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Month: June 2019

Nasal Congestion – Do You Have Sinusitis?

If you are like a lot of individuals in the Washington, DC, Northern Virginia, and Maryland metropolitan area, then you may suffer from allergies. There is an old adage that says that if you move to the Washington, DC area and you do not have allergies, you eventually will! This is not true of course, however, many individuals in the area (whether or not they grew up or moved to the Washington, DC area) do in fact have allergies, particularly allergic rhinitis (i.e., hay fever).

The classic symptoms of allergic rhinitis as well as non-allergic rhinitis may include any or all of the following: nasal congestion, runny nose, post-nasal drip, itchy nose, sneezing, itchy throat, itchy eyes, watery eyes, red eyes, puffy eyes, snoring, fatigue, sinus congestion, headaches, and dark circles under the eyes. Allergies commonly trigger asthma as well. Affected individuals may experience chest tightness, wheezing, coughing, and/or shortness of breath.

It should also be noted that allergies increase the risk of sinus disease, sinus infections, and nasal polyps. Sinus infections can be categorized into 3 distinct types: acute, chronic, and recurrent. It is important for the allergist to be able to distinguish between the three, as the treatment is different for each type.
Acute sinusitis: This type of sinus infection is the most common of the three types and often presents with nasal congestion, sinus pressure and/or pain which can radiate to the teeth, discolored nasal discharge, and a post-nasal drip. Occasionally, a fever may be present in some individuals with acute sinusitis. The diagnosis is usually made by a detailed history and a physical examination. Treatment may necessitate the use of antibiotics, nasal corticosteroids, saline irrigation of the nose, and/or decongestants. Rarely, it may be beneficial to use oral corticosteroids is severe cases.

Chronic sinusitis: The common manifestations of a chronic sinus infection generally include nasal congestion, facial pressure/pain, headache, discolored nasal discharge, post-nasal drip, cough, loss of taste and smell, and/or malaise. The diagnosis requires a comprehensive history of onset and progression of specific symptoms, a detailed physical examination, and imaging studies such as CT scans and/or sinus X-rays. The management of chronic sinusitis usually entails a prolonged course (e.g., 30 days) of antibiotics in addition to nasal corticosteroids, saline irrigation of the nose, and/or decongestants. It may be necessary to give another prolonged course of antibiotics in recalcitrant cases. Surgical intervention may also be necessary if medical therapy is unsuccessful. It is important to note that some individuals may only present with chronic nasal congestion as their only symptom.

Recurrent sinusitis: This type of sinus condition is merely repetitive acute sinus infections. Individuals that get repeated episodes of acute sinusitis may have an immune disorder or a weakened immune system. It is thus important to see a board certified allergist/immunologist like the ones at Black & Kletz Allergy. Blood tests to assess a patient’s immune system are often ordered in individuals who suffer from recurrent sinusitis in order to rule out or diagnose an immune defect. Patients who are found to have an immunodeficiency are then treated with appropriate therapy depending upon their specific immune defect. In addition, the sinus infection is treated with antibiotics, topical nasal corticosteroids, saline irrigation of the nose, and/or decongestants.

The prevention of sinusitis includes identification of specific allergen sensitivities by allergy testing by a board certified allergist. Allergy testing may be done by skin testing or blood testing depending upon the circumstance and age of the patient. The aggressive treatment of allergic seasonal and/or perennial rhinitis (i.e., hay fever) promotes proper sinus drainage and improves upper airway function.

Therapies used to treat allergic rhinitis may include antihistamines, nasal corticosteroids, nasal antihistamines, saline irrigation of the nose, decongestants, leukotriene antagonists, and/or allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization). Allergy shots are effective in 80-85% of patients who take them. They have been used in the U.S. for more than 100 years and are used in both children and adults.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating sinusitis for more than 50 years. We treat both adult and pediatric patients. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from allergies and/or sinus-related symptoms, we are here to help alleviate or hopefully end these undesirable symptoms that have been so troublesome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Chronic Cough

Coughing is a protective “reflex” given to us by nature as part of our body’s vital defense mechanisms.  It forcibly expels harmful bacteria, viruses, foreign objects, and excessive mucus from the respiratory tract protecting our lungs from irritation, inflammation, and infections.


There are 4 stages in a cough reflex:

  1. An initial deep inspiration filling the lungs with air.
  2. Closure of epiglottis [the flap over the opening of the windpipe (i.e., trachea)].
  3. Forcible contraction of the muscles of the chest and abdomen which pushes up the diaphragm causing compression of the lungs.
  4. As the pressure builds up, the epiglottis is forced open allowing the air to rush out at a high speed producing a whooping noise.

Coughing can be a voluntary act, conscious action, or more commonly an involuntary uncontrollable process.  The reflex is initiated by stimulation of the nerve fibers in the respiratory tract by various substances such as smoke, cold air, allergens, microbes, and tumors, as well as from irritation by normal secretions such as mucus and/or stomach acid.

All of us cough from time to time.  It is very common during colds (i.e., upper respiratory infections), which are usually viral in nature.  Coughing also is common during acute bronchitis and pneumonia (i.e., lower respiratory infections involving mainly the lungs).  It should be noted that following infections, a cough may linger for a few weeks before it subsides.

A cough that lasts for months (and sometimes years) is described as “chronic” and is one of the most common reasons why healthcare providers are consulted.  A cough may interrupt sleep resulting in daytime somnolence and affect school and work performance. Vigorous coughing may also cause physical effects such as urinary incontinence and rib fractures.


  1. Smoking:  Most cigarette smokers eventually develop a “smoker’s cough”. Irritation by noxious chemicals is the predominant cause.  Smoke also plays a significant role in causing chronic bronchitis, emphysema, and lung cancer.
  2. Post-nasal Drip:  In addition to aiding in the perception of smell, the nose also protects the lungs by filtering, warming, and humidifying the air entering the lower respiratory tract.  It accomplishes this by secreting warm, moist, and sticky mucus. When the nose is irritated by chemicals, allergens, microbial organisms, etc., it secretes excessive mucus which is usually thin and watery.  When these copious secretions run down the back of the throat, they irritate the nerves in that area, cause a tickling sensation which may trigger a cough reflex. A post-nasal drip can often be controlled by avoiding exposure to known triggers and stimuli.  Medications such as antihistamines, decongestants, and nasal sprays may help relieve the cough caused by a postnasal drip. Home remedies such as steam inhalation and saline nasal irrigation also may play a role in treatment.
  3. Asthma:  Chest tightness, wheezing, and shortness of breath usually accompany cough in individuals with asthma.  However, in a variant of this condition, a cough may be the only presenting manifestation.  This is called cough variant asthma. The diagnosis is established by pulmonary function testing (sometimes after inhalation of a chemical (e.g., methacholine) that can trigger symptoms which can then be relieved by a medication that opens up the airways).  Occasionally, a therapeutic trial of anti-inflammatory inhaled medications (i.e., inhaled corticosteroids) on a regular basis for a few weeks is helpful in arriving at the diagnosis.
  4. Gastroesophageal Reflux Disease (GERD):  When stomach acid travels up the food pipe (i.e., esophagus), it usually causes heartburn, belching, sore throat, and/or hoarseness.  However, in one third of patients it manifests only as a chronic cough without the other symptoms. Confirmation of the diagnosis is established by placing a probe in the esophagus and monitoring the pH for acidity for 24 hours.  A simpler approach is to empirically treat the individual with lifestyle modifications (e.g., avoiding alcohol, spicy foods, citrus fruits, bulky meals, and carbonated beverages). If the symptoms persist, medications to neutralize the acid and/or reduce acid secretion may be utilized.
  5. Chronic Bronchitis:  Prolonged inflammation of the tissues in the lungs from chemical irritants and pollutants can cause a chronic cough.  Imaging studies are sometimes needed to rule out anatomical and structural abnormalities. Some patients may need long term anti-inflammatory inhaled medications (e.g., inhaled corticosteroids) to control a chronic cough.
  6. ACE inhibitors:  These medications [e.g., lisinopril (Prinivil), enalapril (Vasotec), benazepril (Lotensin), quinapril (Accupril), ramipril (Altace)] are often used to treat high blood pressure and/or heart failure.  Up to 20% of people receiving these medications may develop a cough after a few weeks, which is a known side effect of these types of medications. They may need to discontinue these medications and begin taking an alternative medication in order to get relief from their cough.
  7. Heart Disease:  Congestive heart failure can cause either a dry cough or a productive cough associated with a frothy, thin, white sputum.  Leg swelling (i.e., edema), fatigue, and exercise intolerance are other common symptoms of congestive heart failure.
  8. Aspiration:  When food finds its way into windpipe (i.e., trachea) instead of food pipe (i.e., esophagus), it triggers a recurrent cough.  This is more common in patients with strokes and other chronic neurological disorders.
  9. Lung Cancer:  It is a rare cause of chronic cough in non-smokers, and more common in smokers.
  10.  Stress:  “Psychogenic” coughing increases at times of stress and usually disappears or diminishes during sleep.
  11.  Chronic sinusitis:  It is fairly common for individuals with a chronic sinus infection (i.e., chronic sinusitis) to experience a chronic cough.  In some cases, it is the only symptom of their sinus condition.  In others, it may be accompanied by symptoms such as nasal congestion, decreased ability to smell and/or taste, post-nasal drip, discolored nasal discharge, sinus pressure, and/or sinus headaches.

Cough Medications

  1. Dextromethorphan is a commonly used, partially effective cough suppressant.  Prescription medications containing codeine and its derivatives are more effective but have more undesirable side effects and may be habit-forming.
  2. Guaifenesin is the most commonly used expectorant which may be useful in thinning out viscous secretions which ultimately help the mucus drain more easily.

Warning Signs:  One should consult his or her physician as soon as possible if one experiences any of the following symptoms:  bloody sputum, fever, weight loss, night sweats, breathlessness, excessive fatigue, and/or chest pain.

The board certified allergy doctors at Black & Kletz Allergy have a great deal of experience in diagnosing and treating both adults and children with a chronic cough.  It is important to find the underlying reason for a cough in order to treat it appropriately.  At Black & Kletz Allergy, we search for a cause beginning with a comprehensive history and physical examination.  Breathing tests, X-rays, blood tests, and/or allergy skin tests may be performed depending upon each individual’s history and physical, as it is tailored to each person’s own situation.

The allergists at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Our Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call one of our offices or alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the greater Washington, DC area for more than 50 years and we look forward to providing you with excellent state of the art allergy care in a welcoming and professional environment.