The ENT Carolina Allergy Program                         

The incidence of allergy, asthma and sinus infection is increasing and billions are spent annually on doctor visits and medications. Despite this, surveys show patients are increasingly frustrated and searching for answers. All of this at a time when there are better treatments available than ever before.  What is missing? (Why Patients are so Frustrated)

First, you must determine what is the problem (What's Your Problem?) and then what to do about it (How to Treat Allergies). Allergy testing (Allergy Testing) must be done properly and interpreted for your specific situation.   

Our approach involves all three pillars of allergy treatment:   avoidance measures (Environmental Control), medications (Allergy Medication Overview) and desensitization (Immunotherapy).  When necessary we perform surgery to correct nasal problems (Nasal/Sinus Surgery).  Finally, it is important to set reasonable goals and expectations tod etermine effectiveness (Expectations).

There may be compicating issues affecting  allergy patients and deserving special attention.  These include the impact of foods on respiratory allergy (coming soon),"Sinus" headache (Allergy, Sinusitis and Headache), Asthma (coming soon), and issues effecting athletes (Allergies, Asthma and the Athlete).

Why Are Patients So Frustrated?

A growing concern  
It seems today almost everyone has allergies. In fact, up to a fourth of all households are affected.  While often considered just a nuisance, allergies can have a significant impact on quality of life.  Worsen over time, allergies may progress to asthma, sinus and ear infections, sleep disturbances, and chronic headaches.

Allergies hit the wallet
The financial impact to allegy is enormous. Half of all workers have allergies and it's the most significant disease affecting productivity.  Sedating medications and compromised sleep increases work related accidents and injury. The direct costs of treating allergic related disease is staggering.

Looking for help
Allergic Americans are searching for answers. In 2002, the Asthma and Allergy Foundation of America survey found fascinating answers as to why patients are frustrated. 

Problem One: Patients are using multiple medications without satisfaction:

An ounce of prevention is better than a pound of cure
No one likes to take medication, however, using medications before symptoms start is vital to control.   The natural tendency is to wait until you are sick. This is the wrong approach.

That’s the best I can do under the circumstances…
For severe cases, medications may be only a partial solution.High level exposures cause symptoms despite medications. Environmental control and immunuotherapy are an important additions to the treatment of allergies.

The right man for the job
A third reason for failure is confusion over what is the right medication for the problem. Not all "allergy medications" are alike.  Some work for itchy, runny, watery symptoms, while others are better for blockage, pressure and congestion.  You have to know what is best for your symptoms.

The right tools for the job
Finally, not everything that seems like allergy is allergy.  Migraines, TMJ and other non-allergic diseases mimic allergies. You must start with the correct diagnosis to get the proper result.

Don’t try this at home…
A qualified specialist can guide you appropriately.  

Problem 2: Patients are discontent with their doctors:

There’s never enough time 
"My doctor doesn’t spend enough time with me". Physicians are being challenged to increase efficiency and yet be compassionate and attentive.  We utilize alternatives resources and extenders for education. ENT Carolina has worked hard on our website resources to better serve our patients.

Know it alls…no, but we are trying
It is not possible for physicians to be experts in every area of medicine.  Treating upper respiratory allergy includes medical and surgical knowledge of  the ear, nose, sinuses, throat, lungs, eyes, and skin. As ENTs (otolaryngologist) we possess the knowledge and skills that uniquely qualifies us to care for nasal allergies.

Problem 3: Patients’ perceived knowledge exceeds actual knowledge:

Not as smart as you think you are (about allergies)
Almost all patients surveyed felt they were “somewhat” or “very” knowledgeable about allergies, but when asked basic questions, the majority answered incorrectly. Up to half of the patients didn’t know the contents of the medications they were taking.

Knowledge is the best medication
We truly believe education is the most powerful weapon for allergies.  Our goal is to provide you with the best, most complete resource available.

What’s The Problem?

            Allergies are a result of your genes

and

your exposures. The immune system is complex and functions as a defense system for the body. Allergy is an overly enthusiastic reaction to common proteins in the environment. There are many triggers, but once your immune system starts reacting it is more likely to do so again, and more severely. Prevention and early intervention is the best approach.

How to Treat Allergies:

Where do you start?
Once you determine allergies are a problem, where do you begin? How do you sort through the many options and find what is right for you?

There are a staggering array of medications claiming to offer relief. Television ads tell you just what to ask from your doctor. There are air purifiers, mattress covers, and duct cleaning services all claiming to save you. Then there are so-called natural remedies, with claims of miraculous success without side effects.

Family members and co-workers are quick to offer suggestions, but this advice is rarely what is best for you.
Frustrated and confused, you may turn to books, the internet, and even strangers who may claim to have the ideal solution. Beware! There is plenty of misinformation and unscrupulous people waiting to take advantage of your desperation.

You may just decide to “try everything”, but this rarely works either. Time, money and energy are wasted, and frustration reaches a point where you feel there is no hope. So what is the best approach? Well, here are a few suggestions.

Stop looking for miracles:
First, understand the problem. Allergy is a chronic disease meaning it can be controlled, not cured. People realize arthritis and diabetes are not cured, and control is not always optimal. A diabetic won’t tell his doctor insulin doesn’t work for him simply because his blood sugar runs high occasionally. An arthritis patient doesn’t stop anti-inflammatory medication because her joints still swell at times.

Unfortunately, this is what allergy sufferers may do. They’ll switch from one medication to the next, looking for the “ideal” cure. They quickly discount helpful treatments as failures if they get less than total or permanent relief.
There’s no magical cure without cost, side effects, or effort. It doesn’t exist now, and never will. Remember, “If it sounds too good to be true, it is”.

Beware:
Whenever there is a problem without a perfect solution, there are people waiting to take advantage of the situation. In the allergy field, there is a wide range in quality of care available. There are practitioners offering less than reputable treatments making outlandish claims.

Be careful, and check with reputable sources before agreeing to any treatment. Take advice from family and friends with the proper amount of skepticism. Remember, no treatment is free of side effects, and all take time to succeed.

Treating allergy is like investing money, aim for the long term, manage your risk, and leave the get rich quick schemes to the foolish.

Find a treatment with which you can live:
Allergy management can be like dieting. Many diets have quick effects, but no diet is truly successful without lasting results. In order to keep weight off, the plan has to be easily incorporated into your life style. Strange fads and inconvenient allergy treatments not part of your daily routine will never be the answer.

Be patient:
Find a plan and stick with it. Make adjustments only when necessary. Decisions about success or failure shouldn’t be made over short periods of time or based on single events. Remember, patients without allergies catch colds and get sinus infections on average once or twice a year, and so will you. So don’t change your plan every time you get sick.

There are three treatments for allergy:
All allergy treatments can be broken down into one of three areas: 1) environmental controls, 2) medications, and 3) immunotherapy or allergy vaccines. In order to better explain the role of each, I created the “house fire theory of allergy”.

The House Fire Theory:
Consider treating allergies like trying to keep from being burned in a house fire. There are three things you can do.
First, limit the fuel for the flames, environmental control. Allergens are the fuel triggering the reactions causing symptoms (“the explosion”).
Secondly, you can throw buckets of water at the flames. Medications are these buckets of water. Highly effective for small fires, they are rarely enough for larger ones. Relief is fast but has no lasting benefits.

Patients often say “I tried antihistamine X, and it just doesn’t work”. “Does a bucket of water put out a fire?” A small fire, yes, but for larger fires it will take other measures. The antihistamine is probably working, but it may not be sufficient to do the entire job.

Finally, the third way to limit getting burned is to put on fire protective clothing, like a fireman's suit. This increases your tolerance for heat. Over time, by taking allergy shots or drops you develop this tolerance or “protective armor”. You raise the threshold for exposures at which symptoms will begin.

Now, let’s look at each one of these three methods in more detail.

Tool One- Environmental Control: Get rid of the fuel for the fire:
This is theoretically the most successful form of treatment. It can be as simple as removing a pet or controlling humidity in your home.
If one can avoid or limit the exposure to allergens, then symptoms will never begin. Most severely allergic patients can’t use this as the sole form of treatment, but it’s still important. Unfortunately, it is often neglected.

Environment controls are mostly for indoor antigens such as dust mites, molds and pets. Techniques do not have to be expensive, but it is important to learn what to do before taking any measures so as not to waste money.

Do not become discouraged. Improvement is the goal, not total avoidance.

Tool Two- Pharmacotherapy: For controlling symptoms:
Medications block symptoms most effectively if given before exposures. There are several classes of medications, including nasal steroids, antihistamines, decongestants, leukotriene inhibitors, and mast cell stabilizers. Combinations can maximize effects and be tailored for symptoms and side effects. A qualified allergy specialist is best suited to determine what is right for you.

Tool Three- Immunotherapy: Building up tolerance:
I have told my patients for years immunotherapy is like saving for retirement in a 401K. You invest regularly for a benefit not realized until the future. For immunotherapy, this might take 6-12 months. If immunotherapy is your retirement savings, then allergy medications are your paychecks, providing relief to spend for today. Our goal is eventually to build up enough tolerance with immunotherapy (savings), so we can stop medications (paychecks).

In the financial world, you wouldn’t save for the future when you couldn’t pay today’s bills. In the allergy world, we don’t give allergy shots or drops when you are severely ill from allergies. We don’t want to add more allergens to the “fire” at times when you are having the most problems. Avoid shots or drops during times of severe worsening.

In conclusion, while allergies may seem frustrating and difficult to manage, treatment always comes back to the three areas:  environmental control, medications and immunotherapy.  Each of these is covered in greater detail in other overviews.

Allergy Testing:

When should I get tested?
If you have symptoms more than three months a year, despite medications and environmental control, then it’s time for allergy testing.

There are two goals:   to properly direct avoidance measures and to enable immunotherapy. It isn't reasonable to cover mattresses or exile the cat if  you aren't sure dust mites and pets are the problem.  Each positive skin test identifies a particular allergy.  If you are allergic to 10 common antigens in the area, then a mixture of these allergens is made for injections or as drops under the tongue.

How is the test done?
There are many different methods of testing and variation among doctors. Results can vary greatly depending on the type of testing performed.

At ENT Carolina, we use a combination of a prick and intra-dermal test called modified quantitative testing (MQT). It takes approximately an hour for 40 tests. Prick testing uses an 8 pronged, plastic device gently creating a small wheal in the skin of the arms. With positive reactions, no further testing is required. For negative results, a small TB needle is used to raise a skin wheal read in 10 minutes.

What am I tested for?
Our carefully selected panel includes the area’s most common weeds for the fall, grasses for the summer and fall, trees for the spring, molds, animal dander and other non-pollens for year long problems. Some antigens are so structurally similar to others, they do not have to be tested individually (cross-reactivity).

What about food allergies?
We do not do skin testing for foods for a number of reasons. In most cases, other than patients under 5 years of age, we believe food allergies are not significantly responsible for upper respiratory tract diseases. In addition, we recommend elimination and challenge diet testing as the gold standard test when necessary. Anaphylactic (shock) allergy to foods do exist such as shellfish and peanut allergies and cause life threatening swelling, and airway compromise. These should be diagnosed with blood testing (RAST) and treated with avoidance, not immunotherapy.

Can I have a blood test for allergies?
There are occasions when blood testing (RAST) for environmental allergies is recommended. We find blood testing to be less sensitive than skin testing, especially for molds, and we limit its use to only a few situations.

Can you use previous allergy test results from other doctors’ offices?
There are times when this is possible for making sublingual immunotherapy SLIT, but not injections (SCIT).

Are there medications that can affect my testing?
It is very important to inform us of all medications you are taking prior to testing. Antihistamines or medications with antihistamine like effects will block reactions giving false negatives. A class of anti-hypertensive medication, known as “beta blockers”, is specifically contraindicated for both testing and immunotherapy. They block the effectiveness of rescue medications used in the unlikely event of an anaphylactic reaction.

What can I expect after the test?
Patients will often note delayed skin reactions usually to molds. This is normal, but these reactions can be large and bothersome. Cortisone cream and an oral antihistamine can help with itching and redness.

Are there any risks to allergy testing?
Risks include: itching, nasal congestion or drainage, throat tightness, cough, or breathing difficulty. These can progress to more severe, potentially life-threatening situations such as anaphylactic shock or death.

Can I be tested if I am pregnant?
Patients who are pregnant should not be allergy tested. Patients who become pregnant while on immunotherapy may continue at the current dose but may not advance on therapy until after delivery.

Environmental Control for Allergies

The purpose of this article is to introduce environmental control and to stress its importance in your treatment plan. Ignoring it, may lead to treatment failure despite medications and immunotherapy. On the other hand, one can easily waste considerable time and money on unnecessary and inappropriate measures. This article doesn’t cover everything you need to know, but I hope it motivates your to do further research.

Basic Information: