April, 2016
Springtime has arrived and so have spring allergies. The spring is notoriously referred to as the “tree allergy season”. With warmer weather comes the onslaught of tree pollination. Billions of tiny airborne pollen particles are released into the environment and are carried great distances by the winds. As the pollen particles waft through the air they are easily inhaled by allergy sufferers which trigger a series of bothersome symptoms. This condition is sometimes referred to as “Hay Fever,” or seasonal allergic rhinitis, and affects roughly 30 to 60 million people in the United States on an annual basis.
Seasonal allergies can cause a variety of symptoms. The most common include recurrent sneezing, a runny nose, watery/itchy eyes, and nasal or throat congestion. Severe allergies may cause polyps to form in the nose and sinus, further blocking the ability to breathe comfortably through the nose and triggering recurrent sinus infections. Conditions associated with hay fever include asthma, eczema, conjunctivitis, nasal polyps, sinusitis, sleep apnea, laryngitis, and ear infections. Individuals with asthma may become more symptomatic when exposed to tree allergens, and often report increased wheezing, shortness of breath, or coughing. Another strange symptom that may indicate that you have seasonal allergies is itchiness of the mouth and throat after eating raw fruits (apples, bananas). This condition is called oral allergy syndrome and is highly prevalent in individuals with tree allergies such as birch.
The first step in minimizing spring allergies is to determine which trees you are sensitized (or allergic) to. An allergy test determines whether your body has an allergic reaction to a specific substance in the environment, in this case tree pollen. Because tree pollen particles have very unique proteins (and therefore have less cross-over between different types of trees), patients are often tested for several different tree species, usually dependent on which trees are found in their region. A tree allergy test panel for New England may include oak, elm, maple, sycamore, and birch to name a few of the more common tree pollen offenders. Allergy testing can be performed either via a quick pain-free skin test or by a blood test. Both types of testing are safe and can be effective for diagnosing tree allergies, as well as other types of allergies. Skin testing has the advantage of being performed in the office setting, and other benefits may include: immediately available results, the ability to test for multiple tree allergens, and the immediate patient feedback regarding how they react to certain tree pollens in their environment. In preparation for skin testing, patients are advised to discontinue taking antihistamines and other types of medications that may interfere with test results.
Tree allergies can be treated in variety of ways. Firstly, environmental modifications are recommended for anyone who is allergic to pollen. This includes keeping home windows closed, staying indoors on high pollen days, not drying clothing outside, and showering before bedtime. If environmental modifications are not enough, medical management may be necessary. This includes over the counter antihistamines (e.g. Claritin, Zyrtec) and intranasal steroid sprays (e.g. Flonase). Other types of medications include nasal inhaled antihistamines, mast cell stabilizer nasal sprays, and oral decongestants.
For patients who are interested in additional improvement and decreasing their usage of allergy medications, immunotherapy should be considered. Immunotherapy can be given in two different ways, including subcutaneous immunotherapy (SCIT or allergy shots) and sublingual immunotherapy (SLIT or allergy drops). SCIT (allergy shots) has shown repeatedly over the past 50 years to be a very safe and effective way to minimize both seasonal and year round allergies. SLIT (allergy drops) is the most common form of allergy treatment in Europe, and has been shown to be as effective and safe as traditional allergy shots, but has the added benefit of being able to do this treatment in the convenience of your home (you can self-administer the drops daily). The major disadvantage of SLIT is that it is currently not FDA approved in the USA (although the drops are made from the exact same allergy extracts that are used to create the allergy shots), and therefore this treatment would not be covered through medical insurance.
If you or a family member have any concerns regarding spring allergies, please do not hesitate to contact Colden Ear Nose Throat and Allergy and schedule an allergy evaluation as your first step towards symptom relief.
Opinions expressed here are those of Dr. Daryl Colden and Christopher Jayne, BA. They are not intended as medical advice and cannot substitute for the advice of your personal physician.
Recurrent nose bleeds are very common and can range in severity from being a nuisance to being on rare occasions life threatening. The clinical term for bleeding from the nose is epistaxis.
Nose bleeds occur due to the bursting of tiny blood vessels known as capillaries that are found throughout the nasal cavity. Roughly 90% of bleeds start near the front of the nose in a small region called Kisselbach’s plexus. Kisselbach’s plexus is a collection of fragile blood vessels on the surface of the nasal septum (the wall that divides the left and right nasal passages) that is exposed to irritants, such as cold weather, dry heat, digital manipulation and trauma. These blood vessels can be easily broken by simple trauma such as excessive nose blowing, or they can on occasion rupture for no apparent reason. Bleeding that occurs towards the back of the nose (posterior) is less common and may be more difficult to control. If bleeding occurs on one side of the nose, it can sometimes drip to the back of the throat and be coughed up, or even pass through to the other side of the nose through the back of the throat or breaks in the septum.
Causes of nose bleeds can be divided into three categories, local, systemic, and idiopathic (unknown). Local causes, which are the most common, include nasal trauma, nasal dryness, and septal abnormalities. Trauma of the nose might be related to a nasal fracture, frequent nose picking, excessive nose blowing, or nasal surgery. Nasal dryness mostly occurs during winter months when patients live in warmer and dryer environments. When the nose is dry and irritated becomes more susceptible to bleeding. Abnormalities of the nasal septum include septal deviations (bending of the wall that separates the passages) and septal perforations (a hole in the septum). Such abnormalities can cause turbulent airflow in the nose which may contribute to nasal irritation, and subsequent nasal bleeding.
Systemic causes include various blood disorders and certain types of medications that may thin the blood. Patients with high or poorly controlled blood pressure are at higher risk for nasal bleeding because the blood vessels are more likely to burst when they are under high pressure. In addition, patients who take anticoagulants (blood thinning medications) are also at a higher risk. Some of the more common prescribed medications include Coumadin and Plavix, but there are many others. Many over the counter medications taken in high quantities can thin the blood, such as Advil/Motrin or aspirin. Other conditions associated with nose bleeds include liver disease (which makes platelets that are necessary for clotting not as effective), and primary bleeding disorders, such as Von Willebrand’s disease.
It is very important to know what other medical problems co-exist, what medications a patient may be taking, and family or personal history of bleeding or bruising to best determine the potential cause and treatment of nose bleeds. No matter what the cause of a nosebleed, one should apply pressure to the front of the nose when an active nosebleed is occurring. Holding pressure in this area for 10 minutes will put pressure on the capillaries that commonly bleed (Kisselbach’s plexus), and is the most effective way to stop the bleeding. Nasal decongestants such as oxymetazoline or neosynephrine may also be used, either directly sprayed in the nose or applied to a cotton ball then placed in the nasal cavity. Ice to the nasal regions can also reduce bleeding in some cases. If bleeding persists, medical intervention is recommended. One common procedure that can be done in the office setting is cauterization, whereby a chemical called silver nitrate is applied to the nasal vessels to help seal them up. If bleeding still doesn’t resolve, either an electrical cautery can be used, or various types of nasal packing can be applied to tamponade the blood vessels and stop bleeding. Usually these nasal packs need to remain in place for a few days, and although they may be uncomfortable, they typically have a 95% chance of stopping a nosebleed. Because nasal packs can sometimes cause infections, it is very important that patients be placed on an oral antibiotic at the same time. Nasal packing can be absorbable or non-absorbable.
Preventative measures include nighttime humidification, avoiding digital manipulation of the nose, and applying daily moisturizers to the inner nose. Common moisturizers that are effective are Vaseline, nasal emollients, and saline nasal sprays. Minimizing aspirin and Motrin as well as controlling your high blood pressure may also help to reduce nose bleeds. Resting and avoiding undue force in the nasal cavity can be effective, so we usually recommend 2-3 days of light activity and avoiding bending or lifting. If you experience recurrent nose bleeds, or have had a severe one that is difficult to stop, please consider an evaluation by a trained expert, i.e. Ear Nose Throat specialist, that can better evaluate the entire nasal cavity by performing a quick painless in office procedure called a nasal endoscopy to better determine potential causes and treatment options.
Opinions expressed here are those of myself, Dr. Daryl Colden. They are not intended as medical advice and cannot substitute for the advice of your personal physician.
The ear is made up of three major parts: the outer, middle, and inner ear. All of these various areas are essential for hearing, and when there is an abnormality in one area, it can affect hearing adversely. The outer ear consists of the pinna (the rigid cartilage covered by bone that we can see) and the auditory canal (a short tube from the pinna to the eardrum, or tympanic membrane). The middle ear contains the eardrum (tympanic membrane), and a small air-filled cavity behind it which contains three tiny bones, known as ossicles. These ossicles transmit sound to the inner ear, or the organ of hearing (cochlea), which will then transmit impulses via a major nerve (acoustic nerve) to the brain, which completes the hearing loop.
The middle ear periodically becomes swollen (inflamed) and fluid accumulates in the air-filled region behind the eardrum. This condition is called otitis media with effusion (or middle ear fluid). Viral and bacterial infections are the most common cause of middle ear infections and the subsequent middle ear fluid that may accumulate. Children are more prone to infections and fluid buildup due to a variety of factors, including frequent exposure to others with illness, poor Eustachian tube function, or an immature immune system.
Often, this middle ear fluid will result in a “blocked ear” feeling with decreased hearing. Under acute and more severe circumstances, patients will experience a localized ear pain, fever, irritability, and upper respiratory symptoms. Children with chronic middle ear fluid or recurrent ear infections may present with hearing deficits, poor attention, and even speech and language delays.
Middle ear fluid can be diagnosed through a variety of methods. This includes use of a pneumatic otoscope (a small device that visualizes the ear canal and blows air towards the eardrum), a tympanogram (a test to evaluate eardrum mobility), and a specialized hearing test.
Treatment options depend on the duration or frequency of ear symptoms. For patients experiencing their first ear infection, antibiotics and ibuprofen are usually the treatment of choice. If there are nasal or allergy symptoms occurring with the ear issues, it would be helpful to evaluate and treat these potential triggers. If a patient experiences recurrent ear infections or chronic middle ear fluid, ventilation ear tube insertion may be considered (ear tubes). These microscopic tubes are placed to remove ear fluid, reduce or eliminate ear infections, and restore the ability to equalize pressure between the middle ear and outside atmosphere (for example: no ear pressure when flying). Placing ear tubes is a short and painless procedure which can sometimes be done in the office setting but other times may require anesthesia in the hospital.
