An estimated 50 million Americans suffer from seasonal allergies. Here's what happens when things like grass, pollen, trees and molds affect your body. (Jhaan Elker,Osman Malik and Jorge Ribas/The Washington Post)

For the allergic, spring can be a roller coaster ride as pollen counts dip then spike, sometimes in reaction to fluctuating weather patterns. For the puffy, red-eyed and itchy, this year’s ride has begun.

Pollen counts had been far below normal because of a colder-than-usual February, but they made up for it as temperatures rose, spiking to above-average levels in March, said Susan Kosisky, a microbiologist for the U.S. Army Centralized Extract Laboratory in Silver Spring, Md.

The seasonal trek is especially bumpy for those who have more than allergies — people who often have no idea they have another problem. How do you tell if your allergy-like symptoms are being caused by allergies, another condition or both?

With allergies, the body’s immune system produces excess antibodies that attack what it perceives as invaders. This response causes inflammation and irritation of the eye and/or nose, among other symptoms, said Michael Kletz, an allergist/immunologist whose practice has offices in McLean and Washington.

Jill King, a 38-year-old Gaithersburg resident, had allergies for years. When her symptoms worsened during her pregnancy, she figured it was because she had chosen not to take antihistamines while carrying her child. She improved a little after the baby was born, but by her second pregnancy she had to use an inhaler.

Rhinitis, an inflammation of the nasal lining, can cause runny nose, congestion, decreased sense of smell, headache and facial pressure. (ISTOCKPHOTO)

“I was wheezing, and my whole face felt full,” she said. “It was even worse during my third pregnancy.”

The allergist who later prescribed antihistamines for King noticed a polyp, so it was on to an ear, nose and throat doctor.

“When the ENT examined me, she said, ‘You have polyps throughout your sinus area — they’re everywhere,’ ” recalled King, who was going through half a box of tissues a day and breathing through her mouth.

Two steroids did little to shrink the growths. King bit the bullet and had surgery — a six-hour procedure to remove the clusters of polyps that were completely filling her nasal passages.

“My congestion and the asthma I was diagnosed with disappeared. Now I just do nasal rinse and take Allegra for allergies. My garage is no longer filled with Sam’s Club-size tissue boxes. And I can breathe.”

King’s surgeon, Suzel Hall, sees many patients with persistent nasal and sinus complaints.

“A lot of them tell me they have horrible allergies. This time of year we strongly expect this to be the case, but it is not unusual to find another medical condition,” said Hall, of ENT Specialists of Shady Grove in Rockville, Md.

Figuring out what is driving many allergy-like responses takes some digging. Symptoms may overlap. Sometimes one problem triggers another. And even when a condition besides an allergy is found, the question may remain: Are allergies still part of the equation?

For instance, rhinitis, an inflammation of the nasal lining, can be allergic. But it can also be nonallergic, where patients are sensitive to environmental irritants such as chemical fumes and cigarette smoke. Both types can cause runny nose, congestion, decreased sense of smell, headache and facial pressure.

Rhinitis? Sinusitis?

“We tease out disease states by looking at differences in symptoms. With allergies, patients might have watery eyes and sneezing,” Hall said.

“With sinusitis, there may be fever, facial pain or cloudy nasal drainage. If these symptoms last longer than 10 days, or improve and then worsen in that time, this could suggest something other than allergy, such as sinusitis,” she said, explaining that sinus infections could be secondary to allergic or nonallergic rhinitis. The nasal cavity swells, as do the sinus passages, which open into the cavity. They can’t drain, leading to infection.

Many patients have complaints suggestive of abnormal physical structures, such as persistent congestion on one side of the nose, or congestion following a trauma. So the investigation typically starts with rhinoscopy or a CT scan.

“With rhinoscopy, we place a pencil-size instrument into the nasal passage to view the nasal cavity. It happens in the office in a few minutes,” Hall said. The test may reveal a deviated septum (cartilage that divides the nostrils). Or obstructions caused by bones on the side of the nose or by nasal polyps.

A CT scan of the sinus cavity may uncover abnormalities such as underdeveloped sinuses or blocked sinus openings.

The good news is that surgery typically corrects these anatomical problems. Unless there is allergy, too, it’s usually the end of the back-and-forth trips to the pharmacy and doctors’ offices.

Chronic dry eye, perhaps?

While Jonathan Solomon specializes in eye diseases, he sees so many people who may have allergies that he also tests for them at his offices in Greenbelt, Bowie and Tysons Corner.

More than half of his patients learn they have more than one problem, with chronic dry eye disease sometimes among them.

“Chronic dry eye is an inflammatory disorder where there is less tear production, which diminishes lubrication on the surface of the eye. It can affect anyone but is especially common in older adults, as well as women due to hormonal changes,” Solomon said.

Both chronic dry eye and allergy produce redness and tearing, because the body’s response to irritants, including dryness, is to signal the tear gland to produce fluid to flush the irritant.

Eye doctors pinpoint the diagnosis by looking for anything that can decrease tear production, which may suggest chronic dry eye. This includes autoimmune diseases, cataract surgery or Lasik surgery. Excessive computer use can cause or aggravate dry eye by suppressing the blink reflex.

Patients can have both allergy and dry eye, with one condition exacerbating the other.

“If you don’t have tears to flush the eye of allergens, it can irritate allergies. And some allergy medications dry the eyes,” Solomon explained.

One way to distinguish the two, he said, is that “with dry eye there is typically intermittent blurry vision and light sensitivity. There may be a burning sensation, while with allergies there is itching. And with allergies the eyelid may swell, too.”

But some symptoms that help distinguish between chronic dry eye and allergies could be yet another problem: blepharitis. With this condition, debris or allergens build on eyelids, and glands behind the lashes produce oil and become blocked. The swollen eyelids generally not seen in chronic dry eye but common with allergies also occur with blepharitis, as does the itchiness that often accompanies allergies.

Confirming blepharitis is often as simple as pressing on the eyelid. Oil comes up through a healthy gland, but you see a cheesy expression with blepharitis.

Two tests look for chronic dry eye. In one, which checks for high salt content in tears, an eye doctor touches the inside of the eyelid with a swab to take a sample that is then evaluated. Another looks for inflammatory markers, using test strips to collect and evaluate tears.

Treating the problems

Treatment for chronic dry eye starts with lubricating drops. “If patients use them more than twice a day we usually transition to Restasis, a medication that increases volume and quality of tears that may be reduced by inflammation,” Solomon said.

He suggests that patients with blepharitis or allergy clean their eyelashes with baby shampoo or tea tree oil. And to help reduce eye inflammation of any cause, he recommends probiotics and omega-3 fatty acids such as fish oil.

What to do

Kletz tells people to start with over the-counter antihistamines if symptoms suggest allergies.

“You will know within a few days if nasal sprays are helping, and within about half an hour with eye drops that have antihistamine. Pills should work within a couple of hours,” he said.

If you don’t get relief, visit your doctor to determine if you should see an ENT, ophthalmologist or allergist, he said.

“In the case that it is allergy, allergy shots [immunotherapy] work in 80 percent of patients. But first, avoid irritants. Then try over-the-counter medications. If they don’t work, that is when I would try allergy shots.”

Karidis is a freelance health writer.