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Vocal Cord Dysfunction

The vocal cords are V-shaped tissue folds within our voice box (i.e., larynx). The gap between the arms of the V is the opening into our windpipe (i.e., trachea). These are dynamic structures and move with the contraction and relaxation of the muscles attached to them. Normally the vocal cords open when we inhale and exhale, allowing the air to get in and out of lungs. They close while we eat, blocking food from entering into the windpipe. The vocal cords become narrowed when we speak. It is the vibration of the vocal cords that generates voice.

When the vocal cords malfunction, they may become narrowed or even close when we inhale. This narrowing or closing will result in difficulty for air to enter the lungs which may cause a feeling of breathlessness. This shortness of breath may be confused with the symptoms of asthma. When this situation occurs, it is referred to as paradoxical vocal fold movement (PVFM) or vocal cord dysfunction (VCD).

In asthma, the airways (i.e., bronchial tubes) constrict and tighten, making breathing difficult. In vocal cord dysfunction, the vocal cord muscles tighten, which also makes breathing difficult. Unlike asthma, vocal cord dysfunction is not an allergic response. It is usually more difficult to inhale during an episode of vocal cord dysfunction. On the contrary, it is usually more difficult to exhale during an exacerbation of asthma. It is very important to differentiate vocal cord dysfunction from asthma since the treatments are quite different. One study showed that approximately 40% of individuals with vocal cord dysfunction are misdiagnosed as having asthma. It should be noted that in some instances, asthma and vocal cord dysfunction can coexist in a person at the same time.

Vocal cord dysfunction is found in people of all ages, although it tends to be more prevalent in individuals between the ages of 20-40. It is more common in women.


  • Tightness of the throat
  • Hoarseness
  • Choking or suffocation feeling
  • Difficulty in breathing
  • High pitched noise during Inhalation (i.e., stridor)
  • Coughing
  • Wheezing
  • Frequent throat clearing

Causes and Triggers:

  • Strong odors, fumes, or other irritants
  • Upper respiratory infections (URI’s)
  • Post-nasal drip associated with allergic rhinitis (i.e., hay fever) or a URI
  • Acid reflux [i.e., gastroesophageal reflux disease (GERD)]
  • Exercise
  • Emotional stress


  • Comprehensive history of the symptoms and triggers
  • Breathing test (i.e., spirometry) with a flow/volume loop demonstrating diminished air entry into the lungs during an episode
  • Direct inspection of the of the vocal cord through a laryngoscope (i.e., flexible fiberoptic tube with a camera attached) during the episode revealing paradoxical movements
  • An episode may need to be “induced” either by exercise or by inhalation of a chemical called methacholine


There is very little role of medications in the management of this vocal cord dysfunction. The mainstay of treatment is behavioral techniques to relax the muscles in the throat that control the vocal cord movements.

  • Speech therapy by a trained and qualified speech pathologist and therapist is the main course of treatment. One may need several sessions of speech therapy and regular practice at home even during asymptomatic periods in order to manage vocal cord dysfunction.
  • Deep breathing techniques to reduce the discomfort and fear
  • Relaxation techniques, biofeedback, and psychotherapy have been shown to be helpful in controlling vocal cord dysfunction by reducing emotional stress
  • Better control of asthma, if it is co-existent
  • Managing post-nasal drip and acid reflux

The board certified allergy specialists at Black & Kletz Allergy have 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The 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. The allergy specialists at Black & Kletz Allergy are extremely knowledgeable about the most current treatment options for patients with vocal cord dysfunction, asthma, and related conditions and can promptly answer any of your questions. The allergy specialists at Black & Kletz Allergy diagnose and treat both pediatric and adult patients. To schedule an appointment, please call any of our offices or 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 state-of-the-art allergy and asthma care in a welcoming and pleasant environment.

Thanksgiving and Food Allergies

Thanksgiving Day is usually a time when people gather with family and friends in order to be with each other, watch football, and of course, eat! Unless you or a family member has a food allergy, you may not think about food allergies or food sensitivities much. It is important however to be more than cognizant of the topic of food allergies especially if you are hosting a Thanksgiving Day celebration. One must learn that food allergies can be very serious and even fatal to some individuals. Cooking and preparing Thanksgiving Day food as well as collecting various dishes from other guests, which is commonly done during this holiday, must be taken very seriously with respect to food allergies and food sensitivities.

It is important to note that approximately 4% of adults and 5% of children in the U.S. have food allergies. The most common 8 food allergens are milk, egg, soy, wheat, peanut, tree nut, fish, and shellfish. These 8 foods cause nearly 90% of most food allergy reactions.

It should be noted that peanuts are not actually nuts because they grow from the ground and not from a tree. Peanuts are classified as legumes and are closely related to other legumes such as beans (e.g., black, lima, navy, kidney, pinto, fava, lupin, mung, soybeans), chickpeas (i.e., garbanzo beans), lentils, and peas. Most allergists instruct their peanut allergic patients to avoid all legumes in addition to avoiding peanuts.

Knowing the above information, the person hosting a Thanksgiving holiday celebration should ask their guests if they have a food allergy or food sensitivity. They should also inform their guests who are preparing and/or bringing food to the host/hostess’ house about any food allergies or food sensitivities that any of the guests have so they can provide a list of ingredients used in their dishes. The goal is to make sure that the food-allergic or food-sensitive individual does not ingest any of the offending food allergen on purpose or accidentally.

When one thinks of Thanksgiving, the food most thought of is turkey. Although a turkey allergy is not very common, it is more common to have individuals experience sleepiness or fatigue after eating turkey meat. This adverse reaction to turkey is not an allergy, but classified as a food sensitivity to the amino acid “L-tryptophan.” L-tryptophan is found in high levels in turkey meat. The L-tryptophan travels from the gastrointestinal tract to the brain where it is converted to a serotonin. It is this chemical, serotonin, that is responsible for causing this sleepiness or fatigue.

There are 2 other common food sensitivities that should be known to all. The first food sensitivity is called “lactose intolerance.” It occurs when the body is unable to fully digest the sugar called lactose which is commonly found in milk and dairy products. This inability to break down lactose is due to a lack or decreased amount of the enzyme lactase. Lactose intolerance may cause gastrointestinal side effects such as abdominal bloating, abdominal pain, nausea, and/or diarrhea in affected individuals. The second food sensitivity one hears a lot about recently is called “gluten intolerance” or “gluten sensitivity.” No one is exactly sure of the mechanism of gluten intolerance but individuals with this condition experience abdominal bloating, abdominal pain, nausea, diarrhea, and/or constipation after eating foods containing gluten (i.e., wheat, barley, rye). Some patients also complain of fatigue and headaches as well. The symptoms resemble individuals with wheat allergy (i.e., celiac disease) and/or irritable bowel syndrome. Unlike celiac disease, however, gluten sensitivity does not cause damage the intestines.

The gravy used for turkey and mashed potatoes commonly contains dairy (e.g., milk), wheat, and/or soy. It is important to remember that tiny amounts of a food allergen may be all that is necessary to cause a severe allergic reaction is a sensitive individual. One must be careful about every ingredient in a food or dish.

Common food allergens such as milk, egg, soy, wheat, nuts, and peanuts are often found around the Thanksgiving Day table. Tree nuts are frequently found on string beans as well as in some types of stuffing.  Tree nuts and peanuts are common in many desserts such as brownies, cookies, cakes, and pecan pie.  Eggs and milk (i.e., dairy) are also used in many baked goods.  Although pumpkin allergies are not common, pumpkin pie may contain an assortment of ingredients that may trigger a food allergy in susceptible allergic individuals.  Many families incorporate a multitude of ethnic foods in their celebrations.  These cultural foods may not be traditional, but they increase the possibility of other allergenic foods such as fish and shellfish to be the causative agent of an approaching food allergy.  If someone has a serious food allergy, it is sensible for that person to bring their own food rather than eat food in which they are not 100% sure of its ingredients and origin.

The board certified allergists at Black & Kletz Allergy have been diagnosing and managing food allergies, other allergies, and asthma for more than 50 years in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We have convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Each office has on-site parking. The Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Please call for an appointment if you would like a consultation with one of our allergists, or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy prides itself in providing quality allergy and asthma care to the Washington, DC, Northern Virginia, and Maryland metropolitan area community.

Hypereosinophilic Syndrome

Eosinophils are types of white blood cells which are part of our normal immune system. They tend to be elevated in allergic disorders. Eosinophils also play an important role in protecting us from certain infections and infestations from parasitic organisms.

Hypereosinophilic syndrome (HES) refers to a condition where there are excessive numbers of eosinophils in the bloodstream. Normally there are less than 500 eosinophils per microliter of blood. HES is defined as having equal or more than 1,500 eosinophils per microliter consistently for more than 6 months.

Though we need eosinophils for defending us from microbes and helminths (i.e., parasitic worms), excessive numbers can be deleterious. These cells accumulate in tissues and cause inflammation. The resultant inflammation may lead to dysfunction of various organs. The most common organs that are typically affected are the skin, heart, lungs, bone marrow, gastrointestinal tract, and nervous system.

The exact prevalence of this condition is unknown however, it is estimated to occur in between 1 and 9 persons per 100,000 population. It is found equally in both sexes and is most common in middle-aged individuals, though it can occur in any age group.


Certain genetic abnormalities in chromosome 4 were observed in some affected individuals. Infestations by helminths (e.g., roundworm, hookworm) could be a trigger for this condition in a few individuals. In a vast majority of cases however, no cause can be identified. When no cause is recognized, the condition is called idiopathic hypereosinophilic syndrome.


The organ system and corresponding symptoms of hypereosinophilic syndrome may include the following:


The diagnostic tests are individualized according to the particular symptoms of the patient and may include:

  • Blood test to screen for number of eosinophils
  • Stool evaluation to detect a parasitic infection
  • Allergy testing to diagnose environmental, medication, and/or food allergies
  • Biopsies of the skin or other organs
  • Blood tests to screen for autoimmunity
  • CT imaging of the affected organs
  • Genetic and molecular studies
  • Chest X-ray and echocardiogram
  • Liver and kidney function tests
  • Serum tryptase levels
  • Miscellaneous tests to evaluate for cancers


The treatment for hypereosinophilic syndrome is aimed at reducing the numbers of eosinophils in order to prevent or restrict tissue damage and preserve organ function. Some of the medications that are used to treat HES may include:

  • Corticosteroids: Prednisone, dexamethasone
  • Chemotherapeutic agents: Hydroxyurea, chlorambucil, vincristine
  • Cytokines: Interferon alpha
  • Tyrosine kinase inhibitors: Gleevec (i.e., imatinib) is also used to treat acute lymphocytic leukemia and chronic myelogenous leukemia that are Philadelphia chromosome-positive, certain types of gastrointestinal stromal tumors, chronic eosinophilic leukemia, systemic mastocytosis, and myelodysplastic syndrome.
  • Monoclonal antibodies: Nucala (i.e., mepolizumab was approved by the FDA for the treatment of hypereosinophilic syndrome in the last week of September 2020 for patients 12 years of age and above at the dose of 300 mg. subcutaneous injection every 4 weeks.


The outlook for hypereosinophilic syndrome has improved significantly in recent years. In 1975, only 12% of HES patients survived 3 years. Today in 2020, more than 80% of HES patients survive 5 years or more.

The board certified allergists of Black & Kletz Allergy have been diagnosing and treating both adults and children in the Washington, DC, Northern VA, and Maryland metropolitan area for over 5 decades. 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. Our allergy doctors of Black & Kletz Allergy specialize in all types of allergic conditions including hypereosinophilic syndrome. They are also experts in the treatment of allergic rhinitis (i.e., hay fever), asthma, sinus disease, hives (i.e., urticaria) , eczema (atopic dermatitis), swelling problems, medication and food 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. Our goal at Black & Kletz Allergy is to serve the greater Washington, DC metropolitan community with top-notch allergy care with boundless dedication and great pride as we have done for many years.

Sinus Infections

Sinus infections are quite common. They can vary in severity from being a nuisance on one end of the spectrum to severe and debilitating on the other end. The sinuses referred to in “sinus infections” are actually called “paranasal” sinuses because they are “near the nose.” Paranasal sinuses are cavities in the cranial and facial bones (i.e, skull) near the nose which help in filtering and moisturizing inhaled air that is inhaled through the nose. They also lighten the weight of the skull and are involved with voice resonance. There are 4 pairs of sinuses named for the corresponding bone that they are situated upon:

  • Maxillary sinuses: Located on the cheekbones to the right and left of the nostrils.
  • Frontal sinuses: Located above the eyes in the forehead region.
  • Ethmoid sinuses: Located on each side of the upper nose between the eyes.
  • Sphenoid sinuses: Located behind the eyes in the deeper recesses of the skull.

In the medical field, sinus infections are referred to as “sinusitis.” Technically, the word sinusitis means inflammation of the sinuses. Sinusitis can be classified into 4 main types: acute sinusitis, subacute sinusitis, chronic sinusitis, and recurrent sinusitis.

  • Acute sinusitis: Lasts less than 4 weeks. Usually comes on suddenly. Most often caused by viruses such as the common cold, although bacteria and less often, fungi are responsible for this type of sinusitis. Allergic rhinitis (i.e., hay fever) is a risk factor.
  • Subacute sinusitis: Lasts 4-12 weeks. Commonly occurs with bacterial infections or partially treated infections. Allergic rhinitis is a risk factor.
  • Chronic sinusitis: Lasts greater than 12 weeks. Commonly occurs with bacterial or rarely fungal sinus infections. Partially treated acute or subacute sinus infections may fester into a chronic sinus infection. Allergic rhinitis is a risk factor.
  • Recurrent sinusitis: Sinus infection occurs 4 or more times a year.

Sinus infections are usually caused by viruses; however, bacteria, fungi, and parasites can also infect the sinuses. It should be noted that bacterial sinus infections are much more common than fungal infections and parasitic infections of the sinuses are quite rare. Sinus infections occur when fluid builds up in the air-filled sinus cavities. In addition to the fluid buildup, the affected sinuses become inflamed. This inflammation causes an increase in the internal pressure of these sinuses. As a result, some common symptoms of a sinus infection may include the following:
Nasal congestion

  • Post-nasal drip (i.e., mucus dripping down the back of the throat)
  • Sore throat
  • Cough
  • Facial pain or pressure
  • Headache
  • Bad breath
  • Exacerbation of asthma

Although anyone can come down with a sinus infection, there are a number of risk factors that facilitate one’s likelihood of developing a sinus infection. Some risk factors for sinus infections may include:

  • Allergic rhinitis (i.e., hay fever)
  • Previous “cold” or viral upper respiratory infection (URI)
  • Structural abnormalities of the nose or sinuses
  • Smoking and/or exposure to smoke
  • Nasal polyps
  • Immunodeficiency (i.e., weakened immune system)


The diagnosis of an acute or subacute sinus infection is often made by the history and physical examination alone. Rhinoscopy is sometimes utilized as a tool to visualize the nasal passages and sinuses in individuals with any type of sinus infection. During rhinoscopy, a thin flexible tube with a fiber-optic light at the end is inserted in the nose. In patients with either chronic or recurrent sinus infections, a CT scan of the sinuses may be needed in order to establish the diagnosis. Rarely, a culture from the sinus is taken in order to either diagnose fungal sinusitis or to determine which antibiotic is necessary to treat a recalcitrant bacterial sinus infection.


Most sinus infections resolve without any treatment. This may be because most sinus infections are viral in nature. Nasal corticosteroids are often prescribed to help treat the inflammation associated with sinus infections. Decongestants may also be recommended in certain people depending on their underlying medical history. Bacterial sinus infections are normally treated with oral antibiotics. Amoxicillin or Augmentin (i.e., amoxicillin + clavulanic acid) is the antibiotic of choice for most areas in the U.S. unless an individual is allergic to penicillin. Whereas antibiotics are typically prescribed for 10-14 days for an acute sinus infection, the course of an antibiotic for a chronic sinus infection is typically 3-4 weeks in duration. Rest and fluids are also generally recommended. Breathing in steam from a hot shower or bowl of hot water brings symptomatic relief in many sufferers. Using saline irrigation in the form of a nasal spray or a Neti pot is helpful in some people. Pain relievers may need to be taken for individuals who have accompanying fever, headache, and/or sinus pain.

It should be emphasized that allergies (i.e., allergic rhinitis) play an important role in the development of sinus infections in many individuals. It is thus important to see a board certified allergist if you or someone you know suffers from sinus infections, as an underlying allergy may make that individual more susceptible to getting sinus infections.

The board certified allergy specialist physicians at Black and Kletz Allergy have over 50 years of experience in diagnosing and treating all types of sinus infections. We treat both pediatric and adult patients. Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The 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 any of our offices or 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 metropolitan area for many decades and we look forward to providing you with the utmost state-of-the-art allergy care in a friendly and pleasant environment.

The Flu – What You Need to Know

Viruses cause a variety of illnesses in humans ranging from mild upper respiratory infections (URI’s) to life-threatening pulmonary and extra-pulmonary diseases. Rhinoviruses, adenoviruses, respiratory syncytial virus (RSV), coronaviruses, and influenza are the most common viruses infecting the respiratory tract. Among these rhinoviruses, RSV and influenza viruses are common causes of wheezing in children. Recurrent infections with these viruses may play a role in the development of asthma.

Patients with asthma are more susceptible to contract infections with influenza virus. In addition, they are also more likely to develop serious complications from Influenza. In fact, more than 75% of acute flare-ups of asthma are triggered by infections from either influenza, RSV, or rhinovirus infections.

Influenza infection (i.e., flu) normally occurs in the United States between October and March, although the peak time for infection is between January and March. There are 3 strains of influenza viruses that cause human infections and one other that does not. The ones that cause human infections are known by the names influenza A, influenza B, and influenza C. Influenza D is not known to infect or cause illness in humans and primarily infects cattle.

Influenza A and B are typically associated with seasonal epidemics of disease, known as the flu season. Influenza A is the only influenza virus that has been associated with flu pandemics. There have been several flu pandemics during the 20th century, each with its own severity and outcome. For example, in 1918, the “Spanish flu”, a strain of H1N1 influenza A subtype H1N1, caused between 50 and 100 million deaths worldwide with a mortality rate of 2.5 to 3%. Most of the deaths occurred in adults between the ages of 20 and 40 years. In 1957, the “Asian flu” (influenza A subtype H2N2) caused between 1.5 and 2 million deaths and had a fatality rate of 0.67%. In 1968, the “Hong Kong flu” (influenza A subtype H3N2) has been estimated to have caused between 1 and 4 million deaths and had a mortality rate of less than 0.5%.

Influenza infection begins with invasion of the respiratory epithelium which serves as a site for both viral replication and the host’s immune response. Destruction of the normal airway tissue and a pro-inflammatory immune response are the primary causes of symptoms associated with influenza infection.

The immune response of the host causes many of the symptoms associated with viral respiratory infections and those associated with exacerbations of underlying asthma. Certain individuals seem to be at higher risk for developing infection in the lower airway. The risk of infection increases in children less than 6 months of age, individuals with second-hand smoke exposure, and in people with certain genetic markers. Allergic individuals are also more susceptible to infection due to an impaired immune response.

The classic symptoms of the flu may include:

  • Runny nose
  • Nasal congestion
  • Sore throat
  • Cough
  • Fever/chills
  • Achiness
  • Vomiting or diarrhea
  • Fatigue/Lethargy

Complications of the flu may include:

  • Pneumonia
  • Flare-ups of asthma symptoms
  • Ear infections
  • Inflammation of the heart muscle
  • Inflammation of the brain

Treatment of the Flu:

Most cases of influenza are mild and the symptoms usually resolve in 7 to 10 days. Symptomatic relief of fevers, chills, and achiness can be achieved by over-the-counter medications such as acetaminophen (i.e., Tylenol). Antihistamines and decongestants may be utilized to help reduce the unwanted nasal symptoms. Inhaled medications such as albuterol (e.g., Proventil, Ventolin, ProAir) are given to help relieve wheezing, coughing, and/or shortness of breath. Rest and drinking plenty of fluids may accelerate the recovery process overall.

The indications for antiviral medications include patients that are at high risk of influenza-related complications including pregnant women, adults over 65 years of age, immune-compromised subjects, and those with chronic medical conditions such as asthma, chronic obstructive pulmonary disease (COPD), and diabetes. Antivirals should be used if an individual requires hospitalization, if the infection is severe or complicated, and during pregnancy (even in mild disease).

Antiviral treatment works best when begun soon after the flu illness begins. When treatment is started within 2 days of becoming sick with flu symptoms, antiviral drugs can lessen fever and flu symptoms and shorten the duration of illness. They also may reduce the risk of complications such as ear infections in children, respiratory complications requiring antibiotics, and hospitalization in adults.

  • Oseltamivir (i.e., Tamiflu) is available as a pill or liquid suspension and is FDA approved for the early treatment of the flu in individuals 2 weeks of age and older who have had flu symptoms for 2 days or less.
  • Zanamivir (i.e., Relenza) is a powder that is inhaled and approved for the early treatment of the flu in people 7 years of age and older. Note: Zanamivir is administered using an inhaler device and is not recommended for individuals with breathing problems such as asthma or COPD.
  • Oseltamivir and zanamivir are given twice a day for 5 days.
  • Baloxavir (i.e., Xofluza) is a pill given as a single dose by mouth and is approved for the early treatment of flu in individuals 12 years of age and older. Note: Baloxavir is not recommended for pregnant women, breastfeeding mothers, severely immunosuppressed individuals, hospitalized patients, or outpatients with complicated or progressive illness.

Prevention of the Flu:

Staying home and avoiding contact with others will reduce the risk of acquiring influenza infection.

Routine annual influenza vaccination (i.e., flu shot) is recommended for all persons 6 months of age and older. Many types of flu vaccines are licensed by the FDA this year with varying indications based on one’s age group and health status. Please click on the following CDC link for more information: cdc.gov/flu/prevent/keyfacts.htm

The board certified allergists at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding the flu, asthma, and/or allergies. We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. In addition, the Washington, DC and McLean, VA offices are accessible by Metro. There is also a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Kindly make an appointment by calling one of our 3 offices. Alternatively, you may click Request an Appointment and we will answer your inquiry within 24 hours by the next business day. Black & Kletz Allergy treats both children and adults and we are proud to serve the Washington, DC metro area residents for which we have done for more than 5 decades.

Sleep Apnea and Allergies

Sleep apnea is a condition in which breathing is repeatedly interrupted which results in an individual to not get enough deep sleep that is required to rejuvenate the body. Excessive daytime sleepiness or falling asleep at inappropriate times are the classic symptoms of this disorder.  It can be very serious and is a potentially fatal condition. Other common symptoms may include snoring, fatigue, decreased memory, decreased ability to learn, depression, decreased productivity at school and/or work, and a decreased quality of life. It is interesting to note that allergic rhinitis (i.e., hay fever) has also been linked to many of the same symptoms.  The combination of allergic rhinitis and sleep apnea can have deleterious effects such as an increased risk for motor vehicle accidents, stroke, heart disease, and/or sexual dysfunction. As a result, sleep apnea should not be taken lightly. Although approximately 25 million adults have sleep apnea in the U.S., the actual numbers are probably much higher since cases are underdiagnosed due to a variety of reasons. It should be noted that many individuals with sleep apnea are just unaware that they have the condition.

Sleep apnea may be classified as either “obstructive sleep apnea” or “central sleep apnea.” The severity is categorized into 3 classifications: mild, moderate, and severe. The severity is based on the number of episodes or events of apnea (i.e., complete stoppage of breathing for at least 10 seconds) or hypopnea (i.e., shallow breaths for at least 10 seconds) that occur per hour of sleep. Sleep apnea is deemed “mild” when there are 5-14 episodes of apnea or hypopnea per hour. It is considered “moderate” when there are 15-29 episodes of apnea or hypopnea per hour. Likewise, it is called “severe” when there are 30 or more episodes of apnea or hypopnea per hour. In obstructive sleep apnea, the breathing is obstructed by the blockage of air flow. It is often caused by the tongue sliding back in the throat, in combination with a relaxed airway which changes shape to a more oval shape which gives way to less room for air to be able to get to infiltrate the lungs from the nose or mouth.  In a sense, the muscles of the throat relax and fail to hold the airway open during sleep. In central sleep apnea, the normal unconscious breathing simply stops, usually due to the brain not sending the normal signals to the muscles that control breathing. Central sleep apnea is much less common than the obstructive variety and not associated with allergies, so we will only be discussing obstructive sleep apnea in this blog article.

Individuals with allergic rhinitis (i.e., hay fever) have worse sleep apnea overall than those without allergic rhinitis. The apnea episodes are more frequent and longer in duration. Allergic rhinitis is also a risk factor for snoring. Snoring is one of the most common findings in individuals with sleep apnea. Individuals with allergic rhinitis often have nasal congestion which causes the upper airway to narrow.  Individuals with hay fever also are more prone to sinus infections.  Most individuals with sinus infections also have concurrent nasal congestion as part of their symptoms.  The upper airway narrowing that occurs due to nasal congestion in allergic individuals increases the likelihood of snoring and obstructive sleep apnea. Some other risk factors for obstructive sleep apnea include obesity, large neck circumference, enlarged tonsils, deviated septum, males, age over 40, and gastroesophageal reflux (GERD).

The gold standard for the diagnosis of sleep apnea is an overnight sleep study. Allergy testing by allergy skin tests or blood tests are performed by a board certified allergist like the ones at Black & Kletz Allergy in order to identify potential allergens that are causing their allergic rhinitis symptoms (e.g., nasal congestion, runny nose, post-nasal drip, itchy nose, sneezing, snoring, fatigue, itchy throat, itchy eyes, watery eyes, redness of the eyes, sinus pressure, sinus headaches).

The most effective treatment of obstructive sleep apnea is the use of CPAP (continuous positive airway pressure) while sleeping. CPAP machines are used to distribute a constant flow of pressure which in turn forces open the airway obstruction. CPAP can be delivered by the use of nasal pillows or prongs, a nasal mask, or a full face mask. The use of mouth or dental devices are controversial but may help alleviate symptoms in individuals with mild obstructive sleep apnea. Surgery can also be performed in order to improve obstructive sleep apnea, although it is also somewhat controversial in its efficacy. A uvulopalatopharyngoplasty is one of the most common surgical procedures for treating obstructive sleep apnea although not necessarily the most effective. It is performed in order to remove excess tissue in the throat such as the uvula, tonsils, adenoids, and parts of the soft palate. It should be noted that the largest obstacle in the treatment of sleep apnea is compliance, as more than 50% of individuals do not adhere to the recommended usage of CPAP.

The board certified allergy specialists at Black and Kletz Allergy have been diagnosing and treating allergies and asthma for more than 5 decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area. In our allergy practice, we treat both adults and pediatric patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each of our 3 locations. Our Washington, DC and McLean, VA offices are Metro accessible. Black & Kletz Allergy offers a free shuttle service between our McLean, VA office and the Spring Hill metro station on the silver line. If you suffer from sleep apnea, snoring, fatigue, allergies, sinus problems, asthma, hives, or immunological disorders, please call one of our offices to make an appointment. You may also click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy is dedicated in providing the most advanced allergy treatments in a warm, caring, and professional environment.

Asthma-COPD Overlap Syndrome

Asthma is a chronic condition that causes inflammation of the lungs. Inflammatory swelling of the tissues in the walls of the bronchial tubes and excessive mucus secretion within the lumen of the bronchial tubes cause blockage to the free flow of air in and out of the lungs during normal respiration. In some instances, asthma is a genetically determined condition which can be aggravated by environmental factors such as exposure to allergens (e.g., dust mites, molds, pollens, pet dander, cockroaches) and/or irritants (e.g., cigarette smoke, strong scents, air pollution, increased humidity, cold air). The usual symptoms of asthma may include coughing, chest tightness, shortness of breath, and wheezing.

The course of the disease varies widely in individual patients depending on the severity of the condition. Some individuals have symptoms all of the time and their asthma is labeled persistent while others only have symptoms sporadically and thus their asthma is categorized as intermittent. Physical exertion and both upper and lower respiratory infections may increase the frequency and severity of asthma symptoms in susceptible patients. Asthma usually begins in childhood although it may begin in adulthood. Asthma is usually associated with other allergic disorders such as hay fever (i.e., allergic rhinitis) and/or eczema (i.e., atopic dermatitis).

Chronic obstructive pulmonary disease or COPD is a common, preventable, and treatable condition that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. Chronic bronchitis and emphysema are the two most common conditions that fall under the umbrella of COPD. Persistent coughing associated with expectoration and increasing difficulty in breathing as well as effort intolerance are the usual symptoms.

COPD is a progressive condition and it is very common to have increasing severity over time. COPD symptoms typically begin after the age of 40, although symptoms may appear earlier. The symptoms may vary from day to day, but they are chronic even with treatment. Most individuals with COPD also have a history of smoking or smoke exposure.

Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with both asthma and COPD. ACOS is therefore identified in clinical practice by the features that it shares with both asthma and COPD.
Individuals with ACOS may experience wheezing, breathing difficulties, fatigue, and/or excessive mucus that often responds to bronchodilators (i.e., medications that open airways such as albuterol). Patients with asthma-COPD overlap syndrome also seem to experience more shortness of breath than individuals with COPD or asthma alone. “Persistent airflow obstruction with features of asthma” is a common way that this condition is defined. They tend to be younger in age than patients with COPD alone. However, because this condition is still being studied, experts do not yet agree on a single way to define the syndrome.

ACOS generally involves these 3 features compared with people who have COPD alone:

  • more of a response to inhaled bronchodilators
  • increased reversibility of airflow
  • bronchial and systemic inflammation from eosinophils (i.e., a type of white blood cell that is often elevated in allergic conditions).

The diagnosis of asthma-COPD overlap syndrome requires a comprehensive history and physical examination. Pulmonary function tests (i.e., spirometry) are also usually obtained. One may also need imaging studies such as a chest X-ray and/or CT scan.

The treatment of ACOS generally includes:

  • Avoidance of allergens and irritants
  • Total cessation of smoking
  • Medications which usually consist of daily maintenance inhaled corticosteroids which are anti-inflammatory, in combination with inhaled long-acting bronchodilators to keep the airways open, and short-acting bronchodilators to provide quick relief from symptoms during flare-ups
  • Regular immunizations such as Influenza and pneumonia vaccinations
  • Pulmonary rehabilitation (i.e. breathing exercises and healthy eating habits)

The board certified allergists at Black & Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area and are very experienced in the diagnosis and treatment of asthma and asthma-COPD overlap syndrome. We also work in concert with any pulmonologist on patients with COPD. Black & Kletz Allergy treat both children and adults and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location. The Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please call our office to make an appointment or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been serving the Washington, DC metropolitan area for more than 50 years and we pride ourselves in providing exceptional allergy and asthma care in a professional and caring environment.

Ragweed and Other Fall Allergies

It is mid-August in the Washington, DC, Northern Virginia, and Maryland metropolitan area, so that means that ragweed is beginning to pollinate. For those who are bothered by ragweed allergies, this means that it is time to stock up on tissues and over-the-counter medications. Ragweed allergy is common as approximately 10% of the U.S. population suffers from ragweed pollen. It has been estimated that ragweed causes about half of all pollen-associated allergic rhinitis (i.e., hay fever) in North America. Ragweed also causes allergic conjunctivitis (i.e., eye allergies) and asthma in a multitude of sensitive individuals.

Ragweed is very prevalent in the U.S., particularly in the Eastern and Midwestern regions of the U.S. The only state without ragweed is Alaska. There are at least 17 species of ragweed in North America. Each ragweed plant lives only 1 season but can produce approximately 1 billion pollen grains. The pollen is even more widespread in rural areas. It typically is found along the side of the road, in fields, in vacant lots, and along riverbanks. The warm weather in combination with increased humidity and wind enhances the release of ragweed pollen which tends to begin in mid-August, peak in mid-September, and end with the first frost which usually occurs in late October in the mid-Atlantic region. The pollen released from the ragweed plant can travel hundreds of miles, so most of the U.S population is exposed. The ragweed pollen count tends to peak during the midday and is the lowest in the early mornings.

For those who suffer from ragweed allergy, you are very knowledgeable with respect to the symptoms that you develop. For others who are not familiar with ragweed allergy, here are some of the typical symptoms that you may expect: sneezing, itchy nose, runny nose, nasal congestion, post-nasal drip, itchy eyes, watery eyes, red eyes, puffy eyes, fatigue, snoring, sinus pressure, sinus headaches. In some individuals, ragweed may cause asthma symptoms such as chest tightness, coughing, wheezing, and/or shortness of breath. In asthmatics, it is not uncommon for ragweed to exacerbate one’s asthma. In addition, ragweed may also increase the likelihood of sinus infections (i.e., sinusitis) in some prone individuals.

One fairly common but not well known to the public nuance regarding ragweed allergies is its association with foods. There is a condition known as oral allergy syndrome (i.e., pollen-food allergy syndrome) is a type of food allergy where the patient must have a pollen allergy even if they are not aware of it. It is characterized by an itchy mouth, throat, and/or lips in response to eating certain raw or uncooked fruits, vegetables, and nuts. Occasionally, people will experience itching of their hands when touching the raw foods. The syndrome is caused by allergens in foods that are derived from plants. Thus, only foods that come from plants can cause the syndrome. Extra caution needs to be taken in cases where nuts cause symptoms because many individuals can have nut allergies that are not associated with plants and as discussed above, 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 cases, individuals can tolerate cooked and/or canned fruits and vegetables. Some examples of foods associated with ragweed pollen allergy include melons (e.g., cantaloupe, honeydew, watermelon), banana, chamomile tea, white potato, cucumber, zucchini, artichoke, dandelion, and sunflower seeds.

In addition to ragweed allergies, it should be noted that other allergens may play a significant role in Fall allergies. Some of the other allergens that may contribute to an individual’s Fall allergies may include dust mites, molds, pet dander, and cockroaches. It should also be pointed out that these allergens are perennial in nature and may cause allergic rhinitis, allergic conjunctivitis, and asthma symptoms throughout the year, and not only during the Fall season.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating ragweed allergies and other Fall allergies for more than 5 decades. We treat both pediatric and adult patients. If you suffer from allergies and/or asthma, please call Black & Kletz Allergy to schedule an appointment with one of our board certified allergists. We have 3 offices in the Washington, DC, Northern VA, and Maryland metropolitan area. Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible, with a free shuttle between the McLean office and the Spring Hill metro station on the silver line. Black & Kletz Allergy has been providing high quality allergy, asthma, and immunology care to the Washington, DC metro area for many years. Please call us for an appointment today or alternatively, you can click Request an Appointment and we will respond within 24 hours on the next business day.