Sinus & Allergy

Sinus & Allergy

Healthy sinuses are air-filled spaces in the facial bones that open to the nasal cavity. Sinus disease often results when the communication between the nose and sinuses are blocked as a result of infection, allergy, polyps, or structural abnormality. The key to treating acute or chronic sinusitis is to open blocked sinuses through the use of medication, allergy control, and when necessary, surgery.

Sinusitis—an infection of the sinuses—can be classified as acute,  which means that it comes on suddenly, often right after an upper respiratory infection such as a cold or flu. Or sinusitis can be chronic, meaning that it is an ongoing problem. In either case, when the discomfort of sinusitis is severe or the symptoms persist, a comprehensive medical examination with appropriate treatment is recommended.

Learn more about Sinusitis. 

How Will the Doctor Treat Sinusitis? 

Acute sinusitis: Treatment of acute sinusitis is designed to relieve blockage of the sinus opening and restore cilial functions. Antihistamine/decongestants can reduce inflammation and decrease fluid production. Bacteria can be treated with antibiotics and should be taken for the full course as prescribed by your doctor.

Chronic sinusitis: Drugs may releive congestion in the sinuses by reducing fluid secretion and swelling. Sinus irrigation may be recommended to clean out old mucus. Antibiotics can treat recurrent bacterial infections, but your doctor many also recommend an allergy control program for long-term management. In some cases, nasal and/or sinus surgery may be needed to improve sinus drainage or to remove nasal obstructions.

Diagnosis of sinusitis: The diagnosis of chronic sinusitis is usually made on the basis of a medical history. Examination, x-rays, or CT scan help to reveal thickened mucosa, blocked sinus openings, and obstructions such as a deviated septum, polyps, and inflamed turbinates that can interfere with drainage. 

When is surgery necessary? 

Only a small percentage of adults with severe or persistent sinusitis require surgery to relieve symptoms that do not respond to medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections.

Your doctor may advise removing adenoid tissue from behind the nose as part of the treatment for sinusitis. Although the adenoid tissue does not directly block the sinuses, infection of the adenoid tissue, called adenoiditis, or obstruction of the back of the nose, can cause many of the symptoms that are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal drip, bad breath, cough, and headache.

Balloon Sinuplasty

Balloon Sinuplasty (BSP) is a safe and effective procedure for chronic sinusitis patients who are not responding well to medications and are seeking relief from uncomfortable and painful sinusitis symptoms.

With Balloon Sinuplasty, ENT doctors open inflamed sinuses in the same way that heart surgeons open up blocked arteries during balloon angioplasty. The procedure is less invasive than traditional sinus surgery, and effective at relieving symptoms of chronic sinusitis. Balloon Sinuplasty allows patients to return to normal activities quickly. Unlike conventional sinus surgery, it does not include removal of bone or tissue from the nose.

Learn more about Balloon Sinuplasty.

You and Your Stuffy Nose

Nasal congestion, stuffiness, or obstruction to nasal breathing is one of man's oldest and most common complaints. While it may be a mere nuisance to some persons, to others it is a source of considerable discomfort, and it detracts from the quality of their lives.

Medical writers have classified the causes of nasal obstruction into four categories, recognizing that overlap exists between these categories and that it is not unusual for a patient to have more than one factor involved in his particular case.

Infection

An average adult suffers a common "cold" two to three times per year, more often in childhood and less often the older he gets as he develops more immunity. The common "cold" is caused by any number of different viruses, some of which are transmitted through the air, but most are transmitted from hand-to-nose contact. Once the virus gets established in the nose, it causes release of the body chemical histamine, which dramatically increases the blood flow to the nose, causing swelling and congestion of nasal tissues, and stimulating the nasal membranes to produce excessive amounts of mucus. Antihistamines and decongestants help relieve the symptoms of a "cold," but time alone cures it.

During a virus infection, the nose has poor resistance against bacterial infections, which explains why bacterial infections of the nose and sinuses so often follow a "cold." When the nasal mucus turns from clear to yellow or green, it usually means that a bacterial infection has taken over and a physician should be consulted.

Acute sinus infections produce nasal congestion, thick discharge, and pain and tenderness in the cheeks and upper teeth, between and behind the eyes, or above the eyes and in the forehead, depending on which sinuses are involved. 

Chronic sinus infections may or may not cause pain, but nasal obstruction and offensive nasal or postnasal discharge is often present. Some persons develop polyps (fleshy growths in the nose) from sinus infections, and the infection can spread down into the lower airways leading to chronic cough, bronchitis, and asthma. Acute sinus infection generally responds to antibiotic treatment; chronic sinusitis usually requires surgery.

Structural Causes

Included in this category are deformities of the nose and the nasal septum, which is the thin, flat cartilage and bone that separates the nostrils and nose into its two sides. These deformities are usually due to an injury at some time in one's life. The injury may have been many years earlier and may even have been in childhood and long since forgotten. It is a fact that 7 percent of newborn babies suffer significant nasal injury just from the birth process; and, of course, it is almost impossible to go through life without getting hit on the nose at least once. Therefore, deformities of the nose and the deviated septum should be fairly common problems -- and they are. If they create obstruction to breathing, they can be corrected with surgery.

One of the most common causes for nasal obstruction in children is enlargement of the adenoids: tonsil-like tissues that fill the back of the nose up behind the palate. Children with this problem breath noisily at night and even snore. They also are chronic mouth breathers, and they develop a "sad" long face and sometimes dental deformities. Surgery to remove the adenoids and sometimes the tonsils may be advisable.

Other causes in this category include nasal tumors and foreign bodies. Children are prone to inserting various objects such as peas, beans, cherry pits, beads, buttons, safety pins, and bits of plastic toys into their noses. Beware of one-sided foul smelling discharge, which can be caused by a foreign body. A physician should be consulted 

Allergy

Hay fever, rose fever, grass fever, and "summertime colds" are various names for allergic rhinitis. Allergy is an exaggerated inflammatory response to a foreign substance which, in the case of a stuffy nose, is usually a pollen, mold, animal dander, or some element in house dust. Foods sometime play a role. Pollens cause problems in spring (trees) and summer (grasses) or fall (weeds) whereas house dust allergies and mold may be a year-around problem. Ideally the best treatment is avoidance of these substances, but that is impractical in most cases.

In the allergic patient, the release of histamine and similar substances results in congestion and excess production of watery nasal mucus. Antihistamine Help relieve the sneezing and runny nose of allergy. Many antihistamines are now available without a prescription. The most familiar brands include Chlor-Trimeton®, Benadryl®, Clarinex®, Claritin®, Allegra®, and Zyrtec® (although most are also available in generic forms). Decongestants, such as Sudafed® (also available in generic forms) shrink congested nasal tissues. Combinations of antihistamines with decongestants are also available; for example, Actifed®, Allegra D®, Chlortrimetron D®, Claritin D®. All these preparations have potential side effects, and patients must heed the warnings of the package or prescription insert. This is especially important if the patient suffers from high blood pressure, glaucoma, irregular heart beats, difficulty in urination, or is pregnant.

Allergy shots are the most specific treatment available, and they are highly successful in allergic patients. Skin tests or at times blood tests are used to make up treatment vials of substances to which the patient is allergic. The physician determines the best concentration for initiating the treatment. These treatments are given by injection. They work by forming blocking antibodies in the patient's blood stream, which then interfere with the allergic reaction. Many patients prefer allergy shots over drugs because of the side effects of the drugs.

Patients with allergies have an increased tendency to develop sinus infections and require treatment as discussed in the previous section.

Vasomotor Rhinitis

''Rhinitis" means inflammation of the nose and nasal membranes. "Vasomotor" means blood vessel forces. The membranes of the nose have an abundant supply of arteries, veins, and capillaries, which have a great capacity for both expansion and constriction. Normally these blood vessels are in a half-constricted, half-open state. But when a person exercises vigorously, his/her hormones of stimulation (i.e., adrenaline) increase. The adrenaline causes constriction or squeezing of the nasal membranes so that the air passages open up and the person breathes more freely.

The opposite takes place when an allergic attack or a ''cold'' develops: The blood vessels expand, the membranes become congested (full of excess blood), and the nose becomes stuffy, or blocked.

In addition to allergies and infections, other events can also cause nasal blood vessels to expand, leading to vasomotor rhinitis. These include psychological stress, inadequate thyroid function, pregnancy, certain anti-high blood pressure drugs, and overuse or prolonged use of decongesting nasal sprays and irritants such as perfumes and tobacco smoke.

In the early stages of each of these disorders, the nasal stuffiness is temporary and reversible. That is, it will improve if the primary cause is corrected. However, if the condition persists for a long enough period, the blood vessels lose their capacity to constrict. They become somewhat like varicose veins. They fill up when the patient lies down and when he/she lies on one side, the lower side becomes congested. The congestion often interferes with sleep. So it is helpful for stuffy patients to sleep with the head of the bed elevated two to four inches accomplish this by placing a brick or two under each castor of the bedposts at the head of the bed. Surgery my offer dramatic and long time relief.

Summary

Stuffy nose is one symptom caused by a remarkable array of different disorders, and the physician with special interest in nasal disorders will offer treatments based on the specific causes.

Allergic Rhinitis (Hay Fever) 

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens. 

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food—and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life. 

What are allergic rhinitis symptoms? 

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation. 

When should my child see a doctor? 

If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician.

Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?

The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

he physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens. 

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days. 

How is allergic rhinitis treated? 

The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures. 

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks. 

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.