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Month: August 2023

Nasal Polyps Update

Nasal polyps (i.e., nasal polyposis) are soft, benign growths that develop from the lining of the sinuses and nasal cavity. Approximately 4-5% of the general population has nasal polyps. They look like glistening moist grapes and are typically in the shape of teardrops. These new growths result from chronic inflammation of the tissues inside the nasal and sinus cavities. When the nasal polyps grow large enough, they may obstruct the nasal passages which will block the flow of air through the nose. The mechanical obstruction may also block the passage of secretions from the sinuses into the nose which may result in the predisposition of individuals to develop recurrent or chronic sinus infections.

Any condition which ends in chronic inflammation inside the sinuses and nose may lead to the formation of nasal polyps.   Some of these conditions may include:
1. Allergic sensitivity to indoor or outdoor environmental allergens [allergic rhinitis (i.e., hay fever)] mediated by an the IgE antibody and elevated levels of interleukin 5 (IL-5) cytokine.
2. Chronic sinus infections from bacteria such as Staphylococci as seen in chronic rhinosinusitis with nasal polyposis (CRSwNP).
3. Allergic response to fungal organisms in the inhaled air which is called allergic fungal rhinosinusitis (AFRS).
4. Systemic inflammatory disorders such as aspirin exacerbated respiratory disease (AERD) and cystic fibrosis (CF). Aspirin exacerbated respiratory disease is also called Samter’s triad because it consists of 3 features: asthma, nasal polys that re-occur, and an intolerance to aspirin and NSAID’s (nonsteroidal anti-inflammatory drugs). Between 6% and 48% of individuals with cystic fibrosis develop nasal polyps, so cystic fibrosis should be entertained in anyone who presents with nasal polyps.
5. Eosinophil (i.e., a type of white blood cell) disorders such as eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome.
6. Chronic irritation from smoke, strong odors, and pollutants in the air.
7. Immunodeficiencies such as common variable immunodeficiency, selective IgA deficiency, and primary ciliary dyskinesia

The symptoms of nasal polyps usually include nasal congestion and a runny nose in the early stages. As time goes on, nasal congestion resulting in a difficulty in breathing through the nostril(s) may occur. The nasal congestion usually worsens as the size of the polyp increases. Other symptoms of nasal polyps may include post-nasal drip, facial pain, headache, decreased or loss of taste (i.e., ageusia) and/or smell (i.e., anosmia), and snoring.

The diagnosis of nasal polyps is generally made by examining the nasal cavity with a light source. The presence of nasal polyps will be revealed by shiny, mobile, smooth, gray, and semi-translucent masses. These Inflammatory polyps are usually present in both nostrils. It is important to note that some neoplastic polyps may only be present on one side (i.e., in one nostril). Rhinoscopy is often utilized to visualize the nasal cavity. Imaging of the sinuses with a CT scan may be needed in order to estimate the extent of the polyposis and to plan for surgical removal, if indicated. Allergy testing (e.g., skin testing, blood testing) is often performed to check for environmental allergies. A sweat chloride test may also be performed particularly in children in order to rule out cystic fibrosis.

Some complications may arise from having nasal polyps. The problems may include nose bloods (i.e., epistaxis), recurrent or chronic sinusitis, asthma exacerbations, obstructive sleep apnea/snoring, and rarely double vision (i.e., diplopia).

1. Intranasal corticosteroid sprays [e.g., Flonase (fluticasone), Nasonex (mometasone), Nasacort (i.e., triamcinolone), Rhinocort (i.e., budesonide), Nasarel (i.e., flunisolide), Xhance (fluticasone)] on a daily basis.
2. Short courses of oral corticosteroids can shrink nasal polyps.
3. Saline irrigation: High-volume, low-pressure nasal saline irrigations are safe and non-expensive. Irrigation increases the clearance of antigens, biofilms, and inflammatory mediators.
4. Topical antihistamine nasal sprays [e.g. olopatadine (Patanase), azelastine (Astelin)]
5. Irrigation or nebulization with anti-inflammatory agents such as budesonide or mometasone in cases of CRSwNP.
6. Allergy testing and allergy immunotherapy (i.e., allergy shots, allergy desensitization, allergy hyposensitization) with relevant inhaled environmental allergens is effective in the treatment of allergic rhinitis, allergic conjunctivitis (i.e., eye allergies), and asthma in 80-85% of the patients that take them.
7. Deposition of corticosteroid medications higher into the nasal cavity by exhalation devices such as Xhance (i.e., fluticasone).
8. Biologic medications such as dupilumab (i.e., Dupixent) given by injections under the skin every 2 weeks, omalizumab (i.e., Xolair) given under the skin every 4 weeks, or mepolizumab (i.e., Nucala) given under the skin every 4 weeks.
9. Aspirin desensitization for AERD.
10. Functional endoscopic sinus surgery (FESS) and excision of the nasal polyps, restoring the patency of the nasal cavity.
11. Polyps have a tendency to recur after surgery and/or aggressive allergy treatments and intranasal corticosteroids can delay or prevent the recurrence.
12. Placing tiny, corticosteroid-coated implants (e.g., Sinuva) in the sinuses.

The aggressive management of predisposing conditions such as allergic rhinitis, controlling one’s environment [i.e., reducing one’s exposure to offending allergens such as dust mites, molds, pollens, cats, dogs, and cockroaches, allergy medications, and allergy immunotherapy (i.e., allergy shots, allergy injections, allergy immunotherapy, allergy hyposensitization) may all work together to inhibit polyp formation.  In addition, avoiding exposure to strong odors, chemicals, and smoke is important in order to diminish nasal irritation and excessive tissue growth.

Individuals with established chronic sinusitis may require antibiotics, nasal or sinus irrigations, and/or sinus surgery.  Patients with a history of aspirin sensitivity should do better after desensitization to aspirin in terms of improved asthma control, as well as a reduction in the recurrence of nasal polyps.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating both children and adults in the Washington, DC, nNorthern VA, and Maryland metropolitan area for over 50 years. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. There is on-site parking at all of the offices. The Washington, DC and McLean, VA office locations are Metro accessible and there is a free shuttle that runs between our McLean office and the Spring Hill metro station on the silver line. The allergy doctors at Black & Kletz Allergy specialize in all types of allergic conditions including nasal polyps, hay fever, asthma, sinus disease, hives (i.e., urticaria), eczema (i.e., atopic dermatitis, swelling problems (i.e., angioedema), food and medication allergies, and immunological disorders. If you would like to schedule an appointment, please call us or alternatively you can click Request an Appointment and we will respond back to you within 24 hours on the next business day. We look forward to providing you with comprehensive state-of the-art allergy care in a friendly and professional environment.

Fall Allergies

As we approach the end of Summer in the coming month, many individuals will begin to experience an increase of their allergy symptoms. In the world of allergies, these symptoms are considered Fall allergies. Typically in the Washington, DC, Northern Virginia, and Maryland metropolitan area, ragweed begins to pollinate in mid-August. The release of ragweed pollen into the air can be dreadful for many ragweed-allergic individuals. As the ragweed pollen count climbs through the rest of August and throughout most of September, the allergic rhinitis (i.e., hay fever), allergic conjunctivitis (i.e., eye allergies), and/or asthma symptoms of patients with ragweed allergy usually increase proportionally. The end of ragweed season coincides with the first frost which is usually in late October in the Washington, DC metro area. Approximately 10% of the population in the U.S. has a ragweed allergy. There are 17 species of ragweed in North America. Each ragweed plant produces about 1 billion pollen grains per season. The only state in the U.S. without ragweed is Alaska. Ragweed is more common in the Midwest and eastern U.S. Warm temperatures and increased humidity are factors that augment the release of ragweed pollen.

The classic symptoms that people with ragweed allergy experience may include runny nose, nasal congestion, post-nasal drip, sneezing, itchy nose, itchy throat, sinus congestion, sinus pain, headaches, snoring, itchy eyes, watery eyes, puffy eyes, redness of the eyes, chest tightness, coughing, wheezing, and/or shortness of breath. Ragweed may also increase the likelihood of sinus infections (i.e., sinusitis) in some susceptible individuals.

An itchy mouth, throat and/or lips can occur in some ragweed-allergic individuals after eating certain ragweed-associated foods. The foods that may be associated with ragweed pollen allergy include banana, melon (e.g., watermelon, cantaloupe, honeydew), white potato, chamomile tea, cucumber, zucchini, artichoke, sunflower seeds, and dandelion. In general, no other allergy symptoms beyond an itchy mouth, throat, and/or lips occur. This condition is called oral allergy syndrome or pollen-food allergy syndrome. The syndrome in general is caused by allergens in foods that are derived from plants. Furthermore, these foods are usually raw or uncooked fruits, vegetables, and nuts. Only foods that come from plants can cause the syndrome. Extra caution needs to be taken into account where nuts cause symptoms because many individuals can have nut allergies that are not associated with plants which may be life-threatening. Ironically, when the fruit or vegetable is cooked or canned, the protein is denatured and destroyed which usually prevents the allergic reaction from occurring. In most instances, individuals can tolerate cooked and/or canned fruits and vegetables.

In addition to ragweed as a cause of Fall allergies, molds, dust mites, pet dander, and cockroaches are also major sources of Fall allergies. Molds are perennial in nature and occur naturally in both indoor and outdoor settings. Washington, DC is notorious for its mold content as it was built on a swamp. In addition, the amount of mold tends to be worse in the Washington, DC metro area in the Spring with all of the rain and in the Fall with the increased amount leaf mold from all of the moldy wet leaves on the ground. Avoiding damp places, not raking leaves, and keeping the humidity below 50% may help in minimizing one’s exposure to molds. Dust mites are indoor allergens and are a problem for allergy sufferers year-round. Dust mites tend to live in bedding (i.e., mattresses, pillows, box springs), carpeting, and upholstered furniture. Covering one’s pillows, mattresses, and box springs with allergy-proof encasings and limiting stuffed animals and dust gathering objects has shown to help minimize one’s exposure to dust. Pets (e.g., cats, dogs, rabbits) can obviously cause allergy symptoms in pet-allergic individuals. Avoiding contact with pets, keeping a pet out of the bedroom, and washing the pet can all help reduce one’s exposure to pets. Cockroaches are potent allergens that cause perennial symptoms due to their ubiquitous nature. They are notable in the field of allergy and immunology for being a leading aggravating factor of childhood asthma in inner city populations. Extermination of cockroaches by professional exterminators can help reduce one’s exposure to cockroaches.

The board certified allergy specialists at Black & Kletz Allergy have been diagnosing and treating allergies, asthma, sinus conditions, and immunological disorders for more than 5 decades. Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location and the Washington, DC and McLean offices are Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Please call us today to make an appointment at the office of your choice. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing an excellent patient experience in a friendly and pleasant environment.