Allergy Treatments
Education
Allergy treatment includes education about ways to decrease exposure to allergens in the environment. A patient troubled by dust mites, for example, would learn about the special mattress covers that are available to alleviate dust-mite problems and how often to do a hot-water wash of bedding.
Shots
If allergy shots are recommended, we determine the highest safe concentration at which shots should start. Only an allergist can make this determination and prepare the dose vial, which contains a mixture of the various allergens to which the patient is allergic. Some patients come to the division to get allergy shots; others go to their family physician.
The emphasis on starting at the highest safe concentration usually means that a patient is able to reach a maintenance shot schedule within six months to one year of starting allergy shots. If a patient's symptoms are not sufficiently improved after he or she starts maintenance shots, then allergy shots are stopped and the division staff pursues other kinds of treatment.
Sublingual Immunotherapy (SLIT)
SLIT is a common form of allergy desensitization used in Europe. Allergy drops are held under the tongue for a minute and swallowed. The risk of an adverse reaction is less with SLIT than allergy shots. After the initial dose patients receive daily SLIT at home. Currently many insurance companies do not cover SLIT.
Nutrition Counseling
Because food allergies often play a role in sinus problems, the Division of Sino-Nasal Disorders and Allergy offers instruction in performing an elimination/challenge diet as well as skin testing for food allergies.
Treatment for Sinus Disorders
Sinus disorders can be treated in two ways:
Medications
mucus thinners, antihistamines, decongestants, nasal sprays, and antibiotics
Surgery
surgeryeptoplasty, somnoplasty, rhinoplasty, and endoscopic sinus surgery
Medications for Sinus Disorders
The Division of Sino-Nasal Disorders and Allergy uses several categories of medications to treat sinusitis.
Mucus Thinners
Thick postnasal discharge is a common allergy symptom. A mucus thinner allows the mucus to drain better by thinning it so that the patient is less aware of the discharge. Having postnasal discharge is not abnormal. The average person's nose and sinus cavities produce as much as a liter of discharge each day. The discharge is transported as a thin mucous blanket to the back of the nose. The mucus usually goes down the throat during swallowing. Staying well hydrated is quite important in making sure that mucus drainage does not become too thick.
Antihistamines
The body releases histamine during an allergy attack. Histamine causes sneezing, itching, and welting. An antihistamine blocks allergic reactions by blocking histamine receptors. Older antihistamines are associated with more side effects than the newer antihistamines, which include ceterizine (Zyrtec), desloratadine (Clarinex), fexafenadine (Allegra), and loratadine (Claritin). The side effects of older antihistamines include performance impairment, drowsiness, dry mouth, and occasionally urinary retention. The newer antihistamines have a very low incidence of any side effect and in particular do not cause drowsiness, except for ceterizine, which may impair performance or cause sedation, but much less frequently than the older antihistamines.
Leukotriene Modulators
Leukotrienes are potent agents of broncho constriction. Medications such as montelukast (Singulair) are effective for both asthma and allergic rhinitis. Not every patient responds with symptom relief. Frequently a trial of four days of medication is utilized to determine whether a particular patient’s allergic rhinitis or asthma will respond to drugs such as montelukast. Zileuton is indicated for asthma and sometimes used in conjunction with montelukast. Patients whose symptoms improve with zileuton undergo monitoring of their liver functions monthly for at least three months.
Decongestants
Decongestants relieve nasal congestion by narrowing the blood vessels, which decreases congestion in the nasal membranes. Decongestant nasal sprays give prompt relief, but can only be used for three or four days before they start to cause rebound swelling. Pseudoephedrine, a decongestant, is now found behind the counter. Phenylephrine is less effective than pseudoephedrine. All oral decongestants can cause side effects such as urinary retention, insomnia, and jitteriness.
Nasal Sprays
All nasal sprays work best if directed into the nose and slightly tilted toward the outside or lateral portion of the nose. Do not direct the nasal spray toward the center of the nose or septum as this increases the chance of irritation and nosebleeds.
The two most commonly prescribed nasal sprays are steroid nasal sprays which may take several days to become maximally effective and antihistamine sprays, which work more rapidly, sometimes within 15 minutes. Both of the sprays relieve a wide variety of nasal symptoms, including congestion, sneezing, itching, and drainage. Some patients require use of both sprays together to get maximal relief.
Nasal Steroid Sprays
There are many different nasal steroid sprays available. For most patients all are equally effective, although occasionally an individual patient may do better with one particular product. Most nasal steroid sprays do not cause any detectable change in the body. The newest nasal steroid sprays, such as mometasone fuorate, fluticasone fuorate, or propionate, have the lowest detectable systemic levels and are usually recommended when children require a nasal steroid spray.
Antihistamine Nasal Sprays
Unlike oral antihistamines which only treat sneezing and itch, antihistamine nasal sprays are also effective for congestion. Side effects of Azelastine include occasional bitter taste and rare cases of drowsiness. The occasional bitter taste some patients experience with Azelastine can be minimized by leaning forward, directing the spray laterally into the nose, and not sniffing for a few minutes.
Decongestant nasal sprays are available over-the-counter and include medication such as Neo-Synephrine and oxymetazoline (Afrin). These medications should not be used for more than three or four days consecutively because the patient may develop rebound congestion. This “addiction” to the decongestant sprays does occur with prescription nasal sprays and may be minimized if the decongestant spray is used in conjunction with nasal steroid sprays.
Saline nasal sprays which are also over-the-counter, are effective for moisturizing the nose and to reduce the incidence off nose bleeds which occur because of dryness.
Nasal Rinses
Irrigation of the nose and sinus cavity with any of several commercial nasal saline rinses can be very helpful in removing mucus and crusts. If nasal rinses are used they should precede with the application of prescription nasal sprays. Patients can also make their own nasal rinses by mixing 1 ½ teaspoons of salt, 1 tsp. baking soda in 1 qt. of sterile water. There are a variety of irrigation devices available, including the Netie Pot, baby bulb syringes, and water picks. It is important that any device used be cleaned every few days to prevent the growth of mold or bacteria. Patients with cystic fibrosis may benefit from increasing the salt content of the saline wash so that it is hypertonic. This means mixing 3 tsp. of salt to a quart of water.
Topical Antibiotic and Antifungal Rinses
Depending on the bacteria found on the culture from your diagnostic testing and the sensitivities of the bacteria found to antibiotics, a customized antibacterial wash, may be recommended and prescribed. Frequently for staph aureus infections, mupirocin (Bactroban) 5g in 45cc of saline is recommended as a spray or wash. For Pseudomonas infection, gentamicin 80mg per 500cc of saline is recommended. If fungus is detected, then amphotericin B. irrigations may be recommended.
Antibiotics
Antibiotics help fight bacterial infections. Antibiotics are useful in treating bacterial sinus infections but will not help a cold caused by a virus. Many bacteria that were once treatable by common antibiotics have developed resistance, so antibiotics are carefully prescribed to treat sinus problems. A culture of the bacteria found in the sinuses will provide guidelines to the best antibiotic to use. It may help you while taking an antibiotic to replenish the good bacteria in your system by either taking probiotics, acidophilus tablets, or eating foods such as yogurt or kefir that contain large amounts of benign bacteria.
Surgical Treatments for Sinus Disorders
Septoplasty
Septoplasty corrects a deviated septum with no, or minimal, change in the outward appearance of the nose. It is performed when a patient has constricted nasal breathing because of a septal obstruction.
Coblation of the Inferior Turbinates
Coblation is an in-office procedure that reduces the size of the turbinate, the structures that swell up from either side of the nose and can block the airway and impair breathing. Numbing the nose takes about 15 minutes, and the procedure itself takes 10 minutes. The patient waits for 10 to 15 minutes after the procedure to ensure that no bleeding will occur. After a coblation, most patients return immediately to work or regular activities.
Rhinoplasty
Rhinoplasty changes the outward structure of the nose. Sometimes the procedure is necessary to allow the inside of the nose to work properly. For example, a patient with a severely fractured nose may need a rhinoplasty to resolve an airway obstruction. In other cases, the procedure is cosmetic. Some rhinoplasties are performed while the patient is completely asleep (anesthetized); in others, the patient is under "twilight" anesthesia. In either case, rhinoplasty is an outpatient procedure.
Endoscopic Sinus Surgery
An outpatient procedure, endoscopic sinus surgery (ESS) is used to correct structural abnormalities of the nose and sinuses. The surgeon uses an endoscope, a slender instrument with a video camera attached, to guide the surgical instruments. This type of surgery may be performed to relieve chronic sinusitis if medical treatments have been ineffective. ESS is also used to remove nasal polyps. Polyp surgery can be done in the office after an anesthetic is applied to the nasal membranes. The polyps are removed by a microdebrider, a hollow rotating suction that cuts tissue and suctions it away. After nasal polyp removal, the patient is usually able to return immediately to normal activities. Other outpatient ESS procedures require a longer recovery time.