Nasal, Sinus and Eye Conditions
The term “rhinitis” refers to inflammation of the nasal passages. Symptoms include sneezing, itching, congestion (“stuffiness”), runny nose, and postnasal drip. There are many potential causes for rhinitis including seasonal (also known as “hayfever” or pollen allergy) and indoor allergies, which can usually be attributed to pets, molds, or dust. Some patients have no identifiable allergies on testing and fall into the category of “non-allergic” or vasomotor rhinitis, which usually indicates a hyper-responsiveness of the nose due to a nerve imbalance. Treatment for rhinitis varies based on the diagnosis and cause. Allergic rhinitis (AR) (those due to pollen or indoor allergens) can be treated with avoidance techniques, medications, and immunotherapy (allergy “shots” or “drops”). Non-allergic rhinitis is treated with avoidance (when possible) and medications.
Eye allergies or allergic conjunctivitis often coincide with nasal allergies, but in as many as 30% of patients can be the only symptom. Symptoms include eye itching, wateriness, or redness. Treatments include medications (eye drops and/or oral antihistamines) and immunotherapy.
Skin allergies are very common and come in many different varieties. Atopic dermatitis (AD) or eczema is a lifelong skin disorder that generally starts in childhood. It is closely related to seasonal or indoor allergies and is often the first presentation of the “atopic march,” in which children present initially with eczema followed by allergies and then asthma. Contact dermatitis is another type of skin condition that can be from an irritant (such as excessive exposure to water and soap) or from an allergic substance (such as poison ivy or nickel in costume jewelry). Diagnosis is based on a thorough history and physical as well as skin testing, either with prick testing or patch testing to determine if there is a culprit or inciting allergen. Chronic itching without a rash can also be secondary to allergies, and testing can help identify if there are any environmental factors worsening the symptoms.
Hives or urticaria is an intensely itching and red rash that is characterized by a wheal (raised bump) and flare (redness surrounding). Each lesion should last less than 24 hours although new hives can develop at other sides. Angioedema is self-limited localized swelling which is a deeper form of hive and typically lasts several days to the deeper nature. Sometimes a trigger can be identified such as a food, drug, or insect sting but would be consistent (occurring with every encounter), chronologically concordant (occurring within 30-60 minutes of the presumed trigger), and not occur when the trigger is being avoided. Physical triggers such as pressure or elevated body temperature (as in the case during/after exercise) are also possible. If no identifiable trigger is found, the most common causes in acute hives/angioedema (<6 weeks) is acute illness (usually viral) or stress. In chronic hives/angioedema (≥ 6 weeks), the process is not allergic in nature but more likely secondary to an immune stimulating process (such as chronic illness/disease, hormonal imbalance, or unidentifiable). Rare causes include urticarial vasculitis, mastocytosis, and hereditary angioedema. Frequently no cause is found and treatment is aimed at minimizing symptoms. A thorough history can determine if testing is warranted and the best treatment options.
Asthma is reversible airway obstruction with symptoms of cough, wheeze, shortness of breath, and chest tightness which respond to inhalers such as albuterol and to steroids. Diagnosis is based on history, exam, and lung function testing such as spirometry. Some asthma is intermittent only based on certain exposures (allergens, illnesses) or induced by exercise (ie. exercise induced bronchospasms or EIB). Some is persistent and requires daily medications to prevent or control lung inflammation. A chronic cough can be a sign of asthma, especially in children, and is known as “cough variant” asthma. Cough can also be signs of rhinitis, allergic or nonallergic. Immunotherapy (allergy “shots” or “drops”) can help prevent the progression of allergies to asthma when utilized in children. Reflux is another common cause for a chronic cough. Treatment of chronic cough is based on a diagnosis, which usually requires evaluation and testing.
Prior to seeing Dr. Becker, I had had 3 sinus surgeries with little to no success. The problem would persist and I would constantly have headaches, congestion, night sweats, etc… I truly feel that Dr. Becker improved my quality of life with the 4th (and hopefully the last!) sinus surgery. In the four years since his surgery, I have had 1 sinus infection, and I am fine taking the occasional allergy pill or nasal steroid spray on a bad day. I will be forever grateful for his expertise.
Anaphylaxis is a severe systemic allergic reaction to a trigger, although rarely can be “idiopathic” or without a cause. Symptoms encompass the respiratory system (throat swelling, asthma-like attack), gastrointestinal system (nausea, vomiting, diarrhea, cramping), or cardiovascular system (low blood pressure, passing out). Skin manifestations often accompany the above symptoms with hives, swelling, and flushing, but when in isolation without respiratory, gastrointestinal, or cardiovascular symptoms, are not considered anaphylaxis. Evaluation is aimed at determining the trigger, so the patient can avoid subsequent exposure. This is done by a thorough history followed by testing to possible culprits.
Food allergies can be divided into immunologic reactions vs. non-immunologic. Non-immunologic reactions include adverse reactions from gastrointestinal disorders, such a lactase deficiency causing lactose intolerance. There are a wide range of food intolerances that cannot be tested for with the typical allergy testing and avoidance is the best treatment.
Immunologic reactions include immediate reactions mediated by an allergic antibody (IgE) to a specific food. Symptoms for IgE mediated reactions include hives, swelling, respiratory distress, gastrointestinal manifestations (cramping, nausea, vomiting, diarrhea), or signs of cardiovascular involvement (lightheadedness, dizziness, passing out). Trigger is consistent with symptoms always occurring with the specific food ingestion regardless of the form it takes (ie. milk allergy symptoms would occur whether the patient ate cheese or yogurt). Symptoms should occur within 30-60 minutes, although rarely up to 2 hours later. There are rare causes such as allergy to alpha galactosidase – found in mammalian meats and associated with prior tick exposure – that can have more delayed reactions many hours later. Oral allergy syndrome or pollen food allergy syndrome is due to cross reactivity of pollen with certain fruits and vegetables, typically in the raw form. Symptoms are generally limited to the mouth and throat with itching, tingling, swelling sensations. Rarely will symptoms occur beyond the mouth, with systemic or anaphylactic symptoms being even more uncommon. Heating the fruit or vegetable, even for a short period, denatures the cross-reactive protein to allow many patients to eat the food without incident. Immunotherapy (allergy shots or drops) to the culprit pollens have been shown to help improve tolerability to the cross-reactive foods.
Other immunologic reactions that are non-IgE mediated (or mixed reaction) include eosinophilic esophagitis (EoE), food protein-induced enterocolitis (FPIES), and celiac disease (gluten intolerance). EoE and FPIES are evaluated and treated by allergist, while celiac disease is best evaluated by gastroenterology, who can perform a small bowel intestinal biopsy, which is the gold standard for diagnosis.
Adverse reactions to drugs can be separated into Type A reactions and Type B reactions. Most reactions to medications are from Type A reactions and are predictable based on the known properties of the drug. One example would be stomach upset from long-term ibuprofen use. Type B reactions account for 10-15% of adverse drug reactions and are unpredictable. These reactions can be further divided into drug toxicities/intolerances (at lower than expected doses), idiosyncratic reactions (such as sulfa medications causing anemia in patients with G6PD deficiency), or immunologic drug reactions (drug allergy). Drug allergy can be immediate or delayed. Penicillin is the most highly reported drug allergy, however 90% of patients with this history are able to tolerate penicillin. This is due to the fact that many patients are probably mislabeled as allergic. Others may outgrow their allergy as their allergic antibodies wane over time. Patients labeled as allergic to penicillin are more likely to be treated with more expensive and broad-spectrum antibiotics (eg. Quinolones and vancomycin) which contribute to the development and spreading of multiple drug-resistant bacteria and higher health care costs. Skin testing can be performed with an FDA approved product for testing with a high sensitivity and specificity. If testing is negative, an in-office challenge is performed to clear the patient from this diagnosis.
Latex allergy is secondary to hypersensitivity to natural rubber latex from the Hevea brasiliensis tree. Certain populations, such as healthcare workers or those patients using latex-containing medical devices, are at highest risk. Symptoms can vary from a contact rash to full body systemic reaction or anaphylaxis. Avoidance is the key, even in those with just a rash as progression to anaphylaxis is unpredictable. There are a wide variety of products found in the community and hospital setting and include latex gloves, balloons, condoms, anesthesia face masks, elastic bandages, envelope adhesive, rubber bands etc.
Venom or stinging insect allergy is a potential life threatening condition. The most common culprits are the flying hymenoptera (honey bee, yellow jacket, yellow hornet, white-faced hornet, and wasp). Symptoms can range from skin or cutaneous only (hives, swelling) to full body systemic reaction (anaphylaxis). Testing is necessary to determine the culprit insect, as even those that study entomology (the study of insects) can have difficulty telling these various flying insects apart. Immunotherapy (allergy shots) can be lifesaving, reducing the patient’s risk of a future systemic reaction from 60-70% to 1-3% after a 3-5 year course.
Recurrent infections can be a sign of an inherited (primary) or developed (secondary) defect of the immune system. Secondary causes of recurrent infections can include immunosuppressant medications, malignancy, structural defects (such as frequent ear infections in young children). Primary immunodeficiencies often present with unusual organisms causing illness, need for intravenous antibiotics for clearance of an infection, or recurrence of infections as soon as antibiotics are completed. Evaluation is based on a thorough history to determine the extent of the illnesses, and if determined necessary, blood testing to evaluate various components of the immune system.
I have suffered for 3 years with extreme nose bleeds and my previous doctor was cauterizine the nose area which was of no help. I decided to find another doctor, I googled Dr. Becker he resolved my problem easily and cost effective, he recommended a medicine that cost me $1.49 and my bleeding has stopped. His office in Robbinsville is well presented and clean. On my visits I have been called on time to see him, wating time is minimal. Dr. Becker is very friendly and you can converse with him and his approach makes you feel relaxed. He has a sense of humor, do not ask, is it going to hurt because his response will be its not going to hurt me.
Allergy Testing – Pollen, Pet, Mold, Dust, Food, and Drug
There are several techniques for allergy testing. The most common is known as “prick” testing in which a small drop of the allergen is introduced to the skin using a puncture or scratch device. Trauma to the skin is minimal and “reading” the test occurs 15-20 minutes later. Pollen, pet, mold, dust, and food testing is performed in this manner. Rarely in cases of pollen, pet, mold, and dust testing will intradermal testing be required. Intradermal testing uses a very small needle to place a small amount of the allergen within the layers of the skin. The technique is similar to a PPD or TB (tuberculin) test. Drug testing is also performed in this manner. For both prick testing and intradermal testing, patients must avoid antihistamines for 5-7 days prior to the testing. Antihistamines will block the accuracy of the testing and could result in false negative results. Cetirizine (Zyrtec), fexofenadine (Allegra), loratadine (Claritin), diphenhydramine (Benadryl) are all examples of antihistamines. For a more complete list of antihistamines, click here.
Occasionally, blood testing is preferred by the patient or is necessary due to skin conditions of the patient. Blood testing is also accurate although not as sensitive as skin testing, the preferred method. Blood testing is also preferred in those patients with long history of food allergies, in order to follow a specific level to the allergic antibody to determine when a patient may have outgrown his or her allergy, warranting a food challenge in the clinic.
Allergy Shots or Immunotherapy
Allergen immunotherapy, also known as allergy shots, is a form of long-term treatment that decreases symptoms for many people with allergic rhinitis, allergic asthma, conjunctivitis (eye allergy) or stinging insect allergy. Allergy shots decrease sensitivity to allergens and often leads to lasting relief of allergy symptoms even after treatment is stopped. This makes it a cost-effective, beneficial treatment approach for many people. Both children and adults can receive allergy shots, although it is not typically recommended for children under the age of five, due to difficulty with cooperation and trouble articulating any adverse symptoms they may be experiencing. For older adults, medical conditions such as heart disease should be considered and in those patients who have significant medical issues, the risks of allergy shots may outweigh the benefits. Allergy shots are NOT used to treat food allergies.
The decision to initiate allergy shots is a personal one and will be made in conjunction with your allergist. The choice for shots is based on the severity of symptoms, number of allergies, effectiveness of medications or avoidance measures to control symptoms, desire to avoid long-term medications, time available to commit to allergy shot treatment, and cost.
Allergy shots work like a vaccine. Your body responds to the injected allergen by developing immunity or tolerance to the allergen. The treatment consists of 2 phases. The build-up phase involves receiving injections with increasing amounts 1-2 times per week. The length of this phase depends on how often injections are received and any delays between injections, but generally ranges from 3-6 months. Once a maintenance dose or “full dose” is reached, the injections are spaced out to 2-4 weeks between injections and this is called the maintenance phase. You may notice improved symptoms during the build-up but it may take as long as 12 months on the maintenance phase to notice improvement. For best long-term response, this dose is maintained for 3-5 years.
The first allergy shots were given over 100 years ago and there are numerous studies to show they decrease symptoms of allergic rhinitis, allergic conjunctivitis, and allergic asthma. In children, they can prevent the progression of the “atopic march” from allergic rhinitis to asthma. Effectiveness appears to be related to the length of treatment as well as the dose. Many patients experience lasting relief following a standard treatment course, while some may relapse after discontinuation. Treatment doses and lengths are individualized based on the patient’s symptoms and needs.
Allergy shots are not without risk. Injections are given subcutaneously, generally in the back of the upper arm. The typical reaction is local with redness, swelling, and itching at the site of the injection. In some cases, allergy symptoms may increase with sneezing, nasal conjunction, runny nose or eyes. For some patients, hives can occur, and more rarely symptoms of anaphylaxis occur with swelling of the throat, wheezing or shortness of breath, nausea, dizziness, etc. Most serious reactions develop within 30 minutes of the injection, which is why there is a mandatory 30 minute wait following allergy injections. Delay in treatment of anaphylaxis can worsen the outcome. Although death is extremely uncommon (1 in 2 million injections), it is a potential outcome particularly when life-saving treatment is delayed. All allergy shots are given in the clinic under direct supervision of properly trained staff, with ready access to life-saving equipment.
Sublingual Immunotherapy (SLIT) or “Allergy Drops”
Sublingual immunotherapy (SLIT) or “allergy drops” is an alternative method to treat allergies without injections. Currently, the only FDA-approved forms of SLIT are tablets for ragweed, northern grasses, and dustmites. The safety and efficacy of allergy drops is still being determined and therefore are considered off-label treatment in the United States, with insurance companies not paying for this form of treatment. Regardless, the efficacy of allergy drops has been established in numerous studies both in Europe and the US. Treatment with drops does not seem to be as effective as shots, particularly for long-term sustained improvement. Another limitation is the ability to treat with only a few allergens before efficacy appears to be diminished. However, for many patients who cannot tolerate injections due to needle phobia or time constraints to prevent them from coming to the clinic, allergy drops are a good option particularly when medication improvement is sub-optimal. There are still potential risks for full body systemic reactions or anaphylaxis to allergy tablets or drops, however the risk is lower than with shots. The first drops from each new vial is administered in the clinic for safety but subsequently, patients take a daily tablet or drop under the tongue at home as prescribed by their allergist.
Oral immunotherapy to foods is being investigated to determine if common food allergies such as peanuts can also be treated in this manner. Studies are promising but safety, efficacy, length of treatment, and doses are still being determined. Therefore, food allergies are best treated with avoidance at this time.
Contact dermatitis can be secondary to allergic or irritant causes. Patch testing can help determine if an allergy to a substance is the culprit for recurrent rashes. This diagnostic method takes several days as allergic contact dermatitis is a delayed reaction. During the first visit for the test, common potential culprit allergens will be placed on the back and adhered using medical tape. The patient will be instructed to avoid activities that may introduce water to the area (showering, swimming) or cause significant sweating (vigorous exercise). In 48 hours, the patient returns to the clinic for removal of the patches and initial read. Then patients are instructed to return in another 24-48 hours for the final read. Rarely, a 3rd reading is required 7 days after removal. Any positive results can be recorded and instructions on avoidance provided.
Pulmonary Function Testing
Pulmonary function tests help determine how well your lungs are working by measuring the amount of air your lungs hold and how fast the air can enter or exit your system. Spirometry is performed in the allergy clinic and helps to measure the FVC (forced vital capacity) or amount of air you can expel from your lungs during forced maneuvers. This is compared to the FEV1 (forced expiratory volume in 1 second) or amount of air you can “blast” out of your lungs in the first second. These measurements can help determine if you a form of lung “obstruction.” Treatment with albuterol can determine if this obstruction if reversible, and would indicate a likely diagnosis of asthma. The test is a simple procedure performed in the clinic and only requires some practice and patient cooperation to blow into a hand-held tube.