THE SPRING POLLEN SEASON in central Maryland usually starts sometime in March. Trees pollinate first, and the real peak of the tree season typically happens during the second half of April and the first week of May, with OAK serving as the major culprit. No sooner do the oaks wind down than the baton gets passed to wildly growing grasses. They peak later in May and gradually wane during the month of June. Allergy sufferers then get a respite from pollen until ragweed gears up in late August. People allergic to pollens need to keep their windows closed, irrespective of how nice it is outdoors. It is wise for them to start any preventive medicine(s) a week or more before they expect their season to start, based on past experience and diagnosis.

“RHINITIS” is a general term used to describe nasal inflammation and can be used to refer to nasal allergies (“allergic rhinitis”) or an array of other conditions. “SINUSITIS” refers to inflammation in the sinuses and usually suggests infection in the sinuses. Some of the discussion that follows will address different age groups. In children, nasal allergies and enlarged adenoids are the most common reasons for persistent rhinitis. These problems sometimes appear in kids under one year of age but more commonly start sometime thereafter. Allergic rhinitis and enlarged adenoids might occur in the same child and make it more likely that sinusitis will complicate the picture.

OUR APPROACH IN CHILDREN

Pediatricians will often decide to first prescribe an oral antihistamine or nasal spray. If results are not ideal, that doctor will consider referral to an Ear, Nose & Throat specialist if there is strong suspicion of enlarged adenoids OR referral to an allergist if allergic rhinitis is the primary consideration.

As allergists, we carefully review a young patient’s history as a first step. We pay particular attention to things that trigger symptoms. Also noteworthy are any hints of related conditions, since kids with allergic rhinitis often—but not always-- have histories suggestive of eczema, asthma or food allergies. We carefully look at family history. The home environment is assessed by history for allergen and irritant risks. Sometimes the physical exam gives us a good idea whether or not a youngster is likely to be allergic. Adenoids are lymph tissue similar to tonsils but tucked way in the back of the nose (the nasopharynx). This tissue may enlarge and then make it difficult for normal nasal air flow and secretion handling. Adenoids are only accurately seen by our ENT colleagues with their nasal endoscopes, although the procedure is quite a challenge in a young child. We get some sense for adenoid size with a single x-ray view, a test that is occasionally recommended.

ALLERGY SKIN TESTING in children is tailored to a child’s history as much as possible. Common allergens tested in nasal allergy evaluations include pollens, mold spores, dust mites and pet danders. We make every effort to minimize the extent of the testing procedure, while still obtaining data critical to proper diagnosis and treatment decisions. Most kids do just fine. The results are available right then and there in the course of the appointment. We will review the data as part of the wrap-up discussion that day.

TREATMENT OPTIONS are discussed in depth with appropriate emphasis on risks and benefits of any particular approach. We allergists tend to think of three separate realms for treatment: (1) environmental control, (2) medications and (3) allergy immunotherapy (also called allergy vaccination, allergy shots or desensitization). Most children achieve good symptom control with a combination of allergen avoidance measures and reasonable medications. However, it is very difficult to succeed in the presence of lots of exposure to the things to which one might be allergic. The best example of this might be the challenge of treating a pet-allergic child when such a pet remains in the home. Needless to say, some allergens cannot be completely avoided, despite the best of efforts. House dust mite is a good example. Nasal cortisone sprays are available only by prescription and work best if used regularly. They have been in use in the U.S. for over 20 years and have excellent track records for safety and effectiveness. Antihistamines help with both nasal and eye allergy symptoms. However, the patients whom we see often have symptoms too severe to be so easily controlled with any reasonable combination of medications. Allergy vaccination is a long-term, time-consuming commitment (let’s call a spade a spade!). It also happens to be the only treatment modality that has the ability to fundamentally make a person less allergic and favorably alter the natural history of the condition. Persons with symptoms not readily controlled with lesser measures, as mentioned above, should receive allergy shots. Also, parents desirous of seeing their kids not requiring medicines chronically should also consider allergy vaccination, even if symptoms are adequately controlled with maintenance meds. Most individuals need to take shots for about 5 years, with 3 years being a bare minimum. If there is not appreciable improvement over the first 18-24 months, the treatment should be stopped, but the vast majority of properly chosen patients find this treatment worth all their efforts. Seldom is it important to make a decision to start allergy vaccination at the first office visit. Sometimes the writing is on the wall, but other times a period of aggressive pursuit of reasonable avoidance measures coupled with judicious use of medicines, as mentioned above, is the proper path to making a decision about allergy shots.

OUR APPROACH IN ADULTS

Respiratory allergy problems typically start sometime in the first 20-30 years of life. Beyond roughly age 30 years stubborn nasal symptoms are often non-allergic in nature. This puzzles people no end, since the term “allergies” is used loosely in our society to refer to any chronic nasal complaints. Although careful review of an adult patient’s history often points to allergic or non-allergic (or a mix of both) rhinitis, the bottom line is established by skin testing for common inhalant allergens. Adenoids are never part of this equation in adults. Treatment strategies are similar to those outlined above for children.

SUMMARY