Joey Wahler (Host): They can hurt our quality of life, so we're discussing nasal symptoms and their treatment. Our guest, Dr. Afser Shariff. He's an ear, nose, and throat physician for Wood County Hospital. This is Health Matters, Insights from WCH Medical Experts. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Sharif. Thanks for being with us.

Afser Shariff, MD: Well, thank you for having me.

Host: Great to have you aboard. So first, many people, of course, get congested. I would imagine most everyone at some point or another, but when does it reach a point that a doctor should be consulted?

Afser Shariff, MD: Well, that varies from person to person. Some people are much more symptomatic than another person may be, so not a clear cut score that you could use to say, well, I hit 75 percent on my symptom score, so I must go in. Nothing like that. But for most people, they kind of know it's time to go in.

If their daily life is just misery, meaning that they're constantly sniffling, they're constantly congested, they're constantly fatigued; and over the counter medications aren't doing the job like they used to, it's time to come in. And for many people, it's because they've already tried using some of the medications incorrectly for far too long.

For example, people who are using Afrin nasal spray, or oxymetazoline nasal spray, or neosynephrine nasal spray, if they're using that every single day, beyond what the package says, they need to come in.

Host: Gotcha. And so we'll talk a bit about allergies, of course, but allergies aside, what are other typical causes of nasal congestion?

Afser Shariff, MD: Well, that runs the gamut. If you're talking about children, sometimes for kids they may have adenoid hypertrophy, their adenoids or tonsils in the back of their nose, and when they get big, children will come across as being stuffy all the time, sniffling all the time, and that can be a source of recurrent sinus infections and ear infections for some kids.

For older adults, they may not have allergies, but they may have what's called non allergic rhinitis. That's when their nose runs for no reason at all. Sometimes it runs after they eat certain foods. Now, all of us, when we eat something really spicy, might experience a runny nose. But some people, their nose runs just at the thought of food.

And for those patients, it can be quite frustrating because they're walking around with a handkerchief year round. So, runny noses or stuffy noses can run a wide variety of indications or run a wide variety of disease possibilities.

Host: Now, wait a minute, you say there that some people's nose runs even at the thought of food. Tell me about that.

Afser Shariff, MD: Well, you know, some of us salivate when we think of our best foods, but for some people, when they have a vasomotor rhinitis or nonallergic rhinitis, the nervous system doesn't supply the back of the nose with the correct inputs. It doesn't control the amount of secretions or mucus the nose is making.

So it could start to run for no reason at all and sometimes you could be thinking about a meal that you had the other day and all of a sudden your nose wants to run. There are medications that can help with that. There are some newer surgeries that may help with that. But it's one of the more frustrating things that we have to treat as patients and as doctors.

Host: So, allergy wise, what are the most common things that people are allergic to?

Afser Shariff, MD: Well, as we're recording this, it's a beautiful day. It's May, and we are at the tail end of tree allergy seasons. We're having some of the trees still blossoming. That pollen count is going up and everybody's yard is being cut right now because the grass is starting to take off as well. So you've got the beginning of grass allergy season.

So you have your pollen allergies that typically start as early as the last week of February and end as late as the last week of November depending on where you are in the United States. And we're so situated, we're in a swamp. I mean, Toledo, Ohio is basically one magnificent swamp. And so we have significant number of pollen allergies year round.

Plus we have a lot of molds that are year round. So you're an allergy sufferer, this is not the best place to live.

Host: Now, even if you've not had allergies before, you can develop them as you get older, yes?

Afser Shariff, MD: Yeah, that's one of the things that often puzzles people. I didn't have this last year. I didn't have this five years ago, but I just moved from such and such place. And we've been here for five years, I've never had a problem. Well, allergies, you tend to grow out of some and you grow into others.

And it just kind of depends on where you are in your stage of life, what your immune system's like, what your genetics are like, and what's in the environment around you. There are people who spend much of their lives in the city, the movement, they move out to the countryside, they start experiencing new sets of allergies that they didn't have in the city.

And vice versa, because people in the countryside, when they move into the city, they're exposed to a completely different set of things there too.

Host: So, speaking of which, if someone is preparing to move, especially to another state, another region across the country; what should they do to look into this beforehand if they're worried it might affect them adversely?

Afser Shariff, MD: Well, that's a tough question to answer because it's going to vary significantly by genetics and by location. So if you're moving to the dry desert areas that are high altitude, there's not much in the way of allergies there. But for some people who may be sensitive to mold spores, it could be a tough place to be, but thankfully most of us don't have that issue.

So, for people who suffer from significant allergies, the ideal place for them to be would be a low pollen place that has some degree of moisture, and that would generally be like a high altitude, wet zone, but it's not so wet that it creates too much mold. But for many others, being along a coastal beach area, which is like, perfect, we all would like to retire or live at a beach area if we could afford it.

But being along the West Coast or along the Atlantic Coast, where you have the ocean air, that's a naturally humidified air that doesn't have as much pollen count in it. So when we have coastal regions, they have that saltwater feel to them.

And so when we ask people to wash their noses, we ask them to flush their nose with saltwater rinses. That's the same thing as walking around along the ocean side. So yes, there's a reason why we all gravitate towards being by large bodies of water.

Host: Besides the obvious, of course, as you pointed out.

Afser Shariff, MD: Yeah.

Host: So, with global warming, from what I understand, some are getting allergies later in life more than ever before, right?

Afser Shariff, MD: Well, global warming is leading to allergy seasons being much longer, much more intense, the pollen counts are much higher, so the intensity of what people are experiencing has gone up. People who normally don't suffer from allergies, they may be prone to allergies, but they don't really get much in the way of allergies.

But those individuals, what we're seeing is that they are becoming much more symptomatic. We are doing a lot more allergy management now than we ever did before, and we expect those numbers to continue to go up. The number of people who need surgical management with it is also going up. Now, there are new medications that are coming out that are helping considerably.

 Regretfully, not all insurance companies cover them to the full amount, but they are definitely improving the quality of life for a lot of people.

Host: And you led me beautifully into my next question. Let's switch gears a little bit and talk about treatment options. With many nasal sprays available, how does someone know which one is right for them? Sometimes you go into the store, it's kind of like cold medicine and some other things, you're like, ah, which one is right for me, right?

Afser Shariff, MD: Yeah. So that's a common thing. People come in often with a bag of sprays that they've tried. So a lot of things come down to consistency. Are they using the correct spray consistently and in the correct way? So there's a correct spray and there's a correct way. The best spray to start with is fluticasone, and I say that because it's cheap, it's readily available, the big box stores will sell them in a bundle, some of the insurance companies cover them, so it's an inexpensive spray to start with.

When you use the Flonase nasal sprays or fluticasone nasal sprays, the generic name is called, and by the way, the generic is, for all intents and purposes, as good as the brand name, it just comes down to maybe how the packaging is. So, when the spray is used we tell people right hand, left nostril, you're shooting the spray towards your ear, inside the nose.

Left hand, right nostril, so you're criss crossing. What people fail to understand is that even though the shape of the nose is this, the sinuses are really out here and most of your allergy stuff starts out here. So angling the sprays to have the medicine land where the problem is, is the first major correct step. Secondly, how much to spray. It's typically two sprays. For smaller people, maybe kids, it's one spray to each side. For the average adult, it's two sprays to each side. If you're having a very bad week, you can temporarily, for one to two weeks, double the spray up so you're using it in the morning and night, so it's two sprays to each side, morning and night.

So, Flonase or fluticasone would be step number one. Step number two would be azelastine nasal spray. This is a nasal antihistamine spray. If you combine that with the Flonase, or faticazone at the same time, two sprays of each medicine at the same time, you'll find that most people's symptoms will be reasonably controlled. And then you can layer on your Allegra, your Claritin, your Zyrtec, the generics again are equally fine, I use the brand names here because people are more familiar with it, but the generics are equally good. So, you use the oral pills as a supplement to what the nasal sprays are doing. And unfortunately a lot of people just go straight for the pills and they don't think about the nasal sprays. The nasal sprays are more effective and if used consistently will give you better results.

Host: Interesting. And so a couple of things there that I didn't realize, and I know that one thing you just stressed is bottom line, it's not just about which spray, but doing it right and in the right amount, right?

Afser Shariff, MD: Correct. Doing it right, doing it daily, giving it time to work. There's a lot of people that will use the spray for three or four days and then give up. Many of those sprays take about two weeks to fully start kicking in. So, people often will give up prematurely. Another thing that we often find is that people don't understand that they may have a nasal obstruction that's preventing the spray from working.

So, the spray that didn't work today, it might work tomorrow if we've gone in and surgically corrected the blockage in the nose. For example, if you have a severe septal deviation or if you have large turbinates, turbinates are the bones on the sides of the nose that curve inward. Those are the natural radiators of the nose.

Well, those radiators can sometimes have problems and need to be treated, just like your home radiator might need to be treated at some point. So we can go in and surgically adjust the size, move them and position them better. So when you use the sprays, the sprays are more effective. And if you happen to not have the spray, well, we've already adjusted it so you can still function well without using the medications.

Surgery is an adjunct. It helps make the nasal passages process the airflow better, but it also allows for medications to get in and better. So when we talk about surgery, surgery is not a cure, but it is an important part of making sure that the nose is optimized.

Host: Gotcha. And you did a great job there of enabling me to check one of my other remaining questions off the list regarding surgery. Let me backtrack for a moment and ask you more about something you alluded to a little bit earlier, newer medication now available. What might that be?

Afser Shariff, MD: So that's the neat thing. These new medications are actually combinations of older medications. So there's something called ValQuist, which is a combination of I think it's mometasone and azelastine. So people who don't want to carry around two spray bottles, the Flonase and the Astiline spray and having to do two squirts of this, two squirts of that, another two squirts, another two squirts, and having to deal with the taste of all that stuff in their mouth.

Well, there are sprays that have been configured so it's just one bottle with a combination of generics in them so that when you do one squirt, you're getting the optimal dose without having all the extra added taste or the headache with it. Unfortunately, the insurance companies don't cover many of these, but they're not that expensive, and they do work better, than just using the Flonase and the Astiline nasal spray combination.

And the reason why they work better is because you get more compliance. People are more willing to do one bottle versus doing two bottles. I confess, I've switched over to using these newer mixtures. They are available in some pharmacies over the counter, but in many pharmacies, they still have them behind the counter, so you will need a prescription to get them dispensed.

 As far as some of the latest allergy medications, some of these are injections that are given at home. They're for special conditions, for people who are severely allergic, who may have polyps with it. Those medications run into thousands of dollars a month. And right now, they're priced out of many people's affordable range.

And that may change in the future, let's see. But there is something that's been around for a couple thousand years, which again, is not covered by insurance, but it's much more affordable. And that is sublingual immunotherapy. That's where you take whatever you're allergic to in a microscopic amount, and you put it under your tongue.

So I say this has been around for a couple thousand years. Well, that's because back in the time of the Roman Empire, they used honey to treat allergies. Now your bees are your natural pollen collectors. They're collecting the pollen from everything around in the area, and they concentrate it in their honey.

And if you took a little bit of that honey and put it under your tongue on a daily basis, you would develop a tolerance to the allergies. But the problem in this country is that our bee collection, or the honey collection, is a mix. You don't really find a lot of pure honey. And if you do find it, it has to be matched to the season in order for it to be effective.

So if you're going to have honey collected from your region, that honey needs to have a time date stamp that matches the previous year. So if you're having spring honey from last year to treat your spring allergies, that's fine. But if you're having last year's fall honey; that's gonna have a different pollen mix than your spring honey. So, so it gets a little complicated because I have people coming in all the time and it's like, that's perfect. I know somebody who's got a who has honey. They have a beehive. I'll collect it from them. Like it doesn't quite work that way. But modern science has the ability to process that in a lab and collect it and get it to you in the right format.

Plus, we can collect other allergens, such as cat dander and things like that, that normally won't be collected by a bee. So, in this day and age, what you can do is you can take these allergens, these different mixes of what you might be allergic to, get it concentrated in a little vial and put it under your tongue and do home therapy.

Now that exact same stuff is what you would get as an allergy shot in the doctor's office. And we do that as well. We do allergy shots in our office for those whose insurance covers the office setting, but doesn't cover the home therapy. Now between the two, I know more people who are doing home therapy than shot therapy.

We offer both options in our office. And the reason why people tend to go with the home therapy, one, it is safer than shots, and then two, it's much more convenient. And then three, when it comes to cost, if you start adding up the amount of time it takes to go back and forth between the doctor's office and your workplace or home, you start adding up that gas money and the wear and tear, it comes out to be almost the same cost as doing the drops at home.

So, for most people, they end up picking drops instead of shots.

Host: Interesting. Very interesting indeed. Finally, let me ask you, you had touched on children earlier. In summary here, some children tend to be congested naturally, even becoming so called mouth breathers. How is that addressed and when does that usually stop?

Afser Shariff, MD: If you've heard of tonsillectomy adenodectomies, I'm sure you have because many, many kids get that done to them. The biggest reason why we take out tonsils today, the biggest reason why we take out adenoids today is for disturbed breathing. When you have large tonsils and adenoids, you become a mouth breather.

When you have large adenoids, you tend to have more sinus issues. You can develop some hearing issues as well. So, large tonsils and adenoids, surgical removal of that has been shown to greatly improve the quality of life for kids. There's another thing we can do. We can do radiofrequency turbinate reduction.

What that means is that those radiators I mentioned in the nose, well, we have tools now to go into kids noses and adults too. We do a fair number of adults as well. But for kids noses where we don't really want to surgically cut too much, we can put these probes in their nose and shrink down the turbinate tissue, greatly opening up the inside of the nose without any cutting.

And that, I can't tell you how many parents come back and say, Oh my god, I can't believe how quiet he is. He doesn't sound like Darth Vader. Or their daughter doesn't sound like there's always something stuck in her nose. They're not walking around with tissues all the time. So, these little things make a huge difference in the quality of life for the kid as well as for the parent.

Host: Well folks, we trust you're now more familiar with nasal symptoms and their treatment. Dr. Afser Shariff, great information. Thanks so much again.

Afser Shariff, MD: Well, thanks for having me and I look forward to sharing what we know with the rest of the audience again.

Host: Absolutely. And to schedule an appointment with Dr. Shariff to address your own concerns or find out what other treatments may be best for you, please visit woodcountyhospital.org and search ENT. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for being part of Health Matters, insights from WCH medical experts.