Bermuda grass (Cynodon dactylon)

Bermuda Grass flower

Bermuda Grass flower

Because of it’s resistance to heat and drought, Bermuda grass is well suited for Arizona and the desert southwest.  Common Bermuda is propagated by seed and produces significant amounts of pollen. It is used extensively in school sports fields, parks, golf courses, and green belts.  Hybrid Bermuda grasses such as Tif and Midiron, are the result of mating common Bermuda grass with African Bermuda grass resulting  in a plant with a finer leaf texture and which does not produce pollen or seed.    These hybrid varieties are used in many home lawns and smaller fields.     In 1994, Phoenix passed the Airborne Pollen Ordinance which requires that Bermuda grass lawns be kept short to prevent pollen-producing seed heads (see picture)  from forming.  It pollenates May through October

New Advair and Symbicort FDA Warning

This week the FDA announced their recommendations for label changes for products containing long-acting-beta-agonists (LABAs). Long-acting-beta-agonists are found in Advair and Symbicort, two of the most widely prescribed asthma medications in the US and Europe.

The specific label changes recommended by the FDA for Long-Acting Beta-Agonists (LABAs) include:

1. Contraindicate the use of LABAs for asthma in patients of all ages without concomitant use of an asthma-controller medication such as an inhaled corticosteroid.

2. Stop use of the LABA, if possible, once asthma control is achieved and maintain the use of an asthma-controller medication, such as an inhaled corticosteroid.

3. Recommend against LABA use in patients whose asthma is adequately controlled with a low- or medium-dose inhaled corticosteroid.

4. Recommend that a fixed-dose combination product containing a LABA and an inhaled corticosteroid be used to ensure compliance with concomitant therapy in pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid.

Some background and a few thoughts.

A number of large studies conducted over the past 20 years have suggested that there is an increased risk of severe asthma attacks associated with the use of the  long-acting-beta-agonists salmederol and fermoderal.  Salmederol is found in Advair and Fermoderal is found in Symbicort.

Unfortunately, it has not been possible to determine if the patients in the study who had severe attacks were also taking an inhaled corticosteroid at the time. This fact is very important.

Most asthma specialists would predict that, for patients with moderate to severe asthma, using a long-acting-bronchodilator alone  without using a daily anti-inflammatory medication, could cause  problem.    An analogy would be taking an antibiotic and Ibuprofen for pneumonia. Both medications are used to treat pneumonia.  However, if you were given both medications but only took the Ibuprofen, for a time you would feel better with less fever, body aches, and chest pain.  Without antibiotics, however the infection in the lungs could continue to worsen, even to the point were antibiotics would no longer save the patient. In asthma, steroids control the inflammation in the airways which is at the heart of asthma symptoms. Short and long-acting bronchodilators temporarily relieve the chest tightness, cough, shortness of breath and wheezing of asthma but have no effect on the inflammation.  This can lead to a serious, even fatal asthma attack. In the pneumonia analogy it would be short sighted to blame the use of Ibuprofen for a death caused by pneumonia: it has never been  good practice to treat the symptoms of pneumonia alone without addressing the infection, and a poor outcome would be expected. A poor outcome is also to be expected from an asthma treatment that masks the seriousness of the condition by providing temporary relief of symptoms without addressing the dangers of progressive inflammation.   It is possible that the results of the studies that have concerned the  FDA confirm what has always been assumed:  Daily symptom relief medications should not be used without the concurrent use of effective anti-inflammatory agents such as inhaled corticosteroids.   This is not a problem with Advair and Symbicort, both of which contain inhaled steroids.

Is Your Asthma Under Control: The Rules of Two

What Does Well Controlled Asthma Look Like?

Asthma is a long-term disease and although it cannot be cured, it can be controlled.  So what does well controlled asthma look like?
Some have suggested that it would include the following:

  1. Infrequent symptoms such as coughing and shortness of breath
  2. Minimal use of quick-relief medicines
  3. Normal lung function
  4. No night-time symptoms or symptoms associated with exercise.
  5. No severe asthma attacks that could result in a trip to the emergency room or being admitted to the hospital for treatment

The Two Faces of Asthma

Asthma has two parts: inflammation and bronchospasm.
Inflammation is present in the airways of asthmatics all the time, even when symptoms are quiet.  The inflamed airways are hypersensitive and easily irritated and will spasm with exposure to a variety of irritants such as cigarette smoke, cleaning fumes, air pollution, dust, exercises, and even cold viruses.  (In fact most asthma attacks are triggered by viral colds.)  We call the tightening and narrowing of the airways in asthma bronchospasm and it is the cause of most asthma symptoms including cough, chest tightness, and wheezing.

Asthma Inflammation

Although not all asthmatics are allergic, allergy is the primary cause of the inflammation found in children with asthma.  In Phoenix,  pollen and mold levels remain high much of the year. Other environmental factors such as the dry air and fine particulates (dust) and other elements of air pollution may contribute to airway inflammation.

So inflammation causes airway hypersensitivity which leads to bronchospasm which causes the symptoms of asthma.  In other words, if we are having a lot of asthma symptoms, that fact tells us that there is significant inflammation in the airways.

Two Types of Asthma Medications

Just like the two components of asthma, there are two broad categories of asthma medications:  anti-inflammatory medications and bronchodilators.   We call the anti-inflammatory medications “controllers” because they are used daily to keep inflammation under control which in turn will bring asthma symptoms under control.
Inhaled corticosteroids are the most effective anti-inflammatory medications. and are generally safe when taken as prescribed. They’re very different from the illegal anabolic steroids taken by some athletes. Inhaled corticosteroids aren’t habit-forming, even if you take them every day for many years.
Like many other medicines, inhaled corticosteroids can have side effects although most doctors agree that the benefits of taking inhaled corticosteroids and preventing asthma attacks far outweigh the risks of side effects.
Singulair (montelukast) is also used as a daily controller medication although it is not as effective as the inhaled corticosteroids.

Two Types of Bronchodilators

Short-Acting Bronchodilator (albuterol)

There are two types of bronchodilators: short acting and long-acting.  Both act to relax the muscles surrounding the airways.  The short acting bronchodilators are called “relievers” because they  are used as needed to relieve symptoms.   Long-acting bronchodilators (LABAS) are often used with inhaled steroids to reduce the dose of steroid needed to achieve control of symptoms.

One Size Does Not Fit All

Some patients with asthma have very mild and infrequent symptoms while others have continual symptoms or severe attacks requiring emergency treatment in a doctors office or hospital.    How do we know what medications are needed?
To answer this question, the NHLBI Expert Panel Report for the Diagnosis and Management of Asthma suggested dividing  asthma patients into four groups based on indicators of their asthma severity.  The categories ranged from mild to severe.   The first category, called mild persistent, included patients that had symptoms no more than than twice a week,  night-time symptoms no more than twice a month, and no more than one acute attack requiring oral steroids in a year.    For  this “mild intermittent’ group, use of an as needed rescue inhaler was needed.
For asthmatics with symptoms occurring more than twice a day, night-time symptoms occurring more than twice a month. and severe attack requiring emergency treatment or oral steroids more than twice a year, a daily controller medication is recommended, preferable an inhaled corticosteroid.
This  then is the  basis of the rules of two.

The Rules of Two:   If…..

  1. You have symptoms more than twice a day
  2. Night-time symptoms more than twice a month
  3. Severe asthma attacks requiring emergency treatment or oral steroids more than twice a year
  4. Uuse more than two canisters of a rescue medication in a year,

You should be taking two medications: a daily controller medication and an as-needed rescue medication

Medication Guide

Allergy and Asthma Medication Guide (AAAAI)


Nasal Sprays

Eye Medications

Skin Medications

Asthma Medications

Inhaled steroids

Long Acting Bronchodilators (LABA)

Allergic Skin Conditions (overview)

There are several types of allergic skin conditions. They are often itchy and red and may appear scaly, bumpy or swollen. An allergist can determine which condition you have and develop a treatment plan to help you feel better.

While skin allergies are unpleasant and troublesome, there are things you can do to treat them.

Hives and Angioedema
Hives (or urticaria) are red, itchy, raised areas of the skin that can range in size and appear anywhere on your body. Most common are acute cases, where food or drug allergies are triggers. These hives usually go away within a few days. In cases of chronic hives (lasting more than six weeks), people may suffer for months to years.

Angioedema is a swelling of the deeper layers of the skin that sometimes occurs with hives. The areas often involved are the eyelids, lips, tongue, hands and feet.

Food or drug reactions are a common cause of acute hives and/or angioedema. Viral or bacterial infection can also trigger hives in both adults and children. Physical urticaria are hives resulting from a non-allergic source: rubbing of the skin, cold, heat, physical exertion or exercise, pressure and direct exposure to sunlight.

If the cause of your hives can be identified, you should avoid that trigger. With acute hives, some drugs or foods may take days to leave the body, so your allergist may prescribe antihistamines to relieve your symptoms until that happens.

Contact Dermatitis
When certain substances come into contact with your skin, they may cause an eczema-like rash. There are two types of contact dermatitis: allergic and irritant. Irritant contact dermatitis is caused by substances that cause burning, itching or redness in all people if the exposure dose or duration is long enough. It is a common problem in people who wash there hands too frequently. An example of allergic contact dermatitis is the itchy, red, blistered reaction experienced by some people after contact with poison ivy. This allergic reaction is caused by a chemical in the plant called urushiol. Only some people will react with this chemical and is some cases, the reaction is severe. You can have a reaction from touching other items the plant has come into contact with. Allergic contact dermatitis reactions can happen 24 to 48 hours after contact. Once a reaction starts, it takes 14 to 28 days to go away, even with treatment.

Other common cause of allergic contact dermatitis include nckel, perfumes, dyes, rubber (latex) products and cosmetics also frequently. Some ingredients in medications applied to the skin can cause a reaction, most commonly neomycin, an ingredient in antibiotic creams. For irritant contact dermatitis, you should avoid the substance causing the reaction. Gloves can sometimes be helpful. Since these reactions are non-allergic, avoiding the substance will relieve your symptoms and prevent lasting damage to your skin.

Treatment for allergic contact dermatitis depends on identifing and avoiding the offending agent. If the allergen can not be readilly determined by history, allergy patch tests may be used to help identify it. To relieve symptoms, you may be prescribed topical a corticosteroid cream and in severer cases, an oral corticosteroid for a few days may be required.

Atopic Dermatitis
A common allergic reaction often affecting the face, elbows and knees is atopic dermatitis or eczema. This red, scaly, itchy rash is more common in young infants and those who have a personal or family history of allergy.

Common triggers include aeroallergens like cat dander or house dust, overheating or sweating, and contact with irritants like wool or soaps. In older individuals, emotional stress can cause a flare-up. For some patients, usually children, certain foods can also trigger eczema. Skin staph infections can cause a flare-up in children as well. Eczema patients usually have very dry skin and “allergic shiners” (an extra crease, called a Dennie’s line, across their lower eyelids). They are also more at risk for other skin infections.

Preventing the eczema itch is the main goal of treatment. Do not scratch or rub your rash. Applying cold compresses and creams or ointments is helpful. Also remove all irritants that aggravate your condition from your environment. If a food is identified as the cause, it must be eliminated from your diet.

Topical corticosteroid cream medications and topical calcineurin inhibitors are most effective in treating the rash. Antihistamines are often recommended to help relieve the itchiness. In severe cases, oral corticosteroids are also prescribed. If a skin staph infection is suspected to be a trigger for your eczema flare-up, antibiotics are often recommended.


What is Eczema?

Eczema is a general term for any type of dermatitis or “itchy rash”. There are several skin diseases that are eczemas; a partial list of eczemas includes:

* atopic dermatitis
* contact dermatitis
* dyshidrotic eczema
* nummular eczema
* seborrheic dermatitis

All types of eczemas cause itching and redness and some will blister, weep or peel.

Atopic Dermatitis (AD)
Atopic dermatitis is the most severe and chronic (long-lasting) kind of eczema. Atopic dermatitis is a disease that causes itchy, inflamed skin. It almost always begins in childhood, usually during infancy. Physicians estimate that 65 percent of eczema patients are diagnosed in the first year of life and 90 percent of patients experience it before age five. Often the symptoms fade during childhood, though “most” will have AD for life. It is estimated that atopic dermatitis affects over 30 million Americans. It typically affects the insides of the elbows, backs of the knees, and the face but can cover most of the body. Atopic dermatitis falls into a category of diseases called atopy, a term originally used to describe other allergic conditions such as asthma and hay fever. Physicians often refer to these three diseases as the “atopy triad” and AD may be first to appear in what has been called the “allergic march”, the progressive manifestation of allergic conditions from infancy to adult. Although many patients with atopic dermatitis will test postive to several foods on allergy tests, less than 30% of patients with AD will improve when those food are elliminatted. It is safe to say, therefore, that atopic dermatitis is directly related to the conditon of allergy but not necessarily to any one allergic trigger.

Contact Dermatitis (Allergic or Irritant)
Contact dermatitis is a reaction that can occur when the skin comes in contact with certain substances which can cause skin inflammation. Irritants are substances that cause burning, itching or redness in all people if the exposure dose or duration is long enough. Common irritants include solvents, industrial chemicals, detergents, fumes, tobacco smoke, paints, bleach, woolen fabrics, acidic foods, astringents and other alcohol (excluding cetyl alcohol) containing skin care products, and some soaps and fragrances. Allergens are specific substaces, typcially proteins from foods, mold, pollen, or pets, that only sensitized individuals will react to. Contact dermatitis is considered a type of delayed hypersensitivity reaction because it may take 24-48 hrs after contact before the eczmea developes.

Dyshidrotic Dermatitis (Pompholyx)

This is a blistering type of eczema, which is twice as common in women. It is limited to the fingers, palms, and soles of the feet. The hands may have small,tense, fluid filled blisters, scaly patches of skin that flake constantly or become red cracked and painful. Itching is usually severe.

Seborrheic Dermatitis

Red, scaly, itchy rash in various locations on the body. The scalp, sides of the nose, eyebrows, eyelids, and the skin behind the ears and middle of the chest are the most common areas affected. Dandruff (as seborrheic, is caused by a fungal infection) appears as scaling on the scalp without redness. Seborrhea is oiliness of the skin, especially of the scalp and face, without redness or scaling. Seborrheic Dermatitis has both redness and scaling.

Treatment of Eczema

Prescription drugs vs over the counter medications?

Over-the-counter (OTC) medications are available without a prescription because they contain the lowest potency of active ingredients. They are not designed to treat the causes of a disease, but to give some relief of symptoms. Many good moisturizers are available as OTC products. They are important in terms of prevention and maintenance to reduce eczema’s impact. Regular use of these products may reduce the frequency of flare-ups. Prescription medicines, by contrast, are usually much more powerful in providing some relief of the symptoms. They are closely regulated in the U.S. by the Food and Drug Administration (FDA), and are approved for use in treating a specific disease only after they have demonstrated effectiveness and safety. No prescription drug is free of side effects, and FDA approval is given to drugs with the understanding that they must be used with caution to avoid the negative effects which could result in something worse than the disease itself. Consequently, these drugs must be administered under the watchful eye of a licensed prescriber-a doctor, or in some states, a nurse practitioner.

What are FDA approved prescription therapies?

Topical steroids have been the standard treatment for eczema, with oral steroids being prescribed only for severe flare-ups. Recently, however, the FDA has approved a new class of drugs called Topical Immunomodulators (TIMs). At this time there are two FDA approved non-steroid drugs: tacrolimus and pimecrolimus. Topical anesthetics, antibiotics, antihistamines, antibacterial, antifungal and anti-inflammatory drugs are available in creams, gels, ointments, lotions and solutions. Most of these classes of drugs can also be administered orally.

What about alternative or complimentary medication?

Alternative medications also have ingredients that may have irritating or allergenic effects for some people, as with any treatments. It is important to discuss with your physician any alternative medication that you may purchase at a health food store as it may have an adverse reaction to your eczema or another medication you may be taking.

Are there plants and vegetables to avoid?

Everyone knows about obvious culprits like poison ivy, poison oak and stinging nettles, but for people with eczema trying to avoid any plants with fuzzy leaves and stems is a good idea.
Alliums, which include garlic, onions, chives, and leeks, tend to contain allergens that are more irritant than allergen. Citric fruits like lemons, limes and oranges may cause phototoxicity problems. You can get a severe rash from contact with a mango rind. The saps of certain trees are also phototoxic. Daisies (member of a family which includes dandelions, artichokes, chrysanthemum, sunflowers and yarrow) contain a variety of the allergens called sesquiterpene lactones in their stems, leaves, and flowers. If handled, they can produce a localized rash, and they (particularly dried ragweed) may also cause airborne contact dermatitis. Tulips contain an allergen called tuliposideA that often causes a fissured, fingertip dermatitis called “tulip fingers”. Poinsettias are also very irritating mostly because of a sticky sap it exudes. Handle all plants diligently (or with latex free gloves).


Normal Sinus Function
The sinuses are cavities within the cheek bones, around the eyes and behind the nose. Although their precise function is not known, it has been suggested that they play an important role in warming, moistening and filtering the air in the nasal cavity, resonating vocalized sound, and keeping the weight of the skull at a manageable level. One thing is true, the sinuses are constantly at risk of attack from viruses, bacteria, and mold looking to move into the warm, dark, moist, and nutritious environment of the sinus cavity.

The sinuses primary defense against invasion is drainage. Seen under the microscope the sinuses are lined with a tall cell with waving, hair like projections called cilia. There are also numerous mucous glands that provide a constant layer of mucous that is kept in motion by the sweeping cilia. The mucous moves in a coordinated manner around the sinus lining eventually being swept out of small openings in the sinus called the ostia. The sinus ostia are located under wing-like bony structures in the nasal passage called the turbinates. Mucous draining from the sinus ostia is directed backwards toward the throat were it is swallowed. Normal sinus drainage occurs throughout the day and usually goes unnoticed. When the amount of the mucous increases significantly or the character of the mucous changes we may experience it as post nasal drainage.

The coordinated flow of mucous is critical to the health of the sinuses. The mucous not only contains enzymes and antibodies that kill specific pathogens, but the constant tide of flowing mucous prevents viruses and bacteria from infecting the cells lining the sinus causing disease. Oxygen is toxic to many harmful bacteria but necessary for the health of cilia. It is therefore important that the sinuses remain open to the air. When the sinus ostia become plugged – as can occur with allergy, anatomical narrowing or polyps- the mucous becomes thick and stagnant, the oxygen level in the sinus drops, the cilia cannot function normally and bacteria are given an opportunity to grow and cause infection To fight back the sinuses will try to flush out the invaders by producing more mucous. Without proper drainage, however, it is a difficult fight to win. As a secondary defense measure, the lining of the sinus may become thickened.

Inflammation of the sinuses is called sinusitis. This inflammation may be the result of infection, injury, and allergy and can be acute or chronic.

Acute sinusitis is characterized by symptoms lasting less than 4-6 weeks and is usually caused by infection. Symptoms of acute sinusitis are familiar and include pressure around the nose, eyes or forehead, stuffy nose, thick, discolored nasal drainage, post-nasal drip, cough, head congestion, and ear fullness. Some patients with acute sinusitis may also complain of a toothache and occasionally fever.

Acute sinus infections may be caused by viruses or bacteria. The common cold virus frequently infects the sinuses resulting in sinus pressure, discolored nasal discharge, and post nasal drainage. These symptoms will typically begin to improve after 5-7 days without treatment. When symptoms persist beyond a week, or worsen suddenly, it is often because a bacteria has moved in, taking advantage of the weakened condition of the sinuses caused by the cold virus. For many doctors and patients the term “sinus infection” refers to a bacterial infection of the sinus requiring an antibiotic. Because even the best doctor cannot tell the difference between a viral and a bacterial infection based on history of physical exam alone, it may be appropriate to reserve antibiotics for symptoms that have lasted 7-10 days without improvement.

Inflammation of the sinuses lasting for more than 4-6 weeks is called chronic sinusitis. The symptoms of chronic sinusitis may be subtle and limited to recurrent post nasal drainage, frequent throat clearing, recurrent cough, nasal congestion, poor sense of taste or smell, and stuffy ears. The cause of chronic sinusitis may be a bacterial infection that the body has not been able to completely clear, reaching a kind of “stale mate”: the infection is not progressing but the body isn’t getting rid of it either. As a result of the persistent infection, the lining of the sinus may become thickened and drainage less efficient. It is theorized that in some cases a bacterial infection will injure the lining of the sinuses to such a degree that even when the infection is eradicated, poorly functioning cilia, thickened sinus membranes, and inefficient drainage persists.

Some types and mold may find there way into the sinus cavities and begin to grow. Some researches feel that mold in the sinuses is an important causes of chronic sinusitis. Others feel that chronic sinusitis presents an opportunity for fungus to grow, and is therefore an innocent bystander in the disease process. Some mold varieties are highly allergenic and if you are allergic to mold that is growing in the sinuses, symptoms of severe sinusitis and asthma may develop.

Allergies to air-born allergens such as pollen, mold, and animal dander may increase the risk for developing sinusitis because allergies can cause swelling of the nasal tissues limiting normal sinus function. The sneezing, sniffling, and nasal congestion associated with hay fever may increase the chance of bacteria in the nasal cavity finding it’s way into the sinuses.

Management of allergy symptoms with medications and immunotherapy may reduce the likelihood of developing an infection.

In rare cases, immune problems that limit the bodies ability to fight common infections may present with chronic or recurrent sinusitis.

Structural abnormalities of the nasal cavity, such as narrow sinus ostia, tumors or a shifted nasal septum (the bone and cartilage that separate the right from the left nostrils), may also cause sinusitis. If the problem is structural then surgical correction may be curative, however, because many patients with recurring or chronic sinusitis have more than one factor that puts them at risk of infection. a proper evaluation and accurate diagnosis is essential. You cannot fix an allergy problem with surgery.

Sinusitis in a Desert Environment

Living in Phoenix presents unique problems for the sinuses. The sinuses need a constant flow of mucous to stay healthy. Individuals who grew up in a humid environment like Chicago, Portland, or Atlanta and then move to Ahwatukee, Chandler, or Maricopa, may suddenly find that the dry climate of their new home does not provide enough moisture to keep the sinuses functioning as usual. Like the excessive tearing associated with chronic dry eyes, the sinuses may respond to the dry conditions by producing too much mucous, leading to post nasal drip syndrome. In addition, the amount of suspended fine particles in the air such as quartz and diesel particles, is greater in the desert, and when breathed can damage the lining of the nose, sinuses, and airways leading to tissue injury and chronic inflammation. The inflaming effect of particulates and other air pollutants may heighten the effect of air-born pollen and mold. The result if more severe allergies, asthma, and sinus problems.

Sinusitis Versus Rhinitis

Symptoms of sinusitis and rhinitis are very similar. Rhinitis is a swelling of the mucous membranes of the nose while sinusitis includes swelling of the sinuses in addition to the nasal passages. For this reason, sinusitis is often called rhino-sinusitis.

Rhinitis may be allergic or non-allergic. Symptoms of allergic rhinitis often are a runny nose, sneezing, nasal congestion and itchy eyes, nose, throat and ears. People with non-allergic rhinitis may have a very stuffy or a very runny nose. It may be caused by irritants such as air pollution, dryness, smoke, changes in barometric pressure or temperature or overuse of over-the-counter decongestant nasal sprays.


The evaluation of sinusitis should include a detailed history and physical examination. Allergy testing is needed to differentiate allergic from non-allergic rhino-sinusitis. A sinus CT scan may be needed to look for evidence of infection or structural abnormalities. If in doubt, tests to insure that the immune system is in proper working order may be ordered.


Acute bacterial sinus infections are treated with antibiotics and if needed, agents to reduce inflammation and promote drainage Chronic sinusitis can be a challenge to treat for a number of reasons. The inflammation in chronic sinusitis is similar to that seen in chronic asthma. Although the inflammation is asthma is routinely treated successfully with inhaled steroids, we do not have a way to get topical steroids into the sinuses. In fact, the nasal passage and turbinates are designed to keep things from entering the sinuses from the nose. So although nasal steroids are frequently used to reduce nasal congestion, very little makes it into the sinuses. Oral steroids, can provide significant improvement in sinus symptoms but have significant side effects if taken for more than 1-2 weeks. Antihistamines are not helpful in chronic sinusitis for the same reason that they are not helpful in chronic asthma: the inflammation involves many different cells and chemicals besides histamine. Several non-drug treatments can be helpful including breathing warm, moist air and irrigating the nasal cavities with salt water.

For people with allergies, long-term treatment to control and reduce nasal congestion and other allergic symptoms can help in preventing sinusitis.

Vocal Cord Dysfunction

What is vocal cord dysfunction?

Vocal cord dysfunction is a condition caused by abnormal movement of the vocal cords.

Symptoms of vocal cord dysfunction include:

* Shortness of breath
* Intermittent hoarseness and/or wheezing
* Chronic cough and/or throat clearing
* Chest and/or throat tightness
* “Just having trouble getting air in.”

Unlike asthma, which is caused by contraction of airway muscles in the chest (bronchospasm) resulting from inflammation of the airways, the symptoms of vocal cord dysfunction is related to narrowing of the large airway in the neck. Although many patients with vocal cord dysfunction feel more symptoms in the neck and upper chest, the only symptom may be a sensation of not getting adequate air.

Because of the similar symptoms, many people with vocal cord dysfunction may be misdiagnosed with asthma and treated with asthma medications, often with poor results. If vocal cord dysfunction is still not diagnosed, oral steroids (used in other chronic lung diseases like severe asthma) may be prescribed. Significant side effects can develop with long-term use of these medicines. Additionally, a misdiagnosis can also lead to frequent emergency room visits and hospitalizations – even intubation.

Some people have both vocal cord dysfunction and asthma, which complicates both the diagnosis and the treatment.

What happens with vocal cord dysfunction?

To understand vocal cord dysfunction, it is helpful to understand how the vocal cords function. The vocal cords are located at the top of the windpipe (trachea). To produce the sounds of speech, the vocal chords tighten and partially block the airway. As exhaled air moves across the partially closed cords, they vibrate producing sound which is then shaped by our mouth and throat as speech. The vocal cords are relaxed during normal breathing, allowing air to easily pass through the trachea. However, with vocal cord dysfunction, the vocal cords close together, or constrict, during one or both parts of the breathing cycle, partially blocking the windpipe and creating a sensation of not getting enough air.

So what causes the vocal cords to tighten during normal breathing? In many, vocal cord dysfunction is a type of involuntary stress reaction. The vocal cords tighten when they are under pressure. This may be the case even though an individual does not feel particularly stressed or anxious. Vocal cord

dysfunction had recently been recognized a cause of exercise induced shortness of breath, particularly in children involved in school sports. A child, who has a strong internal drive to win or feels pressure from a coach or parents to do better, may exhibit vocal chord problems.

Diagnosing vocal cord dysfunction can be quite difficult because the symptoms are a lot like those of asthma including chronic cough, shortness of breath, difficulty inhaling enough air, chest tightness, throat tightness, hoarseness, and wheezing. In addition, symptoms of vocal cord dysfunction can be trigged by conditions that also trigger asthma symptoms, such as upper respiratory infections, gastroesophagel reflux (severe heartburn), fumes, odors, cigarette smoke, singing, emotional stress, and exercise. Because vocal cord dysfunction doesn’t respond to asthma treatment, however, it can cause frequent emergency room visits and hospitalizations.

Because the symptoms of vocal cord dysfunction mimic asthma, differentiating between the two can be a challenge. Often, the first clue is finding that symptoms do not respond to routine asthma medications. The most specific test for the disease is direct visualization of the vocal cords through laryngoscopy or bronchoscopy during an attack. Because the vocal cords may appear normal between attacks, a negative test may be misleading.

Treatments and Tips

Once a diagnosis of vocal chord dysfunction is made, specific treatment can be recommended. Speech therapy can be helpful to guide relaxed breathing and special exercises can help relax throat muscles and reduce the abnormal movement of vocal cords.
Because stress can worsen the symptoms of vocal chord dysfunction – and vocal chord dysfunction can increase levels of stress – many people with vocal chord dysfunction have found counseling to be an important part of their treatment. Counseling can help identify stresses and build coping skills that aid in minimizing the effects of vocal chord dysfunction on daily life.

Mulberry Tree (Morus Alba)

Mulberry Tree (Morus alba)

Mulberry Tree (Morus alba)

The Mulberry tree (also know as Fruitless Mulberry or White Mulberry)  is often cited in stories  relating how Arizona went from a favored destination for allergy sufferers to one of the worst places to live if you have allergies or asthma.   New Arizona residents moving in from the South and East preferred the stately, large-leaved, shade trees they left behind to the local desert varieties and so  thousands of Mulberry, Olive, and Ash trees were planted throughout the valley.   Spring tree pollen levels in Phoenix were fairly low 40-50 years ago but over the past 30 years,  pollen levels in Phoenix have skyrocketed and along with it,  the Phoenix allergy-misery level.   To stem the flood, Phoenix passed the Airborne Pollen Ordinance which restricted the planting of male Mulberry and Olive trees.  As a result, there are few Mulberry trees in the newer communities of Phoenix such as the Foothills in Ahwatukee, although there are enough established trees  in the valley to supply the rest of the area with pollen for many years ago come.

Pollination: February through April


Arizona Ash (Fraxinus velutina)

Arizona Ash Tree

Arizona Ash Tree

Arizona Ash is a medium to large deciduous ornamental shade tree used in landscaping throughout Phoenix.   Because of it’s high water requirements, it is infrequently used in desert landscaping and therefore is less common in the newer communities of Ahwatukee, Chandler, and Maricopa, although it can be found frequently in older parts of Ahwatukee, equestrian properties such as Warner Ranch, as well throughout Tempe, Scottsdale, Mesa, and Central Phoenix.  Other varieties of Ash are very popular in Ahwatukee and Chandler and a large number have been planted in schools and parks.  The Ash is in the same family as the Olive tree (Oleaceae family) and  individuals who are sensitive to Olive tree pollen will also have problems when exposed to Ash tree pollen.

Pollination: February through April