The Environmental Aspects of Ear, Nose, and Throat Disease: Part I William J. Rea, MDCFACS, Dallas, TX, Director, Brookhaven Environmental Unit; Clinical Associate Professor of Thoracic Surgery, Southwestern Medical School, University of Texas Health Science Center

Abstract: There are numerous ways in which environmental overload can trigger disease processes in man. In considering whether a patient=s illness may be based in part on environmental factors, the clinician must recognize the limitations of medical environmental technology and keep in mind the concept of the total body load of environmental pollutants. Also, the clinician must remember that in many allergic patients a masking phenomenon occurs that initially hides an adverse reaction.

Source: JECORL & Allergy, 41(7):41-56, July 1979. 81979 by Medical Digest. Over the past century physicians have shown much interest in the treatment and prevention of infectious diseases. This has evolved since the development of the germ theory. With the advent of antibiotics and aseptic practices, it has become obvious that the majority of infectious diseases can be controlled. Infection control has also allowed us to delve deeper into the basic cause, or lack, of resistance in certain individuals who are prone to recurrent infections. The weight of the individual=s total environment upon the body=s homeostatic mechanisms appears to be an overwhelmingly important factor in breaking down resistances. Once inflammatory disease occurs, the body becomes prone to secondary recurrent infections. This review is an attempt to better understand the numerous ways in which environmental overload can trigger disease processes.
 
 
PRINCIPLES When analyzing and considering whether environmentally triggered disease is a factor in a given patient=s illness, the clinician must perceive several principles, as follows: First, he must realize that medical environmental technology is about 100 years behind environmental technology. Since our technology and overview are not well developed, it hampers us in diagnosing and treating diseases caused by noninfectious processes. The environmentally contaminated situation present today would be similar to the time when people were rubbing manure into wounds, or physicians were doing pelvic examinations after a post mortem, as was done 100 years ago, before the germ theory became well understood. Also, the public, as well as the medical profession, is generally unaware of potential environmental triggering agents. These substances are readily found in homes, workplaces, and even in hospitals in such abundance at times as to negate all treatment and hope for recovery in many patients. Thus, an individual with environmentally triggered disease may be sensitive to natural gas, but, when exposed to it 24 hrs per day, because it heats his home, water, and food, he may not perceive the acute cause and effect relationship. This may also be true in the individual sensitive to the chemicals in his water supply who is exposed so frequently because he uses it in his food, drinks it, and bathes in it.

The second principle that should be kept in mind is the concept of the total body load, which tends to distort many of the body=s homeostatic mechanisms. This is the sum of all incitants that the body has to handle in order to function. This is the total of the pollutants in air, water, and food. The load principle seems simple until one perceives the amount and scope of pollution that have crept into our environment. The more important components comprising the total load are discussed in the following paragraphs.

Most public water systems are now overloaded with synthetic chemicals, potentially increasing the body load to synthetics from 1,000 to 10,000 times (Table 1). Unfortunately public water supplies are rated only as to bacterial count, the chemical content being ignored. Recent EPA studies of the 83 largest cities show all of the water supplies to be severely chemically contaminated. Apparently, our waters are now as badly polluted with chemicals as they were with bacteria years before chlorination.

Table 1

Synthetic Chemical Contamination

Water
CHCLBr
CHCLBr
CHClBr
CHBr
Spring
26
3
1
10
Well
5
0
0
7
City
29,400
100
12,600
5,700

  Ninety-four percent of commercial foods contain pesticides. It is estimated that the average individual ingests one gallon of food additives yearly. In addition, the air in cities of 50,000 or more population has an outside air pollution gradient as compared to sea air of 150 times on good days, with amounts ranging from 2,000 to 4,000 on average to bad days (Table 2).

Table 2

Pollution Gradients

Area Pollution Gradient
Sea air 0 (Excluding salt particles)  

Desert air

10X  

Towns (over 2,500 pop)

35X  

Urban

150X

1,000 - 4,000

Days

Good

Avg. & Bad


  The average home appears to be the most polluted place in our environment. The fact that homes are being built to be even more airtight tends to increase pollutant contaminants. Homes contain high outgassing synthetics (e.g., dyed nylons, polyesters, foam rubber beds, chairs, floor mats); in addition, many homes have gas heat, further complicating pollution problems.

The summation of all these facts, plus a polluted work environment, results in a massive increase in body load that any one individual must handle just to function daily. This often becomes too great in persons with certain hereditary and acquired tendencies; the resultant individual susceptibility thus allows inflammatory diseases to occur. This chemical overload often distorts the food handling mechanism to the point that no foods are safe for some individuals. Often individuals with chemical overload also become sensitive to pollens, dusts, and molds.

The third principle is that of masking or adaptation (Table 3), i.e., an individual comes into contact with a substance but perceives no harm because there is not an immediate reaction. This occurs if he is exposed daily or more often. In contrast, if he avoids the substance for four days, he becomes unmasked. Then, if he takes the suspected substance into his body, he will have an immediate and clearly definable reaction if it is harmful to him. In this way, cause and effect are easy to establish. Often, food sensitivity is missed because the individual is eating the offending food daily or more often, thus causing symptoms to be masked. This masking principle is commonly understood in the person who is addicted to drugs. In this situation, in order to feel better, the individual often takes drugs whenever he has symptoms. If he omits them for four or five days, he experiences severe withdrawal reactions. Some painters and battery workers say that the substances they work with Abother@ them after they return from vacation until they get Aused@ to the offending substance again. Once they are Aused@ or masked to it, they do not perceive the harmful effects any longer and do well until eventually inflammatory disease develops. But when this occurs, because they are masked, they do not perceive the cause of their illness.

Table 3

The Masking or Adaptation Principle

Stage I Stage II Stage III
Alarm Resistance Exhaustion
Nonadapted Adapted Maladapted
Unmasked Masked Overload

  The fourth concept is that of bipolarity. Often an individual has a stimulatory reaction and perceives the substance as not harming him initially but actually making him feel good. However, after a period of time, be it minutes to months to years, his body=s defenses break down and he has harmful, disabling withdrawal symptoms. This is a well-recognized principle in cigarette, narcotic, or alcohol addicts, but not as well known, yet just as prevalent, in plastic workers, painters, food addicts, and many other individuals who constantly inhale or ingest a toxic substance.
 
 
ORGAN INVOLVEMENT The target organs of environmentally triggered disease appear to be very broad; in fact, any place that smooth muscle exists represents a target. The main categories, however, are few in number. The respiratory tree, the gastrointestinal tract, the genitourinary system, and the cardiovascular system are the main categories of smooth muscle target organs. In addition, the skin is involved in many patients. These five systems will be considered individually in order to define the problem better. Respiratory System Ear, nose, and throat involvement with environmental triggering factors appears to be the main early warning sign of environmentally triggered disease in many individuals. Sensitivity to odors seems to be the most common, many persons being intolerant to the odors of such substances as car exhaust, perfume, cigarette smoke, aerosol sprays, formaldehyde, alcohol, phenol, food, mold, and dusts. Often rhinitis occurs. Probably the largest portion of individuals with vasomotor rhinitis fall into this category. Recurrent sinusitis as well as severe otitis, various forms of vertigo (including Meniere=s disease), and laryngeal edema are frequent presentations of the problem. Of course, any portion of the respiratory system can be involved, resulting in such inflammatory diseases as recurrent bronchitis, bronchiectasis, and asthma (Table 4).

Table 4

Bronchiectasis

Pt.
Food
Chem
E. Rosset. T-Lcyte
Mg./dl.

EOS

CH??

T.C.

F.N.
L.T.
1
18/33
5/5
579
0
80%
+
6 mos.
2
25/41
4/4
600
88
80%
+
24 mos.
3
50/50
8/8
C
160
80%
C
36 mos.
Notes:

T.C. = Total complement

F.N. = Required Food Neutralization

L.T. = Long-Term Follow up 

Gastrointestinal System

When the gastrointestinal system is involved, anything from mouth ulcers to pruritus ani can occur. Disease of unknown etiologic entities (e.g., pharyngitis, esophagitis, gastritis, spastic colon, enteritis, or colitis) may have their etiology in foods and chemicals. Many patients will simply complain of bloating, constipation, or diarrhea. Genitourinary System If the genitourinary system is involved, urinary frequency and urgency are often present while recurrent cystitis requiring dilatation frequently occurs (Table 5). Back pains and uterine bleeding often occur in a patient with environmental disease. Perhaps the fine tuning of hormones is distorted in these patients, because acceleration of symptoms often occurs prior to or during the period.

Table 5

Genitourinary Symptoms Resulting from Environmental Sensitivity

Patient: Woman age 31 years.
Findings:  

 

 

 

 

 

IgE

IgG
IgA
CRP
THSC
C3
 

155

150
29
+
90%
52
 

Symptoms:

1. Recurrent Bronchitis, Life Long

2. Recurrent Myositis, Life Long

3. Recurrent Spastic Colon, Life Long

4. Recurrent Sinusitis, Life Long

5. Recurrent Chest Pain, Life Long

6. Recurrent Bruising, One Year

7. Recurrent Cystitis (Unmanageable), Six months

RX as AtopicCNo Results
 

FoodsCMultiple

ChemicalsCMultiple

 

 

 

 

 

 

1. 5 Sec. Gas Exposure

2. 5 Sec. Pesticide Exposure (Same)

 

 

Symptoms:

 

 

 

1. Writhing in Pain, 48 hrs.

2. Swollen Glands

3. Spontaneous Bruising 

 

 
 
 

Cardiovascular System

If the vascular tree is involved, symptoms can be widespread. Such entities as nontraumatic phlebitis, nonarteriosclerotic arrhythmias, or large or small vessel vasculitis can occur. Raynaud=s disease and phenomenon are often observed. Arthritis, arthralgia, myositis, fibrositis, and myalgia are present frequently.

A symptom complex often occurs with recurrent ear, nose, and throat diseases. If one looks for these, he will often become aware of environmental triggering as a problem. This complex consists of acneiform lesions, petechiae, and/or spontaneous bruising and purpura, peripheral coldness and cyanosis, and peripheral and periorbital edema.

The acneiform lesions usually occur on the face and shoulders, ranging in number from one to thousands. They have been reproduced in patients by injection of 0.05 ml of the food extract (usually the Number Two dilution) followed by ingestion of the same food. If the patient is supersensitive to the food, an acneiform lesion develops at the injection site within 24 to 36 hours. It has been possible to reproduce lesions in this manner using numerous foods and phenol. Localized edema or hives occasionally occur, but the more generalized peripheral and periorbital edema is much more common. However, this is often subtle and may be overlooked. People almost accept as normal swelling of their fingers to the point that rings cannot be removed, and expect cyclic edema to occur around the eyes and feet. If blood vessels leak further, extravasation of red cells causes bruising, purpura, and petechiae. Peripheral spastic phenomenon in the absence of cold occurs when challenge with chemicals and foods is performed. If the ear, nose, and throat physician keeps in mind the possibility of involvement of any or all four of the smooth muscle systems, he will be better able to diagnose and treat environmentally triggered disease.

Skin Chronic itching, eczema, and dermatitis may also be manifestations of food and chemical sensitivity.
 
 
PROPOSED MECHANISMS There are many ways in which noninfectious inflammatory disease develops. Basically, however, triggering may occur through the homeostatic mechanism via the immune system through immunoglobulins or by the amplification systems directly upon the alternate pathway of complement or other mediators, e.g., kinin or prostaglandin. Occasionally, trauma can trigger the entire chain of events. Regardless of the pathways involved, the final result is membrane irritability with increased permeability and leakage of fluid. This results in edema and probable local cell hypoxia with resultant lactic acidosis. Edema, localized or general, seems to be the initial pathologic symptom observed in most individuals sensitive to environmental incitants.

Once inflamed blood vessels develop, myriad symptoms become involved. If the inflammation is generalized, nonlocalized edema occurs; if it is localized, hives are present. If the vessels leak more or even rupture, one sees bruising, purpura, and petechiae. Biopsy of these lesions shows either the leukocytoclastic type with polymorphonuclear invasion of the lymphocytic infiltrative type. As pathologic derangement progresses, clot formation develops with disease processes becoming much more fixed. When diseases become fixed and, therefore, usually irreversible, they become recognized as such entities as necrotizing or hypersensitivity angiitis, giant cell arteritis, Wegener=s granuloma, temporal arteritis, or vasculitis, or collagen disease, e.g., lupus, rheumatoid, and so on. Finally, if local necrosis does not occur, granuloma healing or plaque formation develops.
 
 

MATERIALS AND METHODS

Materials

Once the aforementioned facts and principles are understood, study for food and chemical susceptibility must be done in meticulous detail in order to discriminate and define clearly the particular incitants. The methods used in defining triggering agents are refinements of Rowe=s, Cocoa=s, Randolph=s, and Rinkle=s techniques. Each category of air, food, and water will be discussed separately in order to consider all parameters. It should be pointed out that one must consider all parameters as being of equal importance in order to diagnose and treat patients with environmentally triggered disease. Failure to consider all parameters usually results in a continuation of the disease processes and eventual failure of overall treatment. This at times, however, may take years to perceive.

AirCThis parameter is the most difficult to assess because little attention has been directed toward air analysis of indoor pollution and because the outside air in the United States has become so polluted. According to some authorities, there has been no fresh air here for 15 years.

In order to study the environmental problem better, the Brookhaven Environmental Unit was created taking into consideration the aforementioned facts and principles using material constructed with meticulous detail. A description of the Unit follows so the ear, nose and throat physician may use the principles in his office practice. Inattention to controlling the ambient air of an office often results in misdiagnosis, and, therefore, inappropriate treatment.

A wing of the hospital was used in order to exclude contaminants from other areas. A firewall excluded all other possible pollutants. Double doors were used so that an air lock could be obtained to prevent outside air from entering the adjacent building. Air conditioning was installed in window units using all-metal coolers. Heat is of a local nature and presented a much more difficult problem because many chemically susceptible individuals are also sensitive to many types and sources of heat. Approximately 90% of 400 consecutive chemically susceptible patients are sensitive to the fumes of natural gas, which correlates with Randolph=s findings. In addition, many patients are also sensitive to fumes emanating from different electric devices. Copper radiators with aluminum fins are satisfactory only for 50% of patients. Steel and cast iron radiators appear to be better tolerated but rely on a central blower, which presents a different problem. Radiant glass and ceramic are also available and are tolerable to many individuals. High temperature wires appear to be the most offensive form of electric heat (Table 6). Solar heat, when available directly, seems to be acceptable.

Table 6

Heat: Double-blind Challenge, One to 24-Hour Exposure

 

 

Electric

Patient
Gas
Steel with Motor
Steel without Motor
Copper & Aluminum
Steel with Glass
1
+
+
+
+
0
2
+
+
+
+
0
3
+
+
+
+
+
4
+
+
+
+
+
5
+
0
0
+
+
6
+
+
0
+
+
7
+
0
0
+
+
8
+
+
+
0
+
9
+
+
+
0
+
10
+
+
+
+
+

  Bedding and draperies were cotton, linen, and/or silk. No synthetics were allowed. Air depollution devices are used intermittently to eliminate outside pollutants. Unfortunately, this equipment cannot be left running at all times because many patients are sensitive to the substances that emanate from the units. Materials in these devices should be inert, preferably of metal or stone. Electronic filters are not advisable unless other filters are used distally toward the room. They should be designed to remove the ozone and phosgene which are produced by the electronic filters. HEPA filters seem to be the most toxic of the high efficiency filters, apparently because of the glues that are used to hold the paper together.

Currently, we use sequences of filtration, e.g., cotton or fiberglass as a prefilter followed by aluminum oxide impregnated with potassium permanganate. Then, a loose charcoal filter is used as the final pathway. These filters should all be enclosed in metal cages. Many patients have become sensitive to charcoal from its pure coconut or bituminous coal origin. Ideally, cotton, marbles, and dechlorinated water should be used to remove the charcoal particles.

Basically, rooms can be constructed from any inert material. However, only four or five are easily available:

1. Plaster board is the most common type found in houses and was originally quite satisfactory. However, in recent years it has become contaminated with acronitrile and formaldehyde and continuously outgasses these substances. This has proved troublesome to many individuals.

2. Aluminum wallpaper, which is readily available, is a rather inert covering. It stops the outgassing of formaldehyde and other synthetics, but has the disadvantage of not being acceptable to individuals who are sensitive to aluminum. Approximately one in 50 patients in our Unit cannot tolerate this type of room.

3. Plaster appears satisfactory if it does not have a Aquick-dry@ substance in it. However, it is porous and absorbs and retains odors longer than other materials.

4. Ceramic tile rooms are very satisfactory, but a few patients react to fumes emanating from the grout. Although the number of individuals who react is small, it nevertheless may pose a problem.

5. Porcelain steel appears to be the ideal material for the chemically sensitive individual. Because this is essentially glazed stone, there are few particles or foreign matter released from it. This type of room has been proven the safest for the most severe chemically sensitive patients.

Air in the rooms is assessed by several parameters. The first is whether patients= symptoms are cleared in the rooms; and, second, whether their abnormal laboratory tests return to control level without medication. The third parameter is direct analysis obtained by using gas chromatography and mass spectrometry. Unfortunately, not all parameters are yet easily available for air analysis. It is important to stress the measurement of organics such as aldehydes, pesticides, phenols, benzenes, and the like. Particulate counts, barometric pressure, and relative humidity are constantly monitored.

FoodCSince there are now large amounts of additives, preservatives, pesticides, and herbicides in commercial food, testing must be done with chemically less contaminated foods. In our center, an organization had to be started to foster the acquisition of such food. Farmers were contracted to grow the food in a safe manner. No herbicides, pesticides, or artificial fertilizers are used in growing this food. Food must be stored in uncoated cellophane and glass in order to prevent contamination. Cooperatives are necessary in order to have available safe food and also to monitor the food to insure a chemically less contaminated form. We have seen several examples of contaminated food found by this method. At one time many individuals began reacting to pork. The individuals knew they should have no reaction to pork and that, therefore, the meat must be contaminated. The farmer who supplied the pork informed us that he had acquired six-week-old pigs from another farmer and placed them on the usual feeding regime. Apparently, the gestation time and first six weeks= feeding on chemically contaminated food was enough to contaminate these pigs severely. A second example was when many individuals reacted to cantaloupe from a recent lot. Chemical analysis showed the presence of two parts per billion of dieldrin and chlordane. By using such a network of analysis, one can constantly monitor and help to prevent food contamination.

Food for testing must be cooked in iron, steel, or glass cookware in water normally used by the patient in order to prevent further contamination.

WaterCIt has become evident that many individuals are increasingly sensitive to water. Recent studies show that most of our largest cities have severely chemically contaminated water supplies. We are now at the point of chemical contamination in water where we were 75 years ago with bacteria before the onset of chlorination. Little is recognized of the potential harmful effects of the chemical contamination of the water supply by the average layman or physician. In the Environmental Unit, acute cause and effect for water contaminants can be ascertained in approximately two days. Double-blind studies using tap, charcoal-filtered, and numerous spring and distilled waters have revealed approximately 90% of the chemically sensitive patients to be intolerant of tap water. Some patients are very sensitive to distilled water, while others may be sensitive to many of the spring waters. Spring water appears to be the best of the alternate waters, a finding which correlates well with Randolph=s studies. In an office practice, use of spring water in glass bottles is practical in working out patients= problems.