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Allergic Rhinitis


Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital)
 
Overview: 
Allergic Rhinitis is an inflammatory condition characterized by hypersensitive and overreactive immune system responses to allergens (otherwise harmless substances that do not cause symptoms for other individuals). Common allergens include pollen, airborne mold spores, animal dander, cockroach particles and dust mites. In patients with allergic rhinitis, the immune system responds to allergens by releasing histamine, a chemical that causes a variety of symptoms in the nose, throat, eyes, ears, and skin.[1] Allergic rhinitis can be either seasonal or perennial (year-around). Patients with seasonal allergic rhinitis will notice flare-ups in symptoms around the changing of the seasons or during certain times of the year. Allergic rhinitis is a common condition that impacts over 24 million people in the United States and between 10-30% of the worldwide population[2] [3].
 
A common variant of allergic rhinitis is nonallergic rhinitis with eosinophilia syndrome (NARES). NARES is a condition of unknown cause but presents with symptoms similar to that of allergic rhinitis. The primary difference between allergic rhinitis and NARES is that patients with NARES will test negative to allergens in skin tests or blood tests. Additionally, a key component of NARES is the presence of eosinophils (a type of white blood cell) in nasal secretions.  While the cause remains unknown, treatment for NARES generally consists of steroid nasal sprays which can be combined with antihistamines.
 
Symptoms:
Patients with Allergic rhinitis may experience a combination of any of the following symptoms:

  • Rhinorrhea (runny nose) or nasal obstruction

  • Itchy or watery eyes

  • Itchy skin or mouth

  • Sneezing

  • Sore or irritated throat accompanied by a cough

  • Fatigue

  • Headaches

 
What to expect at your office visit:
Your office visit will begin with your allergist or otolaryngologist asking you detailed questions about the onset and nature of your symptoms in addition to questions about your lifestyle in order to identify the cause of your symptoms. Important considerations include your work conditions, home conditions, exposure to household pets, geographical factors, and family medical history. A clinical diagnosis can be made based on the characteristics of the symptoms, however, in most cases your physician will recommend allergy testing in order to determine specific allergies and the severity of each. If you are experiencing severe nasal symptoms, your physician may also perform a nasal endoscopy during which a nasal endoscope, a long, thin device with a camera and light at the end, is used to access and view your sinuses.   
 
Treatment: 
Treatment of allergic rhinitis depends on symptoms and severity. Luckily, there are a variety of options available.

  • Lifestyle changes (replacing carpet, air filters, using humidifiers, protective bedding)

    • Patients benefit from small lifestyle changes that reduce their exposure to certain allergens. Airborne particulate matter can be controlled by regularly replacing air filters or using a stand-alone air filter. Dusting hardwood surfaces, vacuuming carpeted floors, and using protective bedding to control exposure to dust mites has also proved beneficial to patients with specific dust mite allergies. 

  • Antihistamines

    • Antihistamines act by limiting the amount of histamine produced by the immune system when exposed to an irritating allergen. This mediates the body’s response to the allergen. Many over the counter options are available as either oral tablets, nasal sprays, or eye drops. Some common antihistamines include Loratadine, Ceterizine, and Fexofenadine. Please consult your doctor before beginning a new medication.

  • Decongestants

    • Decongestants are often confused with antihistamines. While antihistamines can help with itching and sneezing, decongestants target the inflammation inside your nose that makes you feel congested or experience sinus pressure. Decongestants are readily available over the counter but can also be prescribed in more severe cases. Decongestants should only be used for a few days at a time, otherwise side effects may occur and result in a worsening of symptoms.

  • Immunotherapy (allergy shots)

    • Immunotherapy, or allergy shots, is an effective way to manage allergic rhinitis that has otherwise failed to respond to medication. Immunotherapy is a long-term treatment option that can last anywhere from 3-5 years. Patients undergoing immunotherapy are incrementally exposed to the allergen(s) that cause their symptomatic response, thereby actually training the immune system to become less sensitive to the allergen. Initially, shots are administered once or twice weekly until a maintenance dose is reached. Once patients are in the maintenance phase, allergy shots are administered every two to four weeks.      

[1] https://www.aaaai.org/conditions-and-treatments/allergies/rhinitis

[2] http://www.aafa.org/allergy-facts/

[3] https://www.healthline.com/health/allergic-rhinitis

Aspirin Exacerbated Respiratory Disease (AERD)

 


Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital)
 
Overview: 
Aspirin Exacerbated Respiratory Disease (AERD), formerly known as Samter’s Triad, is a chronic inflammatory condition and a difficult to treat variant of asthma, known for its triad of symptoms: nasal polyps, asthma, and hypersensitivity or allergy to non-steroid anti-inflammatory drugs (NSAIDs) including Aspirin. Patients with AERD experience acute reactions that mimic an asthma attack when exposed to NSAIDs. AERD is an acquired condition with no known cause and generally presents around age 30-40.
 
Symptoms:
Patients with AERD will find themselves suffering from all of the following symptoms:

  1. Sensitivity to non-steroid anti-inflammatory drugs (NSAIDs) including Aspirin

  2. Nasal Polyps

  3. Asthma

These symptoms can present in any order and are often accompanied by chronic rhinosinusitis and anosmia (loss of the sense of smell).
 
What to expect at your office visit:
Your office visit will begin with your physician asking you questions about the onset and nature of your symptoms in order to gain an understanding of the duration and severity. In cases where a patient has a known history of NSAID sensitivity, asthma and nasal polyps, a diagnosis can be made with minimal further testing. Your doctor will use a nasal endoscope, which is a long, thin device with a camera and light at the end, to access and view your sinuses to determine the presence of nasal polyps. You may also be asked to obtain a CT of your sinuses which will allow your physician to visualize areas unable to be accessed with the endoscope. If NSAID sensitivity is unknown, your physician may also recommend an aspirin challenge during which you will be exposed to a small amount of aspirin to see if you have a respiratory response in a carefully monitored medical setting.
 
Treatment: 
Treatment of AERD is a multifaceted process that almost always involves surgical intervention, aspirin desensitization and long-term aspirin therapy. Once a positive diagnosis of AERD has been made your physician will discuss sinus surgery in order to remove nasal polyps. You can expect approximately four to six weeks after surgery to undergo aspirin desensitization. Aspirin desensitization is a procedure in a closely monitored clinical setting where you are incrementally exposed to a higher dose of aspirin until you are able to tolerate the dosage with no adverse systemic reactions. After this, your physician will place you on a daily aspirin regimen. Over time, the dosage will be lowered until you are on a maintenance dose daily. AERD is one of the most difficult forms of chronic rhinosinusitis and nasal polyposis to manage. Data supports this multidisciplinary approach as patients who are not correctly treated have multiple surgeries and continue to be symptomatic.

Chronic Rhinosinusitis (CRS)
 

Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital)
 
Overview: 
Sinuses are small, air filled cavities between the bones of the head and face. Healthy sinuses are lined with soft tissue called mucosa and a thin layer of mucus. This thin layer of mucus lubricates your nose and acts to drain out allergens and bacteria down the back of your throat. Chronic Rhinosinusitis is a condition in which the sinuses become inflamed for a period of twelve weeks or longer. This inflammation disrupts the normal drainage of mucus, causing it to accumulate within the sinuses.   
 
The causes of CRS are multifaceted and are most commonly a result of the body’s natural inflammatory response to allergens and other airborne particulates. Chronic rhinosinusitis can also be due in part to chronic infections which lead patients to become chronically inflamed and swollen. The physical structure of the sinuses, including a deviated nasal septum and/or nasal polyps, respiratory disorders such as cystic fibrosis, autoimmune disorders and immunosuppressant drugs are also related to chronic rhinosinusitis.    
 
Symptoms:
Patients with CRS will find themselves suffering from two or more of the four following symptoms:

  • Facial pain or pressure or headaches around and above the eyes

  • Thick, discolored drainage running from the nose or down the throat 

  • Congestion and nasal obstruction and difficulty breathing through the nose

  • Loss of sense of smell 

 
What to expect at your office visit:
Your office visit will begin with your physician asking you questions about the onset and nature of your symptoms in order to gain an understanding of the duration, severity and potential causes of your condition. In order to make an accurate diagnosis of your condition your doctor will use a nasal endoscope, which is a long, thin device with a camera and light at the end, to access and view your sinuses. You may be asked to obtain a CT of your sinuses which will allow your physician to visualize areas unable to be accessed with the endoscope. Your physician may also take a culture of your sinuses to determine if a bacteria is present.
 
Treatment: 
If you are actively infected at the time of your visit you can expect to be prescribed a course of antibiotics and/or a steroid taper. Additional therapies may include routine sinus rinses. This can be done with an OTC nasal irrigation squeeze bottle and either a plain saline solution or with steroids and/or antibiotics that can be added to the saline. In some cases, nasal sprays will also be prescribed. Patients with severe allergy induced inflammation can expect to be directed to their local allergist for evaluation and potential immunotherapy/allergy shots. 
 
For patients with a history of long-term sinus disease, lasting over 3 months, who have exhausted all medical management, surgery is an option. Sinus surgery is also commonly known as Functional Endoscopic Sinus Surgery or FESS. Patients undergoing functional endoscopic sinus surgery can expect their surgeon to open up their sinuses by removing small bony partitions and all purulent drainage. If you have a deviated nasal septum, your surgeon will also perform a septoplasty to straighten the septum. In the case of nasal polyps, your surgeon will also remove these during surgery. In general, the vast majority of patients do well with surgery but must continue long-term with nasal rinses and allergy management (if necessary).
 
References:
https://www.uptodate.com/contents/chronic-rhinosinusitis-beyond-the-basics
http://www.entnorthtexas.com/Documents/Sinus%20Surgery%20Description.pdf
https://www.americansinus.com/where-does-sinus-drainage-go/

 Deviated Nasal Septum

 

Authors: Heather N. Ungerer, BA (University of Pennsylvania Hospital), Nithin D. Adappa, MD (University of Pennsylvania Hospital)
 
Overview: 
A nasal septum is the piece of cartilage and bone that separates the two sides of the nasal cavity. A deviated septum is a common condition that occurs when the septum is bent, or deviated, causing one side of the nasal cavity to be narrower than the other. While patients with severe deviations can present with a variety of symptoms, most patients with a deviated septum are asymptomatic and unaware that they have a deviation. A patient with a severely deviated septum often has difficulty breathing through one side of their nose and may notice an unusual amount of nasal obstruction from one or both sides of the nose.
 
A deviated nasal septum can be present at birth or can result from trauma to the face and nose leading to misalignment of the septum. It is important to note that a deviated septum is often not visible from the outside of the nose and does not necessarily change the apparent structure of the nose itself.
 
Symptoms:
The most common symptom of a deviated nasal septum is nasal obstruction which leads to difficulty breathing and the feeling of congestion, predominately from one side of the nose. Other symptoms include:

  • Nosebleeds

  • Snoring or loud breathing during sleep

  • Headaches or facial pain

  • Frequent or seemingly constant sinus infections

 
What to expect at your office visit:
Your office visit will begin with your physician asking you questions about the onset and nature of your symptoms. In order to make an accurate diagnosis of your condition your doctor will use a nasal endoscope, which is a long, thin device with a camera and light at the end, to access and view your septum and your sinuses. You may also be asked to obtain a CT of your sinuses which will allow your physician to more clearly visualize the severity of your septal deviation.
 
Treatment: 
Currently, the only treatment for a deviated nasal septum is a surgical procedure called a septoplasty. During a septoplasty, your surgeon will straighten your septum by removing parts of the septum, repositioning them and then reinserting them. The pieces are then held in place by dissolvable stiches. Patients can generally expect 1-2 follow up visits with their surgeon to make sure that the septum has healed properly and in the correct position. Rather than surgery, patients can also attempt to manage symptoms caused by their deviated septum. Initial treatment consists of nasal steroid sprays. While nasal steroid sprays will not help the deviated septum, they act to shrink the inferior turbinates which will allow more airflow through your nasal cavities decreasing the amount of nasal obstruction. If this is not successful, surgery is the next option. 

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