Now, there’s more and more research suggesting that a lot of people who are experiencing symptoms at disparate areas in the head and neck are actually experiencing allergies. —Christopher D. Brook, MD
Explore This Issue
September 2021
Research supports her supposition. A 2015 retrospective chart review of 998 patients who underwent allergy testing found that 60.9% of patients with chronic sinusitis had at least one positive specific IgE allergen test (Otolaryngol Head Neck Surg. 2016;154:41-45). Approximately 35% of allergic patients with chronic sinusitis had a sensitivity to dust, 35.6% were allergic to insects, 31.2% to tree pollen, 24.3% to weeds, 20.3% to grass, and 12.4% to mold.
“We don’t understand the exact pathophysiology yet,” Dr. Wise said, “but at least we have a baseline understanding and some data to support that.”
The link between allergy and sinusitis wasn’t acknowledged when Ayesha Khalid, MD, MBA, division chief of otolaryngology at Cambridge Health Alliance in Massachusetts, was a medical resident. “We talked about people’s allergies, but in a limited fashion,” she said. “We never really talked about their skin sensitivities or food intolerances.”
Experience and evolving research have taught Dr. Khalid to inquire about patients’ allergies. If a patient exhibits current evidence of allergic involvement, she may decline to perform a surgical procedure unless the patient agrees to also address his or her allergies. “Surgery,” she tells her patients, “isn’t going to cure you. It isn’t going to cure the lining of your nose or your sinuses.”
That’s a message some patients don’t want to hear. They may imagine sinus surgery as similar to a hip or knee replacement—do the surgery and in a few weeks that body part will be as good as new. But although removing nasal polyps may temporarily improve breathing for an allergic patient who has nasal polyps and chronic rhinosinusitis, the congestion (and polyps) will likely return if the allergies aren’t controlled.
“If we can’t embark on a treatment paradigm that includes allergy diagnosis and treatment, there’s no point in doing surgery,” Dr. Khalid said. “If a patient has evidence of severe allergic inflammation and we do surgery without addressing the allergies, it may take six months or six years, but eventually the surgery will ‘fail.’ It isn’t really that the surgery fails, however; it’s that the lining of the sinus isn’t working optimally.”
Larynx
Currently, most cases of chronic laryngitis are attributed to laryngopharyngeal reflux. However, increasing evidence suggests that allergy may play a bigger role in vocal problems and chronic cough than previously suspected.
A 2019 review published in the Brazilian Journal of Otorhinolaryngology noted that individuals with allergic rhinitis have a higher prevalence of dysphonia than non-allergic individuals (Braz J Otorhinolaryngol. 2019;85:263-266). According to the same article, “singers with vocal symptoms are 15%-20% more likely to have allergic rhinitis than those without vocal symptoms.” A study from Taiwan found that individuals with allergic rhinitis were 2.43 times more likely to have laryngeal pathology than individuals who did not have allergic rhinitis (Healthcare. 2021;9: 36).
The Taiwanese study followed patients for several years and found that the median time to onset of laryngeal disease in those who were diagnosed with allergic rhinitis was 3.2 years. The authors estimated the cumulative one-, four-, and eight-year incidences of laryngeal pathology to be 3.0%, 8.1%, and 13.5%, respectively, for patients with allergic rhinitis.
The fact that laryngeal symptoms seem to emerge after years of allergic rhinitis suggests a causative role for allergy, with inflammation leading to hypersecretion of mucus, cough, dysphonia, and laryngeal edema.
The link between allergy and laryngeal symptoms isn’t usually apparent to patients, who typically present with cough, throat, or voice complaints. “Once you start asking them enough questions, though, they might realize that yes, they do have nasal stuffiness or sneezing or mild seasonal symptoms,” Dr. Brook said.
Consider referring patients with a history of allergy and those who have dense endolaryngeal mucus for allergy testing, particularly if previous treatments haven’t yielded lasting relief. “If they’ve tried everything under the sun and are looking for relief, I’ll often allergy test them and institute some sort of allergy treatment, which is quite often successful,” Dr. Brook said.
The 2015 retrospective chart review mentioned earlier also found that approximately 52% of patients with laryngeal symptoms who underwent allergy testing had at least one positive specific IgE allergen test (Otolaryngol Head Neck Surg. 2016;154:41-45). Patients with chronic laryngeal symptoms and positive allergy testing were most often sensitized to dust mites (63%).
Allergy testing may not be worth the effort or expense if the patient isn’t willing to pursue treatment. “If you’re looking at someone with some sort of chronic head and neck issue and you suppose allergy may be a part of that, you have to consider if the patient is bothered by it,” Dr. Brook said. “If they’re not bothered, it’s really not worth allergy testing them. If you’re not going to do anything with that information, it’s a waste of resources.”
It is helpful to have a close working relationship with an allergist; however, Dr. Khalid cautions that it may take some time to establish a mutual plan of care.
“I’ve had allergists send patients back to me and say, ‘Well, why don’t you take care of the sinuses first? Then send them back if they have issues,’” Dr. Khalid said. “I’ve had to work really hard over the last few years to persuade them that my surgery won’t succeed if the allergies aren’t well managed.”
Ideally, the otolaryngologist and allergist will work with the patient (and the patient’s primary care provider) to co-manage the patient’s symptoms and underlying pathology.