Starve a cold, feed a fever? Or is it feed a cold, starve a fever?

David B Engler MD, FACAAI, FAAAI Board Certified Pediatric & Adult Allergist and Immunologist www.allergyhouston.com About the author: Dr. David B Engler is a Phi Beta Kappa graduate of the University of Texas at Austin and a graduate of Baylor College of Medicine. He trained in allergy at The University of Texas Medical Branch. Dr. Engler has served two terms on the Board of Regents at the American College of Allergy, Asthma and Immunology and has published several manuscripts on allergy and allergy testing in national peer-reviewed journals. He has also served as the Chairman of the Section of Allergy and Asthma for the Texas Medical Association.

As we head into cold and flu season, many of us will catch a viral infection that will give us symptoms of a common cold: runny and/or stuffy nose, sore throat, cough, headache, and yellow mucus. So if we’re infected, we should take an antibiotic, right? Wrong! Antibiotics don’t work on viruses, and viruses cause colds. A review of sinus infections from the New England Journal of Medicine (2004;351:902-910) stated that using antibiotics is usually not recommended until the mucus has been discolored for at least 7 or 10 days. Many of the patients we treat for allergy to multiple antibiotics develop those allergies when their antibiotic is changed over and over again. It gets changed because they take the first antibiotic when the “cold” first appears. Amazingly, the antibiotic does nothing to treat the virus, which runs it course. The patient, not feeling any better, asks for another antibiotic. And sometimes another. For years, the line about chicken soup was, “Will it help?” “Well, it couldn’t hurt”. Scientific evidence suggests that chicken soup actually does help. It contains the amino acid, cysteine, which has been shown to thin out thick mucus secretions and help relieve congestion. Hydrating by drinking Gatorade, water or any non-caffeinated beverage helps further. What about “feed a cold, starve a fever”. It’s actually not a bad idea. A fever without cold symptoms may be the flu (influenza), another viral infection often manifest by nausea and vomiting. Starving the fever by withholding food is reasonable if one is nauseated, but make sure you drink plenty of fluids. Gatorade is a good choice here, too. What else works when you have a cold? Rinsing your nose out with a salt-water solution a couple times a day. Some people prefer a Neti Pot, and others like the NeilMed squeeze bottle. Whichever you use, mix the salt with distilled water, not tap water. I’m sure the city makes clean drinking water, but I’m not as confident in the old pipes it runs through. And Mucinex works by increasing the water content in the mucus, so that the mucus thins out and you can cough it up or blow it out. For a stuffy nose, you may want to consider a decongestant spray such as Afrin. But don’t use Afrin more than 5 days in a row or you may become physically dependent on it (addicted).

And remember, unless you have an immune deficiency; skip the antibiotics until the mucus is yellow or green for at least a week.

Note: Information contained in this article should not be considered a substitute for consultation with a board-certified allergist to address individual medical needs. (264)

Using Neilmed’s platform for accomplishing buffered saline nasal lavage in allergic rhinitis and chronic rhinosinusitis with or without nasal polyposis

Daniel E. Maddox, M.D. Diplomate, ABIM, ABAI, with special qualification in Diagnostic Laboratory Immunology Fellow, American Academy Allergy Asthma & Immunology Consultant, Allergic Diseases & Internal Medicine, Mayo Clinic Specialist in the field of Allergy / Immunology, Dr. Maddox is prepared to provide specialized treatment for allergic reactions and immunological diseases. Dr. Maddox treats and manages disorders such as asthma, hives, and all types of allergies (food, environmental, etc.), rhinitis and sinusitis, as well as other disorders and diseases that affect the body’s immune system.

I have been a strong proponent for patients accomplishing buffered saline nasal lavage as part of the management of both allergic rhinitis and chronic rhinosinusitis with or without nasal polyposis for quite some time, as data have accumulated in favor of this element in management of these conditions. In allergic rhinitis, studies of mucociliary clearance times for particulates deposited anteriorly suggest that normal clearance times of 15 minutes may be prolonged by up to 6 hours or more, which means that pollen grains embedded in the mucus blanket as the patient is coming home from work in the evening may persist into the sleeping hours, when the inflammatory consequences are substantially magnified. Even with an evening lavage to clear these materials, most allergic rhinitis patients are most congested on first arising mornings, and attempts to estimate what fraction of total nasal inflammation may be attributable to the barotrauma caused by vigorous noseblowing in a congested state suggest surprisingly high fractions; this may be a significant incentive to clear the nose mornings with a gentle buffered saline lavage instead of vigorous noseblowing, so as to sidestep the barotrauma-induced additional inflammation. I have heard a remarkable range of practices reported by patients who have embraced some form of lavage in terms of what they use and how they compound their lavage fluid. I have emphasized to patients that research studies clearly show that the mediator-containing cells in the nasal mucosa are quite sensitive to changes in the osmolar milieu, so that if their lavage fluid is not carefully compounded so as to be isosmolar, and of appropriate pH, they will in effect be activating the very cells that create the chemistry of their allergic reactions. In my experience, the Neilmed system is the only widely available product which enables patients to accurately compound isotonic, buffered physiologic saline, affordably and reproducibly. I often show the brief instructional video on the Neilmed website to patients when I am discussing this process with them. I wish it could be changed in two ways: 1) in addition to washing the hands before starting the process, I would like patients to further attempt to decontaminate the fingers that will touch the cap/tubing assembly with an alcohol-based hand sanitizer, as self-inoculation with respiratory virus in the process of lavage is self-defeating. 2) studies suggest that bacterial biofilms will be established in the bottle, and I would like patients to conclude their lavage by holding the bottle with a spare set of salad tongs, so that it can be filled 4 or 5 times with steaming hot water that is too hot to touch, and then I ask them to store the bottle horizontally after knocking all the water out of it, so that the interior dries in 3 or 4 minutes, instead of inverted, as the video shows, which would entrap the warm moist air and prolong drying of the interior of the bottle to an hour or more. Properly done at least twice daily, buffered saline nasal lavage improves nasal mucosal quality and reduces accumulation of inflammatory debris with sufficient predictability so as to make it a key component of successful management.

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Is There a Misperception of The Risks of Tonsillectomy?

Steven T Kmucha, MD, JD, FACS Board certified in Otolaryngology – Head & Neck Surgery and in the subspecialty of ear, nose and throat allergy. About the author: Dr. Kmucha is board certified in otolaryngology and allergy, completed an otology fellowship and have additional certification in sleep medicine. He completed law school in 2007 and received a JD with emphasis in health/healthcare law. He has a Masters degree in Medical Management presented by the American College of Physician Executives.

Tonsillectomy remains a common operation, with approximately 737,000 procedures performed annually in the U.S. The two most common indications for tonsillectomy include sleep-disordered breathing and recurrent tonsillitis. These indications have changed from being a surgery performed primarily for recurrent infections in the 1970s to a surgery performed more commonly for sleep-disordered breathing today. A large number of recent clinical trials and medical reports have repeatedly confirmed that adenotonsillectomy improves quality of life, behavior outcomes, quality
of sleep and polysomnographic findings, especially in children with documented obstructive sleep apnea.

Relatively minor surgical complications such as minor hemorrhage, soft tissue injuries, abnormal taste, TMJ dysfunction and others are well-recognized and reported following tonsillectomy. Prior analyses of post-tonsillectomy malpractice claims has documented that hemorrhage is a predominant cause of mortality following tonsillectomy. Based upon data from the 1970s, total post-tonsillectomy mortality has been estimated at between 1:16000 and 1:35000. A 2009 European documented a post-tonsillectomy mortality rate again of approximately 1:16000. Therefore, posttonsillectomy mortality appears unchanged over more than 4 decades of monitoring and numerous studies/reports despite significant improvements in surgical technique, surgical technology, anesthesia equipment and monitoring and an intense system-wide focus on surgical quality and patient safety.

Perioperative arrhythmiae, cardiac death and other anesthesia complications are also associated with tonsillectomy surgery. A 2008 malpractice claims review documented that when monetary awards were paid to plaintiffs associated with perioperative or postoperative tonsillectomy claims, monetary awards against anesthesiologists were more frequent and higher than against otolaryngologists.

The role of obstructive sleep apnea in tonsillectomyrelated malpractice claims remains somewhat controversial. With an increase in obesity, with an increase in the diagnosis of sleep apnea, with an increase in ambulatory surgeries, otolaryngologists and anesthesiologists would appear to be increasingly exposed to new areas of liability. Also, with the shift in the indications for tonsillectomy from recurrent infections in the 1970s to treatment of sleep apnea more recently, it would appear that both otolaryngologists and anesthesiologists are similarly being exposed to increasing liability when treating this growing population of patients with documented sleep apnea.

For those patients without documented sleep apnea, only formal polysomnography (PSG) can provide such documentation; due to the (geographic and financial) inaccessibility of PSG for many patients, such a study may not be available. As there are no clinical metrics that diagnosis OSAS other than PSG, a diagnosis based on patient reporting, family reporting and other clinical symptoms alone may under-diagnose a significant proportion of patients with true OSAS.

While most otolaryngologists and anesthesiologists are familiar with postoperative post-obstructive “flash” pulmonary edema that often occurs after tonsillectomy in a patient with OSAS, some studies also suggest that the frequent episodes of hypoxemia associated with OSAS result in increased opioid sensitivity of mu-receptors such that a normal dose of opioid can be a relative overdose in patients with OSAS. Posttonsillectomy complications also appear to be more commonly associated with OSAS in younger children. The obvious fact that smaller children have smaller and more difficult airways is another important factor. Another recent report published in Pediatrics in 2012 documented that while younger white children received less opioid doses after tonsillectomy than black children, white children had higher numbers of opioidrelated adverse events.

The most commonly reported opioids associated with post-tonsillectomy claims were codeine, morphine, fentanyl and meperidine. Despite its well-known efficacy and safety problems, codeine remains one of the mostly commonly prescribed opioids for home pain management after adenotonsillectomy in the US likely due to cost, availability and perceived safety. Black box warnings were issued in 2013 by the FDA against the use of codeine following tonsillectomy in children. Ultra-rapid metabolizers of codeine have greatly enhanced rate of conversion of codeine to morphine in the blood stream rapidly increasing the possibility of morphine toxicity with associated respiratory depression and death. These risks are not limited to codeine but are associated with all other opioids.

Many otolaryngologists have already switched to protocols which maximize analgesia provided by non-opioids administered on a scheduled basis (choosing medications which do not simultaneously increase the risk of bleeding such as acetaminophen) while reserving the lowest effective dose of opioids not dependent upon pathways present in “ultrametabolizers” on a limited and as needed basis such as hydromorphone, oxycodone and morphine with detailed safety instructions to parents and patients about potential side effects and appropriate use.

Many studies suggest less pain and postoperative nausea is associated with a pre-operative dose of dexamethasone; a recent 2014 report suggests that significant variations persists around the US in the use of perioperative antibiotics, dexamethasone and analgesics. (476)

Maintenance Therapy For Your Nose and Sinuses

Nathan B. Sautter, MD Board certified in Otolaryngology – Head & Neck Surgery Assistant Professor of Otolaryngology Oregon Sinus Center at Oregon Health & Science University About the author: Dr. Sautter completed a fellowship in Rhinology/Sinus Surgery and has been practicing at Oregon Health & Science University for the past 6 years. His practice is devoted to treatment of chronic rhinosinusitis, allergy, and all other disorders of the nose and sinuses.

The nose serves many important functions, including filtration of the air we breathe. Dust, pollution, mold, bacteria, viruses and other microscopic particles are often present in the air that enters the nose. The nasal and sinus membranes are coated with a thin, mobile layer of mucus responsible for trapping particles in the air when we breathe in through the nose, preventing these particles from reaching the lungs where they may cause irritation or infection. The cells that comprise the nasal membranes are covered with tiny hairs, or cilia, that work together to move this mucus blanket along with the trapped particles towards the back of the nose where it is directed into the digestive tract. Acid in the stomach neutralizes any viruses, bacteria or other microorganisms present in the swallowed mucus, and this functions as an important first line of defense against infection.
Any condition that results in inflammation in the nose and sinuses, such as allergies, chronic sinusitis, scarring from prior surgeries, or anatomic abnormalities can impact the normal function of the nasal cilia and mucus blanket. This may result in buildup of sticky, tenacious mucus, crusting, chronic infection and inflammation which can cause symptoms of loss of sense of smell, foul smell, nasal obstruction and thick nasal drainage. Ultimately, the normal function and physiology of the nose and sinuses may be compromised by this process.
Regular saline nasal irrigations aid in cleansing the nasal and sinus membranes, preventing buildup of abnormally thick mucus and crusting in order to maintain a healthy nose filter. Just as the air filter in your car or home ventilation system requires regular maintenance for optimal function, so does your nose. In patients who are prone to nasal and sinus inflammation due to processes such as allergy or chronic sinusitis, I routinely recommend regular, daily saline nasal irrigations. I find this is particularly effective in patients who have had prior surgery to open the sinuses. Regular irrigations also aid in the healing process following sinus surgery, and may help to speed recovery during a routine cold or sinus infection. In selected patients, addition of special medications to the saline nasal irrigations may further help to reduce inflammation, thick mucus and infection.
Nasal saline irrigations are an effective, inexpensive and safe treatment for many different nasal and sinus ailments, and may help to prevent problems in healthy individuals who happen to work or live in dusty, smoky or moldy environments. I encourage my patients to make nasal saline irrigations part of their daily routine along with showering and brushing their teeth. It is a simple, easy and natural method for maintaining the health of your air filter!

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Nasal Irrigation for Pediatric & Adolescent Allergic Rhinitis, Sinusitis, Nasal Congestion & Asthma – A Safe & Effective Non-Prescription Approach

Alan H Cohen, MD, FAAP, FCCP, FAAAAI, FCAAI Board certified Pediatric Pulmonologist Clinical Adjunct Faculty – Stanford University, Packard’s Children’s Hospital About the author: Dr. Cohen is a board-certified pediatric pulmonologist. He currently holds an appointment as adjunct clinical faculty at Stanford University School of Medicine – in the Dept of Pediatric Pulmonology and Critical Care Medicine at Lucile Packard Children’s Hospital seeing patients, teaching and working with the medical students and fellows in both allergy and pulmonary medicine.

As a Board Certified Pediatric Pulmonologist who cares for many children and families experiencing allergic rhinitis, seasonal allergies and nasal congestion – often associated with concomitant asthma, the role of local and topical treatment of the nasal inflammation often comes up and is typically neglected by community physicians. From my first years of training at the University of Colorado and National Jewish Medical Center in Denver, CO – we were always taught of the important role of upper airway inflammation in the management of both upper and lower airways disease. Simply put – you will oftentimes not gain sufficient control of the lower airway symptoms of wheezing, cough and bronchoconstriction – unless you begin to adequately address the chronic inflammation of the upper airway. Long before easy to buy and use premeasured “Nettie Pots” and other nasal irrigation devices to enhance successful nasal clearance for children, adolescents and adults were available – we were preaching the importance of airway hygiene and patency. Using normal saline and gentle irrigation techniques have consistently proven successful in the hands of the many children and families that I recommend using these non-medication approaches to airway care and upper and lower airway health and well-being. At a time where I am regularly fielding questions about the use of topical steroids – both in the nares and lower airways of growing children and adolescents – I have rarely met a family that is pleased or happy to hear that I am also recommending a topical nasal steroid, oftentimes to use after nasal irrigation and treatment. It optimizes the ability of the topic steroids to come into contact with the nasal mucosa more readily, and allows for these useful therapies to work as effectively and efficiently as they can. I remind people that by performing regular nasal irrigation before an intranasal steroid, as well as an inhaled daily controller medication of mild/moderate or severe asthma – like an ICS or ICS/LABA combo – they are optimizing the efficacy and success of these drugs and often enable to use a lower steroid dose, less often and at a more tolerable manner. For those with “steroid phobia” or fearfulness of using intranasal steroids – the mechanical benefits of nasal irrigation are often sufficient and helpful enough that the need for additional treatments like intranasal and lower airways steroids is less critical for optimal care outcomes. What could be simpler and safer then salt water washes in the nasal canals? At a time when many parents of growing children, and adults would like to have less prescription medications in their medicine cabinets and in their systems – more natural treatments such as nasal irrigation with saline makes even more sense.

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