speaker-1: Welcome to today's episode of Rhinology Roundtable, brought to you by the American Rhinologic Society, where we dive into the clinical questions that don't always make it into the guidelines, but absolutely shape how we practice. I'm your host, Ashley Halderman, and on today's episode, my guests and I will tackle a topic that sits right at the intersection of everyday clinical decision making and ongoing controversy. What is the relationship between allergy and chronic sinusitis? If you've ever wondered how Should I be testing every CRS patient for allergies? Or does allergic rhinitis really drive sinus disease? Or when, if ever, should immunotherapy be used to treat CRS? You're not alone. The relationship between allergy and chronic rhinositis is complex, often misunderstood, and the evidence, well, it's mixed. In this episode, we're going to move beyond the dogma and break down a practical, evidence-informed approach. We'll talk through when allergy is relevant, how it differs across CRS phenotypes, what testing adds or doesn't, and where treatments like immunotherapy fit into your management strategy. This is less about memorizing data and more about how to think through the patient in front of you. The one who has tried every medical treatment under the sun, but has persistent symptoms, overlapping diagnoses, and chronic sinusitis that just won't behave. Joining me for today's episodes are two experts in the world of allergy and sinusitis, Dr. Alina Toscala, professor in otolaryngology, head of neck surgery, specializing in rhinology and allergy at Jefferson Health in Philadelphia, Pennsylvania, and current president of the Allergy and Immunology and Rhinology section of the ARS. Thank you so much for joining us, Dr. Tuscala.
speaker-0: Thank you, Ashley, for the invite.
speaker-1: And our other guest, Dr. Stella Lee, Associate Professor of Odolaryngology, Head of Neck Surgery, specializing in rhinology and skull-based surgery, and director of the Brigham Sinus Center at Brigham Women's Hospital. Thank you so much for joining us, Dr. Lee.
speaker-2: Yeah, thank you for having me. Excited to talk about this topic.
speaker-1: Great. That's what I that's what I hope to hear. That's what I love. So right off the top, I wanted to pick your brains by asking some kind of open-ended, very global questions. And whoever wants to can go first. But what do you think is one thing clinicians overestimate about allergy in CRS?
speaker-0: I can start if you're okay with that. Don't think you if you ask, overestimate. I I think it's confusion more than overestimation. I think we underestimate how much patients have allergies, but I think the overestimation might be that taking care of allergy would take care of the CRS, because they are diseases that have different pathophysiology, even they coexist and share similar inflammatory mediators and inflammatory cells, but have to kind of keep in mind that you're treating two separate things in the same patient with somewhat similar background as as a disease pathophysiology.
speaker-2: Yes, allergic rhinitis, It is a comorbid condition, it happens very frequently with CRS with and without NP. in general, I think we do need more training and to be more expert in understanding the pathophysiology of allergic rhinitis and non-allergic rhinitis. as Alina said, there's a lot of confusion, you know, how to parse out the symptoms versus the mechanisms versus then the therapeutic decisions for the patient.
speaker-0: We know from epidemiological studies that up to 40% of patients have allergies. And even your CRS is a a separate disease because they coexist, they do effect off your outcomes, which I'm sure we're gonna talk more.
speaker-1: Yeah. Okay. Excellent. So a lot to dive into in this topic. And I've broken down today's episodes into kind of various controversies surrounding the role of allergy and allergy treatment and how that plays a factor into chronic rhinosinusitis. So Alina, I'm gonna start with you on and you've already kind of alluded to your answer on this. Does allergy cause CRS?
speaker-0: Allergy doesn't cause CRS but coexist often in the same mucosal lining and makes the symptoms worse, can actually mimic chronic sinus disease. We have a lot of patients coming with sinus pain, nasal congestion, sinus pressure, and they're convinced they have a sinus disease and more often than than having acute sinus that sinus disease that causes real facial pain and congest and they have undiagnosed, untreated allergies and then that can mix with the migraine, with the facial pain and all that. But but no, they are not the same disease. And if there's allergic rhinitis is not chronic sinusitis in a different form. we understand them separately.
speaker-2: What you know what's really interesting is that a lot of patients and some physicians, think that the patient has allergic rhinitis and actually is chronic rhinosinusitis or the patients have been treating themselves for years like they have allergies. So they come into our office and they think that the allergies cause the so that's a common misconception. And then we have to re-educate and counsel like actually the allergies are not the cause of this and getting, immunotherapy it's not going to cure chronic rhinosanusitis. there are some nuances though, because you know, there's allergic fungal rhinosanusitis, and there's now central compartment atopic disease, whether you believe in that or not. but there's some interesting overlap too with chronic brhinosinusitis, that IgE and allergy and non you know allergic brhinitis could play a role in the disease severity as a modifier for CRS, right?
speaker-0: allergic fungal we've talked about this in many panels it's really wrong name for that disease the allergy shouldn't be in that word because that's not the way this this disease has developed so just pointing that out
speaker-1: Which we're gonna talk about the phenotypes in the next section. so I wanna definitely delve into that more because I think that we have to consider the different phenotypes when we're thinking about allergy as like an active participant in inflammatory diseases in the nose. I think a better question is probably do you think that allergy acts as a disease modifier or modulator for chronic sinusitis? I'd certainly think that it can really muddy the waters when you are facing a patient that has both situations and they flare. And, you know, I think the two disease processes can flare separately, or one flaring can kind of lead to the other. Certainly, how many patients present to you with like recurrent sinus infections? And actually, this has happened several times where they have allergies, not Chronic sinusitis or they even have non-allergic rhinitis, where something like a change in seasons, especially, really sets them off and sort of takes them down that pathway and they're very symptomatic and they just assume it's a sinus infection. So I guess do you want comment on how you think that it modulates CRS?
speaker-2: Sure. I mean, definitely does. you know, there's a lot of nice papers out there. the ones that I think about are the ones from even you know, Whitney Stevens and PJ Warmold. And, you know, I I always imagine my mind that Kaplan Meyer curve that shows, you know, and also the Whitney Stevens diagrams about how you have the patients who just have CRS, the patients who have CRS with allergic rhinitis and the CRS. patients with asthma and then the CRS patients with AERD. And, we know that patients who have CRS with comorbid allergic rhinitis, they have higher, need for oral corticosteroids, higher need for sinusurgery, and also higher radiographic severity. And then if you look at that Kaplan-Maier curve, it's just you see that the recurrence of disease is higher for the comorbid conditions. Especially for AERD, but allergic rhinitis is on there too. So definitely does make the disease severity worse.
speaker-1: Mm-hmm.
speaker-0: I think about that is that chronic sinusitis is a chronic inflammation of the upper airway, sinuses, and nose, similar to asthma. it's easier to think in the lower airways when you have pollen season, you start to get wheezing, you get bronchoconstriction, increased mucus production, your cough. But same happens in the upper airways. So your underlying CRS gets very similar symptoms that you would have an infection, but it's not actually infection. it's not viral, it's Ig mediated inflammatory reaction in the airways and noses the filter for all these allergens. So really addressing that will keep in control the CRS because it can trigger exacerbation of your CRS as well if it goes untreated.
speaker-1: Yes, excellent points. Okay, so Stella, does CRS phenotype matter when it comes to allergy? And you know, we can kind of let's start with and both both of you can jump in, let's start with CRS without polyps.
speaker-2: Sure. You know, there's a lot of I think fluidity now we're moving away from phenotypes to endotypes. And I I really would eventually want to move beyond that because with and without nasal polyps right now is just a it's nice, very simple way to think about things, but actually it's much more complex. So
speaker-1: Yes, 'cause a lot of CRS without type
speaker-2: no.
speaker-1: two inflammation as an endotype. Yeah. Yeah.
speaker-2: So, let's put it out there right now sensitization does not equate to clinical relevance, right? Because the global population we're becoming more and more a as far as the relationship to CRS, what we see is that perhaps in CRS without NP. That you might have slightly more allergic rhinitis clinically relevant, you know, up to 30%, 40%. And it may be slightly lower on a CRS with NP, but then again, we're using old terms that may not make, you know, it is confusing. So regardless, I think what Lena said was is true is if you have a CRS patient in front of you. It's important to understand what their inflammatory drivers are, what their modifiers are. And if they have symptoms that are clinically relevant to do the testing, that
speaker-1: Mm-hmm.
speaker-2: can really help you. But you do have to think about it for both conditions.
speaker-1: Well, and I think so then how do you tease between what symptoms are due to CRS and what symptoms are due to allergy? Do you go back to those classic like itching, itching eyes, itchy nose? you know, how do you differentiate symptoms of of AR of allergic rhinitis versus chronic sinusitis?
speaker-0: I would say does it matter? And I don't think the chronic allergic rhinitis is the itchy watery is acute reaction. It might happen early on, but often the chronic allergic is more congestion, increased mucus production, and the inflammation overall in the nose. So you you treat it regardless, and the medication is the same. So I I think just knowing that your patient has allergies, their CRS patients, you test them. You need to know if they are allergic and you also have to ask about the lower airway symptoms, obviously, and make sure that they are they are diagnosed if they have asthma. And those all those three diseases has to be addressed because a lot of our patients share these. And you treat allergies a little differently than you treat your CRS exacerbation, but your steroid rinses for your CRS will help with the allergies. And you might need to add only antihistamine topically, orally, or both. So you're kind of just thinking about it and when they have symptoms, thinking about the environmental effect to the chronic disease that's underlying, which is the CRS, and how these often environmentally related allergic diseases contribute to that and address addressing that as well.
speaker-2: And some patients who have CRS with nasal polis, for example, they are so miserable. They just want to breathe through their nose and they can't smell. And then once you treat that, then the allergic symptoms become more of an issue. And we we've seen that's even our cystic fibrosis population, you know, before even the modulators came out. Like now I'm treating so many more individuals who have CF. for allergic rhinitis because that was really on the top of their priority list. Yeah. But absolutely, you have to gauge what is most impactful for the patient's daily life and symptomatology. And then sometimes these other symptoms do pop up after you treat the other ones. It's a dynamic process.
speaker-1: It is, yeah. And I I think it is hard to tease out what is what. And you know, so it really comes down to controlling everything as best you can and reassessing them and sort of seeing how their sense of control is and then tweaking it depending on how they're feeling it, but also what you see perhaps on nasal endoscopy.
speaker-0: ideally even recognize that's one of the things patients said, well, I know I'm allergic. I said, I want to know what your seasons are. I mean, especially when you're high reactivity, when you should start. Obviously allergic, and we talk a little bit about testing and positivity, but but if I know that you have tree grass and wheat pollen, I ask them to start, if they want to take a break wintertime and they're dying up already from the rinses, you can stop antihistamine, might not need that. And then start early on so that the allergies wouldn't exacerbate the CRS during the pollen. And actually believing that these mild medications help and you just have to kind of ope on them because they are mild but they need this consistent usage.
speaker-1: Mm-hmm. Well, and I think giving patients vacations I'm a big fan of that as well. Where if a person's really nothing in the winter and no like indoor allergens and they're they're very specific to certain seasons, then I'll tell them to usually start about a month ahead of time and then carry it through the whole season. And, you know, I think that that is more desirable to them than being on it all the time forever. but also so many patients come in with concerns about, I'm gonna become immune to clonase or I'm gonna become immune to the azolastine. And and I'm always like, well maybe I
speaker-0: Yeah.
speaker-1: don't think so, but well here's a way for we can prevent that. it's like, hey, at least this lessens, the chance of that happening. So that can kind of alleviate some concerns maybe.
speaker-2: I think it's stop the medicines and that might be a good way to determine if it's working because all of us I think see patients who've been on these medicines like for years and they've never stopped and then they stop it and then they're like, that did not make any difference in my so then why do you need to take it?
speaker-1: Absolutely. Or, or, and this is even better sometimes, it did. And I'm like, well, it's good to know that it helps, And then they have this renewed interest in continuing on it,
speaker-0: Because some patients, well, I've been on them for a long time. I've tried everything. Okay, when was the last time? And how many weeks or months did you use? Well, I tried a few days. So it varies what the truth is. You have to really dig into that and said, okay, what exactly did you take and when and how did it have an effect?
speaker-1: I tried flonase three times and I didn't notice anything. So I stopped it. And I'm like, okay, yeah, you're not supposed to. Well, so let's then let's talk about CRS with polyps. And yes, I understand that the endotypes are more what we're skewing for. I'd still say though that for clinical practice, we still are very much, I think it's fair to say, still living in the realm of with or without polyps. most people can't run like the the deeper testing required to truly indotype a patient. I think with polyps is where there's a lot of historic thinking and teaching about allergies and polyps that I still see drives clinical practice. And this is an area that I have a lot of patients who come in from allergists, in the in the region. who are on immunotherapy basically kind of for their polyps. And I'm like, boy, that that ship sailed a long, long time ago. like haven't had surgery. They just got started on immunotherapy. And I'm just kind of like, Huh, okay.
speaker-2: Well that goes back to the you know, our original co statement about maybe these folks think that the allergy is what's causing the polyps
speaker-0: Exactly.
speaker-2: and that's why they're trying to treat it that way. But
speaker-1: Yes. I I think it's done with good intentions. They're misguided. Because the science has told us for a very long time that, you know, this is not an allergic disease and immunotherapy is not gonna really do any it may modulate symptoms, but it's not modulating those polyps.
speaker-0: I think also highlights the fact how ENTs are in a for front line with this because we can look in the nose. We can see is it just allergies or is their polypsy, their infection, and and really your encourage your allergies to send them at least to you once or at for checking, especially if they are not responding well and and patients are still symptomatic. Having that discussion that, you know. I'll send them back, don't worry. I'm not gonna keep your patient, but it'd love to have this dialogue and having treat them together. Let's do both. Exactly.
speaker-1: Yeah. I mean, I think, there's every real possibility that a patient gets started and they come back and they're like, Yeah, I I feel better, but it's I feel better on a scale of my polyps are a little bit less swollen versus they're gone.
speaker-0: I can smell or I can't smell. Right.
speaker-1: Right. You know, there's a lot of shades of gray there. And with a person who's been living with chronic polyps their whole life, feeling a little bit better to them is like, I I feel better, but it's like, okay, well, how about we remove the polyps and then you tell me how you feel? Because you didn't even know that that next gear shift existed. but you almost want to kind of give people that that point of reference now to say, like, this is how it could feel huge. Yes, and and it and but I don't even think that we've really captured that very well, right? 'Cause we do have like the SNOT pre and post surgery. but and we have like, you know, the SNOT scores pre and post starting a a biologic, but it's
speaker-0: I think you can get used to to anything. So when the polyps slowly grow and then you know you maybe you had allergies always and and then you get a chronic sinusitis with nasal pumps and it's slowly developing. You know, you kind of get used to it and you don't even know when you do your snot score, that's your normal. Yeah. So you don't even know how to compare anymore unless we help the patient. So
speaker-1: Right, yes. Yes. okay, so a little bit of a controversial one, but the central atopic, central compartment atopic disease. So do you thoughts on that?
speaker-0: So it's polyp more centrally, right? Medial side of the middle turpinate and non septum. But often these patients have the polyps also lateral side and indocinuses. And so I I'm I don't know. I I think it's interesting concept. I rarely see patients that they are just those very local polyps that would be only medially the classical central compartment, but but I'm sure they they exist. And whether that's again, that's my other question. Is that we say allergic? Is it allergic or is it polypease? That allergies maybe then just trigger or environmental exposure trigger. It kind of makes sense that it would be environmentally I don't know if we know it exactly. Do you, Stella, are you aware that we know exactly the are those polyps different than our other polyps?
speaker-2: controversial. It seems like these patients have more allergic, like atopic, that's why it's called that. But and they respond pretty well to, medical and surgical therapy. So but it is interesting. It does they do seem different endotopic and like if you look at their radiographic imaging and what their response to therapy is like.
speaker-1: Mm-hmm.
speaker-2: So I I you know, I've heard mixed things from, from experts and some folks don't think that it's a good idea to create more and more subcategories of CRS. But I think that's the future is becoming more personalized, tailored to patients' specific inflammatory profile. And that'll help.
speaker-0: Yeah, and yeah. And I I agree with you, Stella. I don't think it's bad. I think it's good we identify. I think it was when when people start to talk about you started to see them more. And you realize, this location is not what you always see. But does it really change our treatment that much? At least this point. I I don't think it changed my treatment, obviously, because I test everybody for allergies anyway. And treat that anyway. And then obviously treat the polyps, but
speaker-1: Mm-hmm.
speaker-0: same whether they are medially or laterally.
speaker-1: Yeah, I'd say it's it's difficult, but I'm not necessarily opposed to going through some of these patient groupings with a fine tooth comb and and seeing what comes out of the overarching umbrella term. Because you know it wasn't that long ago that all we had was CRS and that we had CRS with and without polyps. And I think so much of the literature showing so many mixed results in these various patient populations are likely because of mixed populations of disease, you know, we we sort of applied too broad of a term to patients. And that really, I think, has a way of hiding certain groups of people who do perform really, really well on certain therapeutic things. You know, I think going back to cystic fibrosis and looking at the the genotype and the severity of the disease as dictated by the genotype Cystic fibrosis is not just one disease. It it has very different presentations. And so to think everybody in this group fits under this umbrella, it never made sense to me. you know, somebody who's making no functional protein versus somebody who's making a reduced amount of it, you're calling those both cystic fibrosis, but let's face it, those are very different patients clinically.
speaker-2: Yeah, so even that.
speaker-0: About I'm sorry, go ahead, Sarah.
speaker-2: With even with an AERD, we think these are the most severe, but then again, some patients with ARD respond beautifully to surgery and typical
speaker-0: Mm-hmm.
speaker-2: steroids and they don't need biologics. and I've seen, the opposite with CRS with NP patients without AERD who are extremely difficult to treat and severe. So there's a whole range. We can't simplify too much.
speaker-0: Yeah, I was just thinking the C C A D about the the compartment syndrome that maybe these patients my understanding is that their polyps might be easier to treat, that you might even do an office removal. There's no sinus in classical you have no sinus disease, it's nasal. So would you be able to just kind of remove the polyps and then treat the allergies? Is that enough? I'd love to see some long-term studies whether these polyps respond differently than our classical polyps that tend to come much easily back. And again, not everybody. And that's that's I think the challenge here is that we just can't know how the patient is gonna respond to our treatment options.
speaker-1: Yes. Not yet. Not not until you do it.
speaker-0: You can't be gonna be retired by
speaker-2: That are yeah. Very
speaker-1: No, no, not predictive, yeah.
speaker-2: jealous of the pulmonary colleagues who have all these other tools.
speaker-1: yes. So then let's talk about allergic fungal rhinocytositis. So we've already had a vote to remove allergy from that disease name. So let's let's delve into that a little bit. I do love controversy. So, what what were your thoughts, what has changed for you in that disease to be like allergy shouldn't be part of it.
speaker-0: In Europe we didn't first of all in Scandinavia we don't have allergic fungal basically. We don't have humidity and it's way too dry and cold. So I hardly ever saw it before I came to US. And and then whatever the fungal was, it was the fungal, but this allergy component and this kind of definition that's here. It was very confusing for a long time for me. I kind of understand where it comes from. Again, the mechanistically, is the fungus there because there's been a chronic disease, and then the fungus just kind of loves this warm, nice mucus sitting there and it starts spreading. And would that then cause allergic reaction, or isn't this the CRS we already have and we know it's an eosinophilic inflammation? I'm not sure that the still the mechanistic is is quite clear which way this happens, but What what's clear is that with our surgery and then in the environment where there's a risk of patients getting a lot of exposure, the biologics have changed the the picture of these patients that are s difficult to treat chronic fungal. It is not as big issue here. I mean in Northeast
speaker-1: Mm-hmm.
speaker-2: And geography is so interesting. Geography, also maybe genetics, but likely, this disease, there's a lot of epigenetic, modifiers. but the environment that we live in, the microbiome, I think we still need so much more understanding of the ecology, the microbiome of the perinesal sinuses. And geography, genetic, you know, predisposition, all these things, resilience versus vulnerability. yeah, a lot to be uncovered there. So better understand the mechanistic aspects of it. But the geography is very interesting, right? Because in Boston too, we don't see much of AFRS. But if you go down to Southern states or Middle East or a
speaker-1: Yes.
speaker-2: lot of it.
speaker-1: Yes, you do.
speaker-0: And interestingly what what David told me was that when he treated patients in the Middle East before air conditioning, they didn't have this disease. So there's something that changed.
speaker-1: Yep. Yeah. So I you know, environmental, but is it environmental because of the the climate? Meaning the humidity and the the temperature and the spores and like the sort of the the production, or is it environmental because we're constantly running, air conditioning? And I think that's such an interesting point. And I think a lot of people around the country have realized that when their hospital is doing major renovations, there's a pretty big spike in acute invasive fungal sinusitis in their immunocompromised patients. So there does seem to be some kind of correlation there perhaps. So it does make you wonder for AFRS. Yeah.
speaker-0: Yeah, how clean are the air conditioners? What I mean what can grow there and in spread to the environment? I I don't know.
speaker-1: Well, and in those environments, they're probably getting pretty saturated with moisture and condensation, which is sort of a breeding ground for fungal overgrowth. And then you've got this thing jetting it out, and especially, you know, given that it tends to sort of be more severe perhaps in certain socioeconomic classes and people. And so if you think about are they the ones that are typically having, window units versus central air, and is it a smaller space? that is being covered by these different cooling entities. I think we probably did it a real injustice. We didn't know this at the time. And I'm certainly not saying like, Bent and Coon, you were wrong. No.
speaker-0: I just think yeah.
speaker-1: No, at at the time, the information that we had, yeah, I painted a very compelling picture. But how much have we sort of limited our understanding and our expansion in that disease process by just being like, Yep, that's it. Yep.
speaker-2: As our climate is changing, you know, that could also lead to other behaviors that lead to more air conditioning. And also wildfires, too. It's very interesting how even wildfires carry fungal elements and bacteria and other things. sinusitis exacerbations, upper airway and asthma exacerbations. And we're studying also in there's no indoor air quality standard, we have other air quality standards as of now, but as far as indoor air quality, we spend many of our lives indoors. So it's really important to understand that. So that's one area of our research that we're doing here. And hopefully getting more understanding of how we can improve that. Ventilation is key, right? Yeah.
speaker-1: Yeah, which probably not standard, like you said, or measured really in the various housing options for people, especially if you happened to live in lower cost, housing environment.
speaker-2: So
speaker-0: Yeah, he I I'm the healthy house is a house that breathes. So there was a lot of healthy indoor air interest about twenty years ago in Europe and and occupational airway diseases from from multi buildings at schools, hospitals, public buildings. And it was quite a intensive research on this. And what the studies did show in a bad air quality, it wasn't allergies that these people they didn't get a fungal allergies that wasn't very high. What they did show was irritation, inflammation, asthma exacerbation or development of a lower hyperreactivity. And idea there was that these these molds not only they are not very allergic allergenic, understanding from that was, but they also can form toxins and change the air quality different ways as well. So there's so many things that we we haven't looked into.
speaker-1: Yeah.
speaker-2: This day and age, things that are fragranced, we know those are not natural fragrances anymore. They're hundreds of chemicals. also, candles are wonderful, but they're actually
speaker-0: I get a microwave from any candle that smells.
speaker-2: The other day a patient of mine said she was spraying Lysol into her bed. So you know, it's all these chemicals and things that I think even just our patients don't aren't aware that they're so toxic to our barrier function, our skin, our nose, our lungs, and we have to be more conscientious about that. And we have to educate ourselves and our patients about it.
speaker-1: the next question that I had, and Alina, you've already sort of answered this, is that you test every CRS patient for allergies. And Stella, is that how you practice? It's definitely not how I practice, but I'm not the expert. So
speaker-0: I can just g verify if they haven't had any reliable testing within a couple of years.
speaker-1: Okay.
speaker-2: Yeah, I ask the patient, I involve the patient in the conversation I do offer it. I ask my patients about all these symptoms related to allergy. But then also I say, allergy could be playing a role and you might not realize it, And then I say, well, we can do allergy testing and that might be helpful to just understand your inflammatory picture. And some patients really just don't want it, you know? And some patients really want it. So I think involving the patient in the decision is helpful, but telling them what the rationale is.
speaker-0: Yeah. Of course, I'm not I'm not automatically testing everybody, but I'm asking first of all, do you think you have allergies? if they said I've never had any that's the patient I've okay, we don't need to, but anybody who thinks that they might have allergies or they've had allergies in a childhood and they've had these allergy symptoms, those are the patients I suggest. allergy testing I offer them the options of doing the blood work or a skin test.
speaker-2: And if they have a history of atopic dermatitis and also family history is really important. Their parents, siblings, if they have a strong atopic history, we do know that there's a genetic component for that.
speaker-0: And then when you think the prevalence of forty percent, it's every other patient.
speaker-1: Mm-hmm. But I think what always gives me pause is, what is allergy versus sensitization? What's the difference? And in somebody who has an underlying sinus disease, how do you differentiate? So if they they are pan positive, how do you interpret that?
speaker-0: You have to talk with patients when do they have their symptoms, their allergy symptoms. I mean, if you have year-round symptoms and they have house dust positivity, that's likely where they have the cats and dogs and that's positive and they have year-round. So thinking and talking, like Stella said, you you kind of go through these different exposures when they are in the environment, how they fact, how have you noticed it? And then again. Some of the reactions are small, and if you do a blood work, the Ig level is is low. it's just very patient-dependent. But if you have allergies, I want to address them.
speaker-2: I don't think there's much of a downside of doing it. I mean the testing is quite, benign and you have some
speaker-1: Mm-hmm.
speaker-2: potentially very valuable data.
speaker-1: the issue that I've had is and maybe I remember this too much, is seeing patients who were really heavily managed for allergy doing like immunotherapy, who had underlying chronic sinusitis and it didn't do them any good. They spent three years on it or t a year on it or whatever. And, The patients have then had to dedicate a a significant amount of time and there's risks involved in immunotherapy. And I think that I tend to look at it as I think a lot of people who are put on immunotherapy probably don't need to be on it. So I
speaker-2: Is a study that I read that really has stayed with me for like 10 years at least, or maybe longer, that only 11% of people who are eligible for immunotherapy actually doing immunotherapy in the United States. And
speaker-1: Mm-hmm.
speaker-2: I think especially if you think of the benefits, especially in children, that you can asthma, like wow, you know, we can't say that about a lot of things in our field that you can. prevent disease. We don't talk about prevention a lot.
speaker-1: And this is
speaker-2: I think especially for children, if you know they're sensitized, you know, to like cockroach and the molds and dust and things, and they're highly susceptible to developing asthma. yeah. But then there's the tricky thing with CRS too, I agree. But we do have to be a little bit more conscientious about Allergic Ryanitis role. And this is why you're doing this podcast, I suspect, because it's so important. wanna empower physicians to have intelligent conversations and thoughtful conversations with patients, especially with young children too. And if they have and they tell me about their kids and they're also like this atopic march happening, like God.
speaker-1: Actually every family.
speaker-2: You know.
speaker-0: What frustrates me is the patient that come to me and they've been on allergy shots for 10 or 15 years. Because there's no point for that. The studies are three years max five. You take a break, if you wait ten to fifteen years because you don't get any benefit. And that's just a waste and that really is upsetting when then they finally come to you and then there's an untreated CRS. so but Well done, the right allergens, right clinically relevant allergens, immunotherapy. It's helpful. It is not miracle cure. We know that patients' symptoms score reduce and medications need reduced, but it is not resolving all your allergies and olios symptoms on everybody, but it is kind of shifting the immunity and your hyperreactivity away from that. And like Stella said, if we can prevent any asthma development or asthma exacerbations, because those who already have asthma, often pollen season is the one that you get the worst symptoms and you can be hospitalized, you're really sick. So we can prevent that. And maybe your CRS exacerbation as well.
speaker-1: I think that that's a really great point. And the considerations in children, I agree, are completely different than adults. Because, you know, and I really only see adults. So by the time I'm seeing them, the opportunity to really provide them with like a meaningful it's different in children, right? You do have the opportunity to sort of like intervene early and potentially modulate them developing asthma down the road. So I totally agree. I think definitely being more aggressive about it in children. makes a lot of sense. But I'm glad that you brought up the cystic fibrosis, Stella, because what I started to notice in patients is that they were having kind of seasonal exacerbations of their pulmonary symptoms. And I started to be like, this is allergy. And I started testing them. And you know, we're gonna get into this in a minute, but we offered sublingual immunotherapy where I was previously. And that was perfect for CF patients because it actually enabled them to get the immunotherapy because you know, CF patients a lot of times are sick or they have symptoms. And so doing allergy shots presented a bit of an issue in that they were just never well enough to get the shot or they had to miss them several times. So the sub-lingal immunotherapy in that group I thought was like a phenomenal option. So and had a couple of people who did awesome. you mentioned briefly, so how do you do allergy testing? Do you have a preference? Skin prick testing, intradermal testing, or serum allergen testing?
speaker-0: I offer skin testing. I have an allergy nurse. We do a lot of testing. Not everybody wants to get a skin prick test. Not everybody can if they're on a on a medication they can't stop. but I offer also the blood work. So I offer them both.
speaker-2: I agree with Alina that skin prick testing is the gold standard I offer in vitro testing, especially with if there's a contraindication, dermatographism, they can't come off antihistamines or other issues.
speaker-1: Antipsychotic medications or antidepressants. so between serum allergy testing and skim prick testing, I have patients bring this up a lot. They're like, Well, it's not as, good, the the serum allergy testing. And I'm like, it's pretty equivalent. My understanding is there may be more false positives with the serum allergy testing.
speaker-0: Say, I don't know if it's false positive. If you have IgE in the blood, it is there, but is it clinically relevant? I think that's the question. And what we've seen, the studies have compared, I think I we looked in the testing, and I if I remember correctly, that skin test was maybe twenty percent more sensitive overall. but I think when you have a significant allergy, it would Come up on either testing.
speaker-2: Yeah, I agree. I you know, and it differs between patients, but there is I would say a good concordance between the two. It's yeah, it's gotten the in vitro testing has gotten so much better. it's quite easy to perform. Patients sometimes just prefer it. They don't wanna be tortured with a million things on skin and itchy, et cetera.
speaker-1: if a patient gets serum testing, is there any scenario where you will follow up with skin prick testing?
speaker-0: Not really. Other way around sometimes. Patient, let's say they have had the any reaction and they convinced they have allergies. But let's look at the blood work. I mean, look at the absolute Ig levels and then if that, kind of confirms patients' suspicion that our testing is not good or maybe there's some something in that they took like, you know, antihistamine they didn't. Remember or or that would affect the skin testing, so confirm the platform.
speaker-2: And there's entopy, you know, the local IGE where you just can't. I mean, we're we're testing the skin as a proxy for the nose. and so I think if someone is like dead set on like, my gosh, the cats for sure are the ones, then maybe you know, you can try to do another test with skin because it might show up there, just so that there may be some. more information you could get from there. And if you have a negative test, you can't treat with immunotherapy. that road ends there. I've had a a a few patients where, even if the skin prick testing is negative and there's a significant history of a clinically relevant allergy, then then maybe IDT in case some cases might be helpful too. But then there are so many false positives with that you have to careful. Yeah.
speaker-1: Mm-hmm. Okay, so on to the next topic. Does treating allergy improve or modulate CRS? And and I think that we all kind of be like, yeah, it can modulate it, or it at least controls the allergy symptoms. Sometimes that makes it easier to separate from what's like the CRS symptoms. But I guess after you've, let's say, done surgery on a patient, what's your kind of typical approach for just CRS? Let's talk about. For me, I mean, it's mostly topical steroid rinses for some period of time. and honestly, depending on how they do, I'm a big believer in the intranasal antihistamines for even non-allergic patients because I I think it's so much more effective in non-allergic rhinitis than flonase is, just personally. And I think some of the literature has actually shown that.
speaker-0: if you look at the European studies, they've shown the local allergic reactivity in the nasal epithelium. So there could be a lot of patients that are allergy test negative but have still local allergic reactivity in the nose and nasal mucosa. And if you could isolate the mucus and take the local IgE like they do in their studies, they show much higher prevalence of allergies in non-allergic patients. So these patients definitely would help. from antihistamine. And answering your question, I do the steroid rinses and on my allergy patient I add the nasal antihistamine. Absolutely. I I really believe in that, in addition to oral antihistamine.
speaker-1: In your allergic patients.
speaker-0: In my allergic patients.
speaker-2: maybe we should talk about you know Monteleucast can be helpful too for patients with comorbid asthma and allergic rhinitis and AERD, mainstay is topical nasal steroids and this comorbid allergic patients. One thing I worry about, some patients, have you seen this patients' noses can become like a desert with azlastine.
speaker-0: And also can't be sedative, so you have to tell that to patient. Certain patients do do feel it and I tell them to do it in the evening.
speaker-1: At nighttime. Yeah, that's what I
speaker-2: That's
speaker-1: do as well. And I find that yes, there is that bad taste, but honestly I feel like in the majority of patients it works so well that they're like, I don't care.
speaker-0: You can lean your head forward and spray so it doesn't taste as bad. Now I remember what I wanted to say actually when you're talking previously about allergies and sinus surgery. So studies have shown that your surgical outcomes are better. Epidemiological studies have shown your sinus surgery outcomes are better if you address the patient's allergies when they have.
speaker-2: Correct. And it's actually Dr. Andy Lane who published this paper. it's a very old paper, but it shows that patients who have allergic rhinitis therapy, immunotherapy, their outcomes, as Alina said, are better and the patient satisfaction is better.
speaker-1: So I guess that's the key though. is it just immunotherapy that we're talking about? have the studies been just looking at immunotherapy as treatment of allergic rhinitis? Cause I mean that's the big question, is how aggressive do we need to get in treating patients with allergies and CRS? is it just the topical antihistamines, the topical steroids, those things, or just going that extra step and going to immunotherapy, is it worth it for CRS? Probably dependent on the patient. I'm glad that you mentioned singular or Montelou caste. I I'd say that in clinical practice, I think that this is one that gets over prescribed. So it in my
speaker-0: I don't actually like it as much.
speaker-1: No, I I tell people if they have bad
speaker-0: It's weaker than antihistamine when you look at the studies.
speaker-1: thing. I tell people that this is a marathon medication, not a sprint. and it's for people who have CRS with polyps and bad asthma. And then for the AERD patients,
speaker-0: Minute.
speaker-1: it's very limited how often I use it. And all the black box box warnings have come out about it. And it's not just a nothing drug. You know, it it does have some side effects.
speaker-0: Right. Primary cares tend to send that to every patient with any allergies or asthma. And I think the study shown that only twenty percent of patients have that specific Lucatrian pathway as a major pathway. So eighty percent of patients wouldn't benefit. So you have to do a trial and then be realistic and ask patients, did it make a difference? If you and I to often say, let's stop and see if does it make a difference?
speaker-1: Mm-hmm. Well, and they can't be on an antihistamine at the same time. You know, really just need to be one or the other and not singular.
speaker-2: I would say in my practice I've significantly decreased my prescriptions of Montalucast.
speaker-1: So one question that I get a lot from patients is, which antihistamine is best? And can I get immune to them? Some people swear that if they don't switch between antihistamines, that they're gonna get immune to one. I generally think of them as claritons kind of the most mild and like ZirTech and Zol are a bit more drying
speaker-0: It Any antihistamine the patient's gonna take, that's the best antihistamine at the end of the day. And if they say I I no it doesn't work, let's try something else.
speaker-1: Mm-hmm. Yeah.
speaker-2: And epsofenidine is the one that you can do, twice daily and really go off over dosing, which is nice. But it depends on the patient because some patients take loratidine and they're like, wow, that was really strong. Yeah. What's surprising to me is there are still so many patients that take diphenhydramine. Yes. even just yesterday in my clinic, and these are some of these patients are quite elderly and there's now some good evidence that it's it's not good for your brain or your brain health. but they're very attached to the older generation, antihistamine. So Do actually curious do you have strategies to try to get them off of that? And they say that they don't the other ones don't work as well. So
speaker-0: Probably right. They are potent, but
speaker-2: I know, right?
speaker-1: Yeah. I mean, I think it depends. I think it depends on what symptoms they're trying to treat. Because the reality is if they've got vasomotor rhinitis or real watery sort of anterior rhinorrhea, no, flonase and aslastine, those weren't gonna work. they needed ipertrium spray, various other antihistamines weren't going to, you know, so I think a lot of it is just sort of finding out what symptoms they're actually trying to treat, seeing what they've tried in the past and you know, offering them some updated alternatives. depending on what they've tried. Okay. So then last thing that I wanted to touch on is immunotherapy. So I'm gonna guess that this is something that you're reserved for CRS patients whose allergy symptoms are not controlled on an oral antihistamines and anti antihistamine nasal spray, correct?
speaker-0: Yeah, I I tell every patient, let's try with the medication for your allergies and obviously address the CRS. And if that doesn't help, then allergy immunotherapy is the option. That's also what the guidelines said.
speaker-1: Yes. Yeah.
speaker-2: I do make sure patients know that that option is available. I'm still always shocked by how patients are so amazed that this option is available to them. So I I do make sure that we talk about it ahead of time to just plant the seed in their mind.
speaker-1: Yeah. I tend to separate the two disease processes very clearly with patients to say, like, look, this isn't gonna do this isn't gonna cut it for your your chronic sinusitis, your polyps, your your whatever. This is just going to sort of help with one of these disease processes, which you know, reducing sort of the inflammation burden that you experience from that may help with it. But the evidence out there is not very strong, but this is not a standalone therapy for your chronic sinusitis.
speaker-0: Exactly. It also might help with your lower way. You know, if you have I always have so many patients with asthma as well. So I'm talking about what it what it helps, but but the CRS has its own.
speaker-1: Yeah, especially allergic type asthma. I'm very, you know, encourage them definitely to optimize allergic therapy.
speaker-2: Beauty of it is disease modifying. So that's what's wonderful about it. But
speaker-1: Mm-hmm.
speaker-2: I wish all medications, there could be some component of that. There's just so many medicines out there that don't tr treat the underlying immunologic dysfunction. So that's the beauty of immunotherapy. Right. But it is hard to do and hard to commit to, time cost, all those things.
speaker-0: if we talk about CRS with polyps and now we have those recalcitrant polyps that we start treating with the biologics, do you need immunotherapy? So I've had few patients, I've talked to the patient and I suggest that as an option, but there are a few patients that wanted to finish their three years because they're so committed and I don't see anything they shouldn't. But
speaker-1: Mm-hmm.
speaker-0: I don't think there's good evidence is immunotherapy additionally beneficial in addition to the our biological
speaker-1: I mean insofar as you anticipate that a three year course of immunotherapy is gonna provide you with eight to ten years of coverage, right? So we don't know yet about the biologics. So I'd say I'm in more inclined to say to people like, Look, if you're in this for a year already, finish it out potentially.
speaker-0: Start allergy immunotherapy, while patient on biological.
speaker-1: Think so, because I think I I think they have to sense I would want to know that they sense a benefit, you know, and I think that that would mask it. So I think the problem is that if you are on a biologic and you start immunotherapy, you have no idea if it actually helped your allergies. But I will tell you that we had one patient who had really severe allergies and could not tolerate immunotherapy. And we actually used biologics to get his disease under control to a point that his asthma was better. And he still was committed to doing immunotherapy because he was going for that sort of immune modulation. So it was kind of crazy that we used the biologics to get him to a point where he could do immunotherapy, right?
speaker-2: That's you know, with Omalysimap.
speaker-0: Exactly. It's been used before for that reason.
speaker-2: Is a way
speaker-1: Yeah. And I think when in in the current sort of climate where we're talking about like when do you stop the biologic? How long does the person need to be on it? that's a huge question. And so I am gonna go for the immunotherapy over biologic, if their disease is predominantly allergy driven, because we have much stronger evidence for a much longer period of time that that can give them a sustained benefit. So yeah. And so I guess as we're kind of wrapping up Do either of you do sublingual immunotherapy aside from the tablets?
speaker-0: Yes, we do jobs. Custom made.
speaker-2: Used to but now I only prescribe tablets. We
speaker-1: Okay.
speaker-2: don't have the infrastructure for the compounding for the drops.
speaker-1: Yeah.
speaker-0: I have an allergen nurse who mixes them and we choose the allergens together with the patient and discuss them and then go from there. But it is the price is very limiting.
speaker-1: Yeah. Yeah. Which is a it's a real bummer because I I think it makes sense and I I know I think that there's some literature out there how much more adherent people are gonna be to the sublingual drops versus the shots and just sort of the ease at which you can kind of fold it in. But at the same time, yeah, I can just sit there in the refrigerator and they can just not use it. So some people say I wanna do the shots because I need to show up. I need to have this, like that will be my sort of like way of getting it done. so
speaker-0: A few patients, it's also a social event.
speaker-1: Yeah, gets him out of the house. Yeah. And also I do relationship
speaker-2: that you have that you know the happiness that you have when you see your allergy nurse. It's a really important to hire someone, your allergy nurse that your patients will love. And you know, that's in my experience, our allergy nurses are the ones that they want to see. They don't want to see me.
speaker-1: Has it been a year? Right. Right. one question that I get from patients is are sublingual and subcutaneous immunotherapy equally effective? And I say yes. you know, some people are like, Well, doesn't the sublingual take longer? And I that's not my general impression.
speaker-0: I I think the studies when you look at the head to head view comparison that there were articles that the immunological response from ash might be a little bit stronger.
speaker-1: Mm-hmm.
speaker-0: But subling all is so much safer. So again, I think whatever they take, that's the best for them.
speaker-1: Yes. Yeah, whichever that will do. I I agree with that.
speaker-2: Yeah, I agree with Alina. It seems to be more potent. But then you have all these side effects potentially. And a philosophy, you know, you have to wait in the office for 30 minutes after.
speaker-1: Yeah. I think that there's pros and cons for both for sure.
speaker-0: And yesterday I had a patient who had been on sublingual now for three years and we talked about should we continue? He said, You know, I still feel improving. I said, Yeah, let's go. We can go up to five years. We see every three months and see how he's doing.
speaker-1: Mm. Yeah. And your experience with the tablets has been pretty positive, other than coverage issues.
speaker-0: Yeah, I mean I don't think the side effect profile is any worse. Some itching under the tongue for a while and but unfortunately not many patients can have it. Yeah.
speaker-2: For efficacy, you know, we're doing a study right now sponsored by the AAOA on the effects of a doctrine eustachian tube dysfunction. And you know, it's the I would say I have mixed feelings about what we're seeing. We don't we the data isn't fully analyzed, it'll probably be coming out soon. But yeah, we'll see. It's it seems like it's helpful, but compared to skit, the shots do seem to be more effective than the Dactra tablet.
speaker-1: Mm. Okay.
speaker-2: Then we know based on the old, old Brian Leatherman paper, the dust mite, the amount of actual, the allergen extract is quite high that you have to put into the vial. And for molds, it's just like still wild, wild west, right? The standardization.
speaker-0: Yeah, there's a nice kind of comparison how much more you need certain antigens compared to others. They are not equal. And the old old teaching goes goes how everything is just one CC. So this is a another discussion where we could
speaker-1: Yeah, it's bizarre that that's not been standardized.
speaker-0: I agree.
speaker-2: It's a huge brain.
speaker-1: Yeah. Yeah. So well as we wrap up, just you know, final thoughts. If listeners remember a couple of things from today's episode, what should they be?
speaker-2: The allergen immunotherapy is disease modifying and even though we have
speaker-1: For allergies and asthma. Wow.
speaker-2: For allergic rhinitis and asthma. and we have biologics now. as of now, I we are still understanding whether biologics can be disease modifying, but doesn't seem to have the, you know, same effects as immunotherapy, the benefits of immunotherapy. I in general, across the board in the US at least, from the data that I have seen, it it seems that immunotherapy is underutilized. But I do think it has to be the extracts do need to be standardized better and education for our trainees for understanding how to do allergy testing that you know diagnosis, all of those things, treatment have to be parsed out with in a complex world where we have so many different options now.
speaker-0: So I think what remember, think about allergy on your patient with CRS. Just think about it, ask about it. Ask patients where do they work? Do they have exposures at work? Patients like nail salon workers or working on construction or exposures that come from environment that can make the CRS and potentially allergies worse, working in an animal hospital. there is so many, many environmental patients spend ten hours a day in the workplace. And ask about the home. Do the do you have the pets? Or if you don't have pets, do the kids where you go every other day to, you know. So ask about patients' environment. Be interested how the environment affects their disease. ask about low airway. Do you get prolonged cough after cold viral cold? Do you wake up nighttime cough? Consider that if you don't do it yourself, I do spirometry and treat asthma in my office, but if if don't send them to pulmonology because that's a big part of the quality of life in our CRS patients with allergies. Those are the the critical things, I think.
speaker-1: Well, amazing. Thank you both so much for joining me today and making this such an amazing discussion. And I am in the company of brilliant minds. So thank you. I'm grateful for you.
speaker-0: Thank you, Ashley.
speaker-1: And keep on listening. We'll catch you on the next episode of Rhinology Roundtable.
speaker-0: Thank you, Ashley, for the invite.
speaker-1: And our other guest, Dr. Stella Lee, Associate Professor of Odolaryngology, Head of Neck Surgery, specializing in rhinology and skull-based surgery, and director of the Brigham Sinus Center at Brigham Women's Hospital. Thank you so much for joining us, Dr. Lee.
speaker-2: Yeah, thank you for having me. Excited to talk about this topic.
speaker-1: Great. That's what I that's what I hope to hear. That's what I love. So right off the top, I wanted to pick your brains by asking some kind of open-ended, very global questions. And whoever wants to can go first. But what do you think is one thing clinicians overestimate about allergy in CRS?
speaker-0: I can start if you're okay with that. Don't think you if you ask, overestimate. I I think it's confusion more than overestimation. I think we underestimate how much patients have allergies, but I think the overestimation might be that taking care of allergy would take care of the CRS, because they are diseases that have different pathophysiology, even they coexist and share similar inflammatory mediators and inflammatory cells, but have to kind of keep in mind that you're treating two separate things in the same patient with somewhat similar background as as a disease pathophysiology.
speaker-2: Yes, allergic rhinitis, It is a comorbid condition, it happens very frequently with CRS with and without NP. in general, I think we do need more training and to be more expert in understanding the pathophysiology of allergic rhinitis and non-allergic rhinitis. as Alina said, there's a lot of confusion, you know, how to parse out the symptoms versus the mechanisms versus then the therapeutic decisions for the patient.
speaker-0: We know from epidemiological studies that up to 40% of patients have allergies. And even your CRS is a a separate disease because they coexist, they do effect off your outcomes, which I'm sure we're gonna talk more.
speaker-1: Yeah. Okay. Excellent. So a lot to dive into in this topic. And I've broken down today's episodes into kind of various controversies surrounding the role of allergy and allergy treatment and how that plays a factor into chronic rhinosinusitis. So Alina, I'm gonna start with you on and you've already kind of alluded to your answer on this. Does allergy cause CRS?
speaker-0: Allergy doesn't cause CRS but coexist often in the same mucosal lining and makes the symptoms worse, can actually mimic chronic sinus disease. We have a lot of patients coming with sinus pain, nasal congestion, sinus pressure, and they're convinced they have a sinus disease and more often than than having acute sinus that sinus disease that causes real facial pain and congest and they have undiagnosed, untreated allergies and then that can mix with the migraine, with the facial pain and all that. But but no, they are not the same disease. And if there's allergic rhinitis is not chronic sinusitis in a different form. we understand them separately.
speaker-2: What you know what's really interesting is that a lot of patients and some physicians, think that the patient has allergic rhinitis and actually is chronic rhinosinusitis or the patients have been treating themselves for years like they have allergies. So they come into our office and they think that the allergies cause the so that's a common misconception. And then we have to re-educate and counsel like actually the allergies are not the cause of this and getting, immunotherapy it's not going to cure chronic rhinosanusitis. there are some nuances though, because you know, there's allergic fungal rhinosanusitis, and there's now central compartment atopic disease, whether you believe in that or not. but there's some interesting overlap too with chronic brhinosinusitis, that IgE and allergy and non you know allergic brhinitis could play a role in the disease severity as a modifier for CRS, right?
speaker-0: allergic fungal we've talked about this in many panels it's really wrong name for that disease the allergy shouldn't be in that word because that's not the way this this disease has developed so just pointing that out
speaker-1: Which we're gonna talk about the phenotypes in the next section. so I wanna definitely delve into that more because I think that we have to consider the different phenotypes when we're thinking about allergy as like an active participant in inflammatory diseases in the nose. I think a better question is probably do you think that allergy acts as a disease modifier or modulator for chronic sinusitis? I'd certainly think that it can really muddy the waters when you are facing a patient that has both situations and they flare. And, you know, I think the two disease processes can flare separately, or one flaring can kind of lead to the other. Certainly, how many patients present to you with like recurrent sinus infections? And actually, this has happened several times where they have allergies, not Chronic sinusitis or they even have non-allergic rhinitis, where something like a change in seasons, especially, really sets them off and sort of takes them down that pathway and they're very symptomatic and they just assume it's a sinus infection. So I guess do you want comment on how you think that it modulates CRS?
speaker-2: Sure. I mean, definitely does. you know, there's a lot of nice papers out there. the ones that I think about are the ones from even you know, Whitney Stevens and PJ Warmold. And, you know, I I always imagine my mind that Kaplan Meyer curve that shows, you know, and also the Whitney Stevens diagrams about how you have the patients who just have CRS, the patients who have CRS with allergic rhinitis and the CRS. patients with asthma and then the CRS patients with AERD. And, we know that patients who have CRS with comorbid allergic rhinitis, they have higher, need for oral corticosteroids, higher need for sinusurgery, and also higher radiographic severity. And then if you look at that Kaplan-Maier curve, it's just you see that the recurrence of disease is higher for the comorbid conditions. Especially for AERD, but allergic rhinitis is on there too. So definitely does make the disease severity worse.
speaker-1: Mm-hmm.
speaker-0: I think about that is that chronic sinusitis is a chronic inflammation of the upper airway, sinuses, and nose, similar to asthma. it's easier to think in the lower airways when you have pollen season, you start to get wheezing, you get bronchoconstriction, increased mucus production, your cough. But same happens in the upper airways. So your underlying CRS gets very similar symptoms that you would have an infection, but it's not actually infection. it's not viral, it's Ig mediated inflammatory reaction in the airways and noses the filter for all these allergens. So really addressing that will keep in control the CRS because it can trigger exacerbation of your CRS as well if it goes untreated.
speaker-1: Yes, excellent points. Okay, so Stella, does CRS phenotype matter when it comes to allergy? And you know, we can kind of let's start with and both both of you can jump in, let's start with CRS without polyps.
speaker-2: Sure. You know, there's a lot of I think fluidity now we're moving away from phenotypes to endotypes. And I I really would eventually want to move beyond that because with and without nasal polyps right now is just a it's nice, very simple way to think about things, but actually it's much more complex. So
speaker-1: Yes, 'cause a lot of CRS without type
speaker-2: no.
speaker-1: two inflammation as an endotype. Yeah. Yeah.
speaker-2: So, let's put it out there right now sensitization does not equate to clinical relevance, right? Because the global population we're becoming more and more a as far as the relationship to CRS, what we see is that perhaps in CRS without NP. That you might have slightly more allergic rhinitis clinically relevant, you know, up to 30%, 40%. And it may be slightly lower on a CRS with NP, but then again, we're using old terms that may not make, you know, it is confusing. So regardless, I think what Lena said was is true is if you have a CRS patient in front of you. It's important to understand what their inflammatory drivers are, what their modifiers are. And if they have symptoms that are clinically relevant to do the testing, that
speaker-1: Mm-hmm.
speaker-2: can really help you. But you do have to think about it for both conditions.
speaker-1: Well, and I think so then how do you tease between what symptoms are due to CRS and what symptoms are due to allergy? Do you go back to those classic like itching, itching eyes, itchy nose? you know, how do you differentiate symptoms of of AR of allergic rhinitis versus chronic sinusitis?
speaker-0: I would say does it matter? And I don't think the chronic allergic rhinitis is the itchy watery is acute reaction. It might happen early on, but often the chronic allergic is more congestion, increased mucus production, and the inflammation overall in the nose. So you you treat it regardless, and the medication is the same. So I I think just knowing that your patient has allergies, their CRS patients, you test them. You need to know if they are allergic and you also have to ask about the lower airway symptoms, obviously, and make sure that they are they are diagnosed if they have asthma. And those all those three diseases has to be addressed because a lot of our patients share these. And you treat allergies a little differently than you treat your CRS exacerbation, but your steroid rinses for your CRS will help with the allergies. And you might need to add only antihistamine topically, orally, or both. So you're kind of just thinking about it and when they have symptoms, thinking about the environmental effect to the chronic disease that's underlying, which is the CRS, and how these often environmentally related allergic diseases contribute to that and address addressing that as well.
speaker-2: And some patients who have CRS with nasal polis, for example, they are so miserable. They just want to breathe through their nose and they can't smell. And then once you treat that, then the allergic symptoms become more of an issue. And we we've seen that's even our cystic fibrosis population, you know, before even the modulators came out. Like now I'm treating so many more individuals who have CF. for allergic rhinitis because that was really on the top of their priority list. Yeah. But absolutely, you have to gauge what is most impactful for the patient's daily life and symptomatology. And then sometimes these other symptoms do pop up after you treat the other ones. It's a dynamic process.
speaker-1: It is, yeah. And I I think it is hard to tease out what is what. And you know, so it really comes down to controlling everything as best you can and reassessing them and sort of seeing how their sense of control is and then tweaking it depending on how they're feeling it, but also what you see perhaps on nasal endoscopy.
speaker-0: ideally even recognize that's one of the things patients said, well, I know I'm allergic. I said, I want to know what your seasons are. I mean, especially when you're high reactivity, when you should start. Obviously allergic, and we talk a little bit about testing and positivity, but but if I know that you have tree grass and wheat pollen, I ask them to start, if they want to take a break wintertime and they're dying up already from the rinses, you can stop antihistamine, might not need that. And then start early on so that the allergies wouldn't exacerbate the CRS during the pollen. And actually believing that these mild medications help and you just have to kind of ope on them because they are mild but they need this consistent usage.
speaker-1: Mm-hmm. Well, and I think giving patients vacations I'm a big fan of that as well. Where if a person's really nothing in the winter and no like indoor allergens and they're they're very specific to certain seasons, then I'll tell them to usually start about a month ahead of time and then carry it through the whole season. And, you know, I think that that is more desirable to them than being on it all the time forever. but also so many patients come in with concerns about, I'm gonna become immune to clonase or I'm gonna become immune to the azolastine. And and I'm always like, well maybe I
speaker-0: Yeah.
speaker-1: don't think so, but well here's a way for we can prevent that. it's like, hey, at least this lessens, the chance of that happening. So that can kind of alleviate some concerns maybe.
speaker-2: I think it's stop the medicines and that might be a good way to determine if it's working because all of us I think see patients who've been on these medicines like for years and they've never stopped and then they stop it and then they're like, that did not make any difference in my so then why do you need to take it?
speaker-1: Absolutely. Or, or, and this is even better sometimes, it did. And I'm like, well, it's good to know that it helps, And then they have this renewed interest in continuing on it,
speaker-0: Because some patients, well, I've been on them for a long time. I've tried everything. Okay, when was the last time? And how many weeks or months did you use? Well, I tried a few days. So it varies what the truth is. You have to really dig into that and said, okay, what exactly did you take and when and how did it have an effect?
speaker-1: I tried flonase three times and I didn't notice anything. So I stopped it. And I'm like, okay, yeah, you're not supposed to. Well, so let's then let's talk about CRS with polyps. And yes, I understand that the endotypes are more what we're skewing for. I'd still say though that for clinical practice, we still are very much, I think it's fair to say, still living in the realm of with or without polyps. most people can't run like the the deeper testing required to truly indotype a patient. I think with polyps is where there's a lot of historic thinking and teaching about allergies and polyps that I still see drives clinical practice. And this is an area that I have a lot of patients who come in from allergists, in the in the region. who are on immunotherapy basically kind of for their polyps. And I'm like, boy, that that ship sailed a long, long time ago. like haven't had surgery. They just got started on immunotherapy. And I'm just kind of like, Huh, okay.
speaker-2: Well that goes back to the you know, our original co statement about maybe these folks think that the allergy is what's causing the polyps
speaker-0: Exactly.
speaker-2: and that's why they're trying to treat it that way. But
speaker-1: Yes. I I think it's done with good intentions. They're misguided. Because the science has told us for a very long time that, you know, this is not an allergic disease and immunotherapy is not gonna really do any it may modulate symptoms, but it's not modulating those polyps.
speaker-0: I think also highlights the fact how ENTs are in a for front line with this because we can look in the nose. We can see is it just allergies or is their polypsy, their infection, and and really your encourage your allergies to send them at least to you once or at for checking, especially if they are not responding well and and patients are still symptomatic. Having that discussion that, you know. I'll send them back, don't worry. I'm not gonna keep your patient, but it'd love to have this dialogue and having treat them together. Let's do both. Exactly.
speaker-1: Yeah. I mean, I think, there's every real possibility that a patient gets started and they come back and they're like, Yeah, I I feel better, but it's I feel better on a scale of my polyps are a little bit less swollen versus they're gone.
speaker-0: I can smell or I can't smell. Right.
speaker-1: Right. You know, there's a lot of shades of gray there. And with a person who's been living with chronic polyps their whole life, feeling a little bit better to them is like, I I feel better, but it's like, okay, well, how about we remove the polyps and then you tell me how you feel? Because you didn't even know that that next gear shift existed. but you almost want to kind of give people that that point of reference now to say, like, this is how it could feel huge. Yes, and and it and but I don't even think that we've really captured that very well, right? 'Cause we do have like the SNOT pre and post surgery. but and we have like, you know, the SNOT scores pre and post starting a a biologic, but it's
speaker-0: I think you can get used to to anything. So when the polyps slowly grow and then you know you maybe you had allergies always and and then you get a chronic sinusitis with nasal pumps and it's slowly developing. You know, you kind of get used to it and you don't even know when you do your snot score, that's your normal. Yeah. So you don't even know how to compare anymore unless we help the patient. So
speaker-1: Right, yes. Yes. okay, so a little bit of a controversial one, but the central atopic, central compartment atopic disease. So do you thoughts on that?
speaker-0: So it's polyp more centrally, right? Medial side of the middle turpinate and non septum. But often these patients have the polyps also lateral side and indocinuses. And so I I'm I don't know. I I think it's interesting concept. I rarely see patients that they are just those very local polyps that would be only medially the classical central compartment, but but I'm sure they they exist. And whether that's again, that's my other question. Is that we say allergic? Is it allergic or is it polypease? That allergies maybe then just trigger or environmental exposure trigger. It kind of makes sense that it would be environmentally I don't know if we know it exactly. Do you, Stella, are you aware that we know exactly the are those polyps different than our other polyps?
speaker-2: controversial. It seems like these patients have more allergic, like atopic, that's why it's called that. But and they respond pretty well to, medical and surgical therapy. So but it is interesting. It does they do seem different endotopic and like if you look at their radiographic imaging and what their response to therapy is like.
speaker-1: Mm-hmm.
speaker-2: So I I you know, I've heard mixed things from, from experts and some folks don't think that it's a good idea to create more and more subcategories of CRS. But I think that's the future is becoming more personalized, tailored to patients' specific inflammatory profile. And that'll help.
speaker-0: Yeah, and yeah. And I I agree with you, Stella. I don't think it's bad. I think it's good we identify. I think it was when when people start to talk about you started to see them more. And you realize, this location is not what you always see. But does it really change our treatment that much? At least this point. I I don't think it changed my treatment, obviously, because I test everybody for allergies anyway. And treat that anyway. And then obviously treat the polyps, but
speaker-1: Mm-hmm.
speaker-0: same whether they are medially or laterally.
speaker-1: Yeah, I'd say it's it's difficult, but I'm not necessarily opposed to going through some of these patient groupings with a fine tooth comb and and seeing what comes out of the overarching umbrella term. Because you know it wasn't that long ago that all we had was CRS and that we had CRS with and without polyps. And I think so much of the literature showing so many mixed results in these various patient populations are likely because of mixed populations of disease, you know, we we sort of applied too broad of a term to patients. And that really, I think, has a way of hiding certain groups of people who do perform really, really well on certain therapeutic things. You know, I think going back to cystic fibrosis and looking at the the genotype and the severity of the disease as dictated by the genotype Cystic fibrosis is not just one disease. It it has very different presentations. And so to think everybody in this group fits under this umbrella, it never made sense to me. you know, somebody who's making no functional protein versus somebody who's making a reduced amount of it, you're calling those both cystic fibrosis, but let's face it, those are very different patients clinically.
speaker-2: Yeah, so even that.
speaker-0: About I'm sorry, go ahead, Sarah.
speaker-2: With even with an AERD, we think these are the most severe, but then again, some patients with ARD respond beautifully to surgery and typical
speaker-0: Mm-hmm.
speaker-2: steroids and they don't need biologics. and I've seen, the opposite with CRS with NP patients without AERD who are extremely difficult to treat and severe. So there's a whole range. We can't simplify too much.
speaker-0: Yeah, I was just thinking the C C A D about the the compartment syndrome that maybe these patients my understanding is that their polyps might be easier to treat, that you might even do an office removal. There's no sinus in classical you have no sinus disease, it's nasal. So would you be able to just kind of remove the polyps and then treat the allergies? Is that enough? I'd love to see some long-term studies whether these polyps respond differently than our classical polyps that tend to come much easily back. And again, not everybody. And that's that's I think the challenge here is that we just can't know how the patient is gonna respond to our treatment options.
speaker-1: Yes. Not yet. Not not until you do it.
speaker-0: You can't be gonna be retired by
speaker-2: That are yeah. Very
speaker-1: No, no, not predictive, yeah.
speaker-2: jealous of the pulmonary colleagues who have all these other tools.
speaker-1: yes. So then let's talk about allergic fungal rhinocytositis. So we've already had a vote to remove allergy from that disease name. So let's let's delve into that a little bit. I do love controversy. So, what what were your thoughts, what has changed for you in that disease to be like allergy shouldn't be part of it.
speaker-0: In Europe we didn't first of all in Scandinavia we don't have allergic fungal basically. We don't have humidity and it's way too dry and cold. So I hardly ever saw it before I came to US. And and then whatever the fungal was, it was the fungal, but this allergy component and this kind of definition that's here. It was very confusing for a long time for me. I kind of understand where it comes from. Again, the mechanistically, is the fungus there because there's been a chronic disease, and then the fungus just kind of loves this warm, nice mucus sitting there and it starts spreading. And would that then cause allergic reaction, or isn't this the CRS we already have and we know it's an eosinophilic inflammation? I'm not sure that the still the mechanistic is is quite clear which way this happens, but What what's clear is that with our surgery and then in the environment where there's a risk of patients getting a lot of exposure, the biologics have changed the the picture of these patients that are s difficult to treat chronic fungal. It is not as big issue here. I mean in Northeast
speaker-1: Mm-hmm.
speaker-2: And geography is so interesting. Geography, also maybe genetics, but likely, this disease, there's a lot of epigenetic, modifiers. but the environment that we live in, the microbiome, I think we still need so much more understanding of the ecology, the microbiome of the perinesal sinuses. And geography, genetic, you know, predisposition, all these things, resilience versus vulnerability. yeah, a lot to be uncovered there. So better understand the mechanistic aspects of it. But the geography is very interesting, right? Because in Boston too, we don't see much of AFRS. But if you go down to Southern states or Middle East or a
speaker-1: Yes.
speaker-2: lot of it.
speaker-1: Yes, you do.
speaker-0: And interestingly what what David told me was that when he treated patients in the Middle East before air conditioning, they didn't have this disease. So there's something that changed.
speaker-1: Yep. Yeah. So I you know, environmental, but is it environmental because of the the climate? Meaning the humidity and the the temperature and the spores and like the sort of the the production, or is it environmental because we're constantly running, air conditioning? And I think that's such an interesting point. And I think a lot of people around the country have realized that when their hospital is doing major renovations, there's a pretty big spike in acute invasive fungal sinusitis in their immunocompromised patients. So there does seem to be some kind of correlation there perhaps. So it does make you wonder for AFRS. Yeah.
speaker-0: Yeah, how clean are the air conditioners? What I mean what can grow there and in spread to the environment? I I don't know.
speaker-1: Well, and in those environments, they're probably getting pretty saturated with moisture and condensation, which is sort of a breeding ground for fungal overgrowth. And then you've got this thing jetting it out, and especially, you know, given that it tends to sort of be more severe perhaps in certain socioeconomic classes and people. And so if you think about are they the ones that are typically having, window units versus central air, and is it a smaller space? that is being covered by these different cooling entities. I think we probably did it a real injustice. We didn't know this at the time. And I'm certainly not saying like, Bent and Coon, you were wrong. No.
speaker-0: I just think yeah.
speaker-1: No, at at the time, the information that we had, yeah, I painted a very compelling picture. But how much have we sort of limited our understanding and our expansion in that disease process by just being like, Yep, that's it. Yep.
speaker-2: As our climate is changing, you know, that could also lead to other behaviors that lead to more air conditioning. And also wildfires, too. It's very interesting how even wildfires carry fungal elements and bacteria and other things. sinusitis exacerbations, upper airway and asthma exacerbations. And we're studying also in there's no indoor air quality standard, we have other air quality standards as of now, but as far as indoor air quality, we spend many of our lives indoors. So it's really important to understand that. So that's one area of our research that we're doing here. And hopefully getting more understanding of how we can improve that. Ventilation is key, right? Yeah.
speaker-1: Yeah, which probably not standard, like you said, or measured really in the various housing options for people, especially if you happened to live in lower cost, housing environment.
speaker-2: So
speaker-0: Yeah, he I I'm the healthy house is a house that breathes. So there was a lot of healthy indoor air interest about twenty years ago in Europe and and occupational airway diseases from from multi buildings at schools, hospitals, public buildings. And it was quite a intensive research on this. And what the studies did show in a bad air quality, it wasn't allergies that these people they didn't get a fungal allergies that wasn't very high. What they did show was irritation, inflammation, asthma exacerbation or development of a lower hyperreactivity. And idea there was that these these molds not only they are not very allergic allergenic, understanding from that was, but they also can form toxins and change the air quality different ways as well. So there's so many things that we we haven't looked into.
speaker-1: Yeah.
speaker-2: This day and age, things that are fragranced, we know those are not natural fragrances anymore. They're hundreds of chemicals. also, candles are wonderful, but they're actually
speaker-0: I get a microwave from any candle that smells.
speaker-2: The other day a patient of mine said she was spraying Lysol into her bed. So you know, it's all these chemicals and things that I think even just our patients don't aren't aware that they're so toxic to our barrier function, our skin, our nose, our lungs, and we have to be more conscientious about that. And we have to educate ourselves and our patients about it.
speaker-1: the next question that I had, and Alina, you've already sort of answered this, is that you test every CRS patient for allergies. And Stella, is that how you practice? It's definitely not how I practice, but I'm not the expert. So
speaker-0: I can just g verify if they haven't had any reliable testing within a couple of years.
speaker-1: Okay.
speaker-2: Yeah, I ask the patient, I involve the patient in the conversation I do offer it. I ask my patients about all these symptoms related to allergy. But then also I say, allergy could be playing a role and you might not realize it, And then I say, well, we can do allergy testing and that might be helpful to just understand your inflammatory picture. And some patients really just don't want it, you know? And some patients really want it. So I think involving the patient in the decision is helpful, but telling them what the rationale is.
speaker-0: Yeah. Of course, I'm not I'm not automatically testing everybody, but I'm asking first of all, do you think you have allergies? if they said I've never had any that's the patient I've okay, we don't need to, but anybody who thinks that they might have allergies or they've had allergies in a childhood and they've had these allergy symptoms, those are the patients I suggest. allergy testing I offer them the options of doing the blood work or a skin test.
speaker-2: And if they have a history of atopic dermatitis and also family history is really important. Their parents, siblings, if they have a strong atopic history, we do know that there's a genetic component for that.
speaker-0: And then when you think the prevalence of forty percent, it's every other patient.
speaker-1: Mm-hmm. But I think what always gives me pause is, what is allergy versus sensitization? What's the difference? And in somebody who has an underlying sinus disease, how do you differentiate? So if they they are pan positive, how do you interpret that?
speaker-0: You have to talk with patients when do they have their symptoms, their allergy symptoms. I mean, if you have year-round symptoms and they have house dust positivity, that's likely where they have the cats and dogs and that's positive and they have year-round. So thinking and talking, like Stella said, you you kind of go through these different exposures when they are in the environment, how they fact, how have you noticed it? And then again. Some of the reactions are small, and if you do a blood work, the Ig level is is low. it's just very patient-dependent. But if you have allergies, I want to address them.
speaker-2: I don't think there's much of a downside of doing it. I mean the testing is quite, benign and you have some
speaker-1: Mm-hmm.
speaker-2: potentially very valuable data.
speaker-1: the issue that I've had is and maybe I remember this too much, is seeing patients who were really heavily managed for allergy doing like immunotherapy, who had underlying chronic sinusitis and it didn't do them any good. They spent three years on it or t a year on it or whatever. And, The patients have then had to dedicate a a significant amount of time and there's risks involved in immunotherapy. And I think that I tend to look at it as I think a lot of people who are put on immunotherapy probably don't need to be on it. So I
speaker-2: Is a study that I read that really has stayed with me for like 10 years at least, or maybe longer, that only 11% of people who are eligible for immunotherapy actually doing immunotherapy in the United States. And
speaker-1: Mm-hmm.
speaker-2: I think especially if you think of the benefits, especially in children, that you can asthma, like wow, you know, we can't say that about a lot of things in our field that you can. prevent disease. We don't talk about prevention a lot.
speaker-1: And this is
speaker-2: I think especially for children, if you know they're sensitized, you know, to like cockroach and the molds and dust and things, and they're highly susceptible to developing asthma. yeah. But then there's the tricky thing with CRS too, I agree. But we do have to be a little bit more conscientious about Allergic Ryanitis role. And this is why you're doing this podcast, I suspect, because it's so important. wanna empower physicians to have intelligent conversations and thoughtful conversations with patients, especially with young children too. And if they have and they tell me about their kids and they're also like this atopic march happening, like God.
speaker-1: Actually every family.
speaker-2: You know.
speaker-0: What frustrates me is the patient that come to me and they've been on allergy shots for 10 or 15 years. Because there's no point for that. The studies are three years max five. You take a break, if you wait ten to fifteen years because you don't get any benefit. And that's just a waste and that really is upsetting when then they finally come to you and then there's an untreated CRS. so but Well done, the right allergens, right clinically relevant allergens, immunotherapy. It's helpful. It is not miracle cure. We know that patients' symptoms score reduce and medications need reduced, but it is not resolving all your allergies and olios symptoms on everybody, but it is kind of shifting the immunity and your hyperreactivity away from that. And like Stella said, if we can prevent any asthma development or asthma exacerbations, because those who already have asthma, often pollen season is the one that you get the worst symptoms and you can be hospitalized, you're really sick. So we can prevent that. And maybe your CRS exacerbation as well.
speaker-1: I think that that's a really great point. And the considerations in children, I agree, are completely different than adults. Because, you know, and I really only see adults. So by the time I'm seeing them, the opportunity to really provide them with like a meaningful it's different in children, right? You do have the opportunity to sort of like intervene early and potentially modulate them developing asthma down the road. So I totally agree. I think definitely being more aggressive about it in children. makes a lot of sense. But I'm glad that you brought up the cystic fibrosis, Stella, because what I started to notice in patients is that they were having kind of seasonal exacerbations of their pulmonary symptoms. And I started to be like, this is allergy. And I started testing them. And you know, we're gonna get into this in a minute, but we offered sublingual immunotherapy where I was previously. And that was perfect for CF patients because it actually enabled them to get the immunotherapy because you know, CF patients a lot of times are sick or they have symptoms. And so doing allergy shots presented a bit of an issue in that they were just never well enough to get the shot or they had to miss them several times. So the sub-lingal immunotherapy in that group I thought was like a phenomenal option. So and had a couple of people who did awesome. you mentioned briefly, so how do you do allergy testing? Do you have a preference? Skin prick testing, intradermal testing, or serum allergen testing?
speaker-0: I offer skin testing. I have an allergy nurse. We do a lot of testing. Not everybody wants to get a skin prick test. Not everybody can if they're on a on a medication they can't stop. but I offer also the blood work. So I offer them both.
speaker-2: I agree with Alina that skin prick testing is the gold standard I offer in vitro testing, especially with if there's a contraindication, dermatographism, they can't come off antihistamines or other issues.
speaker-1: Antipsychotic medications or antidepressants. so between serum allergy testing and skim prick testing, I have patients bring this up a lot. They're like, Well, it's not as, good, the the serum allergy testing. And I'm like, it's pretty equivalent. My understanding is there may be more false positives with the serum allergy testing.
speaker-0: Say, I don't know if it's false positive. If you have IgE in the blood, it is there, but is it clinically relevant? I think that's the question. And what we've seen, the studies have compared, I think I we looked in the testing, and I if I remember correctly, that skin test was maybe twenty percent more sensitive overall. but I think when you have a significant allergy, it would Come up on either testing.
speaker-2: Yeah, I agree. I you know, and it differs between patients, but there is I would say a good concordance between the two. It's yeah, it's gotten the in vitro testing has gotten so much better. it's quite easy to perform. Patients sometimes just prefer it. They don't wanna be tortured with a million things on skin and itchy, et cetera.
speaker-1: if a patient gets serum testing, is there any scenario where you will follow up with skin prick testing?
speaker-0: Not really. Other way around sometimes. Patient, let's say they have had the any reaction and they convinced they have allergies. But let's look at the blood work. I mean, look at the absolute Ig levels and then if that, kind of confirms patients' suspicion that our testing is not good or maybe there's some something in that they took like, you know, antihistamine they didn't. Remember or or that would affect the skin testing, so confirm the platform.
speaker-2: And there's entopy, you know, the local IGE where you just can't. I mean, we're we're testing the skin as a proxy for the nose. and so I think if someone is like dead set on like, my gosh, the cats for sure are the ones, then maybe you know, you can try to do another test with skin because it might show up there, just so that there may be some. more information you could get from there. And if you have a negative test, you can't treat with immunotherapy. that road ends there. I've had a a a few patients where, even if the skin prick testing is negative and there's a significant history of a clinically relevant allergy, then then maybe IDT in case some cases might be helpful too. But then there are so many false positives with that you have to careful. Yeah.
speaker-1: Mm-hmm. Okay, so on to the next topic. Does treating allergy improve or modulate CRS? And and I think that we all kind of be like, yeah, it can modulate it, or it at least controls the allergy symptoms. Sometimes that makes it easier to separate from what's like the CRS symptoms. But I guess after you've, let's say, done surgery on a patient, what's your kind of typical approach for just CRS? Let's talk about. For me, I mean, it's mostly topical steroid rinses for some period of time. and honestly, depending on how they do, I'm a big believer in the intranasal antihistamines for even non-allergic patients because I I think it's so much more effective in non-allergic rhinitis than flonase is, just personally. And I think some of the literature has actually shown that.
speaker-0: if you look at the European studies, they've shown the local allergic reactivity in the nasal epithelium. So there could be a lot of patients that are allergy test negative but have still local allergic reactivity in the nose and nasal mucosa. And if you could isolate the mucus and take the local IgE like they do in their studies, they show much higher prevalence of allergies in non-allergic patients. So these patients definitely would help. from antihistamine. And answering your question, I do the steroid rinses and on my allergy patient I add the nasal antihistamine. Absolutely. I I really believe in that, in addition to oral antihistamine.
speaker-1: In your allergic patients.
speaker-0: In my allergic patients.
speaker-2: maybe we should talk about you know Monteleucast can be helpful too for patients with comorbid asthma and allergic rhinitis and AERD, mainstay is topical nasal steroids and this comorbid allergic patients. One thing I worry about, some patients, have you seen this patients' noses can become like a desert with azlastine.
speaker-0: And also can't be sedative, so you have to tell that to patient. Certain patients do do feel it and I tell them to do it in the evening.
speaker-1: At nighttime. Yeah, that's what I
speaker-2: That's
speaker-1: do as well. And I find that yes, there is that bad taste, but honestly I feel like in the majority of patients it works so well that they're like, I don't care.
speaker-0: You can lean your head forward and spray so it doesn't taste as bad. Now I remember what I wanted to say actually when you're talking previously about allergies and sinus surgery. So studies have shown that your surgical outcomes are better. Epidemiological studies have shown your sinus surgery outcomes are better if you address the patient's allergies when they have.
speaker-2: Correct. And it's actually Dr. Andy Lane who published this paper. it's a very old paper, but it shows that patients who have allergic rhinitis therapy, immunotherapy, their outcomes, as Alina said, are better and the patient satisfaction is better.
speaker-1: So I guess that's the key though. is it just immunotherapy that we're talking about? have the studies been just looking at immunotherapy as treatment of allergic rhinitis? Cause I mean that's the big question, is how aggressive do we need to get in treating patients with allergies and CRS? is it just the topical antihistamines, the topical steroids, those things, or just going that extra step and going to immunotherapy, is it worth it for CRS? Probably dependent on the patient. I'm glad that you mentioned singular or Montelou caste. I I'd say that in clinical practice, I think that this is one that gets over prescribed. So it in my
speaker-0: I don't actually like it as much.
speaker-1: No, I I tell people if they have bad
speaker-0: It's weaker than antihistamine when you look at the studies.
speaker-1: thing. I tell people that this is a marathon medication, not a sprint. and it's for people who have CRS with polyps and bad asthma. And then for the AERD patients,
speaker-0: Minute.
speaker-1: it's very limited how often I use it. And all the black box box warnings have come out about it. And it's not just a nothing drug. You know, it it does have some side effects.
speaker-0: Right. Primary cares tend to send that to every patient with any allergies or asthma. And I think the study shown that only twenty percent of patients have that specific Lucatrian pathway as a major pathway. So eighty percent of patients wouldn't benefit. So you have to do a trial and then be realistic and ask patients, did it make a difference? If you and I to often say, let's stop and see if does it make a difference?
speaker-1: Mm-hmm. Well, and they can't be on an antihistamine at the same time. You know, really just need to be one or the other and not singular.
speaker-2: I would say in my practice I've significantly decreased my prescriptions of Montalucast.
speaker-1: So one question that I get a lot from patients is, which antihistamine is best? And can I get immune to them? Some people swear that if they don't switch between antihistamines, that they're gonna get immune to one. I generally think of them as claritons kind of the most mild and like ZirTech and Zol are a bit more drying
speaker-0: It Any antihistamine the patient's gonna take, that's the best antihistamine at the end of the day. And if they say I I no it doesn't work, let's try something else.
speaker-1: Mm-hmm. Yeah.
speaker-2: And epsofenidine is the one that you can do, twice daily and really go off over dosing, which is nice. But it depends on the patient because some patients take loratidine and they're like, wow, that was really strong. Yeah. What's surprising to me is there are still so many patients that take diphenhydramine. Yes. even just yesterday in my clinic, and these are some of these patients are quite elderly and there's now some good evidence that it's it's not good for your brain or your brain health. but they're very attached to the older generation, antihistamine. So Do actually curious do you have strategies to try to get them off of that? And they say that they don't the other ones don't work as well. So
speaker-0: Probably right. They are potent, but
speaker-2: I know, right?
speaker-1: Yeah. I mean, I think it depends. I think it depends on what symptoms they're trying to treat. Because the reality is if they've got vasomotor rhinitis or real watery sort of anterior rhinorrhea, no, flonase and aslastine, those weren't gonna work. they needed ipertrium spray, various other antihistamines weren't going to, you know, so I think a lot of it is just sort of finding out what symptoms they're actually trying to treat, seeing what they've tried in the past and you know, offering them some updated alternatives. depending on what they've tried. Okay. So then last thing that I wanted to touch on is immunotherapy. So I'm gonna guess that this is something that you're reserved for CRS patients whose allergy symptoms are not controlled on an oral antihistamines and anti antihistamine nasal spray, correct?
speaker-0: Yeah, I I tell every patient, let's try with the medication for your allergies and obviously address the CRS. And if that doesn't help, then allergy immunotherapy is the option. That's also what the guidelines said.
speaker-1: Yes. Yeah.
speaker-2: I do make sure patients know that that option is available. I'm still always shocked by how patients are so amazed that this option is available to them. So I I do make sure that we talk about it ahead of time to just plant the seed in their mind.
speaker-1: Yeah. I tend to separate the two disease processes very clearly with patients to say, like, look, this isn't gonna do this isn't gonna cut it for your your chronic sinusitis, your polyps, your your whatever. This is just going to sort of help with one of these disease processes, which you know, reducing sort of the inflammation burden that you experience from that may help with it. But the evidence out there is not very strong, but this is not a standalone therapy for your chronic sinusitis.
speaker-0: Exactly. It also might help with your lower way. You know, if you have I always have so many patients with asthma as well. So I'm talking about what it what it helps, but but the CRS has its own.
speaker-1: Yeah, especially allergic type asthma. I'm very, you know, encourage them definitely to optimize allergic therapy.
speaker-2: Beauty of it is disease modifying. So that's what's wonderful about it. But
speaker-1: Mm-hmm.
speaker-2: I wish all medications, there could be some component of that. There's just so many medicines out there that don't tr treat the underlying immunologic dysfunction. So that's the beauty of immunotherapy. Right. But it is hard to do and hard to commit to, time cost, all those things.
speaker-0: if we talk about CRS with polyps and now we have those recalcitrant polyps that we start treating with the biologics, do you need immunotherapy? So I've had few patients, I've talked to the patient and I suggest that as an option, but there are a few patients that wanted to finish their three years because they're so committed and I don't see anything they shouldn't. But
speaker-1: Mm-hmm.
speaker-0: I don't think there's good evidence is immunotherapy additionally beneficial in addition to the our biological
speaker-1: I mean insofar as you anticipate that a three year course of immunotherapy is gonna provide you with eight to ten years of coverage, right? So we don't know yet about the biologics. So I'd say I'm in more inclined to say to people like, Look, if you're in this for a year already, finish it out potentially.
speaker-0: Start allergy immunotherapy, while patient on biological.
speaker-1: Think so, because I think I I think they have to sense I would want to know that they sense a benefit, you know, and I think that that would mask it. So I think the problem is that if you are on a biologic and you start immunotherapy, you have no idea if it actually helped your allergies. But I will tell you that we had one patient who had really severe allergies and could not tolerate immunotherapy. And we actually used biologics to get his disease under control to a point that his asthma was better. And he still was committed to doing immunotherapy because he was going for that sort of immune modulation. So it was kind of crazy that we used the biologics to get him to a point where he could do immunotherapy, right?
speaker-2: That's you know, with Omalysimap.
speaker-0: Exactly. It's been used before for that reason.
speaker-2: Is a way
speaker-1: Yeah. And I think when in in the current sort of climate where we're talking about like when do you stop the biologic? How long does the person need to be on it? that's a huge question. And so I am gonna go for the immunotherapy over biologic, if their disease is predominantly allergy driven, because we have much stronger evidence for a much longer period of time that that can give them a sustained benefit. So yeah. And so I guess as we're kind of wrapping up Do either of you do sublingual immunotherapy aside from the tablets?
speaker-0: Yes, we do jobs. Custom made.
speaker-2: Used to but now I only prescribe tablets. We
speaker-1: Okay.
speaker-2: don't have the infrastructure for the compounding for the drops.
speaker-1: Yeah.
speaker-0: I have an allergen nurse who mixes them and we choose the allergens together with the patient and discuss them and then go from there. But it is the price is very limiting.
speaker-1: Yeah. Yeah. Which is a it's a real bummer because I I think it makes sense and I I know I think that there's some literature out there how much more adherent people are gonna be to the sublingual drops versus the shots and just sort of the ease at which you can kind of fold it in. But at the same time, yeah, I can just sit there in the refrigerator and they can just not use it. So some people say I wanna do the shots because I need to show up. I need to have this, like that will be my sort of like way of getting it done. so
speaker-0: A few patients, it's also a social event.
speaker-1: Yeah, gets him out of the house. Yeah. And also I do relationship
speaker-2: that you have that you know the happiness that you have when you see your allergy nurse. It's a really important to hire someone, your allergy nurse that your patients will love. And you know, that's in my experience, our allergy nurses are the ones that they want to see. They don't want to see me.
speaker-1: Has it been a year? Right. Right. one question that I get from patients is are sublingual and subcutaneous immunotherapy equally effective? And I say yes. you know, some people are like, Well, doesn't the sublingual take longer? And I that's not my general impression.
speaker-0: I I think the studies when you look at the head to head view comparison that there were articles that the immunological response from ash might be a little bit stronger.
speaker-1: Mm-hmm.
speaker-0: But subling all is so much safer. So again, I think whatever they take, that's the best for them.
speaker-1: Yes. Yeah, whichever that will do. I I agree with that.
speaker-2: Yeah, I agree with Alina. It seems to be more potent. But then you have all these side effects potentially. And a philosophy, you know, you have to wait in the office for 30 minutes after.
speaker-1: Yeah. I think that there's pros and cons for both for sure.
speaker-0: And yesterday I had a patient who had been on sublingual now for three years and we talked about should we continue? He said, You know, I still feel improving. I said, Yeah, let's go. We can go up to five years. We see every three months and see how he's doing.
speaker-1: Mm. Yeah. And your experience with the tablets has been pretty positive, other than coverage issues.
speaker-0: Yeah, I mean I don't think the side effect profile is any worse. Some itching under the tongue for a while and but unfortunately not many patients can have it. Yeah.
speaker-2: For efficacy, you know, we're doing a study right now sponsored by the AAOA on the effects of a doctrine eustachian tube dysfunction. And you know, it's the I would say I have mixed feelings about what we're seeing. We don't we the data isn't fully analyzed, it'll probably be coming out soon. But yeah, we'll see. It's it seems like it's helpful, but compared to skit, the shots do seem to be more effective than the Dactra tablet.
speaker-1: Mm. Okay.
speaker-2: Then we know based on the old, old Brian Leatherman paper, the dust mite, the amount of actual, the allergen extract is quite high that you have to put into the vial. And for molds, it's just like still wild, wild west, right? The standardization.
speaker-0: Yeah, there's a nice kind of comparison how much more you need certain antigens compared to others. They are not equal. And the old old teaching goes goes how everything is just one CC. So this is a another discussion where we could
speaker-1: Yeah, it's bizarre that that's not been standardized.
speaker-0: I agree.
speaker-2: It's a huge brain.
speaker-1: Yeah. Yeah. So well as we wrap up, just you know, final thoughts. If listeners remember a couple of things from today's episode, what should they be?
speaker-2: The allergen immunotherapy is disease modifying and even though we have
speaker-1: For allergies and asthma. Wow.
speaker-2: For allergic rhinitis and asthma. and we have biologics now. as of now, I we are still understanding whether biologics can be disease modifying, but doesn't seem to have the, you know, same effects as immunotherapy, the benefits of immunotherapy. I in general, across the board in the US at least, from the data that I have seen, it it seems that immunotherapy is underutilized. But I do think it has to be the extracts do need to be standardized better and education for our trainees for understanding how to do allergy testing that you know diagnosis, all of those things, treatment have to be parsed out with in a complex world where we have so many different options now.
speaker-0: So I think what remember, think about allergy on your patient with CRS. Just think about it, ask about it. Ask patients where do they work? Do they have exposures at work? Patients like nail salon workers or working on construction or exposures that come from environment that can make the CRS and potentially allergies worse, working in an animal hospital. there is so many, many environmental patients spend ten hours a day in the workplace. And ask about the home. Do the do you have the pets? Or if you don't have pets, do the kids where you go every other day to, you know. So ask about patients' environment. Be interested how the environment affects their disease. ask about low airway. Do you get prolonged cough after cold viral cold? Do you wake up nighttime cough? Consider that if you don't do it yourself, I do spirometry and treat asthma in my office, but if if don't send them to pulmonology because that's a big part of the quality of life in our CRS patients with allergies. Those are the the critical things, I think.
speaker-1: Well, amazing. Thank you both so much for joining me today and making this such an amazing discussion. And I am in the company of brilliant minds. So thank you. I'm grateful for you.
speaker-0: Thank you, Ashley.
speaker-1: And keep on listening. We'll catch you on the next episode of Rhinology Roundtable.
