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Biologics - a NEW treatment in chronic sinus disease
One of the recent focuses of medicine has been to offer personalized treatment specific to the exact cause of an individual’s disease. A recently developed class of medications, “biologics”, looks to address this need for personalization in healthcare. Biologics first became approved for the treatment of sinusitis in July of 2019. We now have two different biologics approved (dupilumab and omalizumab) and several more on the horizon. Of note, this class of medication is currently available only for patients with chronic sinusitis who have nasal polyps. Nasal polyps are typically identified by your ENT when you undergo a nasal endoscopy (when a small camera is used to look in your nose; performed easily, quickly and comfortably in the office). Clinical trials involving each of these medications has shown improvement in patient’s daily nasal symptoms and decrease in the size of nasal polyps when compared to patients who use just nasal steroid sprays. When is the best time and for how long to use biologics in chronic sinus disease is still undetermined. Most doctors are treating their sinus patients with topic steroids and salt water (saline) nasal rinses and then offering surgery if patients do not improve on this regimen. If patients continue to have severe symptoms after sinus surgery and have re-growth of nasal polyps, doctors are now offering biologics. Other doctors are offering biologics to sinus patients who want an alternative to surgery or in patients who are unable to have sinus surgery. As more research comes out, this will continue to be an evolving and exciting topic for patients with chronic sinus disease. Other things to consider with biologics is that these medications are not something you take by mouth. Instead these are medications which are injected under your skin usually once or twice per month depending on certain factors your doctor will help determine. Side effects depend on which medication who receive but are generally well tolerated. These medications are new to sinus disease but have been around since 2003 for omalizumab and 2017 for dupilumab and therefore we know a lot about their safety profile and can talk in detail with you when deciding if this medication is right for you. If you are interested, please reach out to your doctor to see if these medications are right for you. As always, the content in this blog is meant to be informational and not serve as a substitute for a medical evaluation with a physician.
Asthma: the under-recognized symptom of chronic sinusitis
When we think about chronic sinusitis and how it affects a patient, we typically think about the classic sinonasal symptoms associated with chronic sinusitis. Symptoms such as nasal blockage, nasal drainage, sinus pressure and decreased sense of smell. These sinonasal symptoms are also used to diagnose chronic sinusitis. However, chronic sinusitis can cause problems in the lungs as well. Most common and prominently are symptoms of asthma, such as cough and wheezing. Some studies have suggested that if chronic sinusitis is left inadequately treated, it may even lead to the development of asthma. More frequently, problems arise in patients who have both chronic sinusitis and asthma. First, it is worth understanding that chronic sinusitis and asthma frequently occur together. Some studies suggest that up to 40% of patients with asthma will also have chronic sinusitis. Similarly in patients with chronic sinusitis, around 30-40% of them will have asthma. The common overlap of asthma and chronic sinusitis makes sense from a physiology standpoint because chronic sinusitis and asthma have common inflammatory mechanisms causing them—in other words, if the inflammation is happening in one part of the airway, it would make sense that it could occur in a different part of the airway. I even frequently describe chronic sinusitis to my patients as “asthma of the sinuses”. In theory, a flare up of either condition could cause a flare up of the other condition but experience suggests that it is more frequently the case that flare ups (or poor control) of chronic sinusitis is causing flare ups (or poor control) of asthma. Our research group is one of the leaders in studying the relationship between chronic sinusitis and asthma, and we have published many scientific studies on the topic. We’ve shown that the severity of chronic sinusitis symptoms very closely correlates with the severity of asthma symptoms that patients may experience. So much so that we can even use the severity of chronic sinusitis to predict which of our asthma patients are experiencing poor asthma control and in need of escalating asthma treatment. We’ve also shown that flares (or acute exacerbations) of chronic sinusitis are highly associated with flares of asthma as well, causing our asthmatic patients to need medications like prednisone that have many side effects and also to miss work and to visit the ER for their asthma. The bottomline is that asthma symptoms and asthma exacerbation is a symptom of chronic sinusitis. Some patients only experience the worsening of their asthma rather than experiencing or noticing the more classic sinonasal symptoms of chronic sinusitis. If you have asthma that is poor controlled or are experiencing frequent flares/exacerbations of your asthma, it is very possible that you also have chronic sinusitis which may be causing the problems with your asthma. On the other hand, if you know that you have chronic sinusitis, be aware that lung problems and asthma symptoms (such as cough, wheezing, shortness of breath, chest tightness) may be a symptom that is being caused by your chronic sinusitis. And finally, if you know that you have both asthma and chronic sinusitis, then understand that a flare up of either inflammatory condition can cause a flare up of the other. This is all the more reason to stay on top of both conditions with an appropriate maintenance treatment regimen.
Exercise-induced rhinitis: why does my nose run when I exercise?
It has been known for over a hundred years that exercise can induce a runny nose. Between 25% and 50% of athletes will describe experiencing a runny nose during exercise (also referred to as “exercise-induced rhinitis”). While nasal drainage increases, nasal congestion/blockage typically decreases. In fact, studies have shown that during exercise, the resistance of the nasal passages can decrease (i.e. the nasal passages become more open) so that more air can pass through. The characteristic increase in nasal drainage is seen in all manner of sports from typical land sports (for example, running or biking) to skiing to swimming. The exact mechanisms for exercise-induced rhinitis are unclear but it may depend on the exact circumstance and the sport during which it occurs. First of all, at least one study has shown that exercise-induced rhinitis occurs more frequently in people with allergies. It is therefore possible that in some individuals, increased airflow through the nose due to the reflex nasal decongestion and increased respiration (breathing faster) that occur during exercise may introduce more allergens into one’s nose and hence trigger a runny nose. Whether these allergens are pollens floating around outdoors or dust in your at-home exercise studio, this could be a reason for the runny nose your experience when you exercise. Second, irritants can also trigger runny nose. For example, an irritant — in the form of chlorine— is thought to be the likely culprit for the runny nose commonly observed in swimmers. However, it is also important to know that anyone who exercises in an urban environment (or even in the suburbs of an urban environment) is constantly being exposed to irritants in the air in the form of particulate matter and pollution. Moreover, allergens are also irritants to the lining of the nose. So even in a person who doesn’t have allergies, inhalation of allergens can still irritate the lining of the nose. As another possible mechanism for exercise-induced rhinitis, cold air can also cause runny nose by activating nerves in the nose to stimulate the lining of the nose to produce mucus (also referred to as “vasomotor rhinitis”). It is this stimulation by cold air that is thought to cause “skier’s nose” and runny nose in close to 50% of athletes who play winter sports. The question that most people reading this are likely asking is “what can I do about it?” The fact that there may be different mechanisms of action for exercise-induced rhinitis makes it hard to make broad statements about how to treat it or prevent it. However, individuals who know they have allergies may want to consider using allergy medications on a more consistent basis. In fact, there is at least one randomized controlled trial showing that intranasal steroid sprays (an effective, first-line treatment of allergies) may improve exercise-induced reactivity of the airways. Another easy intervention for those who work out at home may to place a portable air purifier in the same room that they exercise in. For those who mostly experience runny nose while playing winter sports, a prescription nasal spray called ipratropium, which directly acts to inhibit nerves in the nose that stimulate mucus production, may be helpful. However, whether to pursue treatment options with your doctor in large part depends on whether exercise-induced rhinitis is a significant burden to you. In most cases, even in high performance athletes, it is not a major impediment to athletic performance, although it can certainly affect quality of life. In many cases, just knowing why these symptoms are occurring may be helpful and put one’s mind at ease. For those who want to do something about, talk to a doctor about it because there are definitely treatment options.
Should I get the COVID Vaccine if I have a history of allergies?
The long-awaited vaccine against SARS-CoV-2 is here and hopefully will be available to our population over the next several months. One question that may arise in patients with a history of allergies, is should I get the new vaccine? The short answer is likely YES, unless you have a history of severe allergic reaction (anaphylaxis, angioedema, respiratory distress or severe hives) to the COVID vaccine or components of the COVID vaccine (most commonly polyethylene glycol). The long answer is - there are many considerations you and your doctor should discuss to ensure you are as safe as possible when you receive the vaccine. The first thing to know is that anaphylaxis (an allergic reaction which causes extreme swelling in your airway which can lead to difficulty breathing and even death) caused by vaccines is an extremely rare event. For most vaccines, anaphylaxis occurs approximately 1 per 1,000,000 doses administered and usually develops within minutes of receiving the vaccine. The Moderna and Pfizer trials did not report any episodes of anaphylaxis following vaccine administration, but in the first week the vaccine was available there were 2 cases of documented anaphylaxis that did occur after the COVID vaccine was administered in the UK. For this reason, the CDC recommends that you be observed for 15-30 minutes after receiving your shot so that healthcare officials can monitor you for a possible anaphylaxis reaction and administer epinephrine immediately if you develop symptoms. So for those patients with a history of allergies - should you get COVID vaccine? The current guidance from the CDC states: -If you have a history of severe allergic reaction to foods, pets, venom, environmental allergens or latex, you should proceed with vaccination. You are no more likely than the general public to have a severe reaction to the COVID vaccine. -If you have a history of mild allergic reaction (no anaphylaxis) to an injectable medicine or vaccine, you should proceed with vaccination. -If you have a history of severe allergic reaction (anaphylaxis) to a vaccine or an injectable medicine, you should discuss the risks and benefits with your doctor. We learn more every day as more people get the vaccine and therefore this recommendation is always evolving. After discussion with your doctor, if you do decide to go forward with vaccination, you should wait the full 30 minutes after injection to be monitored for anaphylaxis. -If you have a history of severe allergic reaction (anaphylaxis) to the COVID vaccine itself or components of the COVID vaccine (ex. polyethylene glycol), you should not proceed with vaccination and instead follow up with an allergist or immunologist. For further details on this chart, please visit https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-product%2Fpfizer%2Fclinical-considerations.html What about receiving other vaccines? Given the lack of research into if the COVID vaccine remains safe and effective when given with other vaccines, the CDC is currently recommending waiting 14 days between COVID vaccine administration and other vaccinations. Although, the CDC does say other vaccines can be administered closer than the 14 day window if benefits outweigh the risks (ie. tetanus toxoid-containing vaccination as part of wound management) What about immunotherapy? If you are currently on allergy shots, the recommendation of the ENT and Allergy national societies (AAO-HNS and AAOA) is to not receive your COVID vaccine and allergy shot within a 24-hour period. This is to avoid uncertainty if there happens to be an adverse effect after receiving either the allergy shot or COVID vaccine. If you are currently taking allergy drops under your tongue or taking sublingual tablets, you do not need to stop taking these medications if you get the COVID vaccine. In a similar manner if you are currently taking a biologic medication (such as Dupixent (dupilumab) or Xolair (omalizumab)), you do not need to stop taking these medications to get your COVID vaccine. These medications are immune system modifying agents and do not cause immunodeficiency. Moreover, if you are immunodeficient, the COVID vaccine is not a live virus vaccine and is safe to use in those patients with immunodeficiency. This post is a summary of the guidelines put forth by the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) and the American Academy of Otolaryngic Allergy (AAOA). Please see this link (https://www.entnet.org/content/allergic-reactions-related-covid-19-vaccinations-allergic-patients)for further details. As always, the content in this blog is meant to be informational and not serve as a substitute for a medical evaluation with a physician.
My Face Hurts ... Is it my Sinuses?
Facial pain can be debilitating, especially if it occurs every day. This can impact your ability to enjoy your daily activities such as eating, socializing and other things you like to do for fun. It can also decrease your sleep quality or your productivity at work. The pain and the subsequent consequences of the pain can leave people desperate for help. So what causes this facial pain and what can you do about it? The anatomy of the head and neck is quite complex and as a result, the causes of facial pain are numerous. Each of the following paragraphs will go through broad categories of diseases that can lead to facial pain. Sinus Disease: One of the main culprits of facial pain is sinus disease. Both a sinus infection and chronic sinus disease can lead to severe facial pain or pressure. Commonly, the sinuses impacted by the infection or inflammation lead to pain in a corresponding area of the face. For example, when the maxillary sinus has disease, patients often feel pain or pressure within their cheeks or teeth. Likewise, disease in the ethmoid sinuses causes pain and pressure between the eyes, disease in the frontal sinuses leads to pain in the forehead and disease in the sphenoid sinuses can lead to pain behind your eyes or on the vertex of your head. When sinus disease is causing facial pain and pressure, other symptoms that are generally present include nasal drainage, nasal congestion, decreased sense of smell, post nasal drip, or fatigue. When you are having severe facial pain or pressure and want to understand if sinus disease is causing this pain, it is best to go see your doctor for evaluation and treatment. Headaches: Another common reason patients experience pain in their face is related to headaches. Even facial pain without the typical symptoms of a headache can still be from a headache disorder. Migraines, cluster headaches, as well as other atypical headache disorders such as trigeminal autonomic cephalgias or paroxysmal hemicrania can lead to recurrent facial pain or pressure. Symptoms such as associated nausea, sensitivity to light or sound, dizziness, seeing flashes of light, scalp sensitivity, tearing, or nasal congestion can also be associated with facial pain related headaches. Treatment is usually focused on headache hygiene behaviors and medication to either treat headaches or prevent headaches depending on the severity and/or frequency of headaches. Your primary care doctor or a neurologist may be helpful in treating you if this is the cause of your facial pain. Orofacial Pain: Another category of facial pain includes orofacial pain. Orofacial pain may either be from dental problems including infection or disease of the teeth, root of the teeth or gums or from temporomandibular joint (TMJ) disease. The TMJ connects your jaw bone to the base of your skull at the side of your face just below your ear canal (see red arrow in picture below). Disease in this joint can be from many different causes including arthritis, trauma or injury to the jaw itself, or simply your genetics. Often people who grind their teeth can also have pain in this joint. Pain in this joint can be felt as pain in your ear, the back of your neck, or in your face. Treatment is dependent on the exact cause of the injury to the joint, but often conservative treatment (such as resting the joint with diet modifications, pain control, and hot compress) may be enough to improve the pain. See your primary care doctor or dentist if you suspect dental or TMJ disease is causing your facial pain. Nerve Disorders: Neuropathy or nerve problems can also be a cause of facial pain. One particular nerve - the trigeminal nerve - provides sensation to the whole face and divides into three separate nerves as it comes out of the skull. These three segments provide sensation to (1) the forehead, (2) the midface, and (3) the chin respectively (see picture below for corresponding locations). If the nerve is injured either from something else compressing the nerve or the nerve has an intrinsic injury, this can lead to facial pain often in a specific area as mentioned above, depending on where that specific nerve provides sensation to the specific area of the face. Nerve pain can sometimes be described as “electric” or “burning” and you will often see people guarding their face to prevent anything from contacting their face to prevent exacerbation of the pain. Conditions that target this nerve include Shingles, Trigeminal neuralgia, Anesthesia dolorosa, among others. Masses - benign tumors or cancerous masses may also push on nerves, causing compression, or grow along the nerve itself resulting in pain. Treatment is dependent on the specific condition. Your primary care doctor can help you figure out if you are suffering from one of these conditions and may make referrals to an ENT, a neurologist, or a pain doctor depending on the specific condition. As you can see, many things can cause facial pain. If you have pain and it is interfering with your daily life - you should seek help. Your doctor will ask you about the nature of your pain and other associated symptoms. They may also ask that you get a CT or MRI scan to further evaluate your head and neck to look into these conditions or make a referral to a specialist such as an ENT, neurologist, or pain doctor. There are effective treatments for each of the conditions mentioned above, so seek medical care and get an answer. As always, the content in this blog is meant to be informational and not serve as a substitute for a medical evaluation with a physician.
The isolated, opacified maxillary sinus: what to do?
One consultation that we often get is related to the an isolated, opacified maxillary sinus - having a "cheek sinus" that is totally (or almost totally) full but without disease in the other sinuses. In the setting of chronic sinusitis, it is certainly possible to have an opacified maxillary sinus but it is usually in the context of disease all throughout the sinuses. When the disease is localized to one sinus - for the purposes of this discussion, the maxillary sinus - the problem is less likely be a generalized or systemic condition like chronic sinusitis, which is an inflammatory condition of the sinuses that typically affects sinus on both sides and usually affects more than just one single sinus. The descriptor "opacified" is a radiology term and essentially means "full". But this also means that when we are talking about an opacified maxillary sinus, we are talking about a finding on imaging, most commonly a sinus CT scan although it could be an MRI as well. When a patient has a single opacified maxillary sinus, the first question in our minds is to ask what is causing the opacification to occur. If a maxillary sinus is opacified, it means that there is "stuff" in it. What is that "stuff" and how did it get in there? The "stuff" could be mucus, pus, fungus, polyps, or even tumor. So the "why" of an opacified maxillary sinus is most commonly related to either infection, blockage of the sinus (preventing mucus or pus from draining) or tumor. Although imaging can give us a hint about what the "stuff" is, it's hard to make definitive statements about the cause of the maxillary sinus opacification based on imaging alone. An MRI can provide more information than a CT scan about whether the "stuff" is liquid (e.g. mucus) or soft tissue (e.g. tumor) but even then the cause may not be completely clear. Infection as the underlying etiology for the opacified maxillary sinus is typically bacterial in nature. This could be odontogenic (dental) or it could just be the result of a sinus infection that never clears. The odontogenic cause is much more common (at least in our experience) than a sinus infection that never clears. Odontogenic maxillary sinusitis can be especially hard to treat. The bacteria in the mouth, which get seeded into the maxillary sinus for example due to infection around a tooth root or from dental work, can cause an especially inflammatory response in the sinuses, so much so that it is common for the infection to cause the opening of the maxillary sinus to swell completely shut causing the infection in the maxillary sinus to fester and drain too slowly for it to ever fully resolve. In these cases where it is a bacterial etiology, patients often complain of foul tasting, malodorous drainage from side of the affected maxillary sinus. Patients also commonly describe pain or pressure in that cheek. We also perform a nasal endoscopy to help confirm the suspicion of bacterial infection by visualizing pus draining from the area of the maxillary sinus drainage pathway. The goal of treatment when a bacterial etiology is suspected is to clear the infection and improve drainage from the maxillary sinus with aggressive medical treatment and if that doesn't work, then with endoscopic sinus surgery to open the maxillary sinus (and wash it out). Once the maxillary sinus is addressed and cleaned out, any underlying dental problem also needs to be addressed. Fungus can also cause opacification of the maxillary sinus. This is usually in the form of a "fungal ball" (a.k.a., mycetoma). It's unclear why fungal balls form but sometimes fungus in the sinuses can begin to grow within the sinus, forming a thick ball of fungus that resembles a glob of peanut butter. This in itself is typically not a big problem since usually the fungus is typically growing within the sinus and is not invasive. The problem arises because the body responds to the overgrowth of the fungus with inflammation, which leads to chronic mucus production. Moreover, the bacteria that live in the sinuses also may use the fungal ball as a scaffold and growth media to set up a low grade, chronic bacterial infection on top of the fungal ball. Many of the patients I've seen with fungal balls will complain of a chronic post-nasal drainage from the side of the fungal ball that is due to chronic mucus production or chronic drainage of pus being caused by the fungal ball. Unfortunately, the only way to definitively take care of a fungal ball is to open the maxillary sinus with endoscopic sinus surgery and physically remove/washout the fungus. When I explain why we need to do this to my patients, I often describe the fact that these fungal balls resemble a glob of thick peanut butter and that there is virtually no chance for this to drain out through the approximately 1-2mm wide drainage pathways of the sinuses. The maxillary sinus can also become opacified through non-microbial mechanisms for blockage of the sinus, causing build up of mucus within the sinus. Sometimes we believe, negative pressure is created in the maxillary sinus and this causes the drainage pathways of the sinus to swell shut. It's analogous to what happens when you suck too hard through a straw - it collapses. In these cases, the maxillary sinus (or its drainage pathway) may be described as atelectatic (i.e. collapsed, or sucked in). An atelectatic maxillary sinus may also be associated with a condition called silent sinus syndrome, in which there is so much negative pressure in the maxillary sinus that it pulls the roof of the maxillary (the orbital floor) downwards and eventually patients may notice that one eye sits lower than the other. Management of this typically includes using intranasal steroids to see if reduction of inflammation in the nose and sinus drainage pathways may allow the maxillary sinus to open up enough to relieve the negative pressure which is causing the problem. More often than not, however, endoscopic sinus surgery is needed to open the maxillary sinus. The good news in relation to silent sinus syndrome is that (we've shown in a past study) opening the maxillary sinus may lead to the orbital floor rising back up. The last consideration in relation to an opacified maxillary sinus is the possibility of a tumor. As I described above, there's usually no way to definitively know based on imaging whether the opacified maxillary sinus is being caused by a tumor that's either filling the sinus or causing the sinus to be blocked. And while most tumors that grow in the sinuses are benign, many of these tumors have "malignant potential" (i.e. chance to turn into cancer if you leave it long enough). This is one of the main reasons (aside from eradicating a festering infection sitting right under the eye) that surgical exploration may be recommended for a persistently opacified maxillary sinus. Every patient is (of course) different and a unique, patient-specific treatment plan is the key to the successful management of any sinus/nasal condition. However, I hope the above gives you some indication of general thoughts that may cross our minds when evaluating and managing an isolated, opacified maxillary sinus.
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.
A nose doctor by any other name... Rhinologist!
I've heard of many patients asking for a "nose doctor" to help them manage any number of common conditions of the nose and sinuses, such as allergies ("allergic rhinitis") and chronic sinusitis. Believe it or not, there are doctors out there who specialize in diseases of the nose and sinuses! We're called rhinologists. What is rhinology? Rhinology is the subspecialty of otolaryngology (ENT) that focuses entirely on the medical and surgical management of conditions of the nose and sinuses (including the anterior skull base, which forms the "roof" of the sinuses). These days, there is additional fellowship training for rhinology/allergy/anterior skull base surgery that happens after otolaryngology residency training. Rhinology is by no means a new field, but the field, as we know it today, really started to develop in the late 1980s as modern methods of minimally invasive endoscopic sinus surgery became more and more advanced, and started to become more popular world-wide. There has since been an explosion of clinical and academic interest in the field of rhinology, which is completely appropriate and expected since diseases of the nose and sinuses are extremely common. For example, some studies suggest that allergies are present in 20-30% of the population while chronic sinusitis is present in about 5% of the population. Those are not trivial numbers. I often illustrate this by telling patients that if they go to a professional baseball game, football game or a concert, there will be thousands of people at that venue with these conditions. Within our group, we've treated tens of thousands of patients, we routinely lecture/teach on these topics all around the world, and we've published hundreds of studies to advance and improve the care of patients with sinus and nasal conditions. Inflammatory conditions of the nose and sinuses (such as allergies and sinusitis) are the most common conditions that we treat as a rhinologists; in many ways rhinologists are like "one-stop shopping" for these conditions because we specialize in every aspect of these conditions. Rhinologists can perform a full evaluation of sinus and nasal problems from performing allergy testing to performing nasal endoscopy (take an up close look at the inside of your nose where the sinuses drain). Rhinologists have the expertise to treat these conditions both medically, and surgically when needed. The focus of rhinologic treatment is the medical management of inflammatory conditions because the vast majority of these patients' allergies and chronic sinusitis can be well-controlled with a personalized, evidence-based treatment regimen. In our studies, we've found that even in patients with the worst-of-the-worst sinus disease, we can get symptoms under control without sinus surgery in a large fraction. When an appropriate medical treatment regimen is not effective at controlling sinus and nasal symptoms, surgery may be an effective treatment option. For medically recalcitrant sinonasal inflammatory conditions, such as chronic sinusitis and allergic rhinitis, rhinologists are the experts in minimally invasive endoscopic endonasal surgery such as endoscopic sinus surgery and septoplasty. There are even endoscopic procedures that can be performed to reduce mucus over-production by selectively cutting the tiny nerves that enter the nose and stimulate mucus production. Beyond just inflammatory diseases of the nose and sinuses (such as allergies or chronic sinusitis), rhinologists are also the experts in surgeries of the anterior skull base as well as endoscopic orbital surgery. Endoscopic surgeries for the anterior skull base are frequently for conditions such as a cerebrospinal fluid (CSF) leak or for tumors, such as pituitary tumors. Rhinologists can also perform endoscopic surgeries for the orbit through the nose. We often perform these surgeries with our oculoplastic surgery colleagues (we're big believers in multidisciplinary approaches). Through the nose, we can access the parts of the orbit that are closest to the sinuses in order to open up blocked tear ducts as well as decompress the orbit (which might have built up pressure due to, for example, thyroid eye disease) or decompress the optic nerve. Tumors in the orbit can also be removed in a minimally invasive fashion through the nose. We've listed conditions we treat and surgeries that we perform on our homepage; these are reflective of the conditions and surgeries that rhinologists are the experts in. I bet you didn't realize everything that a "nose doctor" does!
Don’t blame your tree for holiday allergies
Just when you thought you were done with seasonal allergies, the holidays roll around and you find yourself coughing, sniffling and sneezing everywhere you go. While it is easy to blame culprits, like your Christmas tree, winter allergies aren’t always quite what they seem. Allergies are a response of an overactive immune system to normal features of the environment. They often show up early in life when children are young, but exposure to new stimuli later in life can trigger an allergic response. Allergens are proteins which trigger an “inflammatory response,” leading to the familiar symptoms of coughing, sniffling and sneezing. In our region, the most common culprit for allergies is pollen from trees, grasses and weeds, with spring and fall being the worst seasons for allergy symptoms. Christmas trees themselves are seldom the cause of allergies. Rather, the dust and mold that often comes with live trees (or artificial trees that have been sitting in attics or basements for 11 months) is really to blame for your allergy symptoms. What makes winter allergies particularly harsh is the fact that, especially in our region, the heater is often running, and there is little air flow in homes. That means dust, mold and animal dander, which may settle into ductwork in older homes especially, will circulate, while the drier air causes increased sensitivity in the sinuses. In addition to allergies, the holiday season can bring out chemical sensitivities. While allergies are caused by proteins in the environment, chemical sensitivities are caused by irritants. Sensitivities are not genetic, and not able to be measured with allergy tests. Some common irritants include scented candles and cleaning products, which can cause the same watery eyes and irritation that allergies do. While winter allergies may seem hard to avoid, there are some simple steps you can take to limit your reaction to them. If you are sensitive to dust, mold or dander, be sure to change the air filters in your home every three months (or more frequently if you have a lot of pets or are extra sensitive). If you are going to a place that you know has a lot of allergens, like your great aunt’s who has seven cats, pretreat by taking an over-the-counter antihistamine and rinsing your nose with saline. After exposure, rinse off and change your clothes to get any particles off of you. If you find that your allergies are compromising your lifestyle, it might be time to contact a physician. Even if you simply want help determining what the best over-the-counter options are, we can help to determine the best treatment regimen for you.
How COVID-19 Affects Taste and Smell
A clever data scientist looked at the product reviews of scented candles over the last year and found the overall rating of scented candles has decreased in this time span correlating with the introduction of the Coronavirus disease 2019 (COVID-19) pandemic.(1) While we cannot be sure why product reviews for scented candles have gone down, one can speculate that perhaps in the midst of a global pandemic that is known to cause taste and smell disorders, it could be that many scented candle customers have COVID-19 and cannot smell their candles and are therefore leaving poor reviews. Almost a year into this global pandemic, we now know that Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which causes COVID-19 is associated with both smell and taste loss. This is not a unique phenomenon to this virus, and in fact, many other respiratory viruses have been linked to smell loss; although smell loss seems to be particularly widespread in COVID-19 patients. There have been a wide range of reported taste and smell dysfunction associated with COVID-19. In a recent study of patients with mild to moderate COVID-19, 85.6% of patients reported smell loss and 88% of patients reported taste loss.(2) Today, the Johns Hopkins Coronavirus Resource Center website reports nearly 65,500,000 cases of COVID-19 globally which extrapolates to millions and millions of people with taste and smell dysfunction. The other thing to recognize is that taste and smell are closely related. Much of your sense of flavor is actually from the odors of the food. Therefore when you lose your sense of smell, your sense of taste or flavor of food is drastically altered. The good news is that most patients completely recover both their sense of taste and smell within a relatively short period of time. The chart below is taken from an article which studied patients from Europe and displays the percentage of patients who recover their smell function within a specified amount of days.(Figure 1)(2) The majority of patients in this study recovered their smell function within 8 days and only 3.3% of patients were left with some amount of smell loss after 15 days. Figure 1 reproduced from Lechein JR et al. Although it is a small percentage of patients that are left with lingering smell or taste loss, this still accounts for a large number of patients given the sheer amount of people who have been infected with SARS-CoV-2. Although this inability to completely taste and smell may seem like a small problem to those who have never experienced this issue, it turns out to have several ramifications. Multiple studies have shown that smell and taste loss can decrease your quality of life, your ability to enjoy food, your social interaction with others, and increase your risk of depression. Additionally, if you cannot smell you are also at risk for certain dangerous situations such as not being able to notice a fire or natural gas leak because you cannot smell the smoke or gas. You may also be more likely to eat expired or rotten food because you cannot smell or taste. Finally, studies have also found an association between smell loss and the odds of dying within the next 5 years.(3-5) (Although these studies have only shown an association without an explanation of the underlying cause, so it may be that there is a hidden factor at play in this association.) All this to say, if you have long standing problems with smell and taste, there may be lasting consequences. So what should you do if you have lasting smell and taste loss after having COVID-19? The first thing to do is to mention this to your doctor. They may want to rule out any other causes of smell and taste loss first. Chronic sinus problems (chronic rhinosinusitis), neurological diseases (dementia, Parkinson’s disease), tumors (either in your nose or brain) or head trauma can also cause smell and taste disorders. Your doctor will be helpful in checking for these problems. It may then be worthwhile to understand what level of smell loss you have. Smell loss can be measured through various tests such as the University of Pennsylvania Smell Identification Test (UPSIT) or the Sniffin’ Sticks Test. These tests give you a measure of your smell loss and can categorize your smell loss as complete smell loss (known as anosmia) or a decrease in sense of smell (known as hyposmia). This is important because the severity of smell can give you some idea of how you will ultimately recover. In other words, those with more severe smell loss may have less of a chance of complete recovery. One particularly interesting thing that can happen as your brain works to regain your sense of smell is that you may develop something called parosmia. This is a process where your brain distorts a smell, causing something to smell different (and often more unpleasant) than normal. For example, the smell of freshly baked cookies may smell like rotten onions. No one knows for sure why this occurs. People have hypothesized that perhaps some of the smell system is destroyed and when the brain tries to “rewire” there is an incomplete set of smell nerves which creates this distorted odor. Others have hypothesized that the “rewiring” process is slow in some people and the cells are immature creating a distorted odor. This is usually not permanent but can last several months to years when we have studied this phenomenon in other types of smell loss. We will learn more about what parosmia means for COVID-19 patients as time goes on, but for now if this occurs to you - know that this is a known phenomenon associated with smell loss and you are not crazy. One method of treatment that has been shown to be helpful in other instances of smell loss after respiratory viruses is Olfactory Training.(6) Olfactory training was developed by Thomas Hummel in 2009 and is thought to work by “retraining” your brain by creating new connections in a situation similar to physical therapy after a stroke. The training involves picking four odors from four distinct odor categories (usually lemon, clove, eucalyptus and rose). You then smell each odor and concentrate on the particular odor you are smelling. For example, you would smell rose and tell yourself “I am smelling rose”. This is done for 15 seconds with 10 seconds between each odor and then repeated. This process is completed once in the morning and once at night for 4-6 months.(6) You can buy olfactory training kits or make your own by purchasing essential oils or using the real ingredients. Some people find it useful to journal through this training to monitor this progress. Before starting, it is good to know that recovery is slow and you may not ever make a full recovery. Unfortunately in some instances, you may not make much progress at all. Yet, there are few risks to this therapy, so if there is a chance to recover some smell function it is worthwhile to try. Key Takeaway Messages Smell and taste dysfunction is common among patients with COVID-19 Most people recover their sense of taste and smell within the first 8 days For those left with lingering smell and taste problems, discuss this problem with your doctor Olfactory Training may be helpful for those with lingering taste and smell dysfunction after recovery from COVID-19 References https://twitter.com/kate_ptrv/status/1332398737604431874 Lechein JR, et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol. 2020;277(8):2251-2261 Pinto JM, Wroblewski KE, Kern DW, Schumm LP, McClintock MK. Olfactory dysfunction predicts 5-year mortality in older adults. PLoS One. 2014;9(10):e107541. Liu B, Luo Z, Pinto JM, et al. Relationship Between Poor Olfaction and Mortality Among Community-Dwelling Older Adults: A Cohort Study. Ann Intern Med. 2019;170(10):673-681. Van Regemorter V, Hummel T, Rosenzweig F, Mouraux A, Rombaux P, Huart C. Mechanisms Linking Olfactory Impairment and Risk of Mortality. Front Neurosci. 2020;14:140. Damm M, et al. Olfactory training is helpful in postinfectious olfactory loss: a randomized, controlled, multicenter study. Laryngoscope. 2014;124(4):826-31. As always, the content in this blog is meant to be informational and not serve as a substitute for a medical evaluation with a physician.
How do I know if I have a sinus infection?
Sinus infections (also referred to as "acute sinusitis" or "acute rhinosinusitis") are quite common. Sinus infections can be thought of as either viral (also known as viral rhinosinusitis or the "common cold") or bacterial (also known as acute bacterial rhinosinusitis). When most individuals think of sinus infections, they are thinking of bacterial sinus infections but it is important to remember that sinus infections can be caused by viruses (which are not susceptible to antibiotics) as well. In both cases, the symptoms of a sinus infection, as defined by the American Academy of Otolaryngology - Head and Neck Surgery, are purulent (e.g. discolored) nasal drainage that is accompanied by nasal obstruction and/or facial pain-pressure-fullness. According to guidelines, one must have discolored, purulent nasal drainage to meet the criteria of a sinus infection. Viral sinus infections/"common colds" are more common than bacterial sinus infections. It has been estimated that the average adult will experience 2 to 5 colds per year. Viral sinus infections may produce similar symptoms as bacterial sinus infections: discolored nasal drainage with nasal obstruction and/or facial pain/pressure. However, the key distinguishing factor with respect to symptoms is that with viral sinus infections, the symptoms peak at around day 3 - 5 and begin to improve thereafter (Figure 1). This why it is important to think about both how long sinusitis symptoms have been ongoing as well as their trajectory (getting worse, staying the same, or getting better) when it comes to deciding whether the sinusitis is viral or bacterial. Bacterial sinus infections are a "complication" of approximately 2-5% of colds. In other words, the sinusitis starts as a viral infection but something then happens that causes the sinuses to be overtaken by bacteria, causing a bacterial infection. It is not clear what exactly this "something" is but one could imagine that the viral infection may create an environment that is more amenable to overgrowth of the bacteria that live in the sinuses, for example due to swelling of the lining of the sinuses which may even lead to the sinus drainage pathways swelling shut and leading to build up of mucus in the sinuses. Bacterial sinus infections may also occur spontaneously (without a noticeable cold before it) but these also occur in settings where the environment of the sinuses changes to promote bacterial overgrowth. For example, allergies (allergic rhinitis) may lead to swelling of the lining of the nasal cavity and also swelling of the drainage pathways of the sinuses, which may also lead to blockage of the sinuses and buildup of mucus that can create the perfect environment for bacterial overgrowth. Regardless of mechanism, it is estimated that each yea close to 20% of people experience a bacterial sinus infection. Again, the symptoms of bacterial sinusitis are similar to those of a cold: discolored nasal drainage with nasal obstruction and/or facial pain/pressure. However, those symptoms are persistent and stable (not improving) or worsening after 5 days (Figure 2). The symptoms illustrated in Figure 1 and Figure 2 are from the European Position Paper on Rhinosinusitis and Nasal Polyps 2020, (which I refer to as "EPOS 2020") which is available online as open access. There are a number of criteria that have been established for the formal diagnosis of the acute bacterial sinusitis. From the EPOS 2020 recommendations shown in Figure 2, bacterial sinusitis should be suspected when three of the following signs/symptoms are experienced: Fever of above 100.5°F (38°C) Double sickening (double worsening): when symptoms of a cold are getting better and then worsen as illustrated by the top blue dashed line in Figure 2. Unilateral disease Severe pain (I am not mentioning the raised ESR/CRP because these require a blood test) The 2015 American Academy of Otolaryngology - Head and Neck Surgery Clinical Practice Guidelines on Adult Sinusitis state that "A clinician should diagnose acute bacterial rhinosinusitis when (a) symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening). The Infectious Diseases Society of America also published guidelines on acute bacterial sinusitis in 2012, which is also available online as open access. These guidelines suggested that bacterial sinusitis be considered when: There are persistent symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement, or Onset with severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness, or Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving (‘‘double- sickening’’) The above is intended to show how we approach diagnosing bacterial sinus infections. As it is apparent, the exact diagnostic criteria for a bacterial sinus infection varies a bit depending who you ask and which source you go to. However, there are clearly some trends, which largely are based on the time course and trajectory of symptoms as I emphasized above. From a practical standpoint, if you have symptoms of sinusitis (nasal drainage accompanied by nasal obstruction and/or facial pain-pressure-fullness), think about how long you've had the symptoms and whether the symptoms are improving, staying the same or worsening and then refer back to Figure 1 and Figure 2. But here are some general guidelines that you can use: KEY POINTS Sinusitis symptoms are purulent (e.g. discolored) nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both. If you are not having discolored, purulent drainage, then you probably don't have a bacterial sinus infection. Inside the first 3-5 days it is very difficult to differentiate between a viral and bacterial sinusitis but if sinusitis symptoms are particularly severe, we may lean towards a bacterial sinus infection (and treat with antibiotics, although discussion of treatment for sinusitis is an entirely different discussion altogether!). After 5 days, if sinusitis symptoms are worsening, that may indicate a bacterial sinus infection. If sinusitis symptoms are generally stable and neither improving nor resolving, we generally wait until 10 days before deeming the infection to be likely bacterial in nature. If you have questions, always feel free to reach out to your primary care doctor, local rhinologist or us.
The 411 on Nosebleeds
Nose bleeds are incredibly common. Did you know that 60% of people will experience a nosebleed in their lifetime? Today’s post will discuss why nosebleeds occur, how to stop the bleeding and how to prevent future nosebleeds. Why do nosebleeds occur? As it turns out, the nose has an incredible amount of blood vessels that supply a large volume of blood to the nose. Particularly, the front of the nose, along the front of the nasal septum, has a dense network of blood vessels which are very close to the surface and can bleed easily. When the source of bleeding in a nosebleed is coming from the front of the nose, this is called an “anterior nosebleed”. Anterior nosebleeds are the most common, accounting for 90-95% of all nosebleeds. This is good news because anterior nosebleeds are easier to stop. Anterior nosebleeds occur for several reasons. As we said above, the blood vessels are very close to the surface so any amount of mild trauma to the front of the nose (from a finger in the nose, to a rough wipe of the nose with a tissue, to other things placed in the front of the nose such as a nasal cannula for oxygen delivery) can be enough to start a nosebleed. These bleeds can also start spontaneously - especially if the nose is dry (like when the heat is turned on in the winter or after a bad cold) or a person has risk factors for easy bleeding or bruising (genetic diseases, kidney or liver disease, coagulation problems or certain medications that thin your blood such as aspirin, plavix, or coumadin). The other category of nosebleeds is a “posterior nosebleed”, or a nosebleed where the source of the blood is from the back of the nose. People who experience posterior nosebleeds may only have blood coming down from the back of their nose and out their mouth instead of any blood coming from the front of the nose. Posterior nosebleeds may start and stop suddenly without a trigger and often produce a large amount of blood. Posterior nosebleeds can occur spontaneously or be secondary to facial or nasal trauma. In rare cases, nosebleeds may be the result of a tumor or mass inside the nose that tends to bleed easier than healthy tissue. While this is not often the cause of nosebleeds, if you are someone who suddenly starts to experience nosebleeds over and over again without other risk factors, it is worth having an ENT look in your nose to ensure there is not a mass. Patients with nasal masses may often experience the inability to breathe from their nose or a loss of smell in addition to frequent nosebleeds. I have a nosebleed, now how do I stop it? First, do not panic! Of all nosebleeds, only 6% require medical attention because a person was not able to stop their nosebleed at home. The best way to stop a nosebleed is to be prepared! You will want to gather nosebleed supplies at home, especially if you have risk factors for nosebleeds (see more about risk factors in the next section). Supplies include afrin (oxymetazoline) nasal spray, Vaseline ointment, salt water nasal spray and possibly a nose clip (a specialty clip you can purchase for nosebleeds, see image below). These products are all available over the counter. 1. Lean forward and spit out blood that is coming down the back of your throat to prevent swallowing excess blood or having blood go down your airway. 2. Spray Afrin (oxymetazoline) nasal spray into your nose on the side that is bleeding (or both sides if you cannot tell which side is bleeding). You can spray a generous amount into the nose. Afrin nasal spray may not be appropriate in some heart conditions, talk to your primary care doctor about making sure Afrin is safe for you. 3.Hold your nose at the FLESHY part of your nose (not over the bony part of your nose) with firm pressure for 10 minutes. You can hold your nose or use a nose clip. 4. After 10 minutes of firm pressure, let go and check to see if you are still bleeding. If so, you can repeat the process. 5.If even with firm pressure over the fleshy part of your nose you continue to have bleeding or the bleeding does not stop despite a cycle or two of afrin nasal spray and 10 minutes of firm pressure, proceed to your local emergency room. After your nosebleed, you will want to keep your nose moist as the lining of the nose heals. You can do this with either Vaseline or an antibiotic nasal ointment (Bactroban/Mupirocin available by prescription) and salt water nasal spray (available over the counter). You will also want to avoid trauma to the healing area and therefore should try not to pick away the clot or aggressively wipe or blow your nose for a few days after a nosebleed. How do I prevent nosebleeds? To prevent a nosebleed, it is first important to understand your risk factors. Risk factors include the use of blood thinners (ex. Aspirin, Plavix, Coumadin, Eliquis, Xarelto), genetic diseases that increase your risk of bleeding (hereditary hemorrhagic telangiectasia), coagulation disorders, kidney disease, liver disease, chronic use of nasal oxygen, uncontrolled high blood pressure, or even having your heat on during the winter months. If you are at high risk, you will want to use more aggressive measures to prevent nosebleeds relative to those who do not have a lot of risk factors. One way to prevent nosebleeds, is to optimize your environment both inside and outside your nose. Pay attention to the air around you and your nose. When it is dry outside or dry inside your nose - it is important to find ways to humidify the conditions when possible. For example, sleeping with a humidifier in your room at night (especially when the heat is on) can be helpful. When your nose is dry, applying Vaseline (a pea size amount to each nostril) when you wake up and before you go to bed can be helpful. You may also want to try a salt water spray (available over the counter at most drug stores) which you can spray in your nose every 2-4 hours as you are able when awake. You will also want to minimize trauma to your nose - especially the front part of your nasal septum where many blood vessels are located. Try to avoid picking your nose, wiping your nose aggressively or forceful blowing of your nose - especially if you are at high risk of having a nosebleed or recently had a nosebleed. Key Takeaway Messages Nosebleeds are common Gather your supplies (afrin nasal spray), so you are ready to treat your nosebleed when it occurs When having a nosebleed, apply pressure to the fleshy part of your nose Keep your nose moist (Vaseline and salt water nasal spray) If you cannot control your nosebleed, go to your local emergency department and let the emergency room doctor or the ear, nose and throat doctor take care of you