Category: For Allergy Fellows  

Teaching Case 1: Should this patient have a nasal endoscopy?

This patient is a moderately overweight nonsmoker with a history of seasonal allergy and asthma who presents at the height of the spring hay fever season. He has perennial nasal congestion, anterior rhinorrhea, sneezing and snoring. He has a dog at home which does not bother him but other people’s dogs cause “allergy attacks.” He has slight chest tightness but no wheeze, cough or dyspnea.  Colds always seem to lead to bronchitis.    He has no history of sinus infections. He has episodic GERD symptoms.  He snores heavily but there is no excessive daytime fatigue.

Skin testing to common aero allergens was positive to tree pollen, birch pollen, grass, Bermuda grass, ragweed, sage, weeds, cat, dog and dust mites.
A pulmonary function test showed an FEV1 of 68% predicted improving by 8% with bronchodilator.

Nasal Endoscopy:

The nasal endoscopy showed edematous middle turbinates and left midmeatal drainage. These findings could be seen in a common cold or acute sinusitis and resolve spontaneously but his longstanding symptoms suggest this could be a chronic problem. Performing nasal endoscopy on a patient presenting with upper respiratory symptoms during allergy season may be difficult due to heightened nasal sensitivity. In this case the decision to proceed was based upon the history of chronic nasal congestion, snoring and chest tightness. In this case the chest tightness was attributed to asthma but it could have been due to reflux or LPR.