The Nose








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The Nose

Doctor, explain nosebleeds.
Doctor, what is Post-Nasal Drip?
Surgery of the Nose: Improving Form and Function
You and Your Stuffy Nose
Your Nose: A Guardian to Your Lungs



Insight into care and prevention of epistaxis (nosebleeds)

What causes a nosebleed?

Most nosebleeds (epistaxis) are mere nuisances. But some are quite frightening, and a few are even life threatening. Physicians classify nosebleeds into two kid nose bleeddifferent types.

Anterior nosebleed: Most nosebleeds begin in the lower part of the septum, the semi-rigid wall that separates the two nostrils of the nose. The septum contains blood vessels that can be broken by a blow to the nose or the edge of a sharp fingernail. This type of nosebleed comes from the front of the nose and begins with a flow of blood out one nostril when the patient is sitting or standing.

Posterior nosebleed: More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat even if the patient is sitting or standing.

Which type of nosebleed did I have?

Obviously, when the patient is lying down, even anterior (front of nasal cavity) nosebleeds may seem to flow posteriorly, especially if the patient is coughing or blowing his nose.

It is important to try to make the distinction since posterior (back of nasal cavity) nosebleeds are often more severe and almost always require a physician's care. Posterior nosebleeds are more likely to occur in older people, persons with high blood pressure, and in cases of injury to the nose or face.

Anterior nosebleeds are common in dry climates or during the winter months when heated, dry indoor air dehydrates the nasal membranes. Dryness may result in crusting, cracking, and bleeding. This can be prevented if you place a bit of lubricating cream or ointment about the size of a pea on the end of your fingertip and then rub it inside the nose, especially on the middle portion of the nose (the septum).

What are my treatment options?

Many physicians suggest any of the following lubricating creams or ointments. They can all be purchased without a prescription: Bacitracin, A and D Ointment, Eucerin, Polysporin, and Vaseline. Up to three applications a day may be needed, but usually every night at bedtime is enough. A saline nasal spray will also moisten dry nasal membranes.

If the nosebleeds persist, you should see your doctor. Using an endoscope, a tube with a light for seeing inside the nose, your physician may find a problem within the nose that can be fixed. He or she may recommend cauterization (sealing) of the blood vessel that is causing the trouble.

What about rebleeding?

To prevent rebleeding after initial bleeding has stopped:

Do not pick or blow nose.
Do not strain or bend down to lift anything heavy.
Keep head higher than the heart.
Use a humidifier during dry winter months.

If rebleeding occurs:

Attempt to clear nose of all blood clots.
Spray nose four times in the bleeding nostril(s) with a decongestant spray such as Afrin or Neo-Synephrine.
Perform steps 1 and 2 shown in the "To stop an anterior nosebleed" box in this leaflet. Repeat these steps as necessary.
Call your doctor if bleeding persists.

What causes my nose to bleed?

Allergies, infections, or dryness that cause itching and lead to picking of the nose.
Vigorous nose blowing that ruptures superficial blood vessels in the elderly and in the young.
Clotting disorders that run in families or are due to medications.
Fractures of the nose or of the base of the skull that can cause bleeding and should be regarded seriously when the bleeding follows a head injury.
Rarely, tumors (both malignant and nonmalignant) have to be considered, particularly in the older patient or in smokers.

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Doctor, what is Post-Nasal Drip?


Insight into normal and abnormal secretionspostnasal drip

The glands in your nose and throat continually produce mucus (one to two quarts a day). It moistens and cleans the nasal membranes, humidifies air, traps and clears inhaled foreign matter, and fights infection. Although mucus normally is swallowed unconsciously, the feeling that it is accumulating in the throat or dripping from the back of your nose is called post-nasal drip.

This feeling can be caused by excessive or thick secretions or by throat muscle and swallowing disorders.

What Causes Abnormal Secretions - Thin and Thick

Increased thin clear secretions can be due to colds and flu, allergies, cold temperatures, bright lights, certain foods/spices, pregnancy, and other hormonal changes. Various drugs (including birth control pills and high blood pressure medications) and structural abnormalities can also produce increased secretions. These abnormalities might include a deviated or irregular nasal septum (the cartilage and bony dividing wall that separates the two nostrils).

Increased thick secretions in the winter often result from too little moisture in heated buildings and homes. They can also result from sinus or nose infections and some allergies, especially to certain foods such as dairy products. If thin secretions become thick and green or yellow, it is likely that a bacterial sinus infection is developing. In children, thick secretions from one side of the nose can mean that something is stuck in the nose (such as a bean, wadded paper, or piece of toy, etc.).

Sinuses are air-filled cavities in the skull. They drain into the nose through small openings. Blockages in the openings from swelling due to colds, flu, or allergies may lead to acute sinus infection. A viral "cold" that persists for 10 days or more may have become a bacterial sinus infection. With this infection you may notice increased post-nasal drip. If you suspect that you have a sinus infection, you should see your physician for antibiotic treatment.

Chronic sinusitis occurs when sinus blockages persist and the lining of the sinuses swell further. Polyps (growths in the nose) may develop with chronic sinusitis. Patients with polyps tend to have irritating, persistent post-nasal drip. Evaluation by an otolaryngologist may include an exam of the interior of the nose with a fiberoptic scope and CAT scan x-rays. If medication does not relieve the problem, surgery may be recommended.

Vasomotor rhinitis describes a nonallergic "hyperirritable nose" that feels congested, blocked, or wet.

Swallowing Problems
Swallowing problems may result in accumulation of solids or liquids in the throat that may complicate or feel like post-nasal drip. When the nerve and muscle interaction in the mouth, throat, and food passage (esophagus) aren't working properly, overflow secretions can spill into the voice box (larynx) and breathing passages (trachea and bronchi) causing hoarseness, throat clearing, or cough.

Several factors contribute to swallowing problems:

With age, swallowing muscles often lose strength and coordination. Thus, even normal secretions may not pass smoothly into the stomach.

During sleep, swallowing occurs much less frequently, and secretions may gather. Coughing and vigorous throat clearing are often needed when awakening.

When nervous or under stress, throat muscles can trigger spasms that feel like a lump in the throat. Frequent throat clearing, which usually produces little or no mucus, can make the problem worse by increasing irritation.

Growths or swelling in the food passage can slow or prevent the movement of liquids and/or solids.

Swallowing problems may be caused also by gastroesophageal reflux disease (GERD). This is a return of stomach contents and acid into the esophagus or throat. Heartburn, indigestion, and sore throat are common symptoms. GERD may be aggravated by lying down especially following eating. Hiatal hernia, a pouch-like tissue mass where the esophagus meets the stomach, often contributes to the reflux.

Chronic Sore Throat

Post-nasal drip often leads to a sore, irritated throat. Although there is usually no infection, the tonsils and other tissues in the throat may swell. This can cause discomfort or a feeling of a lump in the throat. Successful treatment of the post-nasal drip will usually clear up these throat symptoms.

Treatment

A correct diagnosis requires a detailed ear, nose, and throat exam and possible laboratory, endoscopic, and x-ray studies. Each treatment is different:

Bacterial infection, when present, is treated with antibiotics. These drugs may provide only temporary relief. In cases of chronic sinusitis, surgery to open the blocked sinuses may be required.

Allergy is managed by avoiding the cause if possible. Antihistamines and decongestants, cromolyn and steroid (cortisone type) nasal sprays, and other forms of steroids may offer relief. Immunotherapy (allergy shots) also may be helpful. However, some older, sedating antihistamines may dry and thicken post-nasal secretions even more; newer nonsedating antihistamines, available by prescription only, do not have this effect. Decongestants can aggravate high blood pressure, heart, and thyroid disease. Steroid sprays generally may be used safely under medical supervision. Oral and injectable steroids rarely produce serious complications in short-term use. Because significant side-effects can occur, steroids must be monitored carefully when used for more than one week.

Gastroesophageal reflux is treated by elevating the head of the bed six to eight inches, avoiding foods and beverages for two to three hours before bedtime, and eliminating alcohol and caffeine from the daily diet. Antacids (e.g., Maalox®, Mylanta®, Gaviscon ®) and drugs that block stomach acid production (e.g., Zantac®, Tagamet®, Pepcid®) or more powerful medications may be prescribed. A trial treatment may be suggested before x-rays and other diagnostic studies are performed.

General measures for thinning secretions so they can pass more easily may be recommended when it is not possible to determine whether an existing structural abnormality is causing the post-nasal drip or if some other condition is to blame.

Many people, especially older persons, need more fluids to thin secretions. Drinking more water, eliminating caffeine, and avoiding diuretics (fluid pills) will help. Mucus thinning agents such as guaifenesin (Humibid®, Robitussin®) may also thin secretions.

Nasal irrigations may alleviate thickened secretions. These can be performed two to four times a day either with a nasal douche device or a Water Pik® with a nasal irrigation nozzle. Warm water with baking soda or salt (1/2 to 1 tsp. to the pint) or Alkalol®, a nonprescription irrigating solution (full strength or diluted by half warm water), may be helpful. Finally, use of simple saline (salt) nonprescription nasal sprays (e.g., Ocean®, Ayr®, or Nasal®) to moisten the nose is often very beneficial.

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Surgery of the Nose: Improving Form and Function


Each year thousands of people undergo surgery of the nose. Nasal surgery may be performed for cosmetic purposes, or a combination procedure to improve both form and function. It also may alleviate or cure nasal breathing problems, correct deformities from birth or injury, or support an aging, drooping nose.

Patients who are considering nasal surgery for any reason should seek a doctor who is a specialist in nasal airway function, as well as plastic surgery. This will ensure that efficient breathing is as high a priority as appearance.

Can Cosmetic Nasal Surgery Create a "Perfect" Nose?

Aesthetic nasal surgery (rhinoplasty) refines the shape of the nose, bringing it into balance with the other features of the face. Because the nose is the most prominent facial feature, even a slight alteration can greatly improve appearance. (Some patients elect chin augmentation in conjunction with rhinoplasty to better balance their features.) Rhinoplasty alone cannot give you a perfect profile, make you look like someone else, or improve your personal life. Before surgery, it is very important that the patient have a clear, realistic understanding of what change is possible as well as the limitations and risks of the procedure.

Skin type, ethnic background, and age will be among the factors considered preoperatively by the surgeon. Except in cases of severe breathing impairment, young patients usually are not candidates until their noses are fully-grown, at 15 or 16 years of age. The surgeon will also discuss risk factors, which are generally minor, as well as where the surgery will be performed-in a hospital, freestanding outpatient surgical center, or a certified office operating room.

To reshape the nose, the skin is lifted, allowing the surgeon to remove or rearrange the bone and cartilage. The skin is then redraped and sutured over the new frame. A nasal splint on the outside of the nose helps retain the new shape during healing. If soft, absorbent material is placed inside the nose to stabilize the septum, it will normally be removed the morning after surgery. External nasal dressings and splints are usually removed five to seven days after surgery.

When Should Surgery Be Considered to Correct a Chronically Stuffy Nose?

Millions of Americans perennially suffer the discomfort of nasal stuffiness. This may be indicative of chronic breathing problems that don't respond well to ordinary treatment. The blockage may be related to structural abnormalities inside the nose or to swelling caused by allergies or viruses.

There are numerous causes of nasal obstruction. A deviated septum (the partition between the nostrils) can be crooked or bent as the result of abnormal growth or injury. This can partially or completely close one or both nasal passages. The deviated septum can be corrected with a surgical procedure called septoplasty. Cosmetic changes to the nose are often performed at the same time, in a combination procedure called septorhinoplasty.

Overgrowth of the turbinates is yet another cause of stuffiness. (The turbinates are the tissues that line the inside of the nasal passages.) Sometimes the turbinates need treatment to make them smaller and expand the nasal passages. Treatments include injection, freezing, and partial removal. Allergies, too, can cause internal nasal swelling, and allergy evaluation and therapy may be necessary.

Can Surgery Correct a Stuffy, Aging Nose?

Aging is a common cause of nasal obstruction. This occurs when the cartilage in the nose and its tip are weakened by age and droop because of gravity. This causes the sides of the nose to collapse inward, obstructing airflow. Mouth breathing or noisy and restricted breathing are common.

Try lifting the tip of your nose to see if you breathe better. If so, the external adhesive nasal strips that athletes have popularized may help. Or talk to a facial plastic surgeon/otolaryngolgist about septoplasty, which will involve trimming, reshaping or repositioning portions of septal cartilage and bone. (This is an ideal time to make other cosmetic improvements as well.) Internal splints or soft packing may be placed in the nostrils to hold the septum in its new position. Usually, patients experience some swelling for a week or two. However, after the packing is removed, most people enjoy a dramatic improvement in breathing.

What Treatment is Needed for a Broken Nose?

Bruises around the eyes and/or a slightly crooked nose following injury usually indicate a fractured nose. If the bones are pushed over or out to one side, immediate medical attention is ideal. But once soft tissue swelling distorts the nose, waiting 48-72 hours for a doctor's appointment may actually help the doctor in evaluating your injury as the swelling recedes. (Apply ice while waiting to see the doctor.) What's most important is whether the nasal bones have been displaced, rather than just fractured or broken.

For markedly displaced bones, surgeons often attempt to return the nasal bones to a straighter position under local or general anesthesia. This is usually done within seven to ten days after injury, so that the bones don't heal in a displaced position. Because so many fractures are irregular and won't "pop" back into place, the procedure is successful only half the time. Displacement due to injury often results in compromised breathing so corrective nasal surgery, typically septorhinoplasty, may then be elected. This procedure is typically done on an outpatient basis, and patients usually plan to avoid appearing in public for about a week due to swelling and bruising.

Will Insurance Cover Nasal Surgery?

Insurance usually does not cover cosmetic surgery. However, surgery to correct or improve breathing function, major deformity, or injury is frequently covered in whole or in part. Patients should obtain cost information from their surgeons and discuss with their insurance carrier prior to surgery. For more information about cosmetic surgery and medical skin rejuvenation please visit our other site www.skintastic.com or call 972-620-FACE (3223) for a free consultation today!

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You and Your Stuffy Nose


Nasal congestion, stuffiness, or obstruction to nasal breathing is one of man's oldest and most common complaints. While it may be a mere nuisance to some persons, to others it is a source of considerable discomfort, and it detracts from the quality of their lives.

Medical writers have classified the causes of nasal obstruction into four categories, recognizing that overlap exists between these categories and that it is not unusual for a patient to have more than one factor involved in his particular case.

Infection

An average adult suffers a common "cold" two to three times per year, more often in childhood and less often the older he gets as he develops more immunity. The common "cold" is caused by any number of different viruses, some of which are transmitted through the air, but most are transmitted from hand-to-nose contact. Once the virus gets established in the nose, it causes release of the body chemical histamine, which dramatically increases the blood flow to the nose -- causing swelling and congestion of nasal tissues -- and which stimulates the nasal membranes to produce excessive amounts of mucus. Antihistamines and decongestants help relieve the symptoms of a "cold," but time alone cures it.

During a virus infection, the nose has poor resistance against bacterial infections, which explains why bacterial infections of the nose and sinuses so often follow a "cold." When the nasal mucus turns from clear to yellow or green, it usually means that a bacterial infection has taken over and a physician should be consulted.

Acute sinus infections produce nasal congestion, thick discharge, and pain and tenderness in the cheeks and upper teeth, between and behind the eyes, or above the eyes and in the forehead, depending on which sinuses are involved.

Chronic sinus infections may or may not cause pain, but nasal obstruction and offensive nasal or postnasal discharge is often present. Some persons develop polyps (fleshy growths in the nose) from sinus infections, and the infection can spread down into the lower airways leading to chronic cough, bronchitis, and asthma. Acute sinus infection generally responds to antibiotic treatment; chronic sinusitis usually requires surgery.

Structural Causes

Included in this category are deformities of the nose and the nasal septum, which is the thin, flat cartilage and bone that separates the nostrils and nose into its two sides. These deformities are usually due to an injury at some time in one's life. The injury may have been many years earlier and may even have been in childhood and long since forgotten. It is a fact that 7 percent of newborn babies suffer significant nasal injury just from the birth process; and, of course, it is almost impossible to go through life without getting hit on the nose at least once. Therefore, deformities of the nose and the deviated septum should be fairly common problems -- and they are. If they create obstruction to breathing, they can be corrected with surgery.

One of the most common causes for nasal obstruction in children is enlargement of the adenoids: tonsil-like tissues that fill the back of the nose up behind the palate. Children with this problem breath noisily at night and even snore. They also are chronic mouth breathers, and they develop a "sad" long face and sometimes dental deformities. Surgery to remove the adenoids and sometimes the tonsils may be advisable.

Other causes in this category include nasal tumors and foreign bodies. Children are prone to inserting various objects such as peas, beans, cherry pits, beads, buttons, safety pins, and bits of plastic toys into their noses. Beware of one-sided foul smelling discharge, which can be caused by a foreign body. A physician should be consulted.

Allergy

Hay fever, rose fever, grass fever, and "summertime colds" are various names for allergic rhinitis. Allergy is an exaggerated inflammatory response to a foreign substance which, in the case of a stuffy nose, is usually a pollen, mold, animal dander, or some element in house dust. Foods sometime play a role. Pollens cause problems in spring (trees) and summer (grasses) or fall (weeds) whereas house dust allergies and mold may be a year-around problem. Ideally the best treatment is avoidance of these substances, but that is impractical in most cases.

In the allergic patient, the release of histamine and similar substances results in congestion and excess production of watery nasal mucus. Antihistamine helps relieve the sneezing and runny nose of allergy. Many antihistamines are now available without a prescription. The most familiar brands include Chlor-Trimeton®, Benadryl®, or Dimetane® (although most are also available in generic forms). Newer, nonsedating antihistamines, which require a prescription include Claritin®, Zyrtec®, and Allegra®. Decongestants shrink congested nasal tissues. Examples include Sudafed®, Guaifed®, and Entex® that are available without a prescription in several generic forms. Combinations of antihistamines with decongestants are also available. All these preparations have potential side effects, and patients must heed the warnings of the package or prescription insert. This is especially important if the patient suffers from high blood pressure, glaucoma, irregular heart beats, difficulty in urination, or is pregnant.

Allergy shots are the most specific treatment available, and they are highly successful in allergic patients. Skin tests or at times blood tests are used to make up treatment vials of substances to which the patient is allergic. The physician determines the best concentration for initiating the treatment. These treatments are given by injection. They work by forming blocking antibodies in the patient's blood stream, which then interfere with the allergic reaction. Many patients prefer allergy shots over drugs because of the side effects of the drugs.

Patients with allergies have an increased tendency to develop sinus infections and require treatment as discussed in the previous section.

Vasomotor Rhinitis

''Rhinitis" means inflammation of the nose and nasal membranes. "Vasomotor" means blood vessel forces. The membranes of the nose have an abundant supply of arteries, veins, and capillaries, which have a great capacity for both expansion and constriction. Normally these blood vessels are in a half-constricted, half-open state. But when a person exercises vigorously, his/her hormones of stimulation (i.e., adrenaline) increase. The adrenaline causes constriction or squeezing of the nasal membranes so that the air passages open up and the person breathes more freely.

The opposite takes place when an allergic attack or a ''cold'' develops: The blood vessels expand, the membranes become congested (full of excess blood), and the nose becomes stuffy, or blocked.

In addition to allergies and infections, other events can also cause nasal blood vessels to expand, leading to vasomotor rhinitis. These include psychological stress, inadequate thyroid function, pregnancy, certain anti-high blood pressure drugs, and overuse or prolonged use of decongesting nasal sprays and irritants such as perfumes and tobacco smoke.

In the early stages of each of these disorders, the nasal stuffiness is temporary and reversible. That is, it will improve if the primary cause is corrected. However, if the condition persists for a long enough period, the blood vessels lose their capacity to constrict. They become somewhat like varicose veins. They fill up when the patient lies down and when he/she lies on one side, the lower side becomes congested. The congestion often interferes with sleep. So it is helpful for stuffy patients to sleep with the head of the bed elevated two to four inches. Accomplish this by placing a brick or two under each castor of the bedposts at the head of the bed. Surgery may offer dramatic and long time relief.

Summary

Stuffy nose is one symptom caused by a remarkable array of different disorders, and the physician with special interest in nasal disorders will offer treatments based on the specific causes. Additional information and suggestions can be found in the AAO-HNS pamphlets "Hayfever, Summer Colds and Allergies" and "Antihistamines."

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Your Nose: A Guardian to Your Lungs


You might not think your nose is a “vital organ,” but indeed it is! To understand its importance, all that most people need to experience is a bad cold. Nasal congestion and a runny nose have a noticeable effect on quality of life, energy level, ability to breathe, ability to sleep, and ability to function in general.

Why is your nose so important?

It processes the air that you breathe before it enters your lungs. Most of this activity takes place in and on the turbinates, located on the sides of the nasal passages. In an adult, 18,000 to 20,000 liters of air pass through the nose each day.

TIP: Keep a list of all your medications; know all the potential side effects; and discuss possible interactions with your doctors.







Your nose protects your health by:

Filtering all that air and retaining particles as small as a pollen grain with 100% efficiency.
Humidifiing the air that you breathe, adding moisture to the air to prevent dryness of the lining of the lungs and bronchial tubes.
Warming cold air to body temperature before it arrives in your lungs.
For these and many other reasons, normal nasal function is essential. Do your lungs a favor; take care of your nose.

Because the connection between the nose and lungs is so important, paying attention to problems in the nose--allergic rhinitis for instance – can reduce or avoid problems in the lungs such as bronchitis and asthma. Ignoring nasal symptoms such as congestion, sneezing, runny nose, or thick nasal discharge can aggravate lung problems and lead to other problems:

Nasal congestion reduces the sense of smell.
Mouth breathing causes dry mouth, which increases the risk of mouth and throat infections and reduces the sense of taste. Mouth breathing also pulls all pollution and germs directly into the lungs; dry cold air in the lungs makes the secretions thick, slows the cleaning cilia, and slows down the passage of oxygen into the blood stream.
Ignoring nasal allergies increases the chance that you will develop asthma; it also makes asthma worse if you already have it.
So, it is important to treat nasal symptoms promptly to prevent worsening of lung problems.

Tips to improve the health of your nose and lungs:

If your nose is dry, its various functions will be impaired. Try over-the-counter salt-water (saline) nasal mists and sprays to help maintain nasal health. These can be used liberally and at your discretion.
Beware of over-the-counter nasal decongestant sprays; prolonged use of these sprays may damage the cilia that clear the nose and sinuses. Decongestants can become addictive and actually cause nasal congestion to get worse.
Think of your nose when you’re traveling. Air-conditioned cruise ships may have high levels of mold in the cabins. Airplane air is very dry and contains a lot of recirculated particles and germs; a dry nose is more susceptible to germs. Use saline nasal mist frequently during the flight, and drink lots of water.
Medications prescribed to treat nasal problems:

Be aware of the nasal effects of other medications

Diuretic blood pressure medications cause dryness in the nose and throat, making them more susceptible to germs and pollens.
Many anti-anxiety medications also have a drying effect on the nose and throat.
Birth control pills, blood pressure medicines called beta-blockers, and Viagra can cause increased nasal congestion.
Eye drops can aggravate nasal symptoms when they drain into the nose with tears.

Be sure you understand their purpose. Each one is important and plays a separate role in treating nasal symptoms.

The foundation of the treatment of chronic nasal conditions is the regular use of an anti-inflammatory prescription nasal spray, which address all types of nose and sinus inflammation. These sprays should be used only as directed by your doctor. This is in contrast to medications that are inhaled by mouth into the lungs, which often have high levels of absorption into the blood stream. Always aim nasal sprays to the side of the nose; spraying into the center of the nose can cause too much dryness.

Antihistamines effectively relieve sneezing, itching and runny nose, but they have no effect on nasal congestion at least in the short term. Over-the-counter antihistamines cause drowsiness, slow the cleaning function of the cilia, and increase the stickiness of nasal mucus--causing germs and pollens to stay in the nose longer. There are prescription antihistamines that do not have any of these side effects. To achieve this safety, the relief is often slower starting, so patience is required.

Decongestants help to unclog stopped up noses but do very little for runny noses and sneezing. They work much faster to unclog the nose, but to achieve this quick action, there are often side-effects such as dry mouth, nervousness, and insomnia. The correct dose often has to be customized to get the benefit without the side-effects.

Be aware of medication side effects; no medicine works well for all people, and all medications can cause side effects.

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