Nasal Disease Handbook

Allergic Rhinitis

Allergies affect 40% of Americans. The symptoms can be seasonal, in which case the condition is called seasonal allergic rhinitis or it can be a continual year round problem in which case it is called perennial allergic rhinitis. The symptoms are nasal congestion, clear or white nasal discharge, sneezing, itchy nose, sometimes an itchy palate and very often itchy eyes. The allergens are small proteins carried in the air. These cause an inflammatory reaction in one's nose, which results in mucosal swelling, and ultimately increased secretions and nasal drippings. Allergies can be quite bothersome.

The simplest treatment for allergic rhinitis is to take over-the-counter antihistamines. If these are effective, they are the best and most appropriate treatment. However, if the allergies become more serious, one needs to determine to what one is allergic. Sometimes one can do this by just paying attention to when one gets the symptoms and what one is then breathing. Sometimes it is best diagnosed by having skin tests performed in your doctor's office. Once you know to what you are allergic, the very best treatment is what we call environmental control. This involves protecting you and your nose from the allergens. If these are seasonal pollens, you may need to be careful about going out, gardening and mowing the lawn during the allergic seasons. If they are specific allergens such as cats and dogs, you either need to live in a pet free environment or you need to keep the pet out of your bedroom and have the pet washed on a weekly basis to reduce the allergic load.

The most common perennial allergens are dust and molds. Actually, the dust is not the allergen, but it is the mites which live in the dust which are the culprits. As disgusting as it might seem, the real allergens are the broken down decayed proteins from the dead dust mites and their feces. The average wool jacket is home for as many as 35,000 mites. The average bed has 100,000 or more dust mites. There are many recommendations for environmental control. These need to be tailored for each person, in each household. The general instructions used at the UCSD Nasal Dysfunction Clinic are listed at the end of this booklet under environmental control for allergy.

There are also a number of specific equipment pieces to help with environmental control. These are specific for dust mites, molds or cat danders and so again, one has to know to what one is allergic. There are superior vacuum cleaners and allergy-free vacuum cleaner bags. There are masks which will filter allergens and these are very useful for those whose lives require exposure. The standard painter's mask is of little benefit. Once one has instituted environmental control and found that the normal antihistamines are not effective, the other medical treatments begin with the use of nasal steroids. These are very weak concentrations of steroids which are sprayed into the nose. They do not adversely effect the rest of your body and they do very effectively suppress the allergic inflammatory reaction within the nose. If this does not control the allergic rhinitis, the next step is called desensitization. This is a treatment in which the individual is tested to determine to what they are allergic. The allergens are injected into the skin two to three times a week in increasing dosages. This desensitizes the individual to the allergen. Unfortunately, this requires injections two to three times a week and this continues for six to twelve months. Once one
becomes desensitized, some level of maintenance injections is required. The injections are usually given once a week for a period of two-five years. This is a rather large commitment and should only be undertaken when simpler forms of treatment have failed.

We have found nasal irrigation to be useful for allergic rhinitis. The allergens are initially deposited in the thick mucus of the nose. Nasal irrigation washes away the mucus and the allergens. This makes your nose more comfortable and it reduces the number of allergens reaching the mucosa and inciting an allergic reaction. For most people, irrigation two to three irrigations a day is all that is really needed. Some prefer weaker salt concentrations, some stronger salt concentrations; some prefer cooler water, some prefer hotter water. These are all things that you have to determine for yourself.

This is the standard medical approach to allergic rhinitis. Different practitioners, depending upon their training, may recommend treatments in a slightly different order.

The following is how I treat my own patients.  If an individual has a mild allergic problem, if it arises only occasionally and if it is well-controlled with an over-the-counter or even prescription antihistamine (and assuming that their allergy does not predispose them to getting sinusitis everytime they get a cold) than the over the counter or prescribed antihistamines are the simplest and easiest treatment. If, however, the allergies are more constant, do not respond well to antihistamines or predispose to sinusitis, then the first step I recommend is to identify the allergens and begin environmental control. Some people know to what they are allergic. If, for example, you were well and then a pet cat was added to the household and now you has symptoms of allergic rhinitis, you either need to relocate the cat or take on a life long treatment for these allergies. You may know that every time a certain tree blooms, you develop allergic problems. You must then either eliminate the tree or avoid it during its blooming. But many people do not know  what they are allergic to and for these individuals a skin test is simple. With a screening battery of 10-15 tests, one can identify 90% of the major allergens. Once you have identified the allergens that give you problems,  you should begin very aggressive environmental control.

Let's assume for a moment that you are allergic to cats. I will tell you that are also allergic to dust and mold. First, you take precautions with cats. Either remove the cat from your household or if the cat remains, keep it out of the bedroom and shampoo the cat once a week. Have the house professionally cleaned once a year. In addition, follow the recommendations for general environmental control. To whatever degree you reduce your exposure to dust, mold and pollens, your nose will be better fit to withstand the allergic challenge of the cat. With environmental control instituted, I would add nasal  irrigation. This is harmless, non-invasive, simple and inexpensive. It adds to the environmental control, reduces the allergic load and makes you feel better by helping wash out the thick nasal mucus. If this combination is not sufficiently effective, I will then add a prescription for a nasal steroid. The usual prescription is Rhinocort AQ, one puff in each nostril, once daily, but this can vary from physician to physician, person to person and for the different nasal steroids.

This regimen should control at least 90% of the allergic nasal problems. If, after all this, the allergic rhinitis persists, it is time to consult a pediatric or an adult allergist. They will fine-tune the above treatments. They will perform more extensive skin testing and, where appropriate, institute immunotherapy.

I am a surgeon and a strong proponent of surgery, but for many nasal disorders, surgery does not play a role in the treatment of allergic diseases. It is common now to recommend surgery on the turbinates, which can mean fracturing the turbinate, crushing the turbinate, partially resecting the turbinate, totally resecting the turbinate, reducing the turbinate with a laser or injuring the turbinate by freezing or by electro-cautery. Turbinate surgery may improve the airway for the short run. As you will read in the subsequent section on the aging nose, these surgeries are potentially harmful. As your nose ages, the mucosa undergoes some shrinkage. When this occurs on top of the surgically reduced turbinate, you are, in my opinion, at serious risk to develop atrophic rhinitis. This is a very dry, painful, infected, crusty nasal disorder. It is probably the most uncomfortable and disabling of all the nasal diseases is irreversible later in your life. It is better to manage the allergic rhinitis to the best of your ability and undergo some suffering rather than to treat the turbinates surgically.

Most of what I have written about turbinates applies to the inferior turbinate. It is not uncommon while performing sinus surgery to reduce or remove the middle turbinate. This is often necessary to gain surgical access and to eradicate the sinus disease. This does not appear to predispose to atrophic problems. I mention this so that if you are contemplating sinus surgery and your physician mentions or you read that the middle turbinate was operated on, this should not concern you.

If you have a crooked septum, this is an anatomic obstruction and it certainly compounds the allergic rhinitis. As we will discuss later, surgery is appropriate for the crooked septum.