A, G, and M, which we need for protection from infections. However, the IgE response is an abnormal response which actually causes the allergic reactions. The IgE antibodies are very specific to each antigen. For example, if you are allergic to cats, you make an IgE antibody very specific to cat proteins. Once these IgE antibodies are made, they affix to the surface of a mast cell. The mast cells are located in the nasal linings, conjunctivae, lungs, GI tract, and skin. These mast cells are loaded with histamine and other inflammatory chemicals. Once there is re-exposure to the antigen, all these chemicals are released and together create an inflammation.
Inflammation in the nose is called rhinitis, inflammation in the eyes is called conjunctivitis, and if there is a tendency for asthma, inflammation in the airways within the lungs causes asthma. If a sensitive person is exposed to a food allergen, he or she can develop hives and angioedema with swelling of the lips and throat, wheezing, or anaphylaxis.
When we do skin testing, we put the antigen on the surface of the skin, and if the person has an IgE antibody to that antigen, a small local reaction, redness and swelling at the site of the skin test occurs.
Asthma Allergy Centers was established in 1980 as a solo allergy practice with one location. Over the years, we have grown to 14 locations and 6 providers. The concept of multiple locations...
We accept most insurance plans; however, because there are hundreds of policies, it is the patients responsibility to find out co-pay and deductibles required and if a referral is needed.
Insect stings usually produce only local irritation and discomfort. However, for an unlucky few, about 1% of us injected with insect venom during a sting can have more serious consequences.
Your initial appointment will take about 90 minutes. Please inform us as soon as possible if you are not able to keep your appointment time.