Category: For Allergy Fellows  

An Intro: Filling in the Gaps in Fellowship Training

As an allergy fellow you are poised to help patients in many ways.  You are being trained to understand IgE-mediated disease and recognize that the unified airway is more than theory.  You are very good at managing asthma.  Yet some patients defy your best attempts at treatment.  Some probably have vocal cord dysfunction but to confirm it you probably need to arrange an endoscopy with ENT.  Some of the asthmatics have sinus disease which you understand to some degree but chronic sinusitis management is difficult because you are trying to manage the disease mostly by symptoms since your tools are limited.  Opacification of the sinuses with a flashlight has very poor sensitivity as do plain films of the sinus but you don’t want to send all your patients with sinus complaints for a sinus CT.  The solution is to make nasal endoscopy and laryngoscopy a routine part of your respiratory patient evaluation.  Technically, it is not a very difficult procedure.  AAAAI fellowship training requires experience with nasal endoscopy and the practice parameters endorse endoscopy as integral to the management of resistant sinusitis.

You should do endoscopy because it is the best way to practice respiratory allergy.  You don’t know how much you are missing until you start to look.  To start with, look at the sections on Vocal Cord Dysfunction, Nasal Polyps and Laryngopharyngeal Reflux.  Vocal cord dysfunction is not so uncommon—it was found in 40% of severe asthmatics referred to a pulmonary clinic in one study ( Newman K.B., Dubester S.N.:  Vocal cord dysfunction: masquerader of asthma.  Semin Respir Crit Care Med 15. (2): 161-167.1994).  The only way to detect is to screen for it .  Vocal cord dysfunction may be intermittent so it’s best done when the patient is symptomatic and when the PFTs are suggestive.

There are also very practical reasons to think about to learn more skills.  Perhaps in the past few decades some allergists have been able to survive economically to a large part on immunotherapy income.  This model has diminishing returns for many reasons including declining reimbursement and advances in therapeutics.

Please advance to the online guide to nasal endoscopy and laryngoscopy.