Allergy: Hypersensitivity caused by exposure to a PARTICULAR antigen(s);
atopy (allergy), is associated with the IgE antibody (immunoglobulin E), the exposure of a specific allergen/antigen in a sensitized individual, mediated by IgE, that results in the "allergic reaction". (Stedman's Medical Dictionary, 27th Edition).
A very common complaint: often involving swollen, irritated mucus membranes with sneezing, nasal congestion, excessive drainage/mucus, headaches and eventually sores in the nostrils, yellow/green infected phlegm. The definition is often broadened in common use to mean all kinds of adverse upper respiratory problems. In reality, doctors and sufferers over use this terminology, "It must be your (my) allergies acting up". They are actually using "allergies" to describe a wide range of recurrent, noxious occurrences that can be occasional, daily or seasonal. This is a "looks like" problem.
To use an old analogy, these people look like ducks, they walk like ducks, they even quack like ducks BUT on close inspection they don't have webbed feet, consequently they are not really ducks! Despite what the media would suggest, only 1/3 of patients are IgE positive. Only they will respond to therapy for allergy since, by definition, allergy involves the IgE protein moiety. Anti-allergy therapy is designed to interfere with the allergic cascade that, in one way or another, involves this allergy mediating protein. The 2/3 of the patient population who are "IGE negative" will there fore not ever respond to this line of therapy directed at allergy.
Many of the "I think I have allergies but I don't seem to get better" people will respond to treatment aimed at "hypersensitive", overactive mucous membranes. But not with therapy directed at allergy. Thus the explanation why Sudafed is so heavily advertised and promoted; it "dries up" secretions regardless of the reason. But at what price? It is only temporally reliving symptoms. This is a derivative of epinephrine, thus it has "speed-like" effects and can cause insomnia, fast heart rate, elevation of blood pressure, excessive sweating and so forth. It can engender constipation and excessive drying of retained mucus. Antihistamines are of little added benefit in this "IgE negative" group. None the less, they are often combined with decongestants like Claritin-D, Allegra-D, Tavist-D, Zyrtec-D and others. In most instance the patients who point out that "such and such" medicine doesn't work, so I only use "such and such-D" (the decongestant added version) likely has more than a respiratory allergy. Their only possibility of relief is by using the decongestant version. Thus almost certainly they have more than true respiratory allergies.
Decongestant nasal sprays are very effective with one huge limitation: if used beyond 3-5 days one runs the significant risk of rebound swelling of the nasal membranes. At this point patients are miserable with unopposed, profound nasal swelling and congestion because they didn't use the decongestant spray. The nasal membranes become "addicted" to the decongestant spray.
The "steroid" nasal sprays are well tolerated (no addiction because they do not contain decongestants) and offer marked resolution of symptoms in "pure" allergic rhinnitis. Treatment failures are uncommon unless the underlying condition is nonallergic. The local, nonsystemic, anti-inflammatory effect on the mucous membranes is of limited benefit in non-allergic conditions.
And that's about the sum total of treatment available to most "allergy/sinus" patients. Antibiotics can be crucial in selected situations. Hot packs, nasal irrigation with warm salt water, steam, postural drainage and Osteopathic Therapy all have their role in the acute situation. Why are so many people experiencing ongoing, chronic trouble with sinusitis, "allergies" and headache to begin with?
A logical approach to these problems would include sinus x-rays or other imaging studies (MRI, CT, etc.); have they already been done? Laboratory studies would likely include blood count, metabolic panel, thyroid studies etc. Have you seen an allergist or a specialist in regard to these problems? Does family history or past medical/surgical history play a role? Does a detailed history and physical exam lead to any suggestions? If you have tried (numerous?) other remedies, what helped the most? What helped the least? What makes you better? Worse?
The intake information and physical findings could lead to consideration of causes other than allergy, infection, "the lousy weather" or "because I have always been like this". It can be very helpful to determine which noxious symptoms are causes and which are effects. If obstructive sleep disordered breathing is the cause, it will be very difficult to enhance quality of life and resolve the "sinus/allergy" problems with antihistamines and the usual measures. If the breathing problem is resolved then the secondary respiratory problems either resolve "on their own" or become manageable.
In my world a great many patients are suffering from these problems because of a whole different reason than one would expect. Our body has the ability to make mucus to trap foreign invaders like dust, allergy particles and infectious bacteria, viruses, etc. We can also make mucus for protection from "inside the body" threats. Many of us have our mucus producing equipment activated to protect us from an internal malfunction, the escape of stomach acid/digestive secretions from the stomach. The escape route is back up the food tube toward the mouth, nose and sinus cavities. The alarm signal put out by our body defenses is so strong that mucus-producing tissues are instructed to produce mucus at any cost (and make as much as you can!) The signal is screamed out so loudly that the mucus pours forth from many different mucus producing tissues. It is as if "my cup runneth over…"
People make mucus, or its equivalent, in the nose, sinus cavities, throat, ears and eyes. This "mucus response" was intended for other mucus producing tissues like the lower esophagus, where the trouble is actually located. If you consider the fact that much of what escapes from the stomach back toward the mouth is hydrochloric acid you may begin to realize the danger this represents. If the stomach acid were left unopposed in the esophagus it would certainly eat or corrode through the tissues in short order. After all that is the "job" of the digestive juices, enzymes and the acid…to breakdown and macerate what we eat.
The stomach is inherently protected from this process by its protective layer of bicarbonate and cellular insulation. It is only when the stomach contents regurgitate that a problem begins. The protective response can be so strong that it's almost like the "mucus" faucet was left on and the bathtub is over flowing. I very often find this to be the cause and the effects take on many differing presentations (headaches, neck pain, plugged ear tubes, sinus pressure/congestion, Etc).
This is happening because of a failed body defense mechanism, the shut off valve at the foot of the food tube fails and instead of preventing regurgitation allows stomach secretions free access to the delicate, easily damaged lining of the food tube. The body's second line of defense takes over (mucus production, swelling, muscle-spasm) and often makes us miserable while it is saving our lives! The irony is that if your are good enough at protecting yourself from the regurgitated stomach juice you might never have heartburn or indigestion and thus never have a clue as to the real cause of your misery.
Ear problems: Pain, drainage, odor, infections, plugging and temporary hearing impairment.
It appears the most common presenting complaint to the emergency room and after hours urgent care clinics is ear pain/problems. This malady has taken over first place very insidiously. (Chest pain, rule out heart problems, is the most common reason for patients to be admitted or kept for observation overnight in the hospital.) Often those suffering pain and fever are pediatric patients. Recent studies have confirmed that over 80% of children with chronic ear problems will demonstrate stomach juice behind the eardrum. How could it possibly get there!? We have known for decades that the Eustachian tube (the internal ear tube) that equalizes the pressure from the outside environment to the middle ear is prone to problems in young children. It likely has to do with the shape and small size of the tube. Now we are finding that the immature Eustachian tube acts as a conduit to allow escaped stomach juices a pathway to a dead-end space, the middle ear. Here they act as a harsh foreign "invader". This often necessitates the placement of artificial drainage tubes through the ear drum, the infamous "ear tubes".
Adults more often complain of swelling of the external ear canal as we often find in swimmer's ear. Sometimes there is pain with no apparent, visible derangement of the ear structures. Quite often there will be a complaint of excessive earwax (cerumen).
What is this all about? If you acknowledge that we in the USA have an epidemic of reflux of stomach contents into the esophagus, then the reasoning becomes apparent. The stomach juice leaves the confines of the stomach pouch and enters the food tube headed toward the mouth. In kids it travels all the way up their short food tube into the oral cavity and the up the ear tubes, probably because they suck and thus create a suction effect that draws the contents all the way into the middle ear where it becomes trapped and creates havoc. The adults have a different mechanism. The wayward stomach contents splash up against the delicate lining of the esophagus (squamous mucosa) thus triggering an alarm. The alarm is mediated by the Vagus Nerve (Cranial Nerve # X). Branches of this nerve carry the warning signal and command the body's resources to protect by swelling, making mucus and squeezing down. A branch of the Vagus Nerve complex goes to the ear drum. Thus when the "volume/intensity" of the Vagus gets "turned up" near maximum, the branch that goes to the ear gets extremely excited. This can cause trouble by making mucus where there is no room left to make mucus and/or by interpreting otherwise ordinary information into pain signals. The pain is from a variety of mechanisms: central sensitization; referred pain; phantom pain; the list goes on. The important point is the pain is real, even if the doctor can't see where it is coming from! When the doctor states, "The ear looks fine" please realize that I will tell you the same BUT it does not mean that is the end of the story. The fact that the ear "looks fine" is only the starting point; it tells us what we don't have to treat. Now we have to get to work and consider what else might be causing the pain/problem and try to remedy the cause of the symptoms.
Fatigue: a feeling of weariness, sleepiness, or irritability…energy expenditure outstrips restorative processes. (Stedman's Medical Dictionary, 27th Edition)
Patients often present with complaints that are nonspecific. The "obvious" causes like anemia, iron deficiency, diabetes, circulation problems, heart disease and underactive thyroid have been or will be sought and corrected. Unfortunately the evaluation often concludes with the reassurance that everything checks out "good".
There has to be more to the story.
Just think how often you see mattress commercials on TV implying that people are seeking improved quality of life by trying to improve their sleep. Also sleep-testing laboratories are opening all over the USA. Large numbers of our contemporaries experience some manifestation similar to this broad, general category of fatigue. Often the epidemic problem of reflux of gastric (stomach) contents is involved. How could this effect a persons sleep? The obvious answer is for the folks who have heartburn/indigestion when they go to bed as the acid washes upward. They tend to be up and down taking something or eating to relieve their symptoms thus their sleep is fragmented and they are often exhausted the next day. Others will know that something is "wrong" with their sleep. They may have trouble falling asleep, staying asleep or both.
The more frequent situation involves less apparent manifestations from a similar cause, GERD. These patients problems are harder to perceive because they don't have anything that is obviously wrong with the mechanics of sleep. They are just tired or unrefreshed. What's that about, you ask?
Many of these "fatigue people", on sleep testing, will turn out to have "multiple spontaneous arousal's". These spontaneous arousals do not awaken them from sleep. They do prevent the natural progression of sleep from one stage to the next that would ultimately result in "organized", normal, refreshing sleep. This occurrence has become apparent during sleep testing (polysomnography) when all deviations or arousals are detected and the cause is recorded. Examples are snoring related arousal's, periodic leg movements interrupting sleep, apnea episodes (apnea = absence of breathing), and more.
The point is this: when there is no apparent reason for the person to have their sleep interfered with the event is called a "spontaneous arousal". It is now coming to be understood that a digestive disorder, GERD, can cause a nonrefreshing, poor quality of sleep. The person has no clue as to why they feel as they do since this whole process goes on while they are asleep and it rarely or never awakens them. They may not have a single clue that the source of their fatigue is the regurgitation of stomach juice. Most often this is only established in hindsight when treatment for GERD, etc. results in dramatic improvement. The therapy is stopped and the condition recurs only to be alleviated by restoring the therapy for the "digestive disorder" with resolution of the fatigue/exhaustion. It is likely that the occurrence of digestive juices encountering the lower food tube causes adrenaline to be released into the blood stream thus interfering with restful sleep "The eyes only see what the mind knows."
Headaches: Pain in various parts of the head
A vexing, perplexing condition that can have a very significant effect on quality of life, to put it mildly. For purposes of our discussion I will assume that numerous treatments and remedies have been utilized. I will also assume that a "normal" MRI, EEG, CT Brain Scan, skull/neck x-ray, lab work and neurological evaluation are acknowledged. The more "things" you have tried and been tested for (unsucessfully) raises the likelihood that you can be relieved of the burden of headaches if you are approached from a different perspective.
I believe a person who fits the above criteria can often find benefit from a unique approach. All the studies tend to confirm what you do not have. Often headache in such circumstances is the result or effect of some other "condition" or cause. Since "silent" gastrointestinal (GI) disorders abound it is entirely feasible, even likely, that treatment of such an underlying cause will result in dramatic relief. I will relate such a classic situation with a patient I have treated since 1977. The man, now in his late 50's, has had horrible, incapacitating, complex headaches since grade school. He coincidentally had the "worst" case of irritable bowel syndrome I have ever seen. Ferocious diarrhea, bloody at times, throughout his adult lifetime. He was evaluated and treated by renowned headache specialists. By spring of 2003, his headaches escalated to the point that they required numerous medications including escalation to Imitrex injections (his only relief) 3 times a day, several days in a row. This was clearly in excess of the range of safety. This focused attention on the severity of the condition.
I was treating for gastroesophageal reflux disorder (GERD) simultaneously with the severe headaches. I suspected there might be some relief from the headaches if his body was not so severely taxed by the burden of protection due to GERD. The above incident convinced him to comply with the therapy I had recommended. He did so largely because of the severity of his bowel problems. He soon found his headaches to be improving. Thus properly treating "the cause" can relieve many different, seemingly unrelated, "effects". Even I was surprised when he appeared in the office and reported that he had not had a single headache in 3 weeks. "This has never happened before", he stated hesitantly. It's now over a year and a half and still no headaches (and by the way his bowel is "the best it's ever been").
No one ever suspected the cause of his incapacitating headaches were rooted in bowel problems. Certainly in my earlier medical career I never had a clue, nor did the headache specialists suspect, that his headaches were secondary to a remote, treatable condition. It appears that swelling in the sinus cavities was in response to his persistent, progressive and unrelenting GERD, which was very severe but lacked the cardinal, expected symptom of heartburn.
Even in the absence of any appreciable complaints, to be thorough, he had been evaluated for upper GI problems. Most attention was focused on his large intestine (colon) due to the persistent, severe diarrhea. The headaches were considered a "different" issue. Our sucessful treatment of the esophageal reflux reduced the need for his sinuses to swell. Thus they were no longer exposed to excessive swelling and mucus production "just in case" the refluxed material came their way. Without the constant intense stimulation of body protective mechanisms his headaches because less frequent and more easily managed.
Heartburn and its absence.
"What's so bad about some heartburn?" "Lots of people get heartburn, just avoid eating things that seem to cause the sensation", is the typical sentiment. "It doesn't bother me that much; I just take something".
In 1976 the incidence of heartburn was reported to be 15%. In 2001 the commonly reported incidence was 45%. The most recent USA surveys report heartburn once a month or more in 60% of adults. The occurrence of heartburn has quadrupled! WHY? What does this really mean?
The symptom of heartburn usually represents acid reflux. Thus acid reflux is becoming more common all the time. Where the confusion begins may be with the converse: "when a person has significant reflux of gastric acid, heartburn will occur." This statement is absolutely not true. Heartburn is a poor surrogate for reflux. Yet this concept is the MAINSTAY of GERD (gastroesophageal reflux disease) therapy. If no heartburn is present then the patient is considered a candidate for stepdown therapy or discontinuation of prescription medication. This and other commonly held concepts about GERD are not supported by the scientific evidence or clinical experience.
Current concept: if you don't have heartburn, there's nothing wrong with your esophagus.
Reality: the majority of patients with ENT (ear/nose/throat) GERD induced symptoms rarely or never have heartburn (they rarely have mucosal change at endoscopy).
Current concept: in the absence of endoscopic mucosal tissue damage no prescription medication is necessary.
Reality: endoscopically negative GERD patients (NERD) commonly require long term twice daily dosing with the most potent of the prescription strength, antisecretory medications to maintain control of symptoms (some may require life long therapy).
Current concept: when your esophagus heals up the PPI (proton pump inhibitor) can be stopped.
Reality: 80% or more of erosive esophagitis patients will relapse within 6 months of stopping therapy.
GERD is a disorder that affects quality of life in a negative way. It is associated with noxious symptoms like headache, sinus problems and asthma. A condition known as Barrett esophagus can develop in 10 to 25% of GERD patients. GERD causes this condition. Barrett's is an identifiable risk factor for cancer (adenocarcinoma) of the esophagus, the occurrence of which is doubling every 5 years since 1970. As common as heartburn is, the MAJORITY of GERD sufferers RARELY HAVE HEARTBURN because our bodies are so clever at protecting us!
SINUS PROBLEMS; THROAT CLEARING, SNEEZING ATTACKS, WHEEZING, EAR PROBLEMS, RUNNYNOSE (FOR NO REASON)?
Millions of people suffer because of respiratory problems. The possibility and the reality is they may have a correctable DIGESTIVE DISORDER as the cause. Many can be helped if the "root cause" is successfully identified/treated. A large number of these people will predictably have their problems as the result of regurgitation of stomach contents. The body is so successful at protection from this internal conundrum, the origin remains concealed. Thus the insidious nature of this condition. Since the individual does not realize the cause, most treatments aimed at the effects are less than satisfactory.
Muriatic acid is industrial strength hydrochloric acid and people who handle it treat it with great respect. So does your esophagus. The normal adult digestive system generates 2 to 3 quarts of "digestive juice" daily; the majority is hydrochloric (Muriatic) acid. It's made by the stomach. The caustic nature of "stomach juice" is the source of the problem. It is not that we make excessive amounts. It is when this harsh chemical "escapes" from the stomach and comes in contact with the delicate tissue lining the esophagus that trouble starts. Heartburn can occur. The most recent estimate is 60% of the adult population of the United States has heartburn monthly.
Even so many, many times a day people have gastric reflux WITHOUT heartburn. When this reflux occurs, your bodily defenses are activated to protect against the "chemical spill". Most of the time you have no obvious, outward manifestation of this protective, tissue-preserving, occurrence. Often the result is mucus production and swelling aimed at the lower food tube. But the alarm signal generated by the acid contacting the food tube is so intense, so potent, that mucus producing tissues throughout the body can activate. This results in mucus and swelling in tissues remote to the site of the "needed protection". The acid does not have to make it all the way to the nose and throat, only up into the lower esophagus, to cause sinus tissues to swell and make mucus inadvertently. They "heard" the distress signal and thus made mucus and swelled (congested) as they were commanded even though they were not in the "direct line of fire".
These are new concepts; they appear in medical journals but not yet in medical textbooks. Contemporary practitioners are only exposed to this information through self-directed learning. Studies in England during 2002 and confirmed at St. Louis in 2004, reveal over 80% of children with middle ear fluid had "gastric contents" behind the eardrum. University of Virginia reports that "82% of asthmatics" have an association with gastric reflux. This means treating gastric reflux reduces wheezing, asthma severity and can improve or prevent fluid behind the eardrum. Copyright Barrett publishing 2004.