Month: June 2015

Allergic Fungal Sinusitis

Allergic Fungal Sinusitis (AFS) is a chronic inflammatory condition involving the nose and sinuses caused by an allergic sensitivity to environmental fungi.  It is usually seen in people with normal immune systems as opposed to invasive fungal infections which usually affect people with compromised immune systems caused by conditions which may include diabetes mellitus, certain cancers, HIV infection, and patients receiving chemotherapy or radiation treatment.  It is similar to a condition that affects the lung called Allergic Bronchopulmonary Aspergillosis (ABPA).

Many patients with AFS are atopic, meaning they have a tendency to develop allergic sensitization when exposed to common harmless substances like pollens, dust mites, cats, dogs, and certain foods.  About two-thirds of patients with AFS also have allergic rhinitis and up to half of them also have allergic asthma.  AFS is most commonly seen in young adults with an average age of 22 years.

CAUSE:

When an atopic person breathes in air containing the fungus, it triggers an allergic inflammation of the mucus lining inside the nostrils and sinuses resulting in swelling of the tissues.  This swelling leads to blockage of the sinus drainage pathways causing the mucus secretions (mucin) to accumulate within the sinus cavities.  This, in turn, creates an ideal environment for further reproduction of the fungus.  The sinuses are eventually filled with a viscous and tenacious fungal mucin which has the consistency and appearance of peanut butter.

SYMPTOMS:

  1. Nasal congestion
  2. Discolored copious nasal secretions
  3. Semi-solid nasal crusts
  4. Polyp formation in the nose and the sinuses
  5. Post-nasal drip
  6. Throat irritation
  7. Occasional headache or facial pressure
  8. Decreased sense of smell

In advanced stages, facial disfigurement and vision disturbances may also be encountered due to extension of the disease to the surrounding areas.

DIAGNOSIS:

  1. Total IgE antibody levels in the blood will be elevated several times the normal limits.
  2. Skin testing to various fungal organisms.
  3. CT scan of the sinuses can demonstrate accumulated fungal mucin in the sinus cavities.
  4. Mucin drained from the sinuses needs to be examined for specific histological characteristics under the microscope and cultured in the laboratory to identify the specific type of fungus.

TREATMENT:

  1. Fungal mucin in the sinuses needs to be drained out by endoscopic sinus surgery.
  2. Systemic and topical steroid medications to reduce the inflammatory changes and shrink the polyps.
  3. Environmental control to reduce the exposure to the fungi and molds.
  4. Systemic or topical antifungal medications may be used to reduce the amount of fungus.
  5. Allergy immunotherapy (allergy shots) with the antigens identified by skin testing to develop tolerance to the fungal allergens and to control the chronic inflammatory reactions.

A comprehensive management plan incorporating medical, surgical, and immunologic care remains the most likely means of providing long-term disease control for allergic fungal sinusitis (AFS).

The board certified allergists at Black & Kletz Allergy in the Washington, DC, Northern Virginia, and Maryland metropolitan area have been treating sinus disease for more than 5 decades.  We have expertise in recognizing and managing individuals with allergic fungal sinusitis.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have on-site parking at each location.  In addition, the Washington, DC and McLean, VA offices are accessible by the Metro.  If you suffer from any of the above symptoms, please contact one of our offices to make an appointment.  Alternatively, you can click Request an Appointment and we will contact you within 24 hours of the next business day.  We strive to serve the community in a professional, friendly, and caring manner.

The Asthma and Acid Reflux (GERD) Connection

There is a surprising connection between asthma and acid reflux.  Anywhere from 75-80% of asthmatics suffer from acid reflux.  Acid reflux is also known by the name of gastroesophageal reflux disease (GERD).   Acid reflux is a condition where the acidic stomach contents travel in the wrong direction and enter the esophagus (swallowing tube).  This causes a variety of symptoms of which the main one is heartburn.  People with acid reflux commonly feel a burning sensation in the chest and/or throat.  They often complain of a bitter or sour taste in their mouth.  Other symptoms can include wheezing, coughing, belching, abdominal bloating, sore throat, nausea, and/or the feeling that something is stuck in one’s throat.  It is the wheezing and coughing symptoms that cam mimic asthma or in fact be triggered in an asthmatic who has acid reflux or GERD.

Acid reflux occurs because the lower esophageal sphincter, a muscle at the lower part of the esophagus near the entrance to the stomach, becomes too relaxed.  This allows the stomach acid to go backwards into the esophagus which can cause damage to the esophagus and cause a burning sensation, commonly referred to as heartburn.  In addition to causing heartburn, it also can aggravate a person’s asthma in a couple of different manners.  The first way this occurs is a result of small amounts of this acid irritating the airways (like a chemical burn) which can trigger asthma symptoms.  The second way may involve triggering a reflex in the airways to become narrower in order to prevent more acid from entering the airways.  It is this narrowing of the airways which causes an asthmatic to wheeze, cough, and/or feel short of breath.  In addition, some asthma medications can decrease the lower esophageal sphincter pressure thereby relaxing this muscle which subsequently will increase the severity of acid reflux.  Asthma medications in the bronchodilator family such as Albuterol (i.e., Proventil, Ventolin, ProAir, AccuNeb), Levalbuterol (Xopenex), Terbutaline, (i.e., Brethine, Brethaire), Salmeterol (Serevent), Formoterol, (Foradil), Vilanterol, Ipatroprium (Atrovent), and Tiotropium (Spiriva) fall into this category.  There are also asthma medications that are combinations of two medications, one of which is a bronchodilator, which can therefore increase acid reflux disease.  The names of some of these medications include Advair, Symbicort, Dulera, Breo Ellipta, Combivent, and DuoNeb.  Theophylline (i.e., Theo-Dur, Uniphyl, Theo-24, Slo-Bid), an older but still useful oral bronchodilator asthma medication, has also been linked with increasing acid reflux in individuals by causing the relaxation of the lower esophageal sphincter as well.  Interestingly, the chemical structure of Theophylline is similar to caffeine which is another trigger of acid reflux.

The cause of acid reflux disease is a failure of the lower esophageal sphincter to function properly.  There are several risk factors that can contribute to acid reflux disease and some of them include:

  • Hiatal hernia – the protrusion of part of the stomach through the diaphragm (a muscle separating the abdomen from the chest) into the chest
  • Obesity
  • Pregnancy
  • Use of certain medications (i.e., bronchodilators, calcium channel blockers, aspirin, prednisone)
  • Alcohol use
  • Smoking
  • Certain foods – caffeine, fatty foods, garlic, onions, spicy foods, and acidic foods (i.e., tomatoes, soda, citrus fruits)
  • Diabetes
  • Eating before bed
  • Eating large meals
  • Certain connective tissue disorders – Scleroderma or systemic sclerosis

The diagnosis can be made with a combination of a good history from the individual along with observing relief when prescribed medications to control reflux such as antacids and/or acid-blocking medications.  If there is no improvement in symptoms of acid reflux, there are several procedures that can be performed to help diagnose acid reflux disease.  Some of these procedures include upper endoscopy with or without biopsy, barium swallow, esophageal manometry (checks the function of the lower esophageal sphincter and esophagus), and pH monitoring (checks the acidity in the stomach).

The treatment of acid reflux disease is aimed at minimizing the risk factors mentioned above in addition to prescribing antacids and acid-blocking medications.  By treating the underlying acid reflux disease in the asthmatics that have this condition, the symptoms of asthma (i.e., wheezing, coughing, shortness of breath, and chest tightness) may also be diminished)

The board certified allergists at Black & Kletz Allergy recognize the association between asthma and acid reflux (GERD) and we treat our asthmatics accordingly after a thorough history and physical examination.  Black & Kletz Allergy has 3 offices and has been serving the Washington, DC, Northern, Virginia, and Maryland metropolitan area for more than 50 years.  We have convenient office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have parking at each location and the Washington, DC and McLean, VA (Tysons Corner, VA) offices are Metro accessible.  If you have asthma, think you have asthma, or have symptoms of wheezing, coughing, shortness of breath, and/or chest tightness, please call us to schedule an appointment.  Alternatively, you can click Request an Appointment and we will respond back to you within 24 hours of the next business day.