On this week's ADVENTing, Dr. Madan Kandula and Dr. Ethan Handler discuss the range of options available for treating spring allergies, and why an airway-first approach gives patients real, lasting results.
Dr. Kandula:
So as we shoot this, we are heading into allergy season. So, what should people know about that?Dr. Handler:
Yeah, I think that, you know, so a lot of people that come in here, you know, the mainstay of treatments really just kind of medical management and like what is that? Well, it's pills. It's sprays. It's stuff to try and get you through that season so you're not hurting.Dr. Kandula:
What does that, what are allergies for the the uninitiated here, what are allergies? It's an easy, everybody thinks they kinda know, like there's words we say. It's like, oh, everybody... allergies. And so why is there an allergy season to begin with?Dr. Handler:
Yeah. So the seasonal component to allergy for the most part when it comes to grasses, trees, weeds, are pollens and things that are released into the air in kind of cyclic ways. And there's different geographies that have different pollen patterns and so, but allergies in themselves is your own body's immune response and it, and it's the reaction to the world around you, you know, and it's kind of innate to who we are. It's our DNA.Dr. Kandula:
Positive reaction or negative reaction?Dr. Handler:
Well, it's a positive. Not in a good way, but it's a positive reaction in the way that inflammation and things can change in the nose.Dr. Kandula:
Why would the body possibly want to do such a thing?Dr. Handler:
Because it wants to fight those pollens or those allergies.Dr. Kandula:
Why would it do that? That's crazy.Dr. Handler:
Cause it's overreacting.Dr. Kandula:
Why?Dr. Handler:
[laughs] I feel like I'm getting why, uh, why is it overreacting? Yeah. That's a good question. I mean it's, it's an over over, uh, you're gonna splice and cut this shit out for sure.Dr. Kandula:
But now they have to.Dr. Kandula:
Um, how about this? Yeah, great answer. How about this answer? [laughs] How about have we cleaned our environment up so much? So clean? So we've gotten rid of everything that when the body experiences something of the world, of nature, it views it as foreign and wants to shut it down and get it out.Dr. Handler:
Yeah, I guess it's the same idea about why peanut allergies for example, there was a whole movement to avoid peanuts all together and then reintroduce actually now at a younger age to try to prevent it.Dr. Kandula:
Did Leonardo da Vinci had a peanut allergy?Dr. Handler:
I think he painted about it.Dr. Kandula:
[laughs] The Mona Lisa did. So peanut allergies, it's a similar concept. You take something that's common and you shield yourself from it and you put it in your body, your body like fights it that we don't want to go into food allergy cause a whole different thing. Right. But well like did he have hay fever?Dr. Handler:
I'm going to go with, no.Dr. Kandula:
I probably, I don't know. We'll have to like teleport ourselves.Dr. Handler:
Good question though. Were there allergies, were the allergies as prominent 500 years ago?Dr. Kandula:
Absolutely not, I wasn't there, but I'm going to give you that solid without- because allergy issues, um, they really started with the industrial revolution is when all this stuff, allergies, asthma now allergies, asthma, airway issues in general started when we as humans stop living like animals, right? You know, and started living as refined, dignified people. And so even even in this earth, the earth we live on right now is you are massively more likely to have allergies and asthma if you live in an industrial country, Western countries specifically versus if you go to wherever you want to go to the, to the off the grid, those people generally, now this is kind of the weird duality of things is those people are both not going to have allergy issues, likely, they're not going to have asthma issues, likely, and they're not going to have sleep apnea issues, likely. They're going to have their wisdom teeth, likely. Their airways are better equipped to handle the world out in the boonies than you or me or all the human beings in our society today. And part of that gets the allergies, but part of it gets to our, our we're animals at heart and we as animals might have, we might be protecting yourself so much that we were doing ourselves harm. So back to this allergy situation, I throw it at almost everything that we do as a practice is focused on unwinding some of the situation that we as an animal have gotten ourselves into. And so allergies are really the body's sort of attempt to deal with challenges that come up against it. And so it takes, so now we're, we're, you know, now we're sitting, coming into springtime it in springtime, you know, flowers bloom, they fall into everything, see there's pollen going around. So you breathe a little pollen in your nose, say pollen is the enemy. What do we do with the enemy? We kill it. And so to kill it, but what did we do? We're going to swell the lining up in your nose. We're going to turn the mucus on. We're going to start making your nose run. We're going to make you sneeze. We're gonna make you itch. We're going to just shut that thing down, man. And that's what's going to happen. And that's what allergies are.Dr. Handler:
So let, so let me ask you a question cause I a, a patient that I saw recently said this was the statement, you know, and they had had procedures done breathing better through the nose, more open, and, and he said, this is the exact words from my allergist. And I was like, okay. And he said, my allergist just said you shouldn't have had that procedure done because now you are getting 10 times the amount of allergens and your nose that you did previous. You're allergies are just going to be worse.Dr. Kandula:
Yeah. Gotcha. So what do you think, what do you think about that? You believe it?Dr. Handler:
Uh, you know, I don't. You know, I don't at all. Now granted I can see how conceptually someone might think that, okay, well I am breathing more through my nose now, therefore I'm 10-X-ing in the amount of allergens. But the reality is, is like you're exposed to those things regardless whether you are fully breathing through your nose or someone in your nose, you're breathing and you're getting exposure.Dr. Kandula:
So the, the allergist is basically saying that you, we should have just left the nose when like the nose that wants to shut down, we should just let it shut down. Right? And I use the mouth man, because that's going to be really, you know, that's the right thing for you. So I would flip it around and I would say I would answer the question, well, so if you have allergies, if you have a nose issue, what, what, what's your issue?Dr. Handler:
It's anatomy and it's lining.Dr. Kandula:
And what are allergies?Dr. Handler:
Allergies are a lining problem.Dr. Kandula:
And if you have a lining problem, by definition, you have allergies, you have a lining problem. Wouldn't the right thing to be if you were a doctor who could do something for somebody. And I say, Hey doc, I got a lining issue. And the doc says, that's, that's, that's too bad. You know how we're going to solve this? We're going to shut your nose. We're going to give you both, we're going to give you an anatomy issue and an allergy issue and then you're not going to breathe any of those allergies in through your nose. Problem solved, right? Here, pay my bill. Yeah. No, that doesn't make any sense. That's exactly what there's that insane statement is what the allergist is saying.Dr. Kandula:
Now, would I would I argue with the fact if your nose is more open, you're going to be pulling more stuff through there? Yeah, that true. That's what the nose is supposed to do. The nose is, suppose you have a nose to breathe. And it's supposed to be moving air. So it's, if you have a lining issue, the best way to treat that lining issue is to make sure you don't have an anatomy issue. And most people have both. Most people who suffer have both of those things. And so if you're suffering with a lining issue and an anatomy issue, the only way we can treat your allergy issue or lining issue is we can make sure your anatomy is open. And the reason we can say that we, the reason we can say that with conviction is because we can do both of those things. If we could only do one of those things or none of those things, then it's the impossible. But it, again, most of what we do is we do it because this is, it's just, it makes sense. It's how I'd want to be treated, it's how you would want to be treated. If you've got a lining issue and an anatomy issue. Okay, let's look at options to address both of those things. And generally speaking, if somebody has both of those things, the first step on the pathway to getting them feeling better is if you've got an anatomy issue, let's get the anatomy working better. And all of a sudden, man, whoa, lo and behold, that lining is much easier to treat if we've got space to treat it right. You know, because most of the treatments for allergy issues that most people experience are medications. And a very common, um, part sub-segment of, of those medications are nasal sprays. And so back to your ridiculous question and statement.Dr. Handler:
[laughs] It wasn't my statement.Dr. Kandula:
The ridiculous words came out of your mouth, is if you have, you know, something that's shut, um, you know, it just doesn't make any sense. So I'd say I'd flip it around and I'd say nice thing is now that the anatomy is open, we can put all our attention into that lining.Dr. Handler:
Absolutely.Dr. Kandula:
And the nice thing is there are options or medication options. There are actually procedural options nowadays to help to treat that lining. Um, you know, so there's many, many options, but it all starts with that same step. And I don't find that controversial, but for some reason it is, for some reason it's controversial to say, let's just, let's start you with an airway that's open or at least let's confirm that your airway is open. Like that to me isn't asking too much and then, you know, we'll move on from there. So back to the allergy situation, you know, we could go both ways. We could, we could flip it around. We could, you know, somebody is on an allergy issue and their, their nose is shut down. We could try to work this with let's leave your nose shot and we're going to try to do everything when we get you on allergy shots and see if we can dial back that allergy situation. That's an okay. Like you could do that. The reason we don't do that often is it tends to be kind of a fool's game. And so if that's the only tool you have, then that's what you're going to use. And you're going to oftentimes, you know, sort of like spinning your wheels if you can go multiple directions and you just see you're going to use the right tool for the job, I guess is the best.Dr. Handler:
Yeah. And so there are a lot of patients who have had procedures probably like, you know, last part of 2019 and, and you know, we're kind of healing up now or maybe in January. And so there'll be getting into their allergy season. And for them they're going to be thinking about, okay, is this season gonna be better or worse? You know, and, and for most of those patients, I tell them it's gonna be better, you know, because those sprays can get in. And the way to use it for all those patients out there to start that, that nasal spray, Flonase, whatever it is that you use a month before the season hits, use it consistently that way you're fully armed and ready when those pollens come in and your body's not going to want to shut down as much because you've primed the lining not to react the way that it maybe had in the past. Right? So, you know, let's really arm in that up. And then, you know, I, I'm very much of a, I don't want patients to take pills type person. And so all these anti-histamines, Claritin, Zyrtec, all these other things, the goal for a lot of our patients and for me for them is also let's get you off that daily pill or those pills that you need during the allergy season. Let's just use sprays because the reality is you and I both know sprays are more effective to treat allergies than medication, than oral pills are. Than Claritin, you know, and a combination maybe of a Flonase or an anti-histamine type spray, but that's more effective in the nose than any sort of, you know, Xyzal, Zyrtec. But those get a lot more marketing dollars and everything else.Dr. Kandula:
Sure. You know, and that's, I mean, again, we're bias, so don't make no mistake about our-Dr. Handler:
But right.Dr. Kandula:
But yet here we are biased in that same mindset. And I've said it many, many times is I don't want to be on a medication I don't have to be on. If I have a choice between fixing a problem versus putting a band-aid on it, I'm going to fix it every day of the week. Especially if the fix is fairly straight forward. Like, yes, absolutely. If we need to or I need to be on a medication because I need it to, I need it because when I take it, I feel better and I feel like that's a fair exchange then I'm going to do that. If I have an opportunity to get rid of it all together, I want it gone. And, um, now that's not everybody.Dr. Kandula:
Not everybody is wired like that obviously because that, that simple thought process is not how the world around us is, is built. The world around it is built around us, is built out of band-aid after band-aid. And I don't know who it's built for because at least for the patients that we treat here, they tend to come from that same mindset. And the other truth there is there are people walking around where, yes, you, the medication, this is really something that you're going to have to learn how to, you know, live with and deal with and we're going to help our best to make it happen. And that's fine. Like if it's a yes, we have to do this because it's really necessary, fine. If it's a, you're going to do this or else, and we're not even going to think about anything else because we, you know, whether you like taking pills or don't like you taking pills, we want you to take a pill that's not, that's not right and was just, it's not, I think unfortunately especially I think especially because all of these, many of these meds are now over the counter. There's a lot of people are suffering needlessly because they have an issue that they don't know what to do with. They go to the pharmacy, they stand there, they look at the hundreds of medications and they just grab something and they say, okay, let me try this. And maybe it helps. Maybe it doesn't help, but at least they're doing something.Dr. Kandula:
And then this, the sad reality is most of those people have issues that could be addressed in a simple manner and it's just not sitting at the pharmacy aisle. The bottom line. And so it's, it's also, um, the challenge for many of those folks is trying to find a doorway into a medical system that's not built for them. That medical system is not built to give you a solution. The medical system is built to keep giving you a band-aid so you keep coming back. And that is not a system that I want to be part of in any way. And so we don't operate like that, but, um, we're just, the lil' us trying to do what we're trying to do. Um, but at least for the patients who come to see us, they, they seem to, you know, sort of mesh with that thought process.Dr. Kandula:
But, you know, absolutely. If you've had allergy issues, there's no reason. I think if you have allergy issues and you've got it handled, wonderful. If you've got allergy issues and you're struggling, there's almost assuredly a better way. There just is. And, it's just, and the way to find that better way is to find somebody who has a variety of, of treatment options that that might work. Because at the end of the day it's, I mean, it shouldn't be that way.Dr. Handler:
Well, and you alluded to sprays are one option, but there are some patients who get a procedure done. They breathe better through their nose, but they don't want to be on sprays long-term. And so there are options to treat the nerve that makes the nose swell inside in reaction to those allergies and things like that. And so there are more long-term solutions that are procedures that can be done for that as well.Dr. Kandula:
Which is, and even if somebody, I guess then I would go the next level, I'd say, well, even if even if, say you, you are a guy that loves your medications, like you are just Mr. Pill-popper and that's how you're built. Um, that's me. That's you. And so that's okay. You know, that's fine. You know, wouldn't you, even if you were Mr. Pill-popper like that, wouldn't you want to make sure that what you are poppin' is the right pill for you? Um, you know, kind of a thing. It just makes sense to make sure that you're on the right pathway for what you're doing. But yeah, I don't know. I guess maybe we're anomalies and maybe, maybe everybody just loves their, um, loves their pharmaceuticals, but not me.Dr. Handler:
Yeah.