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Sinusitis FAQ

by Reid Goldsborough

Editor's Note: This author, Reid Goldsborough, a medical writer, has done a superb job on explaining sinusitis. He emphasizes that much can be done to prevent sinusitis from occurring and recommends a number of remedial actions before resorting to antibiotics. Several of them include using healthy home products such air purifiers, dust mite covers and HEPA vacuums, which we not only offer on AllergyBuyersClub.com but provide full ratings, reviews and test results to help you choose the best for your condition.

Q. Introduction.
A.

Let's face it. Sinus problems are a pain in the ... nose. Sinusitis feels like a cold that never goes away. It often hurts, sometimes a lot. It reduces your energy level. It can cause mental fog. It interferes with sleep. It can dull your senses of smell and taste, make you hoarse, and give you bad breath. It costs time and money in trying to manage it.

On the other hand, for most people, sinusitis is manageable. After discovering the techniques that work for them, many people report a considerably improved quality of life.

This is an FAQ, or Frequently Asked Questions archive, that's designed to provide core information about sinusitis. It's based in part on information gleaned from the Usenet newsgroup (discussion group) alt.support.sinusitis; in part on research using medical journal articles, books, popular magazine articles, and Web sites; and in part on the author's own experiences. This FAQ is targeted to sinusitis patients, its intent being to help them improve their health.

This an attempt at a balanced, middle-ground approach, not too far toward the "antibiotics and surgery" leanings of traditional medicine, not too far toward the "it works for me/anything goes" leanings of alternative medicine.

Q. What Is Sinusitis?
A.

Sinusitis is an inflammation of the sinuses, usually caused by a bacterial infection. It's considered acute if it's short-lived and chronic if it's long-lasting -- longer than three months, according to most doctors. Chronic sinusitis is sometimes also defined as four or more occurrences of acute sinusitis in a year. Chronic sinusitis presents the same kinds of symptoms as acute sinusitis though they may not be as severe.

Acute sinusitis is often preceded by a cold, flu, or allergy attack, which inflames the sinus membranes and blocks the sinuses' drainage openings (ostia). Mucus collects, providing a breeding ground for bacteria.

Chronic sinusitis is often preceded by too many cases of acute sinusitis, which cause the ostia to swell shut permanently and bacteria to grow continuously. Chronic sinusitis may also accompany other structural changes in the sinuses, including thickened and stagnant mucus, a paralysis of the tiny hairs (cilia) that are designed to sweep mucus, bacteria, allergens, and other foreign matter out of the sinuses, nasal polyps (growths), and swollen nasal turbinates (areas inside the nose that warm and moisten inhaled air). Sometimes chronic sinusitis may not involve an infection at all but chronic inflammation, a blockage of the ostia, a buildup of mucus, and sinus pressure and pain. In a small percentage of chronic sinusitis cases, the cause is immunological deficiency, as determined by a blood test.

Sinusitis is more common than many other better-known health problems, such as hypertension and arthritis. It affects 15 percent of people each year, according to the American Academy of Otolaryngology. Some experts believe that sinusitis is increasing in frequency as a result of air pollution and exposure to colds and flu from daycare centers. Other experts feel that sinusitis is only apparently increasing in frequency as a result of better diagnostic techniques. And some experts feel that sinusitis is overdiagnosed, that only about half of patients who see doctors for symptoms of sinusitis actually have the condition. According to one statistic, more than 85 percent of people with colds have inflamed sinuses, though unlike with true sinusitis, symptoms are typically brief and mild. Between 0.5 and 5 percent of people with colds develop true sinusitis.

Q. Diagnosis.
A.

The symptoms of sinusitis are often similar to those of colds or allergies, which can make diagnosis tricky. Sinusitis, however, is more often accompanied by facial pressure or pain, particularly when bending over, thick yellow or green mucus rather than clear or whitish mucus, and post-nasal drip, particularly at night, leading to a sore throat. Also, acute sinusitis typically lasts longer than the 7 to 10 days of a common cold.

Yellow mucus is a possible indicator of a bacterial sinus infection but not a definitive one. Mucus can turn yellow as a result of sinus inflammation without infection or as a result of mucus drying out.

Doctors also look for swelling, tenderness, and redness of the skin over the cheekbones (these symptoms are usually worse in the morning). They may use transillumination by shining a bright light in a darkened room against the cheek or forehead, looking for blockages. They may look at the sinuses directly with a flexible tube inserted into the nose called an endoscope.

For chronic sinusitis doctors often order a CT scan (computerized tomography, sometimes written as CAT scan and pronounced "cat scan"), which is a specialized X-ray technique. CT scans are more accurate in diagnosing sinusitis than conventional X-rays (plain film radiography) or MRI (magnetic resonance imaging), but reports indicate that they still have a false negative rate of 5 to 10 percent, meaning they don't identify sinusitis in a small percentage of cases.

Some patients have reported that neither an endoscope nor a CT scan identified their sinusitis as the infection was in the bone and required nuclear bone imaging, also called a bone scan, for a proper diagnosis.

It's important that sinusitis be diagnosed and treated because, if not treated, it often just gets worse. Acute sinusitis should be treated no later than two to three weeks after symptoms appear. If not treated acute sinusitis can structurally damage the sinuses and turn into chronic sinusitis, which is more difficult to treat and may require surgery.

Sinusitis can clear up on its own (60 to 70 percent of patients recover from acute sinusitis without need for an antibiotic, according to the American Academy of Allergy, Asthma and Immunology), but in rare cases untreated sinusitis can lead to other more serious health conditions involving the eyes, the bones of the face, and the brain, including osteomyelitis and meningitis.

Treating sinusitis is as much art as science. While there is common ground, each person with sinusitis is different. What works for me may not work for you.

Sinusitis can be treated by general or family practitioners, or by specialists, who are popularly called ENTs (ear, nose, and throat specialists) and more formally called otolaryngologists (pronounced OH-toe-lair-ing-GOLL-e-gists) or otorhinolaryngologists (pronounced OH-toe-RIE-no-lair-ing-GOLL-e-gists).

Some ENTs are better than others in treating patients as individuals, keeping up on the latest clinical research, and being receptive to viable alternative remedies. Unfortunately, many ENTs are surgery specialists and know little about the other aspects of sinusitis care. Medical school forces students to spend a disproportionate amount of time learning about esoteric diseases, compromising the ability of general practitioners and even ENTs to treat common conditions such as sinusitis.

Ultimately, you should take control of your own healthcare.

Q. A Healthy Immune System.
A.

The best thing you can do for your sinus health is get your whole self healthier. Gravitate toward a healthier lifestyle and a cleaner environment to bolster, or rebalance, your immune system.

Much of sinusitis has to do with the failure of the immune system to deal effectively with stressors that bombard everybody's sinuses every day -- air pollutants, smoke, dust and dust mites, molds and mildew, pet dander, pollen, viruses, bacteria, and fungi. One of the functions of the sinuses is to help filter out this stuff before it reaches the lungs.

Sinuses, however, can overreact or underreact. Overreacting creates an excessive immune system response, which leads to allergies. Underreacting, by failing to sweep invaders out, leads to infections. With both allergies and infections, excessive mucus production and inflammation results, which can block the ostia, leading to or prolonging infection.

There are no quick fixes in rebalancing the immune system. Eat a variety of veggies and fruit (high in phytonutrients, which you don't get from typical multivitamin pills) -- strive for five servings of veggies and fruit a day -- ten is even better. Eat less, or no, refined sugar (aside from its immune system effects, sugar can also prolong sinusitis if you have the type that's caused by the fungus candida). Cut down on fat, particularly saturated fat and transfat, and refined carbohydrates such as white bread. Try eliminating dairy to see if it reduces mucus production (some experts feel dairy has no effect on mucus production in the sinuses). Eat less in general -- habitual overeating taxes the immune system, while moderation plus an occasional feast and occasional fast can help you live longer. Drink a lot of water. Exercise intelligently -- moderate exercise bolsters the immune system, while killer workouts can depress it, bringing on allergy attacks or sinus infections (it's best to rest, avoiding strenuous exercise, during an acute sinusitis attack). Stop smoking and avoid secondhand smoke (which like smoking can paralyze the cilia). Manage stress with meditation or relaxation exercises. Get enough sleep. Strive to be happy.

Some people take megavitamins such as vitamin C, herbs such as echinacea and astragalus, and foods such as shiitake mushrooms and raw garlic to try to strengthen their immune system. Most doctors and nutritionists say a balanced diet and other measures are more effective, though some people report positive experiences with supplements, herbs, and specific foods.

Q. Allergies.
A.

Various medical journals have reported that chronic sinusitis is associated with allergies in 40 to 80 percent of adults. Although some doctors feel these figures are too high, if you have chronic sinusitis or frequent bouts of acute sinusitis, it makes sense to get tested for allergies (allergy skin testing). Allergists are medical doctors, sometimes called immunologists, who often employ immunotherapy (allergy shots), which desensitizes you to the offending allergen or allergens. Allergy shots work best in highly allergic people, they work only on certain allergens, and they require a considerable time commitment.

Even if you're not formally allergic, common allergens can be sinus irritants. You can employ environmental control to see if this eases your symptoms. Cut down on dust (and dust mites) in your living quarters, particularly your bedroom. Dust frequently, encase pillows and mattresses in dust covers, wash blankets in hot water every week or two, keep pets out of the bedroom, and use high-quality furnace filters if you have a hot-air furnace. You might also consider buying an air purifier (avoid ozone cleaners and negative ion generators) and either investing in a HEPA (high-efficiency particulate arresting) vacuum cleaner or getting rid of rugs entirely. Clean well and frequently to help prevent cockroaches and mold. Keep humidity levels below 50 percent to discourage mold, mildew, and dust-mite growth -- use a dehumidifier if necessary. When working around dust or fumes, wear an appropriate mask.

Doctors don't agree on the role that food allergies play in sinusitis, since they typically affect the skin or the gastrointestinal tract. You can experiment yourself by eliminating one or more of the most common sources of food allergens -- wheat, eggs, nuts, soy, fish, shellfish, dairy, and chocolate. Allergists often recommend an elimination diet -- you eliminate many foods and reintroduce one at a time, noting if symptoms worsen. An easier technique is to avoid one food for a week, then eat lots of it, noting any increase in symptoms.

Q. Irrigation.
A.

The single most effective self-help measure you can take to prevent or treat sinusitis is to wash your sinuses daily with salt water. Sinus washing, commonly called sinus irrigation and medically called sinus lavage (and sometimes called nasal washing or nasal douching), is an age-old practice. Historically, it's been used more in the East than in Western societies, though this is changing as irrigation is increasingly being recognized by doctors and in medical literature for its health benefits. Some general practitioners and ENTS, however, still have little knowledge of sinus irrigation or regard it as unproven folk medicine, and they don't mention it to their patients.

What irrigating with saline (salt) solution does is help your sinuses do what they're supposed to do themselves -- flush away cold viruses, bacteria, allergens, and fungi. If you have chronic sinusitis, your sinuses have lost some or all of their ability to filter out these invaders. Irrigation is compensation for this.

Irrigation Techniques

There are a range of irrigation methods to choose from, some more effective than others. Least effective is splashing water up your nose at the sink or in the shower and sniffing it in. Plain tap water stings -- the same feeling as getting water up your nose when swimming.

More effective is a bulb irrigator, also called an ear syringe, used with salt water. Its chief benefits are that it's inexpensive, easily available, and easily transportable. Ear syringes are available in most pharmacies.

Next up the effectiveness ladder is the neti pot, which looks a bit like a small watering can. It's easier to use than an ear syringe -- you're less likely to splash or leak water over yourself -- and it's easier to regulate the flow of saline.

The most effective technique is pulsatile (pulsating) irrigation. When liquid pulsates, it does a better job of cleaning -- it digs out the dirt. In the sinuses, pulsation is also thought to stimulate the action of the cilia, part of the sinuses' natural defenses, and to remove IgE, a gamma globulin that plays a key role in allergic reactions. Irrigation also pulls out mucus that the saline doesn't reach directly through vacuum action.

There are a number of pulsatile nasal irrigation devices available. The most popular pulsatile irrigation device is the Grossan Hydro-Pulse Sinus Nasal Irrigator invented by Dr. Murray Grossan, which like similar devices, is an attachment that's used with a Teledyne Water Pik to slow the pulsation to a level appropriate for the sinuses.

We sell the Hydro-Pulse Sinus Nasal Irrigator and we offer two free gifts with purchase! Or you can save money and buy a Personal Water Pik at your local pharmacy, rather than a Professional Water Pik, without losing any sinus functionality.

The most common way to irrigate is to bend over the sink and tilt your head to the side to help the irrigation solution drain out. You place the irrigation tip in the upper nostril and let the irrigation solution drain out of the lower nostril. However, if you find this clogs up your ears, hold your head straight, without tilting it. If you want to help the irrigation solution reach further into the frontal sinuses, bend over further, tilting your head downward. You can also experiment tilting your head further to the side to allow the irrigation solution to reach sinus tissue it wouldn't reach otherwise.

Immediately after irrigating, with the irrigation solution still in your sinuses, you can optionally tilt your head back to force it into other sinus cavities. Just clinch your nose shut with your fingers as you remove the irrigation tip.

Many people warm the saline before irrigating, though some people prefer cooler temperatures. Warming it helps it break up mucus, encourages blood flow to the area, and usually just feels better. Anywhere near body temperature is ideal. One technique for warming saline is to simply place the water or solution in a glass and put it in a microwave oven for a minute.

It's recommended that you irrigate your sinuses two times a day when you're experiencing sinus or allergy symptoms or if you have a cold, or three times a day if you're producing a lot of mucus. If you have chronic sinusitis with only mild symptoms, you should irrigate once a day. If you're trying to prevent a cold or allergy flare-up during cold or allergy season, you can irrigate once a day. If you have no symptoms, you typically don't need to irrigate, though some people irrigate anywhere from every other day to once a week as preventive medicine. Over-irrigating can compromise the sinuses' disease-fighting capabilities -- it removes from the sinuses the enzyme lysozyme, which kills bacteria.

Keeping the Water Pik and Grossan Irrigator clean helps keep common household dirt and other contaminants out of your sinuses, where they do no good. After irrigating, run filtered or tap water through the irrigator, and rinse off the Water Pik basin and Grossan tip using warm tap. Place a small sheet of aluminum foil over the basin between irrigations. Some people advocate running a small amount of diluted chlorine bleach or hydrogen peroxide solution through the irrigator every week or so. This is especially good practice if you haven't used the irrigator in a while and are about to do so.

Saline Nose Spray

Many people use saline nose spray, though its benefits are more from moisturizing rather than irrigating. Some people are sensitive to the preservatives used in commercial saline sprays -- their sinuses become irritated. These preservatives can also slow down the functioning of the cilia, also compromising the sinuses' disease-fighting capabilities. Be particularly wary of any product for the sinuses that's preserved with benzalkonium chloride. A number of recent studies have shown that it can damage the cilia and lead to mucosal swelling, the exact opposite of the effect you want.

If you frequently use saline nose spray, mixing a batch of home-made saline solution is safer than buying a commercial brand nose spray in a pharmacy or supermarket. To prevent infected mucus from being sucked into the spray bottle, remove the bottle from your nose before releasing the sides of the bottle. To further reduce the chance of contamination, it's good practice to throw the saline out and mix another batch once a week.

Saline Solution

There are a number of ways of obtaining saline solution for irrigation. First, you can mix it yourself. The optimal salinity is obtained by adding one level teaspoon of salt to a U.S. pint of water (a U.S. pint is 16 ounces or 0.47 liter). Alternately, you can add one-quarter teaspoon of salt to 4 ounces (0.12 liter) of water. This creates an isotonic solution -- same salinity as human blood and other body fluids. Some people prefer a saltier (hypertonic) solution, up to two teaspoons of salt to a pint of water, which can pull moisture out of the sinuses and help shrink swollen mucous membranes. In some people, however, hypertonic saline solution can impair the cilia and dry out the sinuses, compromising their disease-fighting ability.

It's best to use canning, pickling, or kosher salt rather than table salt or sea salt, as they contain fewer impurities, and to use filtered or distilled water for the same reason. You can obtain canning, pickling, or kosher salt in some supermarkets and health food stores. Some people do fine, though, with tap water and table salt.

Some people find that saline solution itself burns from its slight acidity. You can neutralize this by adding a pinch of baking soda (sodium bicarbonate) to the saline. Saline solutions with baking soda are usually referred to as buffered solutions.

The latest development in saline solution for sinus irrigation is the use of Ringer's solution, which has been used intravenously for many years. Along with sodium chloride (salt) and sodium bicarbonate (baking soda), Ringer's solution also contains potassium chloride and calcium chloride. One new study (Boek WM. Laryngoscope, 109(3):396-9 1999 Mar) has shown that salty (hypertonic) saline solution can completely paralyze the cilia and that even isotonic solution can slow cilia down, which is the exact opposite of what irrigation is supposed to do. The study also showed, however, that adding potassium chloride and calcium chloride can prevent the cilia from slowing. The theory is that the addition of these ingredients allows the irrigation solution to approximate not only the salinity of blood and tissue, but also the their complete electrolyte composition.

We sell the Grossan Breathe Ease Nasal Moisturizer soultion which was developed based on Ringer's solution. It's convenient but somewhat expensive, costing $29.95 for 66 pre-measured packets.

Irrigation Additives

Some people are experimenting with, and some ENTs are recommending, other additives you can include with the saline solution when irrigating. You need to be careful, though, because small amounts of these additives are absorbed into the bloodstream through the sinuses' mucous membranes and there's a possibility of swallowing the solution when irrigating.

Two irrigation additives that are commonly used are Alkalol and Betadine. Alkalol is an old-time, traditional remedy that can be found or ordered from pharmacies for about $3 a bottle. It's a solution of eucalyptus oil, pine needle extract, other plant oils and extracts, and a tiny amount of alcohol, ingredients that together are thought to act as a mucus solvent. Some people find it soothing, others stimulating, others irritating. It's better to start with a small amount rather than the 50/50 ratio of Alkalol to saline indicated in the Alkalol directions.

Betadine (and its generic equivalents) is an iodine-based antiseptic used primarily on superficial skin wounds, though some doctors recommend it to help kill off the pathogens that cause sinus infections. It's best to use only a small amount -- from a few drops to a teaspoon -- to avoid potential harm to the thyroid or the kidneys. One technique is to first irrigate with Betadine and immediately afterward to irrigate again without it to wash it away. Some people are allergic to iodine and should avoid Betadine altogether.

Some people are experimenting with other irrigation additives, including tea tree oil (Melaleuca alternifolia), available at health food stores and used for many years in Australia, where it originates. It's described as a germicide, fungicide, and antiseptic, and it's usually used for superficial skin wounds, vaginal candidiasis, foot fungus, and acne. It's very strong, so you need to dilute it -- one study found a 2 percent solution effective. Some people are allergic to the byproducts created when it breaks down (photooxidizes). Some doctors advise against using it or any oil-based product in the sinuses, since any product in the sinuses can wind up in the lungs, and oil, Vaseline, etc., in the lungs can cause pneumonia.

Some ENTs are experimenting with antibiotics such as Bactroban and Gentamycin as irrigation additives. Ask your ENT about this.

Decongesting

If you're clogged, you need to open up your sinuses before irrigating. Techniques include using a steam inhaler, taking a hot shower, applying a hot compress to your nose and cheeks, dabbing eucalyptus oil on the outside of your nose, drinking hot tea and lots of liquids in general, eating hot chicken broth with garlic, and using an oral or spray decongestant medication. Some people find that spicy foods (seasoned with garlic, cayenne pepper, ginger, wasabi, etc.) help open up their sinuses, while others find them sinus irritants.

Some people use a vaporizer or humidifier at night to decongest, though you need to keep it clean as well as keep the humidity in the room from rising above 50 percent to prevent mold and dust-mite growth.

Risks

Daily saline irrigation of the sinuses when done correctly is thought to be no more risky than daily hand washing. Problems can arise, however, if you do it incorrectly. Use too much salt and you can dry out your sinuses and impair the cilia. Use too little salt and you can increase swelling. Use too much baking soda and you may be left with an ammonia odor. Use water that's too hot or too cold and you can increase swelling. Use a Water Pik without an attachment, set the attachment too high, or use a bulb irrigator and squeeze too hard or when your clogged, and you can spread infection to other parts of your sinuses or to your ears. Irrigate too frequently and you may promote infection by removing from your sinuses the enzyme lysozyme, which acts as a natural defense against bacteria.

You can also damage your sinuses and spread infection by blowing your nose too hard. Some doctors in fact feel this is the most common cause of chronic sinusitis. In response, some people have advocated not blowing at all, just swallowing or spitting out mucus, but most doctors find this an extreme precaution (and swallowing too much mucus can cause nausea and potentially other gastrointestinal problems). When blowing, just be gentle. Many people find that unscented white tissues that contain lotion, such as Puffs Plus With Lotion, are best, as they prevent the outside of the nose from getting irritated.

After irrigating, you'll have to blow your nose to rid your sinuses of saline (and remaining mucus), preventing the saline from leaking or rushing out later, often without warning. The most effective technique has been called the "whale blow." Standing up, bend over with your head down for 20 to 30 seconds. Alternately, you can lie down on a bed and hang your head over the side. Have a paper towel or tissue in hand. Slowly rotate your head, moving one nostril upward while keeping the other nostril closed. When your nostril is as high as it will go (like a whale's blow hole breaking through the surface of the ocean), blow gently. Then do the same for the other nostril.

Optionally, you can then lie on your back, which can force any remaining saline and mucus to slide down your throat -- it's always best to spit this stuff out rather than swallow it. Sniff in, though not too hard. This can be a very effective way to complete the process of cleaning out your sinuses.

Nasal Massage

After irrigating, or anytime your sinuses feel inflamed, you can gently massage the sides of your nose and your cheeks to sooth the area, reduce swelling, and encourage blood flow to the sinuses.

Q. Drugs.
A.

Both over-the-counter and prescription drugs can be beneficial to sinus patients, but they're often relied on too heavily. Drugs invariably have side effects, and which can sometimes cause problems as bad as the original sinus infection.

Antibiotics

Broad-spectrum antibiotics are the drug of choice of many ENTs, and they're usually effective in killing the bacteria that cause acute sinusitis, typically Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis (Staphylococcus aureus, Peptostreptococcus, Fusobacterium, and Prevotella may also be found in chronic sinusitis).

Sinus infections usually require a longer course of treatment with antibiotics than other infections, often two weeks and sometimes up to eight weeks, as it's difficult for systemic drugs to penetrate into the sinuses because of the relatively poor blood flow there. Some doctors even administer intravenous antibiotics in difficult cases.

Make sure you take all of the antibiotics prescribed to avoid a situation where some infection remains without your awareness and grows back resistant to the original antibiotic, requiring a new and stronger antibiotic, one with a greater risk of side effects. Some doctors recommend continuing antibiotics for one week after symptoms disappear and the mucus has turned clear.

It's best to avoid taking antibiotics for extended periods of time. One approach to avoid this is to gauge the effectiveness of whatever antibiotic you're taking. If you don't notice a significant improvement after four or five days, the antibiotic you're on may not be effective against the bacteria you're infected with. Ask your doctor to switch you to another antibiotic.

The more sinusitis attacks you have, the less effective antibiotics are, and they're often not effective at all for chronic sinusitis. Some people wind up taking antibiotics for long periods of time, which is risky. Long-term use promotes the growth of both resistant strains of bacteria and the fungus candida (Candida albicans), and it can lead to gastrointestinal problems such as cramps, nausea, vomiting, and diarrhea.

The risk of gastrointestinal upset with antibiotics can often be reduced by drinking a full glass of water when taking them and by ingesting "probiotics" such as acidophilus (Lactobacillus acidophilus) and bifidus (Bifidobacterium bifidum) bacteria, found in certain yogurts (check the label) or capsules (health food stores).

Because of their negatives, avoiding antibiotics should be your goal. Too many patients, and doctors, make the mistake of relying too heavily, even exclusively, on antibiotics in treating sinusitis. Unless you also treat the structural defects that typically accompany chronic sinusitis, particularly inactive cilia and blocked ostia, infection will persist or habitually return.

Antibiotics used to treat sinusitis include Augmentin (amoxicillin/clavulanic acid), Ceclor (cefaclor), Ceftin (cefuroxime axetil), LoraBid (loricarbef), Cefzil (cefprozil), Omnicef (cefdinir), Biaxin (clarithromycin), and Zithromax (azithromycin). They're often more effective on sinus infections, particularly recurring sinus infections that may involve resistant strains of bacteria, than older antibiotics such as amoxicillin, ampicillin, tetracycline, and erythromycin, though they cost more. Other antibiotics that are sometimes used to treat sinusitis include Cipro (ciprofloxacin), Levaquin (levofloxacin), Zagam (sparfloxacin), Avelox (moxifloxacin), Tequin (gatifloxacin), Cleocin (clindamycin), Flagyl (metronidazole), Vantin (cefpodoxime), Suprax (cefixime), and Cedax (ceftibuten).

Steroid Nose Sprays

For many people a prescription steroid nasal spray is the most effective medication for managing their sinusitis. It can shrink swollen nasal membranes, reduce mucus secretions, and help prevent or alleviate allergic reactions by reducing the number of histamine-producing mast cells in your sinuses. Steroid nasal sprays can also prevent the ostia from closing up and shrink or prevent polyps, which in some cases eliminates the need for surgery.

Steroid nose sprays are safer to use than a number of other sinus medications. They don't produce the rebound effect of nasal decongestant sprays or the kinds of serious systemic side-effects as prednisone and other oral steroids, as only a small amount of the steroid (cortisone or a cortisone-like drug) is absorbed into the bloodstream.

However, long-term use of steroid nasal sprays, particularly if you use them in quantities greater than recommended, may depress the functioning of the cilia, possibly due to the preservatives used (avoid products made with the preservative benzalkonium chloride). Long-term use may also promote the growth of candida. Occasionally steroid nasal sprays can increase inflammation -- the solution here is often to decrease the dosage or experiment with a different brand. Some doctors recommend aiming the spray away from the septum inside the nose separating the two sides to avoid the potential perforation of it.

For many people the best steroid nasal spray is a new product called Rhinocort Aqua. Older products such as Flonase and Nasonex contain alcohol, which may cause sinus irritation, and the preservative benzalkonium chloride. Newer products such as Nasacort AQ are water based instead of alcohol based but still contain benzalkonium chloride. Rhinocort Aqua contains neither alcohol nor benzalkonium chloride. Some people, however, do well with older steroid nasal sprays and may even prefer them to newer products.

Decongestants

Over-the-counter oral decongestants such as Sudafed (pseudoephedrin) are also commonly used by sinus patients. Decongestants can help relieve nasal congestion, post-nasal drip, and sinus pressure and pain.

As mild central nervous system stimulants, however, decongestants can interfere with sleep and are best taken in the morning. Decongestants may also aggravate high blood pressure, heart and thyroid disease, and glaucoma, if you have these conditions. Also avoid them if you're taking diet pills. In men with enlarged prostates decongestants can make urinating difficult.

Over-the-counter spray decongestants such as Afrin (oxymetazoline) can quickly open up clogged nasal membranes, often within ten minutes. They're less likely than oral decongestants to aggravate blood pressure, overstimulate the nervous system, or cause urinary retention.

Spray decongestants, however, are addicting. If you use them for more than three days or so and then stop, they can leave you more clogged than you were initially, so the temptation is to continue using them. They can also dry up nasal membranes and depress the action of the cilia, which can bring on or aggravate a sinus infection.

Mucolytics

Some sinus patients report positive results with guaifenesin, a mucus thinner (mucolytic) that's found in small doses in the over-the-counter cough medicine Robitussin. The prescription form may be needed for adequately large doses. You need to drink a lot of water when on guaifenesin, as it can cause extreme thirst. (Some doctors feel guaifenesin's mucus-thinning effects are a result of its prompting people to drink voluminous amounts of water, rather than the effects of the drug itself.) Side effects may include nausea and gastrointestinal upset.

Antihistamines

Antihistamines can reduce mucus secretions and sinus swelling. Second-generation prescription oral antihistamines such as Claritin, Allegra, and Zyrtec are better than first-generation over-the-counter antihistamines such as Benadryl in that they don't lead to drowsiness. Spray antihistamines such as the prescription Astelin or the over-the-counter NasalCrom (technically, an "antiallergic" rather than an "antihistamine") are another option.

Antihistamines, however, are best used if it's clear you have allergies and are experiencing allergic symptoms, since they can dry out nasal mucous membranes, thicken mucus secretions, and compromise the cilia, leading to or prolonging infection. To help prevent nasal dryness, you can use saline nose spray throughout the day.

Pain Medications

The over-the-counter painkillers ibuprofen (in Advil and generic versions) and naproxen sodium (in Aleve and generic versions) can be effective in reducing sinus inflammation, swelling, and pain, more so than acetaminophen (in Tylenol and generic versions).

You need to be careful though if you have a tendency to develop polyps, as nonsteroidal antiinflammatory drugs (NSAIDS) such as Advil, Aleve, and aspirin can worsen them in some people.

Q. Alternative Medicine and Candida.
A.

Some people advocate alternatives to science-based Western medicine, often called alternative medicine, sometimes called holistic, integrative, or complementary medicine. There are different schools of alternative medicine, including herbology, naturopathy, homeopathy, acupuncture, chiropractic, reflexology, hypnotherapy, aromatherapy, Reiki, and Ayurvedic.

The biggest achievement of alternative medicine has been forcing Western medicine, including patients, to view disease not as one or more symptoms that need to be treated but as a signal that one or more aspects of the body/mind/soul continuum is out of balance and needs to be rebalanced. The biggest failure has been spreading information about "cures" without credible evidence about efficacy and with rarely any information about safety.

People with health problems are often desperate, willing to give anything a try, and sometimes their desire for a remedy turns into a self-fulfilling prophesy, a phenomenon known as the placebo effect. You think something is going to work, and your positive thinking marshals your body's own natural defenses, independent of any herb or pill. Alternative healers and herb/supplement companies have long exploited this, consciously or not. Problem is, the placebo effect works for only a small percentage of people.

Herb and supplement companies have little incentive to conduct the kinds of efficacy and safety studies required of drug companies, since under the current (U.S.) law they can make or imply all kinds of benefits without having to prove them. Drug companies don't study the efficacy and safety of alternative medicines either, since these substances are in the public domain and aren't likely to produce much profit.

Alternative healers and their patients instead rely on anecdotal reports, which historically have been unreliable. Anecdotal evidence is what doctors for years used as justification for drilling holes in patients' heads to treat headaches and herbalists for years used as justification for using plants such as chaparral and comfrey despite the fact that, as we now know, these herbs can cause liver damage and cancer.

Some people still promote or use nasal sprays and other products containing silver even though it's been shown that silver is toxic. Long-term use can cause irreversible bluish or ashen-gray tinting of the skin, called argyria. The U.S. Food and Drug Administration (FDA) in September 1999 banned over-the-counter medications containing colloidal silver or silver salt, though silver-containing "dietary supplements" are still on the market.

Manufacturers of natural or herbal medications describe their products as dietary supplements to avoid having to fulfill FDA safety requirements. Herbal medications, however, are drugs just like pharmaceuticals, with side effects and drug interactions. But while the side effects and interactions of pharmaceuticals are usually well documented, those of herbs are often unknown.

The alternative medical community often extols the "natural" qualities of its products as benefits. Just because a substance is found whole in nature, however, doesn't make it healthy. There are plenty of deadly poisons in nature. Some alternative medicine promoters contend that their products are better than pharmaceuticals because they don't contain chemicals. The fact is that all substances in nature are made of chemicals. Just because a product is processed and refined in a laboratory or factory doesn't make the chemicals it contains unhealthy.

The theory, or "science," behind some alternative medical practices strains credibility. Homeopathy, for instance, contradicts the known laws of biology, chemistry, and physics. Its premise is that the best "active" ingredient of a medicine is one that produces the same symptoms as the disease. But because this ingredient typically is toxic, it's diluted to such a great extent ("infinitesimally" is the word homeopaths use) that there are no molecules left in virtually all doses. What's left, say homeopaths, is the "energy" from this ingredient. Problem is, according to the laws of physics and as anybody who's ever built a campfire has observed, energy dissipates quickly over time.

On the other hand, just because an alternative remedy hasn't been subjected to multiple double-blind studies doesn't mean it doesn't work. Some people are great enthusiasts of alternative treatments, reporting beneficial results. The best approach may be to combine up-to-date science-based medicine with credible alternatives.

You can also consciously apply the same mind-body mechanism behind the placebo effect. For sinus infections, employ creative visualization by picturing your white blood cells gobbling up rampant bacteria. For allergy flare-ups, employ progressive relaxation by telling your sinuses, with the same kind of soothing voice you'd use to talk to an upset child, to relax, calm down, take it easy, that everything will be all right. These techniques won't hurt, and though they're not foolproof of course, they might help.

Some sinus patients report good experiences thinning mucus and reducing inflammation using papaya and pineapple enzyme tablets, found in health food stores. We sell Clear-ease Natural Fruit Enzyme Tablets another product from Dr. Grossan. Unlike some other products, Clear Ease is made without sugar and will thus not promote tooth decay. It costs a bit more than similar products, at $17.95 per package (60 tablets). To be effective the tablets need to be slowly dissolved between the cheek and gum rather than chewed.

Candida

Many in the alternative health community have long believed that the fungus candida (Candida albicans) causes or contributes to a host of health problems, including sinusitis. The importance of candida, however, has been downplayed by most mainstream doctors. According to conventional medical wisdom, candida and other fungi are primarily a problem in immunocompromised people such as AIDS patients and organ transplantees, those with diabetes or leukemia, or those who've been on extended courses of antibiotics or steroids (which can include chronic sinusitis patients).

A recent article in the Mayo Clinic Proceedings, however, has brought candida more into the mainstream by reporting that the vast majority of sinusitis patients studied by the Mayo Clinic have fungal growth in their sinuses. Some doctors still dispute the importance of candida and other fungi for sinus patients because the criteria the Mayo researchers used for measuring fungal growth were less stringent than is commonly used and because small amounts of fungi are commonly present even in people not suffering from sinusitis or any other health condition.

So the jury is still out. Researchers at the Mayo Clinic are further investigating, including developing possible new treatments.

In the meantime, antifungal drugs such as Sporanox and Amphotericin B are available, though they don't penetrate the sinuses particularly well and frequently have side effects. Also available are antifungal diets, such as the one described in Dr. Ivker's book. It consists primarily of vegetables and non-red-meat sources of protein, eliminating refined sugar, bread and other foods made with yeast, dairy, mushrooms, fried foods, grapes and some other fruit, alcohol, and a number of other foods and drinks. Substances that are thought to have antifungal properties include garlic, the herbs barberry and oregano, and the bacteria Lactobacillus acidophilus, Bifidobacterium bifidum, and Lactobacillus bulgaricus (in some yogurts or available in pill form in health food stores).

Q. Prevention.
A.

If you're prone to sinus infections, it's important to try to avoid colds and treat them effectively when you do catch them. Daily hand washing (including the use of alcohol-based hand sanitizers) and daily sinus washing have been shown to help prevent colds, as does keeping your hands away from your nose, eyes, and mouth. Some people have positive experiences avoiding or treating colds with vitamin C, echinacea, and zinc lozenges (though zinc in larger doses can weaken the immune system).

If you have a cold, you should control sinus inflammation and congestion to try to prevent a sinus infection. Techniques include those described in more detail elsewhere in this document, such as sinus irrigation, gentle (as opposed to forceful) nose blowing, steam inhalation, using a hot compress on the nose and cheeks, nose/cheek massage, drinking lots of liquids, eating hot chicken broth with garlic, avoiding dairy, using a vaporizer at night, using a steroid nasal spray, taking an oral decongestant, taking ibuprofen or naproxen sodium, and taking papaya enzyme tablets.

If you have sinus problems, it's best to avoid air travel when you have a cold, are experiencing an allergy attack, or are suffering from acute sinusitis. Changes in air pressure can potentially cause a vacuum to form in the sinuses, leading to severe pain. Dry cabin air can also dehydrate sinus membranes, leading to or aggravating an infection. Finally, air in airplanes is often high in carbon monoxide and bacterial and fungal contaminants.

If you need to fly, before take-off, you can use a nasal spray decongestant or take an oral decongestant. During the flight you should drink plenty of nonalcoholic beverages (alcohol at any time can cause dehydration and swelling of sinus membranes, and when flying it will just exasperate the effects of dry cabin air). One trick is to bring a water bottle on board with you. You can also use saline nose spray during flight to help keep your sinuses from drying out.

Along with alcohol, antidepressants and antihistamines can dry out the sinuses and exasperate sinusitis symptoms.

Q. Surgery.
A.

If your ostia are permanently swollen shut and you've unsuccessfully tried other methods, sinus surgery may be your best option. Surgery can help return your sinuses to healthy functioning by returning the ostia to their normal size. Without proper drainage, mucus will build and your sinuses will continue to get infected. Sinus surgery can also repair other structural problems with your sinuses, including a deviated septum, polyps, cysts, and swollen nasal turbinates.

Surgery, however, is not a panacea. Even though 80 to 90 percent of patients report improvement after surgery, you still need to deal with the underlying factors that caused your ostia to swell shut in the first place or they may do so again. With some people, prolonged chronic sinusitis causes damage to the sinuses' mucous membranes that's irreversible. Still, surgery and other treatment can greatly ease symptoms and improve the quality of life.

The most common technique today is endoscopic sinus surgery, also called FESS (functional endoscopic sinus surgery). It's considered minor outpatient surgery (you aren't hospitalized overnight) with a low rate of complications -- about 3 percent (primarily bleeding). Unlike earlier techniques, the surgery is done through the nose instead of cutting into the gums or face, so the recovery period usually lasts only several days with patients usually returning to work from four to seven days after surgery. Full recovery takes about four weeks.

The operation itself generally takes one to three hours and may be done under either local or general anesthesia. Local anesthesia is often the better choice, since general anesthesia is riskier, more likely to cause gastrointestinal upset afterward, and typically takes longer to recover from.

Some surgeons routinely pack the sinuses with gauze or other materials after surgery to control bleeding, while others do so only if it's clear that post-surgical bleeding will be a problem. Packing, either while it's in place or as it's being removed, can be uncomfortable or hurt -- it's often the most painful part of sinus surgery.

Endoscopic sinus surgery has largely replaced turbinate surgery, which reduces the size of swollen areas inside the sinuses. Too many patients experienced a worsening of sinus symptoms after turbinate reduction surgery, and most ENTs today feel that the turbinates should be preserved as much as possible.

Choosing A Surgeon

If at all possible, choose an experienced surgeon, as the success of endoscopic sinus surgery is often directly related to the surgeon's experience and skill. Complication rates are higher with surgeons who have completed less than a hundred procedure (Some experts recommend that it's best to go with a surgeon who's performed three hundred or more procedures). More severe complications, though rare, include meningitis, orbital cellulitis, and blindness.

The latest advance in sinus surgery is Image-Guided FESS, which is performed with a computer-imaging surgical device. Image-guided devices are thought to help prevent complications, particularly among patients who previously had sinus surgery or have extreme polypoid disease, advanced tumors, or a distorted anatomy. Among the image-guided surgical devices available are the VTI Insta-Trak, the ISG Viewing Wand, the ISG Infrared Optotrak, and the IGT Flash Point 5000.

Another new technique is Laser FESS, which is promoted as being less traumatic than conventional FESS. Some ENTs feel this is more an advertising gimmick than a genuine improvement and that conventional FESS is more effective.

This FAQ is informational only and should not be regarded as medical advice. The author has worked as a medical writer but is not a medical doctor. If you have symptoms, or if you plan to initiate treatment or undertake a change in treatment as a result of this information, you should consult a doctor. This FAQ is provided as is without any express or implied warranties. While every effort has been taken to ensure the accuracy of this information, the author does not assume responsibility for errors or omissions or for damages resulting from its use.

This information is based on an article by Reid Goldsborough


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