Allergy-Sinus Connection

Q.What percentage of sinus patients also have some allergies?
A.According to a recent report, allergic rhinitis is an underlying condition in 56% of patients with chronic rhinosinusitis. (McNally PA, White MV, Kaliner MA. Sinusitis in an allergist’s office: analysis of 200 consecutive cases. Allergy Asthma Proc 1997; 18: 169-76. From my own practice, I believe this is a pretty accurate percentage. It is absolutely essential to treat allergy-rhinosinusitis patient for both conditions at the same time in order to provide the best patient outcomes. A pure surgical or pure medical approach may not be the best therapy.
Q. Why is there an overlap in the allergy and sinus conditions?
A. There is an overlap in these conditions because allergic rhinitis: 1) produces mucosal edema that may obstruct the outflow tract, resulting in stagnation of secretions and overgrowth of bacteria, or rhinosinusitis; 2) a reduction in mucociliary clearance is seen in perennial allergies-poor evacuation of secretions can produce the effects seen in (1) as well.
Q. Are there any kinds of allergies you see connected to sinus conditions more frequently than others?
A.Perennial allergies seem to predispose patients to chronic sinus disease due to the constant swelling/inflammation taking place in their nose/sinus outflow tracts. Dust allergy seems to be a particularly bothersome one, though the high prevalence of dust allergy might make it appear frequent anyway. Mold allergy is associated with allergic fungal rhinosinusitis. Seasonal allergies alone can precipitate an acute rhinosinusitis event, though these patients typically can be treated successfully medically with attention to the acute infection (i.e., antibiotics), and perhaps more importantly, their underlying allergies (e.g., ragweed, grass).
Q. How does this connection manifest itself in systems?
A. Patients with allergy symptoms frequently complain of nasal congestion, clear rhinorrhea, itchy eyes/nose, and watery eyes. The eye complaints frequently help to differentiate an allergic rhinosinusitis patient from a non-allergic rhinosinusitis patient. When the nasal discharge changes to yellow, green, or brown, and the patient’s symptom complex worsens (i.e., new onset/worsening of major and/or minor symptoms of rhinosinusitis: see for listing), then an infection has possibly complicated their condition. A physical examination, possibly involving an endoscopic evaluation, is then warranted. A CAT scan might be needed to help diagnose the condition as well.
Q. If I have early morning sinus headaches, is it possible there is an allergy component?
A.Yes. Patients with morning complaints frequently are found to have a dust allergy. The patient is lying on a pillow and mattress that are literally crawling with dust mites; the patient breathes the dust allergens all night and wakes up with symptoms. Keep in mind though that morning headaches are also associated with obstructive sleep apnea, a potentially life threatening condition.

Q. How would I know the difference between a real sinus headache and one caused by allergies?
A.A reasonable home approach would be to treat the headache and to see what improves the condition. Antihistamines, available over the counter, would provide an allergy patient some relief. A decongestant (oral or topical) would improve a headache that is of nasal origin (i.e., allergies, sinus disease, etc.). Non-steroidal anti-inflammatory medications will provide pain relief for any of these situations, but work best in cases of tension headache. Of course, allergy evaluation and testing is a successful way to identify the cause of headache.
Q. Do patients with an overlapping sinus-allergy condition suffer from congestion and headaches worse during the pollen season?A.Yes. Their particular allergy season will intensify their underlying symptoms associated with chronic rhinosinusitis. This is due to the edema and inflammation associated with pollen exposure.
Q. If I am allergic to indoor allergens-mold , dust-mites , dander and the like, does a Hepa filter in the bedroom prevent a sinus headache?
A. A HEPA filter is a useful adjunct in allergen reduction/avoidance. This is the first tier of allergy treatment (i.e., (1) avoidance, (2) pharmacotherapy, (3) allergy immunotherapy). HEPA filters are best used in a room that has had maximal allergy reduction techniques employed already. HEPA filters clear lighter allergen particles better than heavier ones that may not float far enough to be ‘sucked into’ the filter (e.g., cat dander may be cleared more effectively than dust mite allergen).

Q. Do you see sinus headaches effected by weather of menstrual cycles?
A.The weather can affect sinus headaches: pressure changes may not be able to be quickly equalized in a patient with minimal egress for the air within the sinuses caused by allergies or sinus disease. This is referred to as osteomeatal obstruction. Unequal pressure leads to pressure/pain symptoms that mimic an acute rhinosinusitis; this is sometimes called barosinusitis. These patients have particular problems while flying: the descent is painful, as the pressure within the sinuses becomes more negative. Spraying the nose with oxymetazoline prior to the descent or flight will help these symptoms. If medical measures do not sufficiently control the symptoms, then surgery may be warranted. The menstrual cycle can affect a sinus headache as the body cycles through water retention; this may lead to increased edema at the osteomeatal complex region within the nose, and intensify underlying symptoms.
Q. If allergies are a disease of a compromised immune system how do you recommend to your patients they build up their immune system?

A. Allergy patients actually have an ‘overactive’ immune system, but it is figuratively ‘wasting time and energy’ to fight non-threatening items (i.e., pollen grains). Allergy patients have a shift in their T helper cell profiles from Th1 (fight infection) to Th2 (promote allergic disease). We do not understand why this shift takes place, though it seems to be genetic along with other factors. Nor do we understand fully how to shift the process back. Allergen immunotherapy may help to blunt the Th2 response. The average American diet provides enough of the RDA to avoid deficiency diseases, such as scurvy, but it probably does not provide enough nutrients of the proper levels. The overfarming of land with minimal replacement of micronutrients within the soil compound this issue. The food that our grandparents ate provided them with more nutrients than a similar meal today. I believe everyone should take a multivitamin with vitamins C, E, B complexes, micronutrients, and antioxidants. We should reduce our use of trans-fatty acids while switching to more polyunsaturated fats. I cannot claim any significant training in this area, but this is a personal conviction.
Q. Any general treatment or preventative suggestions for allergy and sinus sufferers?
A.The nutritional information above is valuable for anyone, allergic or not. Avoidance techniques are a useful adjunct in allergy care, and in mild cases, may be all the treatment that is necessary. Find a physician that will spend the time necessary to evaluate your individual situation, and who will work with you to define an individualized treatment plan. Antihistamine X may not be the right medication for everyone; an allergist (either otolaryngic allergy or general allergy) understands the nuances of the drugs to pick and choose appropriately. Do not present to a physician when your symptoms have become unbearable; the benefits of therapy will take some time to manifest.