Episode 130: Allergic Shiners & Salute: The Myofunctional Therapists Role

Hi and welcome to episode 130 of the Untethered Podcast. It is your host, Hallie Balkan, and it's just going to be us hanging out today, you and me, me and you, and we're going to be talking all about allergic rhinitis and what to do as a myofunctional therapist when it comes to allergies. Let's get started. Quick disclaimer. All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnos and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Hello my friends and welcome to this episode. You all expressed interest in doing more case studies and so I thought we would change it up a little bit. And instead of doing a feeding case or a myo case, you know, obviously this is related to feeding. I wanted to focus on allergic rhinitis. And now while allergies, right, Diagnosing them, assessing for them, all that is ultimately out of scope for a myofunctional therapist. We need to understand some of these concepts. So I want to present a case, or maybe two, where you can take what I'm giving you and ultimately use it to know whether or not you need to refer to an allergist. Right. Because we can do myofunctional evaluations and assessments. However, if we are unaware of when to refer to an allergist, things get a little complicated. Right? So let's start by first of all talking about what allergic shiners are. And then we're going to go on to talk about the allergic salute. Okay. And these are two topics that I think that every myofunctional therapist should be well read up on. And the reason being that a lot of our kids have these issues. A lot of our kids have started in infancy with allergies. Right? Sometimes they're environmental, sometimes they're food based, sometimes they may be sensitivities, and maybe they're not allergies. And I can tell you from experience, as a parent of a child who had an allergy panel done at age 2. Actually, both of my kids have been to the allergist for testing. Um, but my second daughter went at age 2. They did the panel on her back. They said, you know, the prick test and everything. They said, you know what, everything's coming back within normal and no concerns. However, based on her age, it's not, it's not super valid. I was like, well, I love you and I respect you and you guys are awesome, but why don't we just put her through that? If you're telling me this might not be valid and she might still have allergies that are not presenting well, the reason being, and we're going to go over that, but it's very difficult. What they explain to me is it's very difficult to diagnose allergic rhinitis in the first two or three years of life. And that it really peaks in really your 20s or your 40s, and then it tends to gradually diminish is what has been explained to me. And one of the reasons why it's really hard to determine if it's allergies. Allergic rhinitis is one. Again, those tests are not super valid. Sometimes there are just sensitivities to inhaled allergens that maybe they're sensitive to, but they're not actually allergic to. So on an IGE mediated test, which is what they're measuring for ige, we're not going to see it. It's not going to show up, even if they are maybe sensitive and reacting. Okay, now the other thing too is there's a lot of viral respiratory infections that happen in this age group. Young children who are building their immune systems. And that's all I'm going to say about that. But I know this as a mom of a six year old, a mom of a three year old, they go to school and typically their first year in school, they get sick a lot. And that's usually because they're building up an immunity to those illnesses that they're surrounded by. And hopefully they don't continue to get sick chronically. We do have some kiddos, especially those who land in speech therapy and language therapy and MYO at some point. A lot of them have a history of these upper respiratory infections. And we need to be looking at this and figuring out, you know, is there a pattern here? Do we feel like the inability to drain because they're stuffy, or maybe they have chronic nasal drainage? Right, you have that, like clear, thick nasal drainage. That's always happening. We need to look at, like, when is it happening? Why is it happening, happening? Do we feel like it's, it's worth it to refer this patient to an allergist? And obviously, if you're not sure, it's better to refer so they can at least be evaluated by the professional. You know, maybe it's an ENT that we're going to refer to. But if we're concerned about allergies based on what parents share with us, like, let's say the child's fine inside and they go outside and they start sneezing and their eyes are all puffy and, you know, that might, you might want to tell that parent, hey, this is a great opportunity to give your pediatric allergist a ring and get your child over there to have an appointment and maybe do some assessments to see if anything is necessary. Why is this so important? We're going to get into that, but the bottom line is if we can't nasal breathe, we have to mouth breathe. If we have to mouth breathe, we can't address correct oral rest posture. And there goes the whole purpose of myofunctional therapy. Right. So it's really important to rule out issues such as allergic rhinitis. And so let's talk about other instances where we might identify them. One that I mentioned at the very beginning of this is allergic shiners. And like, so what can we do, right, as healthcare practitioners, when this is not really quote unquote in our scope to address and treat. It is our inner scope to identify and refer, however. And so what are allergic shiners? Well, anybody can do a Google Scholar search and look up research studies and medical definitions, but basically, if there's a backflow of the venous system around the eyes that creates that blue gray, or maybe purplish circle color under the lower eyelids. I wouldn't call it a black eye per se, but it's where you get that venous pooling or that puffy look of skin underneath the eyes. And the discoloration, again, it's usually like a blue, gray or purple. There may be a puffy appearance around the skin of the eyes. It might be further reaching than just like right under the eyes, but the intensity of that change in the color to the skin and the puffiness really depends on the individual case. Right. And that's not our job to really know much about that. It's just our job to identify it, recognize it, and notate it on our evaluations. Note it in our referrals, make sure we're referring to the proper source. So While some people call this allergy black eye, there is, there is an issue beneath the surface that we need to help refer on to identify. And so what causes this? So common hay fever allergens to, like, pollen, mold, dust mites, pet dander, high. It's me. I have all of the above. They can help in developing these allergic shiners. We most frequently see them in children and our pediatric cases, over our adult cases. And just kind of figuring out why these dark circles are present and figuring out the cause, it can be tricky for, you know, the professionals that we're referring to. So just keep that in mind that just because you're a fraud doesn't mean they're going to send them right back to you and say, yep, we've confirmed allergies and we know exactly how to treat these. So we really need to work together to figure out, like, what's going on. Is it not only is it safe to expect them to breathe through their nose, but can they physically do it? And are we asking them to do something that their body's not going to allow them to do because of nasal congestion and allergies? So, as myofunctional therapists, you know, the other thing I want to say, too, before I go into what we can do as myofunctional therapists is an allergic salute. Right. So if you have a case where they are constantly wiping their nose up, and if you're watching me on YouTube, you can see me do this. And we actually just in the past two weeks posted some images, one of the Venus pooling with the allergic shiners, and then also one of the allergic salutes. So you guys could see the salute from the side profile as well as the crease that it creates across the nose. Right? It's this, like, upward swipe of your fingers or the palm of your hand along the tip of the nose when you kind of like, sniff in. Do you like that noise? And this kind of tilts the nose upwards. And so when a child is doing this repeatedly, it creates a little horizontal line across the nose and just above the nostrils because of them constantly pushing the nose into that position. And so this line is sometimes known as the allergic or nasal crease. And really, you're not going to see it in someone who might just have, like, very minimal allergies. It's typically going to be in those, like, chronic allergy cases with, like, itchy, itchy eyes, itchy nose, runny nose, maybe sneezing a lot. So. And it is something that can go away on its Own, especially if you address the underlying cause of the allergy response. However, in adults it might stick around permanently, especially if it's been going on for a long time. But anyhow. All right, so what can we do as myofunctional therapists? Well, we need to be asking about sleep. Have patients completed sleep question. Have they had your patients completed sleep questionnaires? Right. Do you have concerns about sleep? Do you? And I say sleep because oftentimes if they can't breathe through their nose, they're going to be mouth breathing when they're sleeping. And then we know if they're doing that, that there's some form of sleep disorder breathing present. It does not have to be sleep apnea to be a concern. And I want to make that like well known that sleep disordered breathing does not equal sleep apnea. Sleep disordered breathing can be a mild form of sleep apnea, a severe form of sleep apnea. It could be upper airway resistance syndrome. Right. If you can hear a child audibly breathing through their mouth and audibly just means like. Right. If you can hear just that, that's a concern children should have. They should be so quiet that you have to get up next to them and put your ear next to their nose to hear if they're breathing or look to see if their chest is raising up and down. If they're sleeping on their back, we should not hear them breathing when they're sleeping. Anyways, the sleep questionnaires, there's a whole variety of them out there, they get into different questions that can be really beneficial in determining if we need to refer to an ENT for a consult, if maybe a home sleep study might be warranted, if they don't want to go to the ENT or they don't want to do it in clinic or a center based sleep study. But if sleep disorder breathing is a concern, we absolutely have. We need to do our due diligence and we need to refer to an ENT and, or allergist and, or both and. Or, you know, there are individuals out there who do home sleep studies that may not be an ENT or you know, allergists are not typically doing them that I'm familiar with. But you know, the ENTs or the other MDs who typically do them. So just know there are other options out there. We also want to ask. So in, in our case history, but also during our myofunctional evaluation, we should be asking about the history of allergies, right? Is there a history of allergies I want to know about them all. Environmental food. I want to know about sensitivities. Most people are not asking about sensitivities, but I am one of those woo woo mamas who has gone down the road of testing myself and I've looked at like certain foods I was sensitive to and when I immediately eliminated them from my diet, my body just like dropped 10 pounds of inflammation in a matter of eight days. I mean, yes, arguably some is water weight, but not all of that. So my body was holding on to inflammation and just hold because it couldn't process. It was too. It was sensitive and not reacting the way it should. It wasn't reacting properly from a digestive standpoint. I obviously it was probably impacting my stomach, sleep. I had other things going on too at the time. And so what's just really fascinating is that food has a major impact on our body. And I'm not going to get into that today, but that can play into allergies and or sensitivity. So don't downplay the sensitivities. Okay, but we're mostly focused on the allergies today. Now, if there's a history of allergies, we definitely want to maybe refer back to the allergist if they haven't been there in a while, if they are being followed by an allergist, you want to see if you can get a copy of recent records so that you can understand what they've been tested for, what they're being treated for, what they might be being treated with, what their response has been and or just have a conversation with the allergist so that you can figure out, you know, are these allergic shiners being addressed or is this a conversation we need to have? Because maybe they are being treated but the allergic shiners persist and if they do well, maybe the treatment is not working as well as we thought it was and. Or maybe something else is needed in addition to. Right. Obviously again, out of scope, not my decision. I'm just sharing information based on a lot of cases I've worked with so that you all have an idea of what kind of conversations to have with the specialist with the allergist who is going to be potentially treating your patient's cases. So common symptoms that I mentioned before that accompany or allergic rhinitis might be sneezing, stuffy nose, runny nose, itchy eyes, watery eyes. Right. So definitely want to be aware of these things. I already listed out some of the common allergens. You know, for me in particular, I am a female, an adult female, 36 year old female, and I have a history. So, like, if we want to look at it from a case study, I have a history of nasal congestion most days of the year, even after moving from Maryland to Florida. Okay. And I feel like I've always had this. This is not new. I have maybe intermittent, like occasionally I have like a post nasal drip. Everything's always clear. I don't really have a lot of sneezing or itchy eyes outside of the fall and spring seasons in Maryland. I have not had that since moving to South Florida, thankfully. But I think that my congestion is twofold. I think, one, I have a deviated septum, and two, I have a pretty significant dust and mold allergy. And we're in a rental home where it's all hardwood floors, there's no carpet. We brought our own furniture. We had it deep cleaned before we moved in, but it's somebody else's home. And there are like, even within my shower, I feel like the shower needs to be regrouted. It's a beautiful shower. This is like a beautiful home. But I see it's either mold or mildew or, you know, and like, I probably need to get in there and scrub it myself to make it to my liking. Even though it's clean every week. Because when I get in the shower, if I spend more than five minutes in there, all of a sudden my nose becomes stuffed up, I start sneezing, and then it's like a 45 minute, like sneeze, stuffy nose attack. And that's bizarre. That's bizarre. But what I do know about myself is that having lived in Maryland, I was always the opposite of what the allergist said. They said, oh, when it rains, most people's allergies go away and they do really well. Well, for me, when it rains, my allergies kick up and I have a really hard time breathing outside. And so I've always managed it with over the counter things and more holistic protocols. I've never required allergy shots. It's never been that severe. But you know, sneezing, nasal itching, itchy eyes, not usually a cough. But like I said, sometimes like that nasal drainage, really post nasal drip for me, not drainage out the nose, but drip is so lovely, this conversation, right? And just the stuffy nose, you know, I have to figure out if it's related to more than just allergies. And I do think that my deviated septum makes it so that it's harder because I typically have an easier time breathing out one side of my nose than the other. And that's pretty consistent anyways. I've never had a situation where I've been like short of breath because of it and I don't take regular medications to manage it. I really do more like homeopathic types of things and try to make sure that I'm in an environment where I'm not going to trigger, you know, a mold or dust allergy to the best of my ability. Right. So we have to consider that some people may be walking around like me, where I've done myo, I've done the tongue tie release, I've done my, my expansion. Right. I was in a DNA vivos appliance for two years, but I do know that one, my maxilla is still turned in a little bit on my top left side and, or the top, I should say the left side of the maxilla is turned in and then my nose is deviated. And no matter what we did as far as body work or appliance therapy went, or myofunctional therapy work, for me, that maxilla was not holding. Like we could get it to shift, but it would not hold. It kept ending up back in its position and that's likely related to my deviated septum. So for me, that's the next piece of the puzzle. Right. In my case, that's where I need to go next. And that's, that's definitely a conversation that's being had right now. I'll keep you posted. But what I want to bring everybody's awareness to is that not everybody needs to go to an allergist or an ENT when you evaluate them. Not everybody has the inability to breathe through their nose. Not everybody has allergies, not everybody has allergic rhinitis. So if you don't see, you know, open mouth breathing with the dark circles, puffiness under the eyes, and, you know, they don't seem congested. And you look in that the tonsils don't appear to be, you know, oversized. And you're looking at all these different things that might signify that you need to refer them to an ear allergist. If none of those things, an anterior allergist, if none of those things are glaringly obvious or jumping out at you, then generally we can proceed with myofunctional therapy without making that referral. I think we get into a very dangerous place when we start to make blanket statements that every patient must see this provider and this provider and this provider before they start myofunctional therapy. And the reason why I say that is because I don't think that everybody has allergies. Now, if we look at. There's one article that was in the New England Journal of Medicine. Of course, this is dated like July 29, 2015. And I did look some others up, but this one kept popping up because this one had the estimates in it. Right. So for allergic rhinitis, it's estimated that 15 to 30% of patients in the United States have allergic rhinitis. And that affects. They basically say it affects productivity and quality of life in children and adults. It often, it coexists with asthma and, and other allergic diseases. But most people with asthma, you know, I think that it goes that most people with asthma have rhinitis. I don't know that it's the other way around. I know that they can. They frequently coexist, but they don't give numbers. So don't, don't spin this off and say, Holly said that. No, go to this article. You can get the article for free. It is, again, it's just titled Allergic Rhinitis by Lisa Wheatley and Algus Togayas, if I'm saying that correctly. And it was in the New England Journal of Medicine, January 20th. January 29th, 2015. It was available online July 29th, 2015. Sorry. So you might see one of those two dates when you're looking it up. Anyhow, the point here is that we do need to be considering this because again, if you have a case like mine, you might hit a wall when you start myofunctional therapy and you realize we can't seem to get too far or we're having trouble moving beyond where we're currently at. Well, why is that? It can be because the patient might not be able to breathe through their. What, their nose. Right. If you don't know by now, we got other problems. No, I'm kidding. But we have to be able to breathe through our nose in order to accomplish the basic goals of myofunctional therapy. Otherwise, there's going to be continued tongue forward posture, might be low in the mouth. They need to be able to breathe somehow, and if it's not through their nose and it's going to be through their mouth. So I hope this is helpful. The goal here again is just to give everybody some education on why we look at this during a myofunctional evaluation, what our responsibility is as a myofunctional therapist and what you can, you know, what to look for and then who to refer on to and when. Because again, and let me say this one more time. We do not need to refer everybody to an allergist or everybody to an ENT or everybody to an oral surgeon or, you know, I know, not sending them to oral surgeons for allergies, but you get my point. So we need to really, truly individualize the care, understand what we're looking at, why we're referring for what we're referring for, and we need to have an end goal in place as to why we're making these referrals. But plus, we should have a plan in place to speak with the provider that we are referring to so they understand why we sent this patient, what our concerns are, what we would like for them to rule out. We want to keep in mind that it's never our job to tell anybody else how to do their job. However, we do want to communicate and collaborate because if we're not having these conversations and they don't know why this patient is showing up in their office, they may be turned away if the patient is unable to explain to them our concerns or what we what our findings were in our evaluation. So I hope that helps and I really thank all of you for giving your feedback, telling me what you want to hear more of on the podcast. I hope that this was a great topic because a lot of you asked about it and we will chat with you next week on the pod. Thanks for listening to this podcast. If you want to hear more of these Myo Taught Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page @hallebulcan biz, on Instagram at Alibulcan, and you can head over to theuntetheredpodcast.com to grab a copy of the show Notes Notes, where you can also subscribe to be kept up to date on the latest podcast episodes.