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- Nasal Congestion -
2/6/02 re: Management problems in two infants What are your thoughts regarding following patients?
1. 1-yr. old child with no history of atopy on trying milk on 3 occ - 24-48 hrs after drinking 12 oz of milk develops hives. Pricks with fresh milk neg. She has been on Similac, eats yogurt, eggs with no problems.
2. 4 months old with life long history of chronic cough and runny nose. Otherwise healthy.I have not participated in the care of young children for many years. Therefore, I consulted Dr. Susan Schuval of the Long Island Jewish Hospital, a very experienced Pediatric Allergist and a member of the AADMC Advisory Committee. Her thoughtful response is enclosed below: "1. Immediate urticaria upon milk ingestion suggests IgE-mediated sensitivity to milk and I would have expected problems with other dairy products as well as a positive skin test to milk. It is possible that the rash is not truly urticarial but a coincident rash due to some cause other than milk allergy. Also possible is a non-IgE mediated sensitivity to milk, but again, I would expect the child to have problems with dairy products as well as milk. You could consider sending a RAST or CAP-RAST to further test for milk/milk protein {casein, lactoglobulin} to further assess the child's reaction. If these tests are negative, I would consider re-challenge with whole milk in 3-4 months.
2. The differential diagnosis of nasal congestion and cough in a 4 month old infant includes a long list of infectious diseases (congenital syphilis, tuberculosis, URI, sinusitis, infectious rhinitis, etc), anatomic abnormalities (choanal atresia, adenoidal hypertrophy), allergic diseases (asthma, rhinitis, food allergy), and genetic disease (cystic fibrosis). I would start with an inclusive physical examination directed at determining whether any pulmonary or nasal pathology is evident (check patency of nares, characterize nasal discharge-clear or greenish yellow-green, lung exam, growth parameters). Any chest abnormalities found on physical examination should be further evaluated by chest X-ray. Is there any family history of atopy, infection, cystic fibrosis, or other disease? If the cough and rhinorrhea are mild and the child is otherwise well, I would probably just treat empirically with diphenhydramine or hydroxyzine."
1/7/01 re: Leukotriene antagonist treatment for nasal polyps In a patient with nasal polyposis, ASA sensitivity, asthma triad, is there any role for leukotriene inhibitors to prevent regrowth of polyps following polypectomy? In the triad situation or with just garden variety nasal polyposis in a patient with demonstrated allergy would allergy immunotherapy play a role in preventing the regrowth of polyps following polypectomy?.
To my knowledge, there has bee no controlled study to see whether treatment with leukotriene antagonists (LTA) inhibits regrowth of nasal poylps (NP) after polypectomy. I have enclosed below my response to a recent Ask the Expert question about the use of LTA treatment in ASA-reactive (triad) asthma. This response deals with issues raised by your question. Since that response was made, there have been reports of a few brief, uncontrolled studies of the effects of LTA treatment on symptomatic manifestations of NP (see enclosed abstracts). Larger, controlled studies are needed before definitive conclusions can be drawn. In contrast, there are at least 2 controlled studies which have shown that regular use of potent intranasal steroids in patients who have undergone extensive nasal polypectomy does retard the reappearance of NP. In the absence of such studies, it would be reasonable to try LTA post-polypectomy, if you wish, considering the low incidence of morbidity from such LTA treatment. However, in view of recent findings, it would be appropriate to monitor liver function tests about every 6 months to detect the occasional, reversible abnormalities induced in liver function. What is the current status of the use of leukotriene inhibitors in the asa triad? As you likely know, there has been evidence for some time of prominently increased urinary leukotriene E4 levels in most cases of aspirin-triad asthma. Therefore, this patient group was one of the first sub-groups of asthmatics for which leukotriene antagonists (LTA) were tried. Most investigators and reviews have concluded that LTA are particularly helpful in triad asthma. Some uncontrolled studies have suggested that LTA are beneficial in the sinus disease of these patients as well. Japanese investigators have found that bronchial hyper-reactivity, as well as symptoms, is improved by LTA therapy in triad asthma. However, the picture may not be as clear-cut as originally reported. Some clinicians have found lack of clinical benefit of LTA therapy in some patients with typical triad asthma. The situation is confused by findings of at least one group that LTA therapy of asthma is particularly helpful in asthmatics with low ratios of LTE4 to prostaglandin levels in the urine. This somewhat unsettled state of affairs may reflect the pathogenic heterogeneity of triad asthma, and of asthma in general. Nevertheless, I believe that a therapeutic trial of LTA in triad asthma is worth undertaking, particularly if the patient's asthma is steroid-dependent with the aim of achieving a steroid-sparing effect. Please see the below abstracts (at www.medline.com) of several relevant articles for your interest in obtaining more details.
- Ear Nose Throat J 1999 Aug;78(8):604-6, 608, 613, passim
- Clin Exp Allergy 2000 Jan;30(1):64-70
- Biomed Pharmacother 1999 Aug;53(7):312-4
- Allergy 1999 May;54(5):489-94
- Thorax 1993 Dec;48(12):1205-10
- Ear Nose Throat J 2000 Jan;79(1):18-20, 24-5
5/6/97 re: Nasal Steroids I work in an Urgent Care Facillity and see may patients with seasonal allergic symptoms. Is it appropriate for be to begin them on nasal steroids before referring them on? I often see these patients only for one visit. The choice of which agent to use first in the treatment of seasonal allergies depends to some degree on the clinical presentation. If the latter is acute, with predominantly sneezing, itching and rhinnorhea, a non-sedating antihistamine like Allegra, one q12h, will likely reduce symptms much faster than treatment with nasal steroids, which generally takes several days to exert beneficial effects. Also, antihistamines may relieve associated acute eye symptoms, generally not relieved well by nasal steroid treatment, which works predominantly within the nose. On the other hand, if nasal congestion is the predominant symptom, nasal steroids will generally be effective while antihistamines have very little effect on congestion. One can add a long-acting oral decongestant (e.g,-pseudoephedrine, phenylpropamine) to the antihistamine
treatment, but one has to watch out for excess stimulation and other adrenergic effects at higher doses of the the oral decongestants. I find that adrenergic side-effects frequently limit the dosage needed for impressive decongestion. Of course, one should avoid long-term use of nasal decongestant sprays ( e.g.,-Afrin) because of the potential for rebound reactions.
If these symptomatic approaches are insufficient or are not well tolerated, I suggest that you obtain consulatation with a certified allergist-immunologist in your region, if needed. If you wish, you can obtain names of such allergisy-immunologists by calling the American Academy of Allergy, Asthma, and Immunology Executive Office at 1-800-822-2762.
