Go to our "CLOSINGS" tab on our website to see our updated Coronavirus Policy

Blog

Eustachian Tube Dysfunction

The Eustachian tube is a small canal that connects the middle ear to the back of the nose and upper throat.  It is normally closed but opens when we swallow, yawn, or chew.

Normal functions of the Eustachian tube:

  1. Ventilation of the middle ear – Helps keep the air pressure equal on either side of the eardrum (i.e., tympanic membrane), enabling the eardrum to work and vibrate correctly.
  2. Drainage of secretions from the middle ear cleft.
  3. Protection of the middle ear from pathogens (e.g., bacteria, viruses, fungi)

Dysfunction of the Eustachian tube or Eustachian tube dysfunction (ETD) may occur when the mucosal lining of the tube is swollen or does not open or close appropriately.

Causes:

  1. 1. Allergic rhinitis (i.e., hay fever) – Seasonal or perennial in nature
  2. Upper respiratory tract infections (URI’s) – Single or recurrent episodes
  3. Nasal septal deviation (i.e., deviated septum)
  4. Cleft palate
  5. Enlarged adenoids and/or tonsils – Especially in children
  6. Nasal polyps

Risk Factors:

  1. Tobacco smoke
  2. Acid reflux [i.e., gastroesophageal reflux disease (GERD)]
  3. Radiation exposure

Symptoms:

  1. Feeling of clogging, fullness or pressure in the ear(s)
  2. Pain or discomfort in the ear(s)
  3. Muffled or decreased hearing
  4. Ringing sensation in the ear(s)
  5. Dizziness, vertigo, or feeling of imbalance

Complications:

  1. Otitis media with effusion (i.e., glue ear)
  2. Middle ear atelectasis (i.e., retraction of the eardrum)
  3. Chronic otitis media

Diagnosis:  

The inability to “clear” or “pop” the ear with changes in barometric pressure, together with other patient-reported symptoms (e.g., aural fullness, pain, muffled hearing) is consistent with Eustachian tube dysfunction.

Tests: 

  1. Otoscopy
  2. Tympanometry
  3. Nasal endoscopy

Treatment:

Non-Surgical:

  1. Supportive care – Includes advice about self-management such as to swallow, yawn, or chew.  These measures are especially useful while flying as sudden changes in barometric pressures aggravate Eustachian tube dysfunction.
  2. Pressure equalization methods – A technique where the Eustachian tube is reopened by raising the pressure in the nose.  This can be accomplished by forced exhalation against a closed mouth and nose which is referred to as the Valsalva maneuver.  Blowing balloons is also helpful in relieving the pressure in the middle ear by forcing air into the Eustachian tubes and keeping them patent.
  3. Nasal douching – The nasal cavity is washed with a saline solution in order to flush out excess mucus and debris from the nose and sinuses.
  4. Decongestants, antihistamines, nasal or oral corticosteroids – These medications are aimed at reducing nasal congestion and/or inflammation of the lining of the Eustachian tube.
  5. Antibiotics – Used for the treatment of rhinosinusitis (i.e., sinus infections)
  6. Simethicone – This is currently being investigated in adults to assess whether or not it can help to break up bubbles that may block the opening of the Eustachian tube in the back of the nose during an upper respiratory infection.  As a result, air should be able to pass between the nose and middle ear easier.

Surgical:

  1. Insertion of a pressure equalizing tube into the eardrum – Also known as a tympanostomy tube, ventilation tube, or grommet.  Pressure equalizing tubes typically fall out of the ears after 6-9 months.
  2. Eustachian tuboplasty – Balloon dilatation of the Eustachian tube

Of note:  The opposite condition of Eustachian tube dysfunction is called patulous Eustachian tube.  In this malady, there is an abnormal patency of the Eustachian tube.  Instead of being in the normal closed position, the Eustachian tube stays intermittently open, causing an echoing sound of the person’s own heartbeat, breathing, and/or speech.  These sounds will then vibrate directly onto the eardrum causing a “bucket on the head” sound effect.  This condition can usually be managed by nasal sprays.  Rarely, surgical intervention is warranted.

The board certified allergists at Black & Kletz Allergy has 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  The McLean office has a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line.  The allergy specialists of Black & Kletz Allergy diagnose and treat both adult and pediatric patients.  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.  The allergy specialists at Black & Kletz Allergy have been helping patients with Eustachian tube dysfunction, allergic rhinitis (i.e., hay fever), asthma, sinus disease, eczema (i.e., atopic dermatitis), hives (i.e., urticaria), insect sting allergies, immunological disorders, medication allergies, and food allergies for more than 50 years.  If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and annoying allergy symptoms.

Chronic Sinusitis Update

The term “chronic sinusitis” is defined as an inflammation of the sinus or sinuses lasting more than 12 weeks in duration. The inflammation can be of any etiology however it is implied and commonly agreed upon that infection is the primary cause of chronic sinusitis. In order to understand chronic sinusitis, it is important to know the anatomy of a sinus. A sinus is a cavity in any organ or tissue, but in reference to allergies, it is a cavity in the skull and often referred to a “paranasal sinuses.” There are 4 paired sinuses in the cranial bones. They are named for their location with regards to the head and face. The names of the sinuses include the frontal, ethmoid, sphenoid, and maxillary sinuses. The frontal sinuses are located in the forehead region above the eyes. The ethmoid sinuses are situated between the eyes on each side of the upper nose. The sphenoid sinuses are positioned behind the eyes and bridge of the nose and lie in the deeper areas of the cranium. The maxillary sinuses are located on either side of the nostrils in the cheekbone areas.

The symptoms of inflammation of the sinuses or a chronic sinus infection may include a sinus headache, facial pressure or pain, post-nasal drip, discolored nasal secretions, cough and/or fatigue. It should be noted that it is not uncommon for an individual to present with just a chronic cough without many additional sinus symptoms. The diagnosis of chronic sinusitis requires a comprehensive and physical examination. There is often a history of onset of the infection as well as a progression of specific symptoms which may help diagnose the sinus infection. In some instances, sinus X-rays and/or CT scans of the sinuses may be helpful in the diagnosis.

The treatment of chronic sinusitis varies depending upon how severe the symptoms are in each individual patient. Oral antibiotics are the most common treatment however a longer course of antibiotics is usually prescribed due to the chronicity of the infection. It is not uncommon to treat these patients with 30 days of continuous oral antibiotics. Topical corticosteroids [e.g., Flonase (fluticasone), Nasonex (mometasone), Nasacort AQ (triamcinolone), Rhinocort (budesonide), Qnasl (beclomethasone), Nasarel (flunisolide), Zetonna (ciclesonide), (Xhance (fluticasone)] are sometimes useful in the local treatment of bacterial infections.  The effects are usually short-lived however. The nasal corticosteroids are not currently recommended for routine use; however, they offer the potential for improved directed treatment of the sinuses. Saline irrigation or saline nasal strays are useful in the mechanical clearance of allergens, irritants, and microorganisms (i.e., bacteria, viruses) from the nasal and sinus cavities.  Saline irrigation is an inexpensive and easy to use method of “cleaning” the nasal and sinus cavities. It is often used in conjunction with other treatments such as nasal corticosteroids and oral antibiotics to treat chronic sinusitis. It should be noted that some individuals do not like saline irrigation as it may cause some discomfort in the nasal or sinus passages. Topical antibiotics are sometimes useful in the local treatment of bacterial infections. As with nasal corticosteroids, the effects are usually short-lived and topical antibiotics are not currently recommended for routine use; however, they offer the potential for improved directed treatment of the sinuses.

Occasionally, a more aggressive treatment regimen for chronic sinusitis is necessary and other medications are then utilized. Oral corticosteroids are implemented in more severe or recalcitrant cases. Oral corticosteroids reduce inflammation and are particularly useful for shrinking nasal polyps, though they also may result in the multisystem improvement of symptoms.  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.  Nasal polyps cause increased nasal congestion and may block the normal drainage pattern of the sinuses. As a result, sinus infections are more likely to develop in these individuals. It should be pointed out that oral corticosteroids carry a risk for significant systemic side effects such as weight gain, peptic ulcers, cataract formation, thinning of one’s bones, depression, and/or endocrine dysfunction. They should be used judiciously and only for brief periods of time. In addition to oral corticosteroids, biological medications [i.e., Dupixent (dupilumab)] are being used more often to treat chronic sinusitis with nasal polyps. Biological medications can offer targeted and more effective treatment than other therapies.  The potential advantages of biological medications include the reduced need for oral or topical corticosteroids as well as the need for sinus surgery. A few of these biological agents [i.e., Xolair (omalizumab), Fasenra (benralizumab), Nucala (mepolizumab), Dupixent (dupilumab)] are currently being used for the control of asthma but only one of them, Dupixent (dupilumab) has been approved for chronic sinusitis with nasal polyps.

Prevention is always the goal in any malady if at all possible. For chronic sinusitis, preventive measures include the identification of specific allergen sensitivities and the subsequent avoidance or preventive treatment for these allergies. Allergy testing should be done by skin testing or blood testing. Aggressive treatment of any seasonal or perennial allergic rhinitis (i.e., hay fever) promotes proper sinus drainage and as a result improves upper airway function. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) is a very effective tool to treat allergies and asthma as it works in 80-85% of patients that take them. The average treatment length of allergy shots is typically 3-5 years.

The board certified allergists at Black & Kletz Allergy treat both pediatric and adult patients. We diagnose and treat chronic sinusitis as well as other types of sinus disease, allergic rhinitis (hay fever), allergic conjunctivitis (i.e., eye allergies, asthma, allergic shin disorders [i.e., eczema (i.e., atopic dermatitis), hives (i.e., urticaria), generalized itching (i.e., pruritus), swelling episodes (i.e., angioedema), poison ivy, poison sumac, poison oak], anaphylaxis, food allergies, medication allergies, insect sting allergies, eosinophilic esophagitis, mast cell disorders, and immunological disorders. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. The Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. You may also click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been a fixture in the greater Washington, DC, Northern Virginia, and Maryland metropolitan area for over 50 years for our outstanding services for the diagnosis and management of allergic, asthmatic, and immunological conditions.

Sesame Allergy

Allergic reactions to sesame are increasing in incidence over the past several years. Sesame is the 9th most common food allergy among children and adults. Approximately 0.23% of the U.S population are allergic to sesame. Although 0.23% seems like a small number, the National Institute of Health’s (NIH) researchers estimate that 17% of food-allergic children have a sesame allergy.

In the past, according to the Center for Science in the Public Interest, only 14 out of 22 major food companies clearly labeled sesame ingredients on their product labels. However, on April 23, 2021, the FASTER (Food Allergy Safety, Treatment, Education, and Research) Act was passed into law. This law requires that sesame be labeled on all packaged foods in the United States. This sesame labeling began earlier this year on Jan. 1, 2023.

Sesame joins the 8 other foods that are already declared as major food allergens by federal law. The 9 major food allergens are as follows:

  • Milk
  • Eggs
  • Fish (e.g., bass, flounder, cod)
  • Crustacean shellfish (e.g., crab, lobster, shrimp)
  • Tree nuts (e.g., almonds, walnuts, pecans)
  • Peanuts
  • Wheat
  • Soybeans
  • Sesame

The protein that is contained in sesame seeds, sesame oil, tahini, etc. binds to the specific antibodies in one’s serum and causes reactions that cause the release of histamine and other chemical mediators which are responsible for the allergic symptoms that occur. Most allergic reactions to sesame are caused by oleosins, the proteins in sesame.

Symptoms:
Individuals with a sesame allergy may experience a variety of symptoms that can range from mild to severe. The symptoms may include itchiness of the throat or mouth, generalized itching (i.e., pruritus), hives (i.e., urticaria), swelling (i.e., angioedema), nausea, vomiting, diarrhea, abdominal pain, flushing of the face, hoarseness, coughing, wheezing, and/or shortness of breath

A person with a severe reaction to sesame may experience anaphylaxis. Anaphylaxis is a life-threatening reaction that requires immediate medical attention. Some of the symptoms of anaphylaxis may include hives, shortness of breath, generalized itching, swelling, wheezing, fainting, dizziness, drop in blood pressure, rapid heartbeat, and/or cardiac arrest. Individuals who experience anaphylaxis due to sesame should carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) with them at all times. If the self-injectable epinephrine device is used, they should go immediately to the closest emergency room.

In packaged foods manufactured prior to January 1, 2023, sesame may appear undeclared in ingredients such as flavors or spice blends.
Some foods that may contain sesame:

  • Asian cuisine – Sesame oil is commonly used in cooking
  • Baked goods (e.g., bagels, bread, breadsticks, hamburger buns, rolls)
  • Bread crumbs
  • Cereals (e.g., granola, muesli)
  • Chips (e.g., bagel chips, pita chips, tortilla chips)
  • Crackers (e.g., melba toast, sesame snap bars)
  • Dipping sauces (e.g., baba ghanoush, hummus, tahini sauce)
  • Dressings, gravies, marinades, and sauces
  • Falafel
  • Hummus
  • Flavored rice, noodles, risotto, shish kebabs, stews and stir fry
  • Goma dango (i.e., Japanese dessert)
  • Goma dofu (i.e., Japanese sesame “tofu”)
  • Herbs and herbal drinks
  • Margarine
  • Pasteli (i.e., Greek dessert)
  • Processed meats and sausages
  • Protein and energy bars
  • Snack foods (e.g., pretzels, candy, Halvah, snack mix, rice cakes)
  • Soups
  • Sushi

Some non-food items that may contain sesame:

  • Cosmetics
  • Medications
  • Supplements
  • Pet food

Diagnosis:
Skin Prick Testing – A safe and low-risk test in which the skin is lightly pricked with a suspected allergen. This can result in a raised bump or hive, with more severe reactions pointing to a greater likelihood of an allergy.

Blood Test – Measures the amounts of IgE antibodies (i.e., “allergy” antibodies) that the immune system has deployed as an allergic response to sesame.

Like tree nut allergies, sesame allergies are sometimes cross-reactive. In other words, if you are allergic to sesame, you could be allergic to similar seeds and nuts.

Treatment:
Mild allergic reactions to sesame can be treated with antihistamines. Systemic reactions with generalized symptoms needs to be treated with injectable epinephrine.

Prevention:
Diligent reading of the labels and strict avoidance of exposure to all sesame-containing products is necessary in order to prevent allergic reactions to sesame. Most patients with sesame allergy unfortunately do not “outgrow” the sensitivity.

If you suffer from or suspect a sesame allergy or any other type of allergy, the board certified allergists at Black & Kletz Allergy have the expertise in diagnosing and treating your condition. We treat both pediatric and adult patients and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible. Please either call us for an appointment or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy have been treating allergy, asthma, and immunology patients in the Washington, DC metropolitan area for more than 5 decades and we strive to provide state-of-the-art allergy care to its residents and visitors.

Allergies to Mold, Mildew, Yeast, and Fungus

It is quite common for individuals to be allergic to mold, particularly in the Washington, DC, Northern Virginia, and Maryland metropolitan area. Not only is the humidity elevated in this region, but Washington, DC was built on a swamp. In the Spring, it rains quite often contributing to an increase in moisture and thus mold. In the Summer, the metro area tends to be hot and humid which is ideal for mold growth. During the Fall, the leaves fall from the trees and get wet which is the perfect environment for the development and progression of mold. Even during the Winter mold can flourish particularly since mold lives both indoors and outdoors. In the home, molds tend to be more prevalent in bathrooms, kitchens, and basements, where moisture is more common. It is interesting to note that some molds can survive in very arid environments such as a desert. Any way you slice it, mold is year-round problem for residents and visitors of the Washington, DC metropolitan area.

Mold is a fungus that grows in the form of multicellular filaments that are known as hyphae.  There are over 400,000 types of molds. Mildew is also a fungus that closely resembles mold. Mold typically looks fuzzy in appearance while mildew characteristically is flat in appearance. The color of mold tends to be black, blue, green, or red whereas the color of mildew tends to be white, brown, or gray. Mold and mildew produce undesirable odors that many people find offensive or downright problematic as they can cause “sicknesses” to those exposed. Fungi that grow in a single-celled environment are called yeasts.  Regardless of their characteristics, mold, mildew, and yeast can all play havoc to individuals who are either sensitive or allergic to them. Regarding allergies to mold, mildew, yeast, and fungi, an allergy to any one of them is generally grouped into one category as “allergy to mold,” as opposed to an allergy to mildew, an allergy to yeast, or an allergy to fungi.

Molds produce tiny microscopic which are their reproductive structures. The diameter of a mold spore generally varies between 3 to 45 microns which is less than half the width of a typical human hair. The mold spores begin are released into the air and since they are tiny in size, they are able to float in the air, where they can be easily inhaled by sensitive individuals. Mold spores flourish in any milieu with a constant source of moisture. As mold grows, the tiny spores begin to undergo chemical reactions that allow them to consume nutrients and further replicate.  These chemical reactions produce fumes which are released into the atmosphere. These fumes are responsible for the unpleasant musty odor that everyone is familiar with.

Mold generally can cause annoying symptoms in 4 different ways. The first is from a true allergy to the mold. The most common type of symptoms from mold allergy are the kinds of symptoms one may experience from other environmental allergens such as dust mites, pollens, pets, or cockroaches. These allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies) symptoms may include sneezing, runny nose, post-nasal drip, nasal congestion, itchy throat, sore throat, sinus headaches, snoring, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. Severely affected individuals as well as asthmatics may also develop asthma symptoms or an exacerbation of their asthma which may include wheezing, chest tightness, coughing, and/or shortness of breath. The diagnosis of mold allergy necessitates a comprehensive history and physical examination in conjunction with allergy testing (skin tests and/or blood tests). The treatment of mold allergy always begins with prevention. Avoiding mold is always preferable if at all possible. Some of the ways to help reduce mold exposure may include decreasing outdoor activities when mold counts are high, repairing any leaks, lowering the humidity, using a dehumidifier, using air conditioner with a HEPA filter, removing carpets in locations where they are in danger of becoming wet, and masking when engaging in yardwork. The treatment of mold allergy consists of allergy medications (e.g., antihistamines, decongestants, nasal corticosteroids, nasal antihistamines, leukotriene antagonists, eye drops, asthma inhalers) to help relieve one’s symptoms.  Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are extremely effective in the treatment of mold allergy.  They are effective in 80-85% of the patients who receive them. Allergy injections have been given in the U.S. for more than 100 years as they get more to the root of the underlying problem by allowing a patient to develop protective antibodies against mold as well as other allergens such as dust mites, pollens, pets, and/or cockroach.

An unusual allergy to mold exists in roughly 1-2% of individuals with asthma. These individuals have an allergic reaction to a specific type of mold known as Aspergillus fumigatus.  Similarly, between 2-15% of children with cystic fibrosis have the same reaction to this same mold. Asthmatic and cystic fibrosis patients that react to this mold have a condition known as allergic bronchopulmonary aspergillosis (ABPA). The symptoms of ABPA are similar to that of asthma except they may also cough up sputum with brownish flecks and they may also have a mild low-grade fever. Such patients should be worked up for ABPA via X-rays/CT scans, pulmonary function tests, sputum cultures, blood tests, and allergy skin tests. The treatment of ABPA usually involves the use of medications to treat asthma with the possible addition of oral corticosteroids and/or antifungal medications.

The second way mold can affect an individual is from a non-allergic irritant reaction. Molds can release substances known as volatile organic compounds (VOC’s) which can irritate skin and mucus membranes inside the mouth, nose, and eyes resulting in burning sensation of the skin, itchy throat, runny nose, itchy eyes, watery eyes, and/or cough. Avoidance is the best way to prevent irritant reactions. Using air filters may also be of help.

The third manner in which a mold can cause bothersome symptoms is via a toxic reaction usually by way of inhaled or ingested toxic compounds called mycotoxins, which are produced by the mold. The molds that produce mycotoxins can pose serious health risks to humans and animals.  Some studies claim that the exposure to high levels of mycotoxins can result in neurological complications and prolonged exposure may be particularly harmful. The research on the health effects of these types of molds is somewhat controversial and it has not been conclusive. The term “toxic mold” refers to molds that produce mycotoxins, such as Stachybotrys chartarum and not to all molds in general. Mold remediation by a professional mold remediation service is the best way to remedy this situation.

The fourth method in which a mold can cause unwanted symptoms is by causing an infection. This results from the growth of a pathogenic mold within the body. The most common way that molds/fungi cause infections is through the skin. It should be noted that different types of molds/fungi can cause infections in other organ systems which may lead to gastrointestinal, respiratory, and/or neurological problems. Antifungal medications and occasionally other medications are used in order to eliminate the fungal infection.

The board certified allergy doctors at Black & Kletz Allergy will promptly respond to any questions regarding mold allergy or any other allergic or immunologic disorders. We have been treating mold allergies for more than 50 years and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have been serving the Washington, DC, Northern Virginia, and Maryland metropolitan area for a long time and treat both pediatric and adult patients. All 3 offices at Black & Kletz Allergy offer on-site parking and the Washington, DC and McLean, VA 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. If you are concerned that you may have a mold allergy or any other allergy, asthma, sinus, skin, or immunology problem(s), please call us to schedule an appointment. You may also click Request an Appointment and we will answer within 24 hours by the next business day. At Black & Kletz Allergy, we strive to improve the quality of life in allergic and asthmatic individuals in a professional and compassionate environment.

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.

CAUSES:
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

SYMPTOMS:
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.

DIAGNOSIS:
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.

COMPLICATIONS:
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).

TREATMENT:
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.

PREVENTION:
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.

Food Allergy vs. Intolerance vs. Sensitivity

There are different mechanisms that play a role in the causation of adverse and undesirable effects triggered by the consumption of food. In the world of food allergies, It is important to distinguish between these mechanisms in order to arrive at an accurate diagnosis. Allergy, intolerance, and sensitivity to foods require different diagnostic approaches including a careful history and skin or blood testing in order to diagnose the condition. The management of these conditions also varies based on the underlying mechanisms.

An allergy to a food traditionally means that there is an immunologic reaction to proteins in that food. This reaction is usually mediated by specific antibodies (IgE antibodies or immunoglobulin E antibodies) to these proteins. These antibodies react with the protein antigens in the food. These reactions result in a release of chemical mediators such as histamine and tryptase from mast cells and basophils into the tissues and bloodstream.

These chemical mediators (e.g., histamine, tryptase) also have adverse effects on the blood vessels, heart, lungs, and other vital organs. The result of this release of chemical mediators could vary in severity from mild itching of the skin to a severe life threatening reaction such as anaphylaxis. Ingestion of even small amounts of food can trigger such reactions, which usually begin within minutes of exposure.

The most important element in diagnosing food allergies is taking a careful and comprehensive history from the patient. It is important for the board certified allergist to focus on the specific food ingested (including the list of ingredients in prepackaged foods) as well as the timeline of the onset and progression of the symptoms. The history is complemented by the detection of specific IgE antibodies to the food(s) in question by way of skin testing and/or blood testing. These specific IgE allergy tests should be limited to only the foods that could have triggered the reaction suggested by the history.

Treatment of food allergies traditionally has been focused on the identification and subsequent strict avoidance of the offending food(s). Patients are also prescribed an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) to be used in case of a systemic reaction following an inadvertent exposure to the food. However, more recently, a desensitization procedure to foods such as peanuts by way of oral immunotherapy has become available.

As opposed to an allergy, an intolerance to a food is not mediated by an immunologic process. Instead, the process primarily involves the gastrointestinal system rather than the immune system. An insufficiency of certain enzymes usually found in the gastrointestinal system may hinder the proper digestive process and result primarily in gastrointestinal symptoms. A common example is lactose intolerance, where an enzyme called lactase is deficient. Lactose is a sugar found in dairy products. The enzyme lactase breaks down the lactose in normal individuals. In patients with lactose deficiency (i.e., lactose intolerance) the undigested lactose becomes fermented in the intestines which causes uncomfortable gastrointestinal symptoms such as nausea, abdominal discomfort, abdominal bloating, flatulence, and/or diarrhea after the consumption of dairy products. The symptoms are usually dose-dependent, meaning that the symptoms are usually worse the more you eat/drink.

Breath hydrogen tests are sometimes helpful in confirming the diagnosis of lactose intolerance. The treatment involves either avoidance of the foods one is intolerant to or supplementation with the oral enzymes (e.g., lactase enzyme) along with these foods in order to help in their digestion.

A sensitivity to a food is a poorly understood phenomenon and may involve non-specific inflammation of the gut. The symptoms are widely variable and may include abdominal pain, nausea, diarrhea, fatigue, joint pain, brain fog, and/or vague constitutional symptoms. The symptoms can begin hours or days after the food exposure and can be chronic in nature. The symptoms may be mediated by an immunologic processes but IgE antibodies are not usually involved. Some researchers speculate that IgG antibodies specific to foods may be involved, although it has not been scientifically proven. Interestingly, some IgG antibodies to certain foods can protect an individual from sensitivity and in fact, their levels are shown to rise after desensitization to those foods.

As the value of IgG antibodies in diagnosing food sensitivities has never been conclusively established, tests to measure IgG levels in blood against foods should not be ordered or obtained.

Of note, some physicians will lump food intolerance and food sensitivity into the same category.

Another caveat in the diagnosis of food allergies is that even elevated IgE antibody levels against specific foods do not always correlate with reactions after the consumption of these foods. False positives and false negatives can and do occur. Hence, the results should always be interpreted in the context of clinical reactions after exposure.

In view of the above mentioned nuances, ordering “broad panels” of specific IgE to various foods without correlating it to the patient’s history is not helpful in the diagnosis of food allergies. IgE levels should be obtained only to those specific foods that the patient could have reacted to, which should be based on the patient’s history. It is important to correlate the timeline of symptom onset as well as the progression of the symptoms after the exposure to the food.

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 food allergy, food intolerance, and food sensitivity. Black & Kletz Allergy diagnose and 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 and the Washington, DC and McLean, VA offices are Metro accessible. 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 5 decades and we pride ourselves in providing exceptional allergy, asthma, and immunological care in a professional and pleasant environment.

Summer Allergies vs. Summer Cold

summer cold vs summer allergiesSo, you have a runny nose, nasal congestion, sneezing, post-nasal drip, sore throat and coughing and it is the Summertime. Are you confused? You thought allergies occur in the Spring and Fall. You thought that “colds” occur in the Fall and Winter. Well, both “colds” and allergies can occur anytime and Summer is no exception.

“Colds” are caused by more than 200 different types of viruses. Some common viruses responsible for colds may include rhinovirus, other enteroviruses, coronavirus, influenza virus, parainfluenza virus, adenovirus, human respiratory syncytial virus (RSV), and metapneumovirus. Rhinovirus, an enterovirus, is by far the most common cause of the common cold than any other virus. Typically, the symptoms of a “cold” are similar to those of allergic rhinitis (i.e., hay fever). In addition to the classic sneezing, runny nose, nasal congestion, and post-nasal drip of allergic rhinitis, individuals with “colds” may also have other symptoms that may include sore throat, coughing, headaches, fatigue, achiness, fevers, chills, and/or discolored nasal discharge. It should be noted that discolored nasal discharge, fevers, and chills do not occur in most individuals with a common cold. In patients who have the influenza virus (i.e., flu), achiness, headaches, and fever are much more common than in individuals who only have the common cold.

In contrast to “colds” which are caused by viruses, Summer allergies are caused by common environmental allergens. The most common allergens found in the Summer include grass pollen, weed pollen, molds, dust mites, cockroaches, and pets (e.g., cat, dog, birds). Occasionally some tree pollen may cause some Summertime allergies in the Washington, DC, Northern Virginia, and Maryland metropolitan area, but in general, trees pollinate in the Spring and are not much of a nuisance by the time Summer rolls around. Grass pollen tends to become a problem in May and it may continue to be irritating to allergy sufferers until August. Ragweed usually begins to pollinate in mid-August and is generally done pollinating by the first frost in October. Molds, dust mites, cockroaches, and pets are perennial allergens and can bother allergic individuals throughout the year, including the Summer. Molds are found both indoors and outdoors and tend to be worse in damp places in the house such as kitchens, bathrooms, and basements, although mold can be anywhere in the house. Dust mites, cockroaches, and pets are indoor allergens, although pets can transfer outdoor allergens (i.e., pollens) to the inside of a house by means of their coats, as pollen may stick to the pet’s hair or fur.

The diagnosis of whether the “allergy” symptoms are a result of allergies or of a “cold” depends on many factors. The length of time one has had symptoms, auxiliary symptoms (i.e., sore throat, coughing, headaches, fatigue, achiness, fevers, chills, and/or discolored nasal discharge), other effected individuals, and response to treatment all play a role in diagnosing the cause of the symptoms. Typically, a “cold” lasts about 1 week in duration unlike allergic rhinitis which generally last at least a season and sometimes is perennial in nature. If other individuals that live in the same household have similar symptoms, a “cold” should be thought of as the cause before allergies. Supplementary symptoms to the classic allergic rhinitis symptoms such as sore throat, coughing, headaches, fatigue, achiness, fevers, chills, and/or discolored nasal discharge should trigger the allergist to think of a “cold” or flu before allergies as a cause. Lastly, the response to the treatment that an individual tries may also help the allergist determine the cause of the symptoms, be it an allergy or a “cold.”

The treatment of the symptoms may be similar regardless of whether the symptoms are a result of allergies or a “cold.” Symptomatic treatment typically may include oral antihistamines, nasal antihistamines, nasal corticosteroids, decongestants, and/or analgesics. Ongoing treatment may be needed in individuals with allergic rhinitis, whereas symptoms typically abate on their own within 1 week in individuals who have a “cold.”

Regardless of whether you have allergies or a “cold,” it should be emphasized that the classic symptoms of allergic rhinitis (i.e., sneezing, runny nose, nasal congestion, post-nasal drip) may occur at any time of the year. Yes, even Summer. Whether or not the symptoms are due to allergies or are a result of a “cold” however is another story. Either way, seeking the advice of a board certified allergist is an important step in determining the ultimate cause as well as finding the solution to reduce and hopefully eliminate those unwanted and annoying symptoms.

The board certified allergists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC metropolitan area. Our office locations are in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Each office has on-site parking 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. Our allergists see both adult and pediatric patients. To make an appointment, please call our office location that is most convenient for you or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy strive to provide our patients with the highest quality allergy, asthma, and immunology care in the Washington, DC, Northern Virginia, and Maryland metropolitan area.