This case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder. Where gender, age or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.
The patient could be male or female. The patient could even be you.
Doctor: Good morning, how can I help you today?
Patient: I made an appointment with you because I am having problems with my nose.
Doctor: What kinds of problems do you have?
Patient: Well, I think I have allergic rhinitis.
Doctor: What are your symptoms?
Patient: Well, I have sneezing, itchy eyes, a runny nose and constant nasal congestion.
Doctor: Do you have any symptoms of sinusitis, such as postnasal drip, cough, pain or fever?
Patient: No, but I do have a runny nose.
Doctor: What color is the nasal discharge?
Patient: Well, that which comes out the front is typically clear. I sometimes have a postnasal discharge and that is usually clear, but sometimes sort of yucky white.
Doctor: As you have probably guessed, this sounds like allergic rhinitis. Do you know what you are allergic to?
Patient: No, I really don’t.
Doctor: Do you have this problem all year long, or is it somewhat seasonal such as Spring, Summer or Fall?
Patient: I mostly have it all year long, but it certainly gets worse in the Spring, and in the Fall, particularly when we have an east wind here in Southern California.
Doctor: Does anyone in your family have similar problems?
Patient: Yes, my mother does, and she said so did her grandparents. My father and his family do not. Both my brother and my sister have similar sorts of problems.
Doctor: Have you used any medications to treat this?
Patient: Yes, I’ve taken over the counter antihistamines such as Benadryl and Dimetapp. They dry it up, but they also make me feel sleepy.
Doctor: Well, let me take a look.
The doctor examines the patient and notes that the mucosa of the patient’s nose is swollen and congested. The mucosa has a pale blue appearance. Clear secretion is present in the nose. Other abnormalities in the head and neck are not evident.
Doctor: My impression is that you have allergic rhinitis. In part, this is seasonal, meaning that you are allergic to pollens, grasses and perhaps trees in and around where you live, and part of this is perennial, meaning you have it all year long. The perennial allergens are primarily dust, mites and mold. Many people are also sensitive to animal danders such as cats and dogs. Do you have animals at home?
Patient: No, we do not, but I have always wanted one.
Doctor: Well, based on what I’m hearing today, you would be best off with a lizard, fish or a pet rock. I am concerned that a cat, dog, bird or other animal might make your allergies worse.
Patient: How did I get these?
Doctor: Well, to some degree you inherited the tendency to react to allergens. Your immune system detects the allergens in the air you breathe, and as part of its defense mechanism produces the nasal discharge and the nasal congestion. Unfortunately, the defense system is a little overzealous and so it is causing you unpleasant symptoms.
Patient: Will this ever go away?
Doctor: Well, I hope to make the symptoms less with treatment.
Patient: Will it go away?
Doctor: Not for a very long time, and probably not until you are at least in your fifties, sixties or even seventies.
Patient: Can it get worse?
Doctor: Things can always get worse.
Patient: It is hard to imagine my nose being any worse. I already can’t breathe through it.
Doctor: Well, there are probably forty million people in the United States with allergic rhinitis. There are thirty million people afflicted with chronic sinusitis, many a direct result of their allergic rhinitis, and there are approximately seventeen million who have asthma, the majority of whom have the same reaction in their lungs that you are experiencing in your upper respiratory tract or nose. I believe it behooves you to treat your allergic rhinitis, for if you can reduce these symptoms, it certainly reduces the chance of your developing sinusitis and/or asthma.
Patient: Well, how do I treat it?
Doctor: Different physicians treat allergies with different philosophies. My own philosophies are to treat with environmental control, topical nasal steroids and nasal irrigation.
Patient: Some of my friends use antihistamines and decongestants. Aren’t you going to try those first?
Doctor: I have never been a fan of the antihistamines, for they thicken secretions, impair normal ciliary function and predispose you to sinusitis. I am also not really sure that they work, and in any case, they do not work as well as the other treatments.
Patient: Well, then what does work?
Doctor: Well, the best treatment, although the hardest to comply with, is environmental control. If we could send you to the moon where there presumably are no allergens, you would be immediately well. That is unfortunately not a practical solution, but there are many things that you can do to clean up your environment here on earth. Rather than going through all of these, I am going to suggest information available on our website which you might read. There are several companies which make products for environmental control, and these companies maintain information brochures which will provide information about the allergens and about ways you might protect yourself. You can access this information by going to the Environmental Control section of the Handbook of Nasal Disease.
Patient: I understand that environmental control is difficult to do.
Doctor: There is no question that it is somewhat time consuming, and at least difficult to initiate, but I really encourage you to read through the materials, identify those things which you can do easily and protect yourself from the greatest contamination, for the fewer allergens to which you are exposed, the easier it will be to treat and manage your allergic rhinitis.
Patient: What is next?
Doctor: Next are nasal steroids.
Patient: I’m not taking steroids.
Doctor: I understand that these are steroids, but they are topical. They are not absorbed into your body, and they will not affect your normal physiology.
Patient: You are telling me that these are different than steroids that you take as a pill?
Doctor: Yes.
Patient: Well, how do you take these nasal steroids?
Doctor: They come in a small canister, and when you pump that canister, a small measured amount of nasal steroid is puffed into your nose. It is very important that you take them exactly as I instruct you to, for most people take them incorrectly and most do not derive the maximum benefit. You hold the canister up to your nose and place the nozzle into your nostril. You should point it away from your septum, that is away from the midline, almost as if you are pointing it half way between the back of your head and your ear. You then puff it once or twice, you remove it from your nostril and then you breathe in slowly. The biggest mistake that people make is to point it towards their septum. That causes irritation and bloody noses. The second mistake is that they take a great big sniff, I call it the Hollywood sniff, and instead of the steroid being deposited on the nasal mucosa, it is sucked into the back of the throat where it does no good and often causes sore throat. Typically you put one or two puffs in each nostril once a day.
Patient: How long do I have to do this for?
Doctor: Well, for starters I would like you to use the nasal steroids every day for six weeks. We will then meet and see how you are doing. If we have gotten control of your allergic rhinitis, then you can use this on an as needed basis. If that works fine; if it does not work, you may be required to take it on a more regular basis.
Patient: Is this safe to use for a long period of time?
Doctor: To the best of our knowledge, it is safe to use for a very long period of time, and we currently feel that it is healthier for you to use the nasal steroids on a regular basis for years than it is to suffer from allergic rhinitis, and certainly than it is to suffer from sinusitis and/or asthma.
Patient: You also mentioned that I was supposed to irrigate my nose. What exactly are you talking about?
Doctor: Well, nasal irrigation has been something we have pioneered and utilized extensively in the UCSD Nasal Dysfunction Clinic. We recommend irrigating your nose with 500 cc. of body temperature, warm water twice a day. It is important when you start out to use the lowest pressure settings. Many people find that as they get used to nasal irrigation, they can increase the pressure or flow and complete the nasal irrigation in a shorter period of time. Normally 500 cc. of warm tap water is mixed with a teaspoon of salt. Table salt is fine. Most people irrigate at the bathroom sink. After mixing the salt into the warm water, you turn the irrigator on, bend over the sink, bring the nozzle up to your nose, and then as you press it against your nose, the water rushes through your nose, sometimes coming out the back of your throat and out your mouth, other times coming out the opposite nostril. It makes absolutely no difference where it comes out. You irrigate both sides with approximately half of the bowl, that’s 250 cc., and as I said, you do this twice a day.
Patient: That sounds like a controlled drown to me.
Doctor: Well, it may sound a little funny, but the majority of our patients, once used to a nasal irrigation, become as dependent upon this as they do upon brushing their teeth. We have yet to have a single patient drown from irrigating their nose. What I believe this does is that the allergens that you inhale all day long or all night long are trapped in the mucous of the nose. If you wash this out twice a day, it seems to not only refresh the nose, but significantly reduce the allergic load, and thereby reduce the symptoms of allergic rhinitis.
Patient: I have some friends that get shots. What is that all about?
Doctor: Well, if the simple things we just talked about don’t work, then we can test you, either with skin tests or with blood tests to see what you are allergic to. If specific allergens are identified and particularly if there are one or two or three allergens, then a special cocktail is made up and this can be administered as an injection, at first three times a week.
Patient: What does that do?
Doctor: Well, this is a small injection of the allergen to which you are allergic, and because it is injected into the skin, you develop a different kind of antibody. Once you develop antibodies, they will protect you against developing allergic reaction to the allergens.
Patient: How many shots do you have to get?
Doctor: Well, unfortunately you will need to go for a period of three, six or more months, three times a week. When you start to develop antibody resistance, then it can be cut down to two shots a week, and after a year or two, can sometimes be decreased to one shot a week.
Patient: That sounds like a rather long, arduous process.
Doctor: Yes, it is.
Patient: Is success guarantee?
Doctor: No, unfortunately it is not.
Patient: Do you recommend getting tested and getting desensitized?
Doctor: Not if simpler treatments will work. If all else fails, it is a treatment paradigm which we can explore.
Patient: Aren’t there any surgeries that will cure allergic rhinitis?
Doctor: No, there are not.
Patient: I have heard that there are laser surgeries which at least reduce the symptoms of allergic rhinitis.
Doctor: Yes, there are all sorts of procedures using knives, cauteries, lasers, cold instruments, hot instruments, etc. All of these procedures are aimed at reducing the turbinates which are responsible for humidification, filtering and warming inspired air. If you damage enough of the turbinate, then your nose will remain open and the symptoms of the allergic rhinitis may be reduced.
Patient: That sounds like a good treatment to me. It certainly beats filling my body with steroids and twice daily controlled drownings.
Doctor: Well, while I appreciate your humor, there is a down side risk to the turbinate surgery. Assuming that the surgery goes well, the less invasive surgeries only work for a short period of time like a year, and then require repeat treatments. The more permanent procedures like the laser surgery that you mentioned, leave your nose permanently damaged. Later in life when your mucosa undergoes a certain atrophy associated with aging, all of a sudden you do not have enough mucosa to maintain a humidified, filtered and warmed inspiration and your nose will become dry, crusty, infected and painful. This is a horrible condition. It is called atrophic rhinitis, or in some cases it is called empty nose syndrome. This is a long term consequence of turbinate surgery, and for this reason turbinate reduction is something I rarely recommend. There is no question that in some people, after appropriate consultation with their physician, some limited turbinate reduction may be beneficial, but as a routine, this is a procedure I try to discourage.
Patient: Well, this has certainly been a lot of information. Is there anything else I should know?
Doctor: No, I think that this has been a good consultation. I will get your prescription written, the nurse will provide you with the nasal irrigation materials, and you will take it upon yourself to look up the environmental control. I would like to see you back in six weeks. I would like you to tell me how you are doing, and I would like the opportunity to help you adjust and improve whatever might be of benefit.
Patient: I thank you.
Doctor: It is my pleasure.