For otolaryngologists, who are often the first-line of defense in diagnosing and treating many common respiratory ailments, differentiating the potential culprits behind sneezing, wheezing, stuffy nose, heavy chest, and chronic cough demands an ever-growing need to recognize and identify underlying conditions that include allergies and asthma.
No new turf for otolaryngologists, managing allergies has long been a central part of many otolaryngologic practices going back to the 1940s. What is fairly new to otolaryngology over the past 10 to 15 years, as evidenced-based medicine has taken root among all clinical areas, is the increasingly organized way in which otolaryngology manages allergies-and this, in turn, has forced a more comprehensive way of looking at patients.
As education in otolaryngology has become more codified, it has forced us to look at how effectively we are treating allergies, said Bradley F. Marple, MD, Professor of Otolaryngology at University of Texas Southwestern Medical School in Dallas. It has become more apparent that people with allergic rhinitis will frequently have lower airway disease-in other words, asthma-and that to safely and effectively take care of allergies, many times we need to be aware of the asthma component.
Best Patient Care Is Comprehensive Care
Recognition of the presence of asthma in many patients who present with allergies has steadily increased over the years, with many studies now showing the high incidence of these conditions coexisting. The recently updated Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines report that up to 80% of people with asthma also have allergic rhinitis.1 Conversely, data show that patients with known allergies have a 50% chance of having or developing asthma.
There is a very large overlap between allergic rhinitis and asthma, given that these are diseases of the respiratory tract, albeit at different ends of that respiratory tract, one being north and the other south, said Richard C. Haydon III, MD, of the Division of Otolaryngology in the Department of Surgery at the University of Kentucky in Lexington. A list of the many ways these conditions overlap is shown in Table 1.
Given the high incidence of interaction of these conditions with one another, an effort is under way in otolaryngology to increase awareness of the need to recognize, diagnose, and possibly treat asthma in patients who present with allergies. In a recent editorial, Pillsbury and colleagues emphasized that otolaryngologists, as specialists in the upper airway, are in a unique position to diagnose, and perhaps manage, patients with lower respiratory problems such as asthma, and encouraged their colleagues to gain knowledge and expertise in this area.2
Although the vast majority of patients presenting with symptoms of asthma continue to be initially seen by primary care physicians, otolaryngologists are increasingly seeing patients with symptoms of asthma that either have not been correctly identified or are not being adequately treated. As such, incorporating asthma into otolaryngologic practice seems a natural evolution of a specialty that focuses on regional diseases between, what is common parlance among otolaryngologists as, the dura and pleura, according to Harold C. Pillsbury III, MD, Chair of the Department of Otolaryngology-Head and Neck Surgery at the University of North Carolina School of Medicine in Chapel Hill. Already, he said, including asthma into an otolaryngologic practice is quite widespread among 40% to 50% of otolaryngologists within the American Academy of Otolaryngic Allergy (AAOA) who already treat allergies; however, this is less common among members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS).
Efforts to increase awareness of the need to adequately diagnose and, where appropriate, treat asthma are under way within the academies. Similar to the previous adoption of allergies as a condition to include within the realm of otolaryngologic practice, the expansion into asthma reflects the evolutionary character of a specialty that continues to adapt to the changing demands and needs of the times.
Why the focus on asthma now? One reason, according to Dr. Haydon, may simply be the increased incidence of asthma owing to more indoor and outdoor pollutants, which is placing a high demand on the health care field. The prevalence of asthma is on the rise, and there are a number of patients with asthma who are not being adequately treated, he said. We, as otolaryngologists, are going to encounter these patients, and it is appropriate, where there is a need and interest, to try to assist other physicians taking care of these patients.
For Dr. Pillsbury, the need for otolaryngologists to address asthma in their patients with allergies comes from a growing body of evidence that shows substantial improvement in these patients when treated with new asthma medications such as montelukast (Singulair) and pulmonary inhalers.
And perhaps most important, diagnosis of asthma is now easier as pulmonary function tests have become more accessible. We’re doing pulmonary function tests on our patients, which used to be a big deal, but now there is a little computerized version of a pulmonary function test that you can do in the office, he said.
Any otolaryngologist caring for patients in a general or rhinologic practice, whether or not they choose to treat allergies or asthma, should know the basic diagnostic testing and at least first-line therapy for these conditions, said John A. Fornadley, MD, an otolaryngologist with Associated Otolaryngologists of PA in Hershey, PA.
As with other medical conditions, diagnosis of asthma begins with recognition of its signs and symptoms. Along with wheezing, shortness of breath with exertion, and improvement with inhalers, additional indicators of asthma may be found by asking patients what they do not do, said Dr. Fornadley. Patients with mild to moderate untreated asthma may avoid wheezing attacks by withdrawing from activities such as skiing or biking that can bring on symptoms, he said, adding that patients without a diagnosis of asthma may have used inhalers to get through gym class or a game of tennis.
Another important symptom is a cough, which, according to Dr. Pillsbury, may be a subtle sign but is almost always universally present in asthma. In the past, otolaryngologists would not look for asthma in patients with allergies who presented with a cough, he said. We’d wait for the diagnosis to hit us in the face.
For a simple guide to initially assess patients with allergies who may also have asthma, the updated ARIA guidelines suggest asking patients a number of targeted questions (Table 2).
To confirm a diagnosis of asthma, a pulmonary function test or pulmonary spirometry should be done. As mentioned earlier, the increased availability and accessibility of these tests that now can be done as in-office procedures have made it easier to diagnose asthma. Although these tests are considered the chief diagnostic tool for objectively assessing the presence and severity of asthma, opinion is divided on their use within otolaryngologic practice. Some will say that any patients with allergic rhinitis and symptoms suggestive of asthma should have a pulmonary spirometry, said Dr. Haydon, adding that he thinks this test should be used more often than not.
Part of the utility of these tests, for Dr. Pillsbury, is to help with a differential diagnosis. When you see people with abnormal pulmonary function tests and you treat them with a bronchial dialator and they get better, that tells you that asthma is likely a component of their problem.
Dr. Fornadley agreed that a pulmonary function testing is needed for the diagnosis of asthma, but he doesn’t think it necessarily falls to the otolaryngologist to do it. For the otolaryngologist, the key factor in making the diagnosis is to have a high index of suspicion, he said. If you don’t think about asthma, you may miss this diagnosis.
An additional use of these tests, according to Dr. Marple, is to ensure the safety of patients undergoing immunotherapy who may present with symptoms of asthma. If a patient comes in with a tight chest, new cough, or exacerbation of cough and there is concern about an underlying asthma flare, it is important to realize that giving an injection of immunotherapy may exacerbate the flare, put the patient at risk of going into a bronchospasm, or increase the chance of triggering anaphylaxis, he said, emphasizing the benefit of a pulmonary function test to identify these patients prior to delivering immunotherapy.
To Treat or Triage
Patients with allergies who are diagnosed with mild or moderate asthma can be treated by otolaryngologists who are trained and comfortable treating these patients, said Dr. Pillsbury, but he recommends referring patients with severe asthma to pulmonologists.
In addition to referring patients with difficult or severe asthma, Dr. Marple also suggests referring patients with asthma who do not have upper respiratory disease to a pulmonologist or allergist.
For otolaryngologists who choose to treat asthma along with allergic rhinitis, the updated ARIA guidelines offer a comprehensive description of management approaches, including a guide to a single approach to treating both conditions (Table 3).
In addition to the updated ARIA guidelines, detailed treatment approaches for long-term management of specific populations of people with asthma (ie, children, youth, adults) are available in the recently published updated Guidelines for the Diagnosis and Management of Asthma by the National Institutes of Health.3
As specialists with expertise in the region of the body that includes the upper and lower respiratory tract, otolaryngologists are in a good position to assist in diagnosing and treating allergy patients who also may have asthma. With improved efficacy seen in patients with allergies treated with new asthma medications, evidence is increasingly pointing to the need to treat both allergies and asthma for optimal patient outcomes. Critical to the ability of otolaryngologists to incorporate asthma into clinical practice is the use of pulmonary function tests that are now more accessible and can be done in the office setting. With training on how to conduct and interpret these tests, along with recognizing the symptoms of asthma to make a differential diagnosis with allergies, otolaryngologists can play an instrumental role in providing comprehensive care for their patients with these chronic conditions.
- Updated 2008 ARIA Guidelines can be downloaded at www.whiar.org/ .
- Pillsbury HC, Krouse JH, Marple BF, Parker MJ. The impact/role of asthma in otolaryngology. Otolaryngol Head Neck Surg 2007;136:157.
- National Heart, Lung, and Blood Institute. Expert panel report 3: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health; 2007. Available at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf .
©2009 The Triological Society