CHRONIC SINUSITIS

Chronic sinusitis is the most common chronic illness in the United States. Both the diagnosis and treatment are, unfortunately, controversial. Some feel that signs of obstruction and inflammation are required to accept it as an appropriate diagnosis. Others feel confident that chronic sinusitis is defined by its symptoms regardless of Xray findings, etc. Similarly, one group of physicians feels that evidence of infection is necessary before prescribing antibiotics. Another group considers worsening of symptoms alone as justification for their use.

Some Cautions: Natural treatments for sinusitis are quite appropriate after considering several caveats. See your doctor if you develop a fever, severe facial pain, or symptoms not typical of your experience with chronic sinusitis in the past. Remember that a fever may indicate an acute sinus infection or a worsening of chronic sinusitis. Antibiotics are usually needed in the presence of fever and may be required for persistent colored nasal discharge, poor response to other treatments, unrelenting fatigue, continuing facial pain, or simply failure to improve.

Diet: Remember the basics: What are you putting into your body each day? One of the most common dietary causes of nasal congestion is milk. Eliminating milk and milk products from your diet will tell the tale; no need for a medical allergy evaluation. Give it two weeks. Often the results can be dramatic. Eliminating milk and milk products cures sinusitis and fatigue in approximately 10% of patients.

Wheat, although less often than milk, can cause sinus symptoms. A wheat elimination diet is difficult but can be fruitful. Likewise other foods and food additives such as artificial sweeteners can cause problems. Try eliminating different groups either by yourself or with the help of a dietician. As you might guess, it's often the foods we like best that cause the trouble.

On the other hand some foods clear the sinuses. Garlic, horseradish root, and cayenne (red pepper) may produce a desirable effect. Drinking substantial amounts of water or other fluids frequently help to loosen the nasal mucous.

Few people with sinus trouble can drink wine or beer free of trouble. Spirits, however, are generally better tolerated.

Medication Side Effects: Certain medications can cause or exacerbate sinusitis. In vulnerable individuals these would include particular medicines for high blood pressure, depression, and heart conditions. The oral contraceptive pill occasionally causes problems.

CLIMATE A crisp cool day with a slight breeze and no dust, no molds, no pollens, and no pollutants is just what you need. Heavy humid still days with atmospheric inversions are terrible, particularly if smog and pollutants are present. Dry dusty days are also a problem. Barometric shifts often swell the nose blocking the sinus drainage ducts, as the spongy areas within the nose expand to equalize in pressure with the outside lower pressure.

INDOOR CLIMATE At home evaluate your house for allergens, irritants, humidity, and dust. Clean scrupulously, watching out for dust collectors such as books, carpets and bedding. Bedding is tough to deal with. Try covering the mattress and box spring with a special fabric encasing (a product is available through National Allergy Supply, Inc.ª at www.nationalallergysupply.com) and equipping the heating, ventilation, and air conditioning duct system (HVAC) with good filters. For a single room the high efficiency particulate air filter (HEPA) is, I believe, the best (a good one is available through Bionaire, Inc.ª at www.bionaire.com). A caveat: air supplied continuously to a room (house or office) from a central fan through a duct system washes out the filtered room air. Consider a HEPA filter for the entire central air system. Alternatively, you could apply disposable filters monthly over the incoming air ducts to the room (also available through National Allergy Supply, Inc.ª at www.nationalallergysupply.com). Many of the "sealed buildings" of the last 30 years, particularly office buildings with no functioning windows, do not permit the introduction of adequate fresh air causing sinus symptoms (sick building syndrome). Smoke, substances in cleaners, copiers, rug adhesives, etc. are very irritating to those who are vulnerable. Try talking to the building engineer. Are the fresh air intake valves open far enough or, for reasons of economy, is the same air being continuously recycled? Where is the fresh air intake duct located-on the top of the building to minimize pollution or is it near street level where exhaust fumes are highest?

Similar problems exist in planes. The "virus" many people feel they caught on a plane ride is actually a sinus infection caused by the dry, stale, polluted airplane air. Air pressure changes as the plane adjust to and then from 8,000 feet above sea level exacerbate the problem.

HABITS SMOKING irritates the sinuses and should be avoided. Some people become exquisitely sensitive to perfumes, soaps, newsprint, etc. Individuals should avoid these and other substances that prove problematic.

The right amount of sleep is good but excessive amounts, however, can be trouble. Lying down reduces the size of the sinus ducts by 20%. Raising the head with a few pillows can help restore flow. Curiously, sleeping on one side of the body improves airflow in the opposite nostril. Stick with the amount of sleep that you usually require when healthy during times when the sinuses act up.

EXERCISE can be a highly effective and healthy way to deal with sinus trouble. It can open the nose and improve sinus drainage. Sinus clearing is responsible for the benefit many people feel after exercise.

SUPPLEMENTS AND VITAMINS Many feel that vitamins and dietary supplements are a definite help. It's a difficult point to prove. Vitamins, herbs, and food supplements can cause beneficial changes in the nose and occasionally a marked improvement. Large does of certain vitamins, supplements and certain herbs, however, can cause medical problems. Additional concerns include the lack of standardization and government testing of the herbal products. Those with medical problems as well as those on medication should consult with their doctor before taking such preparations. Of course when pregnant or nursing no product should be taken without careful consultation. For some the following are helpful: a multivitamin, vitamin C in large doses, zinc (25 mg), evening primrose oil (linoleic acid and gamma linolenic acid in a gel cap, twice daily), echinacea pallida herba and ginseng.

LOCAL TREATMENT NASAL SALINE SPRAY often soothes the dry, inflamed nasal membranes and reduces mucous viscosity. In some individuals it has a separate decongestant effect. All commercial preparations are not the same. Some contain a preservative that may be irritating. Ayrª is a well-tolerated product. (Available from B.F. Ascher and Co., Inc. at www.bfascher.com).

Warm hypertonic saline nasal rinses (rinses with an extra amount of salt) may be quite helpful, but occasionally are counterproductive and cause irritation. The saline is prepared easily by mixing 2 to 3 heaping teaspoons of pickling or canning salt (not table sale) and 1 teaspoon of baking soda with one quart of clean tap water and instilled by using a bulb syringe or a pulsating jet (Water Picª with nasal adapter, Teledyne Water Picª at www.waterpic.com). Store at room temperature and discard after one week. If the solution seems too strong you can decrease the salt content to 1 or 11Ú2 teaspoons. A similar spray in prepackaged form is available as ENTsolª (available from Kenwood Therapeutics at www.entsolwash.com).

WETTING AGENTS (propylene and polyethylene glycol) may offer an additional benefit between or instead of the nasal rinses (available at Pretzª, Parnell Pharmaceuticals, Inc. at www.parnell.com).

Because of the tendency of the nose to dry and crust paving the way for sinus infection nasal emollients are often helpful. Spraying with sesame oil is quite effective. Alternatively, an antibacterial ointment moisturizes and kills the germs in the nose that often lead to infection. Bactrobanª (available at pharmacies) is particularly effective against these nasal staph germs.

Nasal barriers protect against continual irritation during vulnerable times. Ayr gelª (at www.bfascher.com) protects the delicate membranes. Viscous lidocaine (a topical anesthetic) applied inside the nose with the tip of the small finger may also help.

NASAL STEAM INHALATION with or without astringents (eucalyptus, pine oil, or menthol) decongests and soothes the nose. Warm dry air alone is also often productive. Likewise, infrared heat directed at the face may help. Nasal steamers offer convenience (available as the Steam Inhaler, Bernhard Industries, Inc. at www.steaminhaler.com and as the Virothermª from Sunbeam-Oster Household Products, Inc. at www.sunbeam.com). Many simply inhale from a cup of hot water at work or home. Try a damp face cloth heated by the microwave for approximately 20 seconds. A warmed or chilled mask filled with jell and placed on the face is another alternative. In the colder months or in drier climates indoor humidification helps prevent drying, irritation, swelling, and secondary infection. Steam humidification I believe is superior to cold mist or ultrasonic. Warm mist may be added to filtered air in a single unit (available as the Bionaireª CM series of warm humidifiers, at www.bionaire.com). The Bionaireª CM 1 is small and particularly convenient for simple humidification. Larger, evaporator type humidifiers for the house include: the Bionaireª W-65 (www.bionaire.com), the Toastmasterª 3435 (www.salton-maxim.com), and the Emersonª HD850 (emersonelectric.com).

NOSTRIL EXPANDERS Occasionally, abnormalities of the nasal openings predispose to chronic sinusitis symptoms. These small passageways, control the flow of air across the nasal membranes. Minor changes because of accidents or inflammation can cause increased nasal obstruction. Even in the absence of abnormalities spreading this area, by a small stainless steel dilator spring (available as the Mechanical Therapeutic Nasal Dilatorª from Breathe With Eezª, Inc. Brooklyn, New York 11207 U.S.A.; telephone number (718) 498-1686) occasionally offers dramatic help with nasal symptoms. An adhesive spreader (available as the Breathe Rightª External Nasal Dilator manufactured by CNS Inc., Chanhassen, MN 55317 U.S.A.; telephone (612) 474-7600) externally applied to the lower nose can give similar benefit with greater comfort although it is visible on the nose unlike the dilator spring which is placed inside the nose.

LOCAL NASAL TREATMENTS NASAL DECONGESTANT SPRAYS may be of help when used sparingly, three times daily for three days or less. Xylometazoline (Otrivinª) or oxymetazoline (Afrinª) is effective but not particularly harsh. Chronic use (more than about 3 consecutive days) can induce "rhinitis medicamentosa," a problematic condition of rebound swelling often requiring oral corticosteriods as therapy. The risk of rebound is less with more dilute nasal sprays. Adding water to the spray bottle to accomplish 1:2 to 1:8 dilution is helpful.

LOCAL CORTICOSTERIODS (Beconaseª, Nasacortª, Rhinocortª, Vancenaseª, Flonaseª, Nasalideª, and Nasonexª) have been effective in seasonal and other nasal conditions. They offer useful ancillary treatment for chronic sinusitis in some cases. Flonaseª and Nasonexª are the sprays least associated with absorption into the body. Cromolyn (NasalCromª), blocks the nasal response to allergic challenge but is usually less effective than the steriod sprays. Both local corticosteriods and cromolyn can cause nasal irritation and drying. Often it is prudent to discontinue these medications during a worsening of sinus symptoms. Atroventª is another type of nasal spray that is used primarily to stop a watery nasal discharge. Astelinª is an antihistamine nasal spray blocking the allergens as they come in contact with the nose.

ORAL MEDICATIONS ORAL DECONGESTANTS often help the symptoms of chronic sinusitis. Pseudoephedrine reduces nasal blood flow and, thereby, nasal engorgement. Occasionally it is associated with blood pressure elevation. Some people find the drying agents used in "cold preparations" to be helpful and others do not.

ANTIHISTAMINES are sometimes helpful with the symptoms of chronic sinusitis. Allergic inflammation, often seasonal, predisposes some individuals to chronic sinusitis. For these, a selective H1-antihistamine (Claritinª, Allegraª, Zyrtecª) may be a desirable option. Iodinated glycerol is a mucolytic agent that stimulates mucous flow. Guaifenesin (Humibidª or, with an oral decongestant, Entexª) reduces mucous adhesiveness.

ANTI-INFLAMMATORIES Sinus disorders not responsive to local steriod sprays may be greatly helped by oral corticosteriods. Their effect can be dramatic, although they must be used with caution. Aspirin and nonsteroidal anti-inflammatories (Motrinª, Advilª, etc.) can trigger asthma, nasal problems, and sinusitis in a few susceptible individuals. Occasionally these medications are helpful as anti-inflammatories, decreasing the symptoms of chronic sinusitis.

ANTIBIOTIC THERAPY usually offers the most help for those with sinusitis. When the sinus actually has pus in the cavity antibiotics may be required for a number of weeks. In settings where this does not appear to be the case antibiotics can still offer help. Often the nasal membranes are covered with an infected mucous and the individual experiences sinus pain, aching, and fatigue. Antibiotics can resolve the problem in days although the medicine should be taken for an entire week or more. In the absence of an infected nasal discharge or evidence of superimposed acute sinusitis the use of antibiotics for chronic sinusitis has been questioned. Some feel that most cases do not represent an infectious process and do not require antibiotics. Most authorities, however, consider the evidence for the importance of antibiotics to be strong. It is a difficult problem to study. People often find a one week course to be of great benefit.

OTHER OPTIONS Remember also that surgery is an excellent option if medical treatment isn't working. The more recent method (endoscopic surgery) is much less traumatic than older techniques. Most people armed with their own determination and the help of a doctor can beat this illness or substantially reduce the symptoms.