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Interviewer: There is no cure for allergies. Really the best you can do is manage the symptoms, and the first step to doing that is to avoid the things that give you allergy symptoms, but that can be hard. A lot of times you can't do that. So then the next step are sprays, pills, and eye drops.

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's also an allergy expert, and she's going to take us through the process of trying to figure out how to manage those symptoms and then maybe help us understand when you might need to get professional help. So Dr. Oakley, let's first start with allergy sprays.

Dr. Oakley: There are a couple main nasal sprays that work really well and have great evidence behind them for the treatment of allergies. Our first-line treatment based on the literature and just how well it works in patients is nasal steroid sprays, and fortunately they're all over the counter. Some of those sprays would be, if I were to name some, Fluticasone nasal spray, Mometasone, Budesonide. Those are probably some of the three most common. There're a couple others in that, you know, similar family and those work really well.

You can use them up to twice a day, more than that is not going to help anymore, but once or twice a day use. They're very reliant on regular consistent use, and they have a bit of a slower ramping up effect, so you really want to use them for at least, you know, a few weeks on a daily basis just very regularly to get their full effect rather than, you know, here and there when your symptoms bother you.

Interviewer: If the over-the-counter stuff doesn't work, are their prescription ones that are very different from that, or is most of them over the counter nowadays?

Dr. Oakley: There's an antihistamine spray that is a prescription that can actually work great for a lot of patients too, either as their primary treatment or as a, you know, secondary, an additional treatment if the corticosteroids sprays alone don't work enough for them. That antihistamine spray is called Azelastine, and it works particularly well for those let's call them the wet allergy symptoms, which is, you know, more of those like sneezing, runny nose, itchy, watery eyes, that kind of tickle sensation that we can get with allergies. They work okay for the nasal congestion symptoms, but the steroid sprays work better for that.

Interviewer: What is it that makes it so different from person to person that perhaps maybe a steroidal spray would work for one person but not another, they'd have to use, you know, an antihistamine spray? Is it just the difference in us as humans?

Dr. Oakley: We don't always know exactly why some patients respond better to some sprays, you know, versus others. It may just be a severity of their symptoms. You know, they may get 75% better with the steroid sprays, but it may just not quite be enough. Whereas somebody else where their symptoms are maybe moderate rather than severe, they may do great, and that's all they need.

Some patients may be a little more bothered by like the runny nose and the sneeze, whereas, you know, in those cases antihistamine sprays would work better for them. So sometimes we just get different presentation of our allergies, different symptoms and different severities. But you're right that the other factor is we're all just a little bit different and we respond just a little bit different to certain treatments.

Interviewer: It can be a little frustrating as an allergy sufferer sometimes because I think sometimes as patients we think, "Well, I'm going to go in and the doctor's going to give me the cure," right? But with allergies it sounds like, you know, sometimes you have to do some experimenting on what's going to work best for that individual person.

Dr. Oakley: Exactly. There's definitely some trial and error there to try to get it just right for that patient. The third thing in terms of nasal treatments I didn't mention, that I'd be remiss if I didn't mention, is very straightforward, and it's just some saline in the nose, saline irrigations specifically. Those can work really well as an adjunct treatment. It's not going to in and of itself fix your allergies, but it can help with some of the symptoms along with some of these other treatments by mechanically washing, you know, those allergens, those irritants, those pollens out of the nose so they're not just sitting, you know, on the lining of the nose inflaming it. So it can help, you know, in some of those ways as well.

Interviewer: So do you normally go nasal spray first and then oral medication? Is that how that usually goes?

Dr. Oakley: I would say, in general, yes. I like to give people topical treatments over oral treatments if possible, just because your side effects tend to be lower. The other thought in that however, that I'll talk to patients about, is that certain oral treatments, like oral antihistamines specifically, those tend to work similarly to a nasal steroid spray, have similar effectiveness, but sometimes patients will have symptoms that are not just in the nose. They'll have, you know, maybe some dermatitis that they get with their allergies that bother them or, you know, symptoms like that that are elsewhere, and sometimes the systemic therapy, an oral therapy in that case can be a little bit more helpful than a localized therapy.

Interviewer: So oral medications, let's talk about over the counter first. What are kind of the choices there?

Dr. Oakley: I would say the main one, the front runner are those oral antihistamines. So the newer versions that tend to work better for patients with fewer side effects are those medications like Loratadine and Cetirizine and Fexofenadine. Those are the main kind of newer generation oral antihistamines. The older generation antihistamines would be, you know, what we know as Benadryl, which can work too but has, tends to have higher side effects and be more sedating for patients. So we generally recommend those newer generation, non-sedating medications. And they have great evidence behind them, they work well, and those are over the counter.

Interviewer: And then itchy eyes is another symptom that a lot of people have with allergies. I used to suffer terribly, and then I was prescribed some eye drops, which now I think I can just get over the counter because I've bought them. I think they're the same thing, which makes all the difference in the world. Can you talk about some of the eye drops you might want to look for if itchy eyes are part of your allergy symptoms?

Dr. Oakley: Yeah, eye drops can actually help a lot, and it is generally an antihistamine eye drop. There are a couple different ones. One that's popping into my mind is Olopatadine. That can actually help patients significantly because a constant itchy eye will drive you crazy.

Interviewer: And just like all the other things, the nasal sprays, the oral medications, I had to try a couple of different antihistamine eye drops before I found the one that really kind of worked for me. So you know what, I started out thinking, well, let's see if we can give people, you know, some things they can try on their own, but then you start talking about how, you know, this combination isn't proven to work as well as that combination, and it can get really complicated really fast. So I'm starting to think maybe if like the first nasal spray doesn't work, maybe go see a doctor to try to figure out what combinations of stuff because that does get complicated pretty fast, doesn't it?

Dr. Oakley: It does get complicated pretty fast. It is certainly reasonable to try a couple over-the-counter meds on your own. I personally, you know, if I were in the patient's shoes, I would start a nasal spray and give that a few weeks personally. If that didn't work, you know, I'd maybe try an oral antihistamine for a couple weeks and see how I do. But after that, I don't see a lot of sense in just suffering. I think it's worth going in and talking to your doctor about some alternative options that may help quite a bit rather than just being miserable.

Interviewer: There's a cause for hearing loss in children that might be entirely fixable. We'll talk about that next on The Scope.

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Interviewer: I'm talking with Dr. Albert Park about cytomegalovirus. It turns out that cytomegalovirus or CMV is really pretty common and a lot of us are probably infected with it but don't even know it. But it's a different story for newborns, right? What happens there?

Dr. Park: Yes. So many of us may get the infection, maybe when we were toddlers or later in life. And so, especially in underserved areas, you could have prevalences of as high as 80% or 90%. In Utah, it's much lower, but still a significant number of the adult population here has been exposed to this virus. Fortunately, when you get it, when you're older maybe you may have a bit of a runny nose, a cough, but really no other significant symptoms.

The problem really is in the unborn child. So if a mother contracts the infection during her pregnancy, unfortunately that virus then can be passed on to the unborn child, and then that child can really develop devastating and very severe problems from this infection. It can range from unfortunately fetal demise or death to less severe but still really impactful conditions, such as brain defects, hearing loss, developmental delay issues, speech and language. And so, because I'm a pediatric ear, nose, and throat physician interested in hearing loss and because hearing loss is a really big factor in this infection, that's how I became involved in this.

Interviewer: So if this virus is so common and so easily transmissible, why have we not really heard more about it before?

Dr. Park: Oh, that's a great question. I don't know. I mean, I know that, for instance, Down syndrome, spina bifida, other conditions are actually much less common than cytomegalovirus, have a lot more press and a lot more awareness. It's interesting that Zika, which is a huge issue globally and it certainly is, but actually, cytomegalovirus, which also causes microcephaly and central nervous system abnormalities is a bigger problem in the United States and in Utah than Zika is.

Interviewer: And so is it that every unborn child that's infected with CMV has birth defects?

Dr. Park: So the numbers are that it's believed that congenital CMV can affect as high as maybe 0.5% to 1% of all live births, so it's a huge number of children who are exposed and can be infected. Fortunately, the majority of these children will develop the infection but not develop any disease. So they won't develop CNS or central nervous system problems. They won't develop severe hearing or mental, sort of, developmental problems.

But in a significant number of these children, unfortunately, that can occur. I think our task as providers and as parents is to really be aware of this condition. There are very good approaches that one can do when you're pregnant to minimize the risk to your unborn child. The sort of a classic scenario would be that a mother may have an older child, maybe two or three, who unfortunately gets the infection and that child doesn't have any problems. But then that child, maybe when, at two or three, then passes on the infection to the mother and it's passed through contact exposure so that could be, maybe in sharing utensils, kissing on the lips, playing with toys. And again, if the child puts the toy in his or her mouth and somehow that then gets into the saliva of the pregnant mother, that can cause infection.

So simple as hand washing is really crucial. Not partaking in sort of practices that can increase your risks of transmission have been shown to be very helpful in reducing the risk of developing it to the unborn child.

Interviewer: And now, you're taking this even one step further and you hope to be able to treat these children who have tested positive for CMV and have hearing loss. What are you doing there?

Dr. Park: I think what has been the controversy, at least, among the American Academy of Pediatrics and other societies is whether treatment of some sort could be effective. And so we have really wanted to answer that question. The question, really being, could a medication such as an antiviral possibly improve the hearing outcomes or at least prevent the progressive hearing in these children with congenital CMV. There is some data from some other studies showing that severely affected children with congenital CMV when treated with this antiviral medication, they had better hearing and neurocognitive or mental, sort of, developmental outcomes.

But the question really is this large group of children with just hearing loss from congenital CMV, what could an antiviral potentially provide for them? And so we are embarking on an NIH-funded clinical trial. It will involve about 30 different sites. So this will be a national study. And what we're going to try to determine is whether the antiviral treatment will provide better hearing outcomes or speech and language outcomes compared to children who do not undergo the treatment. If we are able to demonstrate this and that, I think, could change the, sort of, picture of CMV testing around the country and may even push us toward universal screening.

Interviewer: And so what is your hope with these different efforts that you're involved in? But you know, what do you hope to accomplish?

Dr. Park: Well, I think there's a number of sort of goals. I think, one is I would love it so that every family when I go down the street and bump into them know what congenital CMV is, that they know that, you know, simple hand washing and measures to prevent the transmission and the infection can be done and that they do this on a regular basis, that in those children who are identified that these kids are all being identified so we have a screening program that's nationally available to do this. And if we are able to find an intervention like an antiviral that prevents further progress or worsening the hearing, that the families and the children have the opportunity to have that treatment available to them.

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Dr. Miller: So you have a deviated septum. Does that need to be fixed and what symptoms does a deviated symptom cause? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ear, nose and throat physician. He's also a professor here at the University of Utah and a member of the department of surgery. Jeremiah, what's the story of the deviated septum? What is a deviated septum and, if you have one, do you always need to have it fixed?

Dr. Alt: We commonly have patients who come in with complaints of just simple nasal obstruction. Commonly, we have to go through the differential diagnosis of what that is.

Dr. Miller: You mean they can't breathe out of one side or both sides of their nostrils, is that right?

Dr. Alt: Yeah, correct. As a rhinologist, I commonly see patients with sinus disease and congestion and allergies. It also commonly comes up that they just have what's called septal deviation and the septum itself separates basically the right and left side of the nose.

Dr. Miller: So it's your nose bone?

Dr. Alt: Yeah. It's made up of both cartilage bone. The septal deviation can occur just from normal development as everything is not perfectly symmetric as we develop. So it can be deviated to one side or the other. It can also occur from trauma.

Dr. Miller: Getting boxed in the nose.

Dr. Alt: Getting boxed, vehicle accidents, getting bumped in the nose. So after the trauma, this is an acute event, someone would come and say, "I can't breathe out of the right side of the nose," after getting bumped or something that's been there their whole lives and they've just noticed that they're having increased trouble breathing, they can't sleep as well.

Dr. Miller: I'm curious, is deviated septum mostly due to trauma or are people born with it?

Dr. Miller: I think the majority is they're born with it or we have a known etiology of why it's deviated.

Dr. Miller: Okay. So the come to you and they complain that they have difficulty breathing out of one side of the nose or the other or maybe both. At what point do you say, "Well, look, maybe we can repair this surgically if you need to have it repaired"?

Dr. Alt: A lot goes into talking about the deviated septum. In many instances, it's found incidentally, which means we look in their nose and they have a deviated septum but they don't describe nasal obstruction.

Dr. Miller: And under those circumstances, you probably wouldn't recommend surgery?

Dr. Alt: Correct. In those situations, I don't even like to bring it up because then it's something that patients start to worry about. But if it's significantly deviated and we look at it and we assess the patient and it's significantly closing off one side of the airway, we can discuss different surgical options and how to correct that.

Dr. Miller: I have a question. How often do people come to you to looking for cosmetic reconstruction of that bone?

Dr. Alt: That bone itself is usually not cosmetic. It's functional. It doesn't correlate into how the nose looks.

Dr. Miller: So that's a whole different type of surgery.

Dr. Alt: Correct.

Dr. Miller: Not to be confused with the symptoms that a deviated septum would cause.

Dr. Alt: So that's really talking about what we usually term open septorhinoplasty is where were able to change the look of the outside of the nose or [Inaudible 00:03:12] and changed inside the nose for functional breathing, which sometimes we do in combination if the nose is broken or twisted on the outside, we also have to fix the outside in addition to the inside.

Dr. Miller: So how often do you find the patients with need to have surgical correction for a deviated septum?

Dr. Alt: It's actually quite common. It's one of the most common procedures we perform. Not only is it bothersome in the sense that they can't breathe but it substantially affects patients quality of life, which has been shown over and over again by improving the way we breathe through our nose substantially affects how we feel in our day-to-day activities. And this is most likely partially contributing to the way we sleep and the way we get good night's sleep. If we can't breathe through the nose, it forces us to breathe through the mouth and we may have more obstructive events and it can also potentially lead to what we call obstructive sleep apnea.

Dr. Miller: So how do you do the surgery?

Dr. Alt: So there are several options to do surgery and one that we're doing more and more that gets great results is doing endoscopic septoplasties. So it's using angled and straight, rigid endoscopes with that special high-definition camera. And we're able to make very specific and delicate incisions within the septum to take out those crooked parts and so there are no external incisions on the nose. It's all done on the inside of the nose and we feel that patients get great functional responses and, at the same time, have quicker healing.

Dr. Miller: Now, do you tell your patients that they are going under general anesthesia? Do you put them to sleep when you do these or is it a local sort of anesthetic you use?

Dr. Alt: Yeah. I would not recommend local and patients probably wouldn't like me very at the end of the procedure. So we really counsel the patients that these should be done under general anesthesia where they're totally asleep, they're not moving. We have the ability to take our time and do the job correctly.

Dr. Miller: What's the recovery like?

Dr. Alt: Really, the recovery's not too bad. We normally tell the patients they'll probably have to take pain medications for two to three days. Commonly, these type of procedures used to be packed with nasal packing. We no longer pack the nose. We moved into placing splints on the inside of the nose like flexible plastics splints, but even now we're even moving away from that. So many times, we can get away with doing the what we called endoscopic septoplasty without putting any packing in the nose and so this helps patients feels better and recover quicker too, as they're not obstructed with something in their nose we don't have to take out in a week. Usually, at a week, at that point, the patient feels great, usually back to light activity. At two weeks, you're completely healed.

Dr. Miller: Now, for a patient who is going to primary care physician, is a primary care physician usually able to tell if they have a deviated septum or do they usually refer them to make that diagnosis?

Dr. Alt: I think in general, you can determine what we call a caudal septal deviation. It's more towards the front of the nose because you can just look at it with the simple measure of using the nasal speculum looking at the front of the nose and you can tell if it's deviated. Interesting enough, those septums that are more deviated or caudally towards the front of the nose actually usually need a more significant type of surgery, which we'll discuss with the patient, but that usually actually leads to what we call an open septorhinoplasty.

Many times, the posterior septal deviations are easier to fix endoscopically and those are actually harder to diagnose because you need to see further into the nose. So seeing someone like an ENT or rhinology person like myself, we're able to use scopes to look at the septum more posteriorly in the nose to diagnose it.

Dr. Miller: So in conclusion, what three things might you told the patient that would lead them to your doorstep to where you would make a diagnosis of a deviated septum?

Dr. Alt: I think the first thing is if they're having trouble breathing through their nose. Typically, it's unilateral, but it can be both sides, bilateral. The next thing is if this is causing significant changes in how they feel and how they function during the day, if the obstruction's bad enough where they feel like they need some improvement. And third, which we didn't mention, but I think should be mentioned here conclusion, is that many times, medical management can improve nasal obstruction even with septal deviation. So commonly of pretrial of medical management needs to be done before you start discussing . . .

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updated: January 23, 2019
originally published: November 11, 2015

Swimmers get water in their ears a lot. But when fluid starts coming out of the ears, it's time to see the doctor.

If your child has swimmer's ear, you'll probably know it pretty quickly. He or she may have painful ear canals, their ear will hurt if it's moved up and down or if the tab on the outer ear that covers the ear canal is pushed in. If the child's ear feels really plugged up or you see discharge coming out of the ear. Now the discharge will be clear at first. But if it's not treated within 24 hours, it usually becomes yellow, and more like puss coming out of the ears. Clear drainage without ear pain is most likely water. That's not concerning for an infection.

Swimmer's ear occurs when your child's ears have been in the water for long periods of time and the water gets trapped in the ear canal. And the lining becomes damp, swollen, and prone to infection. Children are more likely to get swimmer's ear from swimming in a lake or a river compared to swimming in swimming pools or the sea. During the hottest weeks of summer, some lakes have really high levels of bacteria and narrow ear canals of children increase the risk of swimmer's ear.

Cotton swabs also contribute to the problem by causing wax build up. When you go to clean your clean your ears with a Q-tip, you're actually pushing the wax in further, and then you can get water trapped behind it. Swimmer's ear is easy to treat and the symptoms should be better within three days of starting treatment and cleared up within seven days.

Your child will need eardrops prescribed by your pediatrician that have both an antibiotic and a steroid in them. Be sure to run the eardrops into the ear canal with your child lying on his side so that air isn't trapped under the drops. Move the earlobe back and forth to help the eardrops pass down deep into the canal. And be sure to finish the eardrops as prescribed to make sure the infection is completely treated.

Generally, your child should not swim until the symptoms are gone. Continued swimming may cause a slower recovery, but it won't cause any serious problems. For mild swimmer's ear without puss coming out of the ear or serious ear pain, you can treat it at home. Use a mixture of one part water and one part white vinegar, and put 3 drops in the affected ear. After five minutes, remove the drops by turning the head to the side and rubbing the ear. Do this twice a day until the ear canal feels normal again.

So often parents ask, "How can I prevent swimmer's ear in my child?" First, limit how many hours a day your child spends in the water. The key to prevention is keeping the ear canals dry when your child is not swimming. After swimming, get all of the water out of the ear canals by turning the head to the side and pulling out the earlobe in different directions to help water run out. You can also put a towel into the ear and help soak up the water. Dry the opening to the ear canal very carefully so you don't injure the ear canal by going too far in.

If recurrent ear infections are a big problem, rinse your child's ear canals with three drops of rubbing alcohol each time he or she finishes swimming to help dry the ear canal and kill germs.

Another helpful home remedy is to use the solution of half water and half vinegar. The vinegar will restore the normal acid balance to the ear canal. Your child may also benefit from using earplugs or a swimming cap to keep the water out of the ear canal in the first place. Remember, rubbing alcohol is helpful for preventing swimmer's ear, but not for treating it because it stings the ear too much.

Interviewer: TMJ, what causes it, how awful it is, and what you can do about it.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Dr. Gary Lowder is a practicing dentist at the University of Utah School of Dentistry and also a professor there as well. And more importantly he has 30 years of TMJ experience. So, Dr. Lowder, tell me about TMJ.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier, healthier life. You're listening to The Scope.

Interviewer: If your one of those people in the wintertime that gets a dry throat, maybe it's inching all the time, irritated throat. We're going to talk about that and maybe come up with some things you can do to feel better. Doctor Marty Trott, ear, nose and throat specialist at St. John's Medical Center in Jackson Hole Wyoming. Let's talk about that itchy, sore throat.

Dr. Trott: Boy, an awfully common problem. I'd say one of the most common reasons are upper respiratory tract infections or viral illnesses and they're always moving through the school system. So if you have school aged children you're going to be exposed to them. The other reason, are just being outside. Being dry, we're in a very, one of the advantages of living in this part of the country is that we're high and dry. But that's one of the disadvantages as well.

Interviewer: So how does that affect my throat? What's going on?

Dr. Trott: Well, your throat has mucus covering, just like your nose does and the job of the nose in general is to make sure that the air that gets to your lungs is warm and humidified. And if you're exercising with your mouth open, which you need to do if your exercising, then you're going to get a little bit drier.

Interviewer: Okay. Is it a good idea to try to breathe with your mouth closed as much as possible if you live in this environment?

Dr. Trott: I suppose it's possible. If it's possible. It's hard to exercise, it's hard to move enough air through your nose alone with your mouth closed. If you tried even getting on a treadmill if you close your mouth, you won't be able to do it for very long without breathing through your mouth.

Interviewer: Okay.

Dr. Trott: So it's just one of the necessary evils.

Interviewer: Gotcha. What are some things that I can do to maybe find some relief then?

Dr. Trott: Humidification is key, particularly in the home and it's a trade off, because the more we humidify our homes the potentially more we can get allergens in the home. But I would tell people that if they're very dry every morning that it's a good idea at least in the bedroom to get a humidifier in the bedroom and run the humidifier all the time with the bedroom door closed. That would keep the relative humidity at least in that area up.

Interviewer: Okay. Any other thoughts on throat health in high, dry climates?

Dr. Trott: Well in general the other big issue that's coming to the fore, is potential for re-flux. So, heartburn or re flux symptoms that manifest themselves only with a sore or irritated throat. So I tell patients that they have a sore or irritated throat, if it's new it's something that hasn't been there before, it's going on for more than two and three weeks, you should see your family doctor, your provider about that.

Interviewer: So is it essentially three different causes of the sore throat or are there more than that? Illness, re flux, dry air.

Dr. Trott: I think that's a good characterization, we can always figure out more aciduric things, but I think those are the common.

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Interviewer: When we say allergies most people think of springtime, flowers, trees, pollens, but winter allergies are also a problem. We're talking with Dr. Marty Trott, an Ear, Nose, & Throat Specialist at St. Johns Medical Center in Jackson Hole. Let's talk about winter allergies. I've never heard of such a thing, but it exists.

Dr.Trott: Yes. Allergies exist all year round. We think of things typically during summertime as you mentioned, tress, grasses, weeds, but there are things that happen all year round and some of those things happen during the summer and winter, like cats and dogs, and in Wyoming, horses.

Interviewer: Yeah, sure. Okay.

Dr. Trott: But in the fall and winter and spring, people talk about snow mold or other things that exist in the home.

Interviewer: Snow mold?

Dr. Trott: Well, basically when the snow is melting and there's a high humid condition, mold spores and fungi, which people can have allergies to, also exist.

Interviewer: Really? Can you see those on the snow?

Dr. Trott: You can see fungus in the snow, but what you see may not be the symptoms you're actually experiencing.

Interviewer: Okay. What are some of the other winter allergies?

Dr. Trott: I think those are the main ones. I mean, in places that are warm enough and wet enough, potentially like Salt Lake, you could have dust mites.

Interviewer: Okay.

Dr. Trott: Up here in Jackson Hole, where it's a little bit drier, the humidity is lower, dust mites are less of a problem.

Interviewer: Okay. So a lot of your allergies it sounds like, other than snow mold, probably happen inside.

Dr. Trott: Right.

Interviewer: Explain some of those things and maybe what I can do to avoid them.

Dr. Trott: Well, high humidity environments are probably the biggest problem creating where there's potential issues with allergies. And the other places that are a problem are barns and those people that have barns and there's many of them here. So people that are out there with horses kicking up dust, or there out feeding their cows or horses, they potentially are around high humidity environments and all kinds of bacteria and fungi grow better in high humidity environments than low humidity environments.

Interviewer: The same types of symptoms, I suppose.

Dr. Trott: Yeah. Itchy eyes, sneezing, runny nose, and patients who have asthma. One of the biggest challenges for us treating asthma are patients who are exposed to things in the home that trigger their asthma, like mold allergies or fungal spore allergies.

Interviewer: Can I get a shot for a snow mold or . . .

Dr. Trott: Yeah, I suppose one could. It's our last line of therapy. We typically, like everything else, try avoidance first where possible, and then use medical management, pills or nose sprays or inhalers, in those cases where they are necessary and then the absolute line of defense is to use desensitization which usually comes in the form of some kind of allergy shot.

Interviewer: All right. So I come in and I'm suffering some sort of allergies, and these sprays or pills, are they pretty decent? I remember as a kid I suffered allergies terribly and it didn't seem like the pills ever worked.

Dr. Trott: Well, a lot of the pills work but we have a trade-off between the side-effects of the pills and the benefits of the pills. So a lot of the pills that are highly effective also cause a lot of side- effects like fatigue. Some of the newer medications which are now available over-the-counter, like Claritin, which is always on the radio, those medications have a lot less in the way of side-effects, but they're also slightly less effective in terms of potency. But if it works for the patient, that's what matters. It's not a matter of what we call it or what the side-effects are from our standpoint, it's really important how it effects the patient.

Interviewer: Okay. So you do some pills, you do some sprays, and then what's the second level?

Dr. Trott: The second level, in patients who are not responsive to conservative therapy, we consider doing allergy testing. And I don't typically allergy test patients right off the bat because if they tell me that they're allergic in spring, it's typically trees.

Interviewer: Sure.

Dr. Trott: And if they're having problems when they're cutting the grass it's probably the grass.

Interviewer: Is this the scratch test?

Dr. Trott: It is a scratch test. There's also a blood test that can be done. I think the scratch tests are a little bit more cost effective, and from my perspective, trying to determine if we're going to treat a patient with any kind of an allergy shot, we want to know specifically what they're allergic to.

Interviewer: Sure. So the shots, now, is that a higher potency? What's in the shot?

Dr. Trott: Well, shots are made of things that you're allergic to. Essentially, if you're allergic to bees we can give you bee venom and desensitize you to the bees. So if you get stung by a bee in the future you won't have a life threatening reaction. And patients that have asthma that's triggered by grass pollen, we give them grass pollen injections that desensitize them to the grass pollen with high degrees of efficacy. Coming up in the near future, within the next six months, the FDA will be approving medications that you can use under your tongue that will also be effective for specific types of allergens and it looks like Timothy grass, a type of grass, will be one of the first of them.

Interviewer: And where is that going fit into the whole ladder of treatment options?

Dr. Trott: Well, I think it's going to be dependent on what the patient and the physician decide together is best for that particular patient. I try to steer patients to the easiest things to do, the most cost- effective things to do, that's going to resolve their symptoms.

Interviewer: What would you want one person to take away from this conversation, who's suffering from allergies, maybe, like me, disillusioned as a kid, the shots didn't work? Have things gotten better?

Dr. Trott: I think things have gotten better and I think allergies are also more of a problem. There are more people who are allergic now than there ever were before, and we have a little bit of an understanding of why that is.

Interviewer: Why do we have more allergies nowadays?

Dr. Trott: There's a lot of theories about that. Some are fairly complex, immune discussion theories. Allergies weren't even really described until the late 1800's and when they first were described they were with the wealthiest of people in England. There's a thought that there's a connection between hygiene, vaccinations, and allergy and the more we immunize ourselves against other things that would otherwise kills us, the more likely we are triggering our immune system to be responsive to things that less harmful but potentially harmful.

Interviewer: It's a trade-off really. You don't get diseases that kill you, but you might have a plugged up nose.

Dr. Trott: Right. And I would never advocate for someone not getting measles vaccinations, or chicken-pox vaccinations, but we are understanding somehow that the instances of allergy and asthma is far greater here in the developed world than it is, for instance, in Africa.

Interviewer: Interesting.

Dr. Trott: And it's not dietary necessarily, it's got to be something else that we're doing, and there's a lot of people looking at this.

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