Ahmad R. Sedaghat, MD, PhD, FACS
When "allergies" are chronic sinusitis
Allergies (allergic rhinitis) and chronic sinusitis are two conditions that share common symptoms and clinical presentations, and they are often present at the same time in the same patient. While they are also treated similarly, there are disease-specific treatments for allergies and chronic sinusitis as well and a thorough understanding of which condition is causing a patient's symptoms is absolutely needed in order to maximize a patient's clinical outcomes, an maximally improve/restore quality of life to patients. When one condition is entirely focused upon, while the possibility of the other condition is ignored, patients can be sub-optimally treated.
The symptoms that patients with allergies experience classically include sneezing, itching, nasal drainage, watery eyes and nasal blockage. These symptoms can range from mild to quite severe, affecting not just one's quality of life but also one's ability to do work or attend to one's errands, etc. The timing of allergy symptoms ranges from seasonal to all year round (also referred to as perennial or persistent allergies). The presence of allergy symptoms all year round indicates chronic exposure to allergens and in the chronic phase of the allergic reaction, allergy symptoms typically transition primarily to a scenario of nasal congestion and blockage, which can be associated with nasal drainage, decreased sense of smell and facial pressure. However, these are also the symptoms of chronic sinusitis, which we've described in another post on our blog.
Chronic sinusitis is an inflammatory condition of sinuses - I frequently call it "asthma of the sinuses". The formal diagnosis of chronic sinusitis (also referred to as chronic rhinosinusitis) includes having at least 2 out of the 4 symptoms of nasal blockage, nasal drainage, facial pressure, and/or decreased sense of smell for at least 12 continuous weeks. The formal diagnosis of chronic sinusitis also includes the need for
objective evidence of inflammation in the sinuses either radiographically (for example, by a sinus CT scan) or endoscopically (for example, seeing polyps or pus draining from the sinuses on nasal endoscopy). However, in a patient who has not had either a sinus CT scan or a nasal endoscopy (which would be performed by an ENT doctor), it is virtually impossible to differentiate severe, persistent/perennial allergies from chronic sinusitis. What makes it more challenging is that patients with chronic sinusitis also frequently have positive allergy testing so without a sinus CT scan or nasal endoscopy, it is easy to mistake chronic sinusitis for allergies. As a result, I have seen many patients who for years are told that they "just" have (and are treated for only) allergies when in fact it is chronic sinusitis that is the primary cause of their sinonasal symptoms, with the end result of persistent and uncontrolled chronic sinonasal symptomatology.
The role of allergy in chronic sinusitis is still being fully worked out but the evidence suggests that allergy is most frequently a modifier of chronic sinusitis and infrequently the sole cause. As a result, allergy-specific treatments such as antihistamines or immunotherapy (such as "allergy
shots") may not fully treat a patient's chronic sinusitis. In fact, the most recent studies and international consensus recommendations tell us that antihistamines and immunotherapy are not the first-line treatments of chronic sinusitis, even if a patient is allergic.
In my practice and those of my colleagues here at the University of Cincinnati Division of Rhinology, Allergy and Anterior Skull Base Surgery, the presence of chronic sinonasal symptomatology triggers the thought of not just the possibility of perennial allergies but also the possibility of chronic sinusitis. And, I would encourage patients with chronic sinonasal symptoms, even with positive allergy testing, to explore whether they also have an underlying chronic sinusitis (talk to your sinus doctor about a sinus CT scan and/or having a nasal endoscopy). I have seen far too many patients in my office after they had been treated for allergies for years while they continued to suffer and their chronic sinusitis was missed. Maximizing outcomes and maximally improving/regaining quality of life requires comprehensive knowledge of what is the underlying problem. More than anything else, we want to empower our patients and the public to have all of the information so they can choose/obtain thoroughly-informed, evidence-based treatments for their sinonasal symptoms.