Dr. Hadley: Many patients come in to an ENT clinic with an inappropriate initial diagnosis, predominantly with sinus disease, and some of them actually have come in with inappropriately obtained CT scans of the paranasal sinuses because they were presumed to have a chronic sinus infection. Most importantly, many of them have come in with inappropriately administered multiple different courses of antibiotics, which is of concern to me. So I agree with Dr. Meltzer in the need to understand the history of the patient’s symptoms—whether they are intermittent or persistent. I also obtain a family history, which helps me to work out whether the patient has an allergic tendency or not. I also have to look back and see what medications have been tried, what has worked (and not worked) in the past. The timing of the medications is really important, and the patient’s own perceptions about whether they want a medication that is going to be beneficial, or whether they want a simple remedy also plays a role. Also, let’s not forget what Dr. Meltzer also talked about—environmental controls that can be helpful to reduce the patient’s symptomatology as well.
Dr. Stoloff: From my perspective, I’m always impressed how a simple explanation of what allergy actually is, in terms of definition and measurement, creates a totally different dialogue with the patient. When my patients come in, they are often past the point of just administering a medicine, and trying others if it didn’t work—especially now there are so many generic over-the-counter products in oral antihistamines available. As a consequence, I really want to talk to them about what is going on— what is the family history, what is the seasonality of the components. I live at a fairly substantial altitude with little or no humidity, so some of the environmental issues that are very clear in San Diego where Dr. Meltzer practices have no role in my patients. However, some of the people I’ve seen have come in with pages of an expensive serum test that shows positive for certain items that have no influence on the patient’s current environment.
Patient history has to guide our workup. Dr. Hadley’s point about family history was important; we look to document what in fact are the causes. If we can figure out what is pushing the disease forward, maybe we can prevent some of those problems or at least lessen them. The history also helps in diagnosis. If we find by their history they’re overusing topical decongestants, that’s important. If we find they’re using their intranasal spray in the wrong way, that’s important. After obtaining the patient history, we then need to individualize our workup based on physical examination. It is important to look in the nose; if we find they have mechanical problems that’s additional information. Certainly allergic specific testing can be helpful, but it has to be targeted based on the location and based on the patient’s story.
Dr. Meltzer: We also need to target treatment. As Dr. Hadley mentioned, we need to know what has and hasn’t worked in the past and what are the contributing mechanism of the rhinitis for a given patient—is it only allergic, is it infectious, is it nonspecific irritants, is it mechanical, or is it a mixture of all of these. Pharmacologic therapy can be stepped up or stepped down depending upon the patient’s progress. And immunotherapy is certainly an appropriate choice in patients who have more severe disease and/or who are not responding adequately. Individualization is the key in terms of management.
Dr. Hadley: There is a clear need for the identification of and appropriate care of patients who need further management. As clinicians, we glean from patients’ history when they have symptoms and when we can appropriately add to the pharmacological management other therapies that would be beneficial in helping patients control their environment a little bit better during specific times of the year. Some patients do need additional treatment at certain times of the year. For example, whereas patients with intermittent symptoms only need to be treated for a short period of time each year, other patients are plagued with year-round symptoms. So we have to gauge those patients appropriately.
Dr. Stoloff: Another point is that at times comanagement with an allergist or otolaryngologist will be beneficial to the patient. But the primary care physician has to recognize that and it takes time to have that discussion. Unfortunately, because allergic rhinitis is often trivialized (from a health care provider’s point of view), physicians do not step back to see how much of a burden this disease is for that individual. This lessens the opportunity to gain effective consultation in the specific fields, and therefore lessens the opportunity for better health for the patient.