Doctors disagree: acid reflux, allergies, sinus, none of the above? (UPDATE post 47)

[LiLIrishChick63]

Your poor son!

When I was younger I had SEVERE sinusitis. The ear, nose, and throat specialist I saw said in all his years he had never seen someone with sinuses as bad as mine.

My GP actually suggested I go see an orthodontist. What we found out was my upper jaw didn't sit correctly and my sinuses were constantly being impacted because of it. I ended up having some retainers and head gear I had to wear for a few years to expand my jaw but it was so worth it! I no longer got those awful sinus infections anymore!

I'm not saying that's what your son has, but sometimes even silly things the doctors recommend can help immensely! Good luck and I hope he is able to find relief!

 

[shortbun]

I would go get some Pepcid A/C complete and give him one before every meal for a couple of weeks. I would also get him a saline nasal rinse bottle(twice a day). They are easier than a neti pot and less likely to put water in an ear. Maybe you'd want to start one and add the next a week later so you can tell which works, if either works. What is he allergic to that you can clean out of his life? Start working on that. The shots didn't work for my son and it was a lot of shots, time and money for no results-especially since yours has the anaphylactic issue. When we went to the ENT, ours said, "no surgery necessary right now." So, some ENTs don't push unecessary surgery. These surgeries almost always have to be repeated unless you can change what's causing the blockage.
Ask more questions, do some of your own problem solving and then make the decision. The coughing after meals does seem to indicate an esophogeal proplem but try the Pepcid-chewable berry flavored is good. You can chew up several a day without a problem. Scoping might be a good idea in case he's got scarring.

 

[LisaR]

IMO, I would try the sinus surgery. I know a lot of people who have had it and it is a very basic and easy surgery.

Has he had his IgE tested? If he has and it's within normal ranges, I'd be inlined to think the symptoms are something other than allergies r at least something in addition to it because *most* people with allergies and normal IgE respond to at least some type of allergy medication.

Has he been tested or eosinophilic gastroenteritis? It's in the same family as EE but much less common. Has he been tested for mastocytosis? If he's had unexplained anaphylactic reactions and GI symptoms, that's a possibility as well. Both are long shots but worth a look.

And as others have mentioned....silent reflux. Have you tried reflux medications? If not, that woud be my first thought.

I have similar symptoms plus a whole host other symptoms that have landed me in the hospital for more than 3 months total over the past 3 years. We are still in the process of diagnosis but my current diagnoses are:

Severe environmental allergies
Severe multiple. Food allergies
Elevated IgE (ranges anywhere from 1200-5000+)
Exercise induced anaphylaxis
Idiopathic anaphylaxis
Possible mastocytosis (were still waiting for confirmation)
Severe asthma
GERD
Eosinophilic gastroenteritis

It has taken 3+ years to get these diagnoses. Its been a ridiculously long process and were still not done (we are probably headed to Mayo clinic sometime this year) so I completely understand the frustration.

Have they mentioned xolair? If he has asthma and allergies and a reasonable IgE, it's an option. It's the medication I need but I'm too sick to qualify because IgE has to be <700.

Getting a second opinion from another allergist or ENT is probably not a bad idea if you aren't satisfied with the current options. Hopefully you find an answer soon.

A lot of the things you mentioned testing for were done, but he was 7 at the time (16 now). I don't know how that works. If he didn't have it at 7 is it something he could develop now?

His IgE is high.

How old is he? My DS15 had a change two years ago as well. I guess we're fortunate this routine works for him - when he uses it. (He's had tons of sneezing, hacking, red eyes and afternoon benadryl naps this summer, too! He obviously didnt do what he was supposed to do!)

It doesn't matter whether it's Claritin or whatever - it's just what works. Just a preventative. I'm surprised an allergist would say it doesn't help, but that's neither here nor there. I think the bigger point is that you just have to keep trying until you find what works for him. Have you considered simply working with your pediatrician on it? They certainly see their share of allergies and asthma!

He is 16. We were working with just his primary doctor until she exhausted all her resources and started sending us to specialists.

Is Allegra, Flonase, and Veramyst all that he's tried?

There are a lot more options for allergy meds. Zyrtec, atarax, Zetonna nasal spray and patanase nasal sray are just a few other options. If your allergist won't prescribe a nasal spray I'd find a different one because that's crazy IMO.

My current regimen is:
Zyrtec, Benadryl, Zetonna spray, patanase spray, and pataday eye drops everyday
I also take Allegra if needed.

If thats all that's been tried for allergy meds I would get a second opinion and try some other meds.

He has been on too many medications to list.

It isn't that the allergist won't prescribe a nasal spray. DS had been using one religiously when he started seeing this new allergist. The allergist said his nose was extremely irritated and it wasn't just from the congestion. He said he recommended stopping the nasal spray because it might be irritating him and making it worse. DS had been using nasal spray religiously for 18 months before stopping at the allergists suggestion. He has only been off of it for 6 weeks. There isn't any difference. None of the nose sprays were working anyway.

 

[LisaR]

I would go get some Pepcid A/C complete and give him one before every meal for a couple of weeks. I would also get him a saline nasal rinse bottle(twice a day). They are easier than a neti pot and less likely to put water in an ear. Maybe you'd want to start one and add the next a week later so you can tell which works, if either works. What is he allergic to that you can clean out of his life? Start working on that. The shots didn't work for my son and it was a lot of shots, time and money for no results-especially since yours has the anaphylactic issue. When we went to the ENT, ours said, "no surgery necessary right now." So, some ENTs don't push unecessary surgery. These surgeries almost always have to be repeated unless you can change what's causing the blockage.
Ask more questions, do some of your own problem solving and then make the decision. The coughing after meals does seem to indicate an esophogeal proplem but try the Pepcid-chewable berry flavored is good. You can chew up several a day without a problem. Scoping might be a good idea in case he's got scarring.

Sorry, I should have mentioned that the allergist put DS on acid reflux meds at that first appointment 6 weeks ago. He also had us raise the head of his bed. DS did the saline wash whenever he had congestion, but the allergist also told him to do it every single day even if he isn't having any problems. DS has done all of that for the past six weeks. At the appointment today, there wasn't any change.

The coughing isn't after every meal. It isn't even daily. But when pinned down to say something about coughing, I did say that I notice that *sometimes* he has a cough after eating, but it goes away within five minutes.

Trust me, I am reading everything I can about it and asking anyone and everyone who will listen. I don't want him to have unnecessary surgery or unnecessary scoping. I want to make the right decision, but it sucks when the doctors completely disagree.

I am thinking of making an appointment with his regular doctor to get her opinion. Of course, she is the one who sent us to the specialists because she had run out of ideas and wasn't able to help him.

Maybe I should just go to another ENT and make sure s/he feels surgery is necessary before taking that step. The earliest I can get him into the gastroenterologist is the end of Sept. He is scheduled for the sinus surgery on Sept. 12th.

 

[disfan07]

A lot of the things you mentioned testing for were done, but he was 7 at the time (16 now). I don't know how that works. If he didn't have it at 7 is it something he could develop now?

His IgE is high.



He is 16. We were working with just his primary doctor until she exhausted all her resources and started sending us to specialists.



He has been on too many medications to list.

It isn't that the allergist won't prescribe a nasal spray. DS had been using one religiously when he started seeing this new allergist. The allergist said his nose was extremely irritated and it wasn't just from the congestion. He said he recommended stopping the nasal spray because it might be irritating him and making it worse. DS had been using nasal spray religiously for 18 months before stopping at the allergists suggestion. He has only been off of it for 6 weeks. There isn't any difference. None of the nose sprays were working anyway.

It might be worth trying patanase. It is different than things like Flonase and Veramyst. It is not as irritating and is not nasal steroids like the others.

And it might be worth retesting for other things because things change with age.

And have they specifically addressed the elevated IgE? If its very high, there can be other causes of it beside allergic conditions

 

[mrsklamc]

They had you raise the foot of the bed? I am having heartburn right now b/c of pregnancy and they suggested raising the head.

 

[LisaR]

They had you raise the foot of the bed? I am having heartburn right now b/c of pregnancy and they suggested raising the head.

Oops! HEAD of the bed! That was a typo on my part.

 

[LisaR]

It might be worth trying patanase. It is different than things like Flonase and Veramyst. It is not as irritating and is not nasal steroids like the others.

And it might be worth retesting for other things because things change with age.

And have they specifically addressed the elevated IgE? If its very high, there can be other causes of it beside allergic conditions

His IgE is 444.

 

[disfan07]

His IgE is 444.

That's not too bad. It's high but only about 150 over the high end of normal. At that number it probably is high because of an allergic process.

I know this will sound strange but Has he ever been tested for parasites? An elevated IgE can indicate a parasitic infection and in turn produce allergy-like symptoms because of an elevated IgE.

 

[HeatherC]

I am so sorry your son is dealing with this. I have a 16 year old DD with terrible allergies....did the shot thing too and spent today at the doctor for a cough.

If you think it could be food allergies, there is a place in TX called Enterolabs that can do testing to see what the sensitivities are. Itis a simple stool test. May be quicker and easier than doing all this testing and trying so many medications that I know can go on for years.

Just thought I would mention it since I know food allergies can manifest any number of ways.

Best of luck to you and I hope you get answers soon.

 

[LisaR]

Thanks for all the great feedback and well wishes. I greatly appreciate it! I have an update and a question.

LITTLE UPDATE:
When I made the gastroenterologist appointment yesterday, they didn't have anything until the end of September. I explained how DS was scheduled for sinus surgery on the 12th and I was hoping to get into the gastro before then. The girl just called back and they had a cancellation for this Tuesday.

QUESTION:
For those of you who have said you had the nasal issues as part of acid reflux, was it nonstop or did it come and go? One thing I find weird with DS is how much the nasal problems seem to flare up. He will be perfectly fine and then out of the blue he looks to be having a major allergy reaction. He has uncontrollable sneezing and blowing and his face gets really puffy. A day or two later (and sometimes only a few hours later) he looks and sounds like nothing happened. Just wondering if that would be "typical" of the nasal problems associated with GERD?

 

[disfan07]

Reflux can cause constant nasal symptoms, voice changes, shortness of breath, cough, hiccups, and heartburn. This is just a basic list. So the nasal symptoms you describe can very well just e reflux.

Regardless of what doctors say, there is no "typical case" of reflux. Everyone I know who has relux all presented a little differently in symptomology.

Based on those symptoms it honestly really could be just sinus and reflux issues.

 

[The Mystery Machine]

Well it is a chicken/egg thing. When you have bad reflux your sinuses go because it is protecting your esophagus.

Go get him scoped for sure. The reason I say this is because since my lightening bolt moment 6 months ago, I realized that you seriously damage your body with reflux.

It is not a "what if" thing to play with. I was thinking of getting off of my Nexium however I had 2 people in my life diagnosed with cancer. It was then I realized that the damage reflux does on your esophagus is very serious.

I see you made an appt. I am glad others chimed in with this.

Yes, my sinus stuff comes and goes and I have allergies. Good Luck!

 

[Snowysmom]

I just found this thread. MY older DS had issues somewhat similar when he was 16. He had the cough, nasal issues, and asthma symptoms. He even had breathing problems to the point where we had to take him to the ER. Then we took him to the ER at Children's Hospital and the ENT doctor diagnosed him with GERD. The doctor put a small scope up his nose into his throat. His trachea was red and swollen from the acid coming up and dripping down to his trachea when he was asleep. He has been on prilosec for years now. He had an endoscopy last year and everything looks good. DS does have allergies too. From the symptoms you describe your DS could certainly have reflux. I am glad you got an appointment with the gastroenterologist before the surgery.

 

[Pea-n-Me]

I re-read your OP and have to say I think I agree with your allergist about the sinus surgery. I definitely sympathize with your son, but I don't feel his symptoms, as you've described, warrant the risks of surgery, and yes, there are always risks with surgery. Sinuses are near the brain and facial nerves, spinal fluid, etc. You make the sinus surgery sound like it's no big deal, and perhaps you were given that impression. But I think you'd be wise to listen to what your allergist is telling you "between the lines". He didn't just drop off the turnip truck and I guarantee he has seen things he is not telling you specifically about; instead he's summing up his experiences by saying he doesn't recommend it. Listen to him! (IMO)

I remember when my DH was in surgery (at Mass and Eye and Ear in Boston) and the surgeon came to the waiting room to update me to say she elected to not touch one area of his sinuses "because it was too close to his brain" and she "didn't want to risk it". I mean, we know these things going into it, but it drives home how serious it it when you hear something like that, or God forbid, if something untoward happens. Hindsight is 20-20. If I did elect surgery, I would make sure I knew every detail about the risks going into it, that the benefit far outweighs the risks, and I'd make sure it was being done by the best person at the best facility, etc.

I know this isn't the exact surgery your son is having, but it is the the typical type of sinus surgery and shares some similarities to the one your son will be having. I was searching for info for you about the risks of sinus surgery, and came across this "brochure" that I thought might be informative to you and help you formulate questions about your son's procedure. http://childrenshospital.org/clinicalservices/Site2149/Documents/SinusSurgery_121608.pdf Also know the ENT may very well recommend some of the meds for him post operatively that you've already had him stop taking, so I'd ask about that, for sure. (And if you don't take them, you become "non-compliant", so follow up may be tricky if he continues to have problems, which many sinus patients do. http://www.kids-ent.com/website/pediatric_ent/sinus_children/index.html )

My gut sense after reading this thread, and because I know you want to get some relief for your son, would be to go back to "Phase 0" with him, as if you're starting all over again. Wipe the slate clean. Find one physican to work with on it, have a heart to heart ahead of time, and start again, knowing what you know now. That is, I would try a PPI, flonase and a decongestant daily, along with other methods to prevent allergens from negatively affecting him, and this will be multi-factorial. I would give it a good month or two or three before deciding it isn't working - maybe longer.

My DS, who is 16 soon, has a good treatment plan that works for him when he follows it. As a typical teen, he doesn't always take his meds until he's in distress. Not a great way to manage things, and as he matures, he sees it. (Not saying this is the case for your son.) I do try to keep his meds on hand and I've put them all in an accessible place for him so there's no excuse for him not to use them. When he has flares and we wind up at the doctor's, we're honest with them about his not taking his meds regularly. He's learning. At any rate, sinus surgery is not even on my radar for him at this point. Again, I know this seems to be different for your son, but just throwing it in there to say, I can relate. I know it's a strong opinion (about the surgery) but I'm assuming you're looking for opinions. Good luck with whatever you decide. It's tough to see our kids not feeling well, even when they get older.

 

[Pea-n-Me]

Sinusitis and GERD http://www.ncbi.nlm.nih.gov/pubmed/12003417

 

[LisaR]

I re-read your OP and have to say I think I agree with your allergist about the sinus surgery. I definitely sympathize with your son, but I don't feel his symptoms, as you've described, warrant the risks of surgery, and yes, there are always risks with surgery. Sinuses are near the brain and facial nerves, spinal fluid, etc. You make the sinus surgery sound like it's no big deal, and perhaps you were given that impression. But I think you'd be wise to listen to what your allergist is telling you "between the lines". He didn't just drop off the turnip truck and I guarantee he has seen things he is not telling you specifically about; instead he's summing up his experiences by saying he doesn't recommend it. Listen to him! (IMO)

I remember when my DH was in surgery (at Mass and Eye and Ear in Boston) and the surgeon came to the waiting room to update me to say she elected to not touch one area of his sinuses "because it was too close to his brain" and she "didn't want to risk it". I mean, we know these things going into it, but it drives home how serious it it when you hear something like that, or God forbid, if something untoward happens. Hindsight is 20-20. If I did elect surgery, I would make sure I knew every detail about the risks going into it, that the benefit far outweighs the risks, and I'd make sure it was being done by the best person at the best facility, etc.

I know this isn't the exact surgery your son is having, but it is the the typical type of sinus surgery and shares some similarities to the one your son will be having. I was searching for info for you about the risks of sinus surgery, and came across this "brochure" that I thought might be informative to you and help you formulate questions about your son's procedure. http://childrenshospital.org/clinicalservices/Site2149/Documents/SinusSurgery_121608.pdf Also know the ENT may very well recommend some of the meds for him post operatively that you've already had him stop taking, so I'd ask about that, for sure. (And if you don't take them, you become "non-compliant", so follow up may be tricky if he continues to have problems, which many sinus patients do. http://www.kids-ent.com/website/pediatric_ent/sinus_children/index.html )

My gut sense after reading this thread, and because I know you want to get some relief for your son, would be to go back to "Phase 0" with him, as if you're starting all over again. Wipe the slate clean. Find one physican to work with on it, have a heart to heart ahead of time, and start again, knowing what you know now. That is, I would try a PPI, flonase and a decongestant daily, along with other methods to prevent allergens from negatively affecting him, and this will be multi-factorial. I would give it a good month or two or three before deciding it isn't working - maybe longer.

My DS, who is 16 soon, has a good treatment plan that works for him when he follows it. As a typical teen, he doesn't always take his meds until he's in distress. Not a great way to manage things, and as he matures, he sees it. (Not saying this is the case for your son.) I do try to keep his meds on hand and I've put them all in an accessible place for him so there's no excuse for him not to use them. When he has flares and we wind up at the doctor's, we're honest with them about his not taking his meds regularly. He's learning. At any rate, sinus surgery is not even on my radar for him at this point. Again, I know this seems to be different for your son, but just throwing it in there to say, I can relate. I know it's a strong opinion (about the surgery) but I'm assuming you're looking for opinions. Good luck with whatever you decide. It's tough to see our kids not feeling well, even when they get older.

I definitely don't think the surgery is a piece of cake. I just meant that compared to years ago, it has come so far that it really is a piece of cake compared to what others had to endure. Personally, I think the best thing anyone can ever do is avoid surgery or procedures. Unfortunately, my son has reached a point where some type of medical intervention is necessary.

Of the four types of doctors we have seen, there is 100% agreement that medication alone won't fix this.

Two doctors (the ENT and an immune specialist) feel sinus surgery is necessary.

Three doctors (general practitioner, immune specialist, and the ENT) do not feel this has anything to do with GERD. All three feel this is directly related to allergies and sinuses.

One doctor (allergist) does not feel any of this has to do with sinuses and has very little to do with allergies. He actually said we could stop the Allegra since it isn't doing any good (he already had us remove the nose spray). When I asked what type of allergy medication he should switch to, he said he really didn't feel it was necessary to take something daily since it is mostly related to GERD.

I am very curious to see what the gastroenterologist says on Tuesday. With our luck she will say it isn't GERD, allergies, or sinuses, but something else that hasn't ever been mentioned before!

 

[Pea-n-Me]

I definitely don't think the surgery is a piece of cake. I just meant that compared to years ago, it has come so far that it really is a piece of cake compared to what others had to endure. Personally, I think the best thing anyone can ever do is avoid surgery or procedures. Unfortunately, my son has reached a point where some type of medical intervention is necessary.

Of the four types of doctors we have seen, there is 100% agreement that medication alone won't fix this.

Two doctors (the ENT and an immune specialist) feel sinus surgery is necessary.

Three doctors (general practitioner, immune specialist, and the ENT) do not feel this has anything to do with GERD. All three feel this is directly related to allergies and sinuses.

One doctor (allergist) does not feel any of this has to do with sinuses and has very little to do with allergies. He actually said we could stop the Allegra since it isn't doing any good (he already had us remove the nose spray). When I asked what type of allergy medication he should switch to, he said he really didn't feel it was necessary to take something daily since it is mostly related to GERD.

I am very curious to see what the gastroenterologist says on Tuesday. With our luck she will say it isn't GERD, allergies, or sinuses, but something else that hasn't ever been mentioned before!

But that's what I mean - sometimes you just have to take matters into your own hands and go by your instincts as a parent. Maybe you are doing that and our instincts are just different, idk. I don't think it's questionable whether there is a link between GERD and sinusitis. There is.

In this small, prospective, open label study, we demonstrated a high prevalence of GERD in patients with CRS, many of whom experienced modest sinus symptom improvement after using omeprazole b.i.d. for 3 months. These findings warrant further randomized, controlled study in a larger patient population.

The question is, what to do about it. Disfan is correct when she says no two cases are ever exactly alike, and I'll add you will only rarely get a group of doctors to agree on things exactly or recommend the exact same treatment plan. I think you might want to take a step back, re=evaluate, start back at Phase 0, and start a new regimen to try. JMO. Oh, and I also wonder about having surgery at the beginning of a school year. What if there are complications and he has to miss a lot of school, or has ongoing issues that take him into winter on antibiotics, etc,?

DS (16) has had problems since he was little (severe allergies, hives, vomiting, unable to gain weight). Thankfully, most of his issues have either resolved or lessened significantly.

About two years or so ago, DS started getting cold like symptoms every single month. His nose pours for days on end and he sneezes like crazy. He has never had a fever with these and none of us have caught it from him.

All the doctors agree that these aren't colds. That is the only thing they agree on.

The allergist feels that DS has GERD or some other stomach issue going on and that is the reason why his nose is in a constant state of stuffiness and he coughs after he eats. He does not and has never had heartburn, nausea, bad breath, or burping. The allergist said the color of his nose and throat are the indicators that it is reflux. He has referred us to a gastroenterologist and feels he should be scoped.

The only thing I know is that my son has sneezing, blowing fits at least monthly, usually more frequently, and it lasts for days. I just want him to have some relief.

It seems to me, in studying your post, that if you take away his issues of the past and the frustration with the doctors, it really boils down to his having a frequent runny, stuffy nose, sneezing and occasional coughing after he eats. I won't say it after this, but I think it does beg the question of whether a potentially risky surgery is worth it for that. (And maybe it is!) Doctors really like to help people who are desperate for a solution. Of course, it's totally up to you, and you very well may have great results and be back here singing its praises. I just don't take procedures lightly because I see every day what can and does go wrong sometimes, so we are just coming from a different perspective. It will be interesting to hear how the GI consult goes.

 

[LisaR]

But that's what I mean - sometimes you just have to take matters into your own hands and go by your instincts as a parent. Maybe you are doing that and our instincts are just different, idk. I don't think it's questionable whether there is a link between GERD and sinusitis. There is.

The question is, what to do about it. Disfan is correct when she says no two cases are ever exactly alike, and I'll add you will only rarely get a group of doctors to agree on things exactly or recommend the exact same treatment plan. I think you might want to take a step back, re=evaluate, start back at Phase 0, and start a new regimen to try. JMO. Oh, and I also wonder about having surgery at the beginning of a school year. What if there are complications and he has to miss a lot of school, or has ongoing issues that take him into winter on antibiotics, etc,?

It seems to me, in studying your post, that if you take away his issues of the past and the frustration with the doctors, it really boils down to his having a frequent runny, stuffy nose, sneezing and occasional coughing after he eats. I won't say it after this, but I think it does beg the question of whether a potentially risky surgery is worth it for that. (And maybe it is!) Doctors really like to help people who are desperate for a solution. Of course, it's totally up to you, and you very well may have great results and be back here singing its praises. I just don't take procedures lightly because I see every day what can and does go wrong sometimes, so we are just coming from a different perspective. It will be interesting to hear how the GI consult goes.

I guess I am not understanding what you mean by starting back at "phase 0 and a new regimen." This has been an ongoing 2 year issue. He has been on multiple nose sprays and allergy meds for a minimum of two months at a time. When they don't work, they try another medication for another period of time and see if there is any difference. He has tried a couple rounds of steroids which work but are far from a long term solution. He has tried long term antibiotics and had the CAT scan again which showed his sinuses were still the same. He has tried neti potting daily without any change. He has been on a six week plus long dose of Prilosec (sp?) for acid reflux and the allergist said there is absolutely zero change in the appearance of this throat. I guess I am not really sure where phase 0 would be? Retry all the medications that have already failed?

At this point one doctor strongly feels it could be GERD. Until researching on the internet, I never knew there was a connection between sinus issues and GERD. I am still skeptical because he doesn't eat any of the common foods associated with reflux and he doesn't have any of the common symptoms. However, I am far from a doctor so I think it makes sense to at least have him checked out. I wouldn't be shocked to hear he has GERD, but I would be shocked if that was his only problem. I think he has a couple different things going on.

As for the timing of it all, well.....I'm pretty sure there is never a good time to have surgery. His problems have caused him to miss activities and work and attend classes when he feels, looks, and sounds like absolute crap. We are looking for a solution. One professional feels it is sinus related and one feels it is GERD. We will talk to a professional on Tuesday about GERD and take it from there. If she doesn't feel it is remotely related to GERD, I will feel very comfortable moving ahead with the sinus surgery. If bells and whistles are going off for her and she is certain this is all reflux related, I will likely follow her advice and postpone the sinus surgery until we see if her methods solve his issues.

 

[Pea-n-Me]

Phaso zero, as I'm using it, means wiping the slate clean and starting over using a different method, i.e. in this case, a different set of medications together. If you have already tried a PPI, a decongestant and a steroid inhaler like flonase, together, at the same time, for months at a time, then I misunderstood you. I took you to mean you have tried them all in various +/- combinations, at different times. (It is very hard to ascertain details here.) There will always be other variables, like age, and season, and many other things, that can affect how medications work, so IMO it's worth a try trying it this way before saying it doesn't work or moving on, but as always, it's up to you.

Any suggestions, things I am overlooking, or opinions on what you would do would be greatly appreciated.

You asked for opinions and suggestions and I'm just giving you mine. It's just how I'd handle it, I think, but there's really no right or wrong way here. I'm going to drop it now so others can chime in, and say good luck, I hope your son gets the relief you seek and I hope maybe something I offered was helpful, somehow.