Alice:

Hi! What should I do with my "allergy"? I have something which I do not really have a term for, but basically the insides of my nose are always inflamed to some extent, causing partial or sometime full blockage of normal breathing through the nostrils. I have been to lots of doctors, and I even took regular allergy shots for a while. However, nothing seems to help. Most doctors agree that this is some "allergic" thing. What can I do about it and where can I get more help?

Thanks!

— Itchy nose

Dear Itchy nose,

What a congestion conundrum! By reaching out for more information, you’re hopefully on a path to finding much-needed relief. As you may already know, inflammation and congestion of the nose associated with allergies is typically referred to as allergic rhinitis or hay fever. In addition to an inflamed and stuffy nose, other symptoms could include itching in the nose, roof of the mouth, throat and eyes; sneezing; runny nose; tearing eyes; and dark circles under the eyes. But, there are several conditions, besides allergies, that could cause your current symptoms (more on this later). While you may have some more probing to do, taking further action might be worthwhile so you can get to the bottom of your sinus symptoms.

Since your health care providers seem to believe that you have allergic rhinitis that may be a good starting point. Folks who can’t seem to shake allergic rhinitis could actually have chronic sinusitis. This condition causes inflammation and swelling around the nasal passages (sinuses) for at least 12 weeks, despite treatment attempts. With chronic sinusitis, folks may experience thick, discolored discharge from the nose or drainage down the back of the throat; pain, tenderness, and swelling around your eyes, cheeks, nose, or forehead; cough (in children) and reduced sense of smell and taste (in adults).

While people with allergic rhinitis are more likely to suffer from chronic sinusitis, there are some other common causes for the chronic condition including:

  • Nasal polyps. These tissue growths can block the nasal passages or sinuses. 
  • Deviated nasal septum. A crooked septum — the wall between the nostrils — may restrict or block sinus passages.
  • Respiratory tract infections. Infections in your respiratory tract — most commonly colds — can inflame and thicken your sinus membranes and block mucus drainage. These infections can be viral, bacterial, or fungal.
  • Other medical conditions. The complications of cystic fibrosis, gastroesophageal reflux (acid reflux), or HIV and other immune system-related diseases can result in nasal blockage.

List adapted from Mayo Clinic.

But what if it's not allergies? One reason why your current treatment may not be working could be that your symptoms are caused by something else. There are non-allergic conditions that can also cause your current symptoms, one of which is nonallergic rhinitis. This condition is tricky to differentiate from its allergy-associated counterpart, because the symptoms are very similar. However, nonallergic rhinitis is triggered by environmental irritants (think dust, smog, secondhand smoke, etc.), weather changes, infections, food and beverages (the spicy and alcoholic kind, respectively), certain medications, and hormone changes.

Since many of the symptoms overlap between different conditions, getting to the bottom of this may involve talking with a medical professional (again). Given that rhinitis can be caused by an allergic reaction, allergy testing may be recommended. This typically involves skin or blood tests (if you have not already had them) that help identify specific allergens or help rule out allergy-related conditions. To rule out sinus issues (e.g., nasal polyps or a deviated septum), it may be necessary to take a gander at your sinuses through nasal endoscopy or a CT scan.

Once the cause of your symptoms is determined, the next step is figuring out the most appropriate treatment. Itchy nose, you mention that you have regularly taken allergy shots, but they don’t seem to work. Interestingly, allergy shots (or immunotherapy) are recommended as a potential treatment option for chronic sinusitis. In some folks, however, immunotherapy is not effective for a number of reasons, including inadequate dose of allergen (allergy trigger) in the vaccine, allergens that were not identified during the allergy test, high levels of allergen in the environment, and significant exposure to non-allergic triggers (such as tobacco smoke). Fortunately, there are other treatments of chronic sinusitis available including:

  • Saline nasal irrigation. This process (including nasal sprays and neti pots) helps reduce drainage and rinse away irritants and allergies.
  • Nasal corticosteroids. These nasal sprays help prevent and treat inflammation. If the sprays aren't effective enough, rinsing with a solution of saline mixed with drops of budesonide (a corticosteroid) or using a nasal mist of this solution may be recommended by your provider.
  • Oral or injected corticosteroids. These medications are used to relieve inflammation from severe sinusitis, especially if you also have nasal polyps. Oral corticosteroids can cause serious side effects when used long-term, so they're used only to treat severe symptoms.
  • Aspirin desensitization treatment. This option may be in order for those that have reactions to aspirin that cause sinusitis. Under medical supervision, folks are gradually given larger doses of aspirin to increase tolerance.
  • Antibiotics. For sinusitis associated with a bacterial infection, prescribing antibiotics may be indicated. If an underlying infection can’t be ruled out, an antibiotic (sometimes with other medications) may be recommended.
  • Surgery. When many of these options have been proven ineffective, endoscopic sinus surgery may be suggested as a last resort. For this procedure, a thin, flexible tube with an attached light is used to explore your sinus passages and fix the source of blockage.

List adapted from Mayo Clinic.

While it may be frustrating to have to speak with more health care providers, getting a second (third, forth…or more) opinion could be in order to further explore the cause(s). This time, you might want to speak with a specialist or allergist (if you have not already), who can provide a more tailored treatment regimen or diagnosis. On that note, it may also be wise to be patient; it may be necessary to try a few treatments in an effort to find relief. To help you get the conversation started, consider writing down a list of questions to take with you to get more information. Further, you may want to jot down when you’re experiencing symptoms, any unusual ones, under what environmental conditions (weather, dust, smog, etc.), and how they change in severity over time.

Good luck!

Alice!

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