Sinusitis FAQ
Editor’s Note: Author, Reid Goldsborough, a medical writer, explains 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 all which we offer at AllergyBuyersClub.com.
Introduction
Let’s face it. Sinus problems are a pain in the neck…wait head. 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 our Frequently Asked Questions archive, that’s designed to provide core information about sinusitis. It’s based experience and research using medical journal articles, books, popular magazine articles, and Web sites. 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 trans-illumination 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:
ENTs (ear, nose, and throat specialists) is their popular name and they are 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 under-react. Overreacting creates an excessive immune system response, which leads to allergies. Under-reacting, 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. We sell the SinusPulse Elite which is consistently well reviewed by our customers and medical professionals alike.
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 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 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 Nasaline Salt solution which was developed based on Ringer’s solution.
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 a pharmacy. 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 sinusitis.