Sinusitis FAQ
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CONTENTS
What is Sinusitis?
Diagnosis
Why Sinusitis Sucks
Role of the Immune System
Allergies
Irrigation
Irrigation Techniques
Saline Solution
Irrigation Additives
Risks
Hydration
Other Home Remedies
Drugs
Antibiotics
Steroid Nose Sprays
Decongestants
Mucolytics
Antihistamines
Pain Medications
Alternative Medicine
Candida
Prevention
Surgery
Web Sites and Books
DISCLAIMER
This FAQ is designed to provide core information about sinusitis.
It's an attempt at a 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. This FAQ isn't designed to cover all issues related to
sinusitis. If you have questions not answered here, visit the Web
sites mentioned at the end of this FAQ or post your questions in the
newsgroup alt.support.sinusitis.
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.
WHAT IS SINUSITIS?
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.
Diagnosis
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.
WHY SINUSITIS SUCKS
Sinusitis feels like a cold that never goes away. It often hurts. It
reduces your energy level (and is sometimes misdiagnosed as chronic
fatigue syndrome). 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.
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. Some ENTs (ear, nose, and throat specialists)
are better than others in treating patients as individuals, keeping up
on the latest clinical research, and being receptive to viable
alternative remedies. (ENTs are more formally known as
otolaryngologists, pronounced OH-toe-lair-ing-GOLL-e-gists, or
otorhinolaryngologists, pronounced
OH-toe-RIE-no-lair-ing-GOLL-e-gists.) 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.
ROLE OF THE IMMUNE SYSTEM
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.
ALLERGIES
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, however, work best in highly
allergic people, work only on certain allergens, and 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 (disposable 3M Filtrete filters,
though more expensive, are considerably more effective than
washable/reusable filters or cheap fiberglass filters, according to
Consumer Reports). You might also consider buying an air cleaner
(avoid ozone cleaners and negative ion generators) and either
investing in a HEPA (high-efficiency particulate) 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.
Another option, though expensive, is to have an industrial hygiene
company test your home or office. Industrial hygiene companies
typically evaluate the indoor environmental quality in industrial,
commercial, or office settings but will test homes too. Among other
things they check the air for bacteria, fungi, carbon dioxide, carbon
monoxide, and volatile organic compounds, and they look for evidence
of mold including checking humidity levels and the moisture content of
building materials. After their evaluation they recommend remedial
procedures, and they can either do the remedial work themselves or
suggest contractors.
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.
IRRIGATION
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 even ENTS,
however, still have little knowledge of sinus irrigation or regard it
as unproven folk medicine, despite numerous studies of it described in
medical literature, 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, but it's harder to find. One
source is the SinuCleanse System at http://www.sinucleanse.com/.
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 antibodies, which play a key role in allergic reactions.
Irrigation also suctions out mucus that the saline doesn't reach
directly through vacuum action (the Venturi effect).
There are a number of pulsatile nasal irrigation devices available --
for a listing, see
http://www.surgery.ucsd.edu/ent/davidson/NASHAND/nasal.htm#NASAL_IRRIG
ATION. The most popular pulsatile irrigation device is the Grossan
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.
You can obtain the Grossan Irrigator in some pharmacies (Bergen
Brunswig part number 344-598, McKesson part number 1443217), through
Hydro Med at http://www.hydromedonline.com/ or 800-560-9007, at Health
Solutions Medical Products at http://www.pharmacy-solutions.com/, or
in Europe from Inmunotek at http://www.inmunotek.com/xcitekindex.htm.
You can save money if you buy a Personal Water Pik (at your local
pharmacy, for instance) rather than a Professional Water Pik without
losing much functionality. The professional version, though, is more
durable, standing up better to corrosion from salt (washing out the
personal unit after each irrigation can prevent corrosion as well).
The professional version is also said to be more versatile when using
saline additives that don't dissolve fully.
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.
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 tilt 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.
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 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.
The second way to obtain saline is by buying it prepackaged, which is
more convenient though slightly more expensive. Premixed packets of
saline with baking soda can be purchased from SinuCleanse at
http://www.sinucleanse.com/. Canning salt is used, at a ratio of four
parts salt to one part baking soda, according to a spokesperson at the
company. Each packet contains a half teaspoon of salt, so add it to
eight ounces of water.
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 their complete electrolyte composition.
HydroMed, at http://www.hydromedonline.com/ or 800-560-9007, sells a
product based on Ringer's solution called Breathe Ease. It's
convenient but somewhat expensive, costing $14.95 per package, enough
for about 30 irrigations, which makes the cost per irrigation about 50
cents. In Europe you can obtain a similar product called SinuSal from
Inmunotek at http://www.inmunotek.com/xcitekindex.htm
You can experiment with making your own Ringer's solution. You need
only a tiny amount each of potassium chloride and calcium chloride --
about 1/30th of a teaspoon per U.S. pint (16 ounces of water), or just
a pinch (there are different formulations of Ringer's solution, so the
amount added doesn't have to be exact). Stores that sell potassium
chloride and calcium chloride powder can be found by searching the
web. Local beer and wine-making shops also sell calcium chloride, the
purpose of it being to adjust the hardness of water used for brewing
beer. Products that are meant for human consumption should be safe
for use on sinus membranes.
Some people use saline solution packaged for use with contact lenses,
though this is expensive, and contact lens solutions made with
preservatives can potentially damage the sinuses' cilia.
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 or from Web sites such as
MediChest.com, at http://www.medichest.com/, 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
(mupirocin) and gentamycin as irrigation additives. Ask your ENT
about this.
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.
The benefits of irrigation, even frequent irrigation, are thought to
be far greater than the risks, particularly if you have symptoms.
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 into 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.
HYDRATION
If you have sinus problems, it's important to keep your sinuses well
hydrated (moisturized), to keep mucus membranes from drying out, which
prevents them from protecting against bacterial infection. Saline
nose spray is helpful in this regard. You can use it between
irrigations or on days when you're not experiencing any symptoms and
are not irrigating.
Some people, however, are sensitive to the preservatives used in
over-the-counter saline sprays -- their sinuses become irritated.
These preservatives can also slow down the functioning of the cilia,
which also compromises 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.
You can make an excellent preservative-free isotonic saline solution
for nose spray with Breathe Ease, which is also used to make
irrigation solution and is available through HydroMed, at
http://www.hydromedonline.com/ or 800-560-9007.
A new saline nose spray on the market is SinusMagic, available at
http://www.sinusmagic.com/. It's pricey at $11.99 per one-ounce
bottle, but it appears to do a better job than saline alone of
clearing out sticky mucus.
Along with salt (sodium chloride), SinusMagic contains thymol;
eucalyptol; menthol; benzoin; potassium alum; potassium chlorate;
sodium bicarbonate; glycerine; oils of sweet birch, spearment, pine,
and cinnamon; and alcohol (1/100 of 1 percent). These ingredients are
similar to those used in Alkalol, but because of the addition of
glycerine and because it's pH balanced, it doesn't sting like Alkalol
can. SinusMagic like any saline-based nose spray can be a good
adjunct to irrigation but shouldn't replace it.
You can make a nose spray similar to SinusMagic and save money, though
you'll have to experiment with the amounts. To water add a small
amount of Alkalol and glycerine as well as sodium bicarbonate (baking
soda) and salt. Alternatively, to water you can add Alkalol,
glycerine, and Breathe Ease. You can skip the glycerine if Alkalol
doesn't bother you.
You can help the saline reach more sinus tissue by tilting your head
back or lying on your back while you squirt the solution into each
nostril.
OTHER HOME REMEDIES
If you're clogged, it's important to try to clear out your sinuses to
prevent infection. Techniques include using Alkalol or Alkalol-like
ingredients in a nose spray, neti pot, or bulb irrigator; 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; and eating hot
chicken broth with garlic.
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. One trick is to carry wasabi (Japanese
horseradish mustard) with you. It's available in small
toothpaste-type tubes from many Asian grocery stores. Just place a
dab on your tongue when you're congested.
Some people use a vaporizer/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.
Another technique is nasal massage, which can sooth your sinuses,
reduce swelling, and encourage blood flow to the area. Gently rub the
sides of your nose and your cheeks with your fingers or knuckles.
DRUGS
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 less likely to cause drowsiness than
first-generation over-the-counter antihistamines such as Benadryl
(diphenhydramine hydrochloride), but some people find that Benadryl
(or its generic equivalent) is more effective. Claritin, now
available over the counter, is the least sedating. Zyrtec is
somewhere between Claritin and Benadryl in terms of both efficacy and
sedation effects.
Spray antihistamines such as the prescription Astelin or the
over-the-counter NasalCrom (technically, an "antiallergic" rather than
an "antihistamine" though it works similarly) are another option.
Alternatively, you can dissolve one or two 50 mg capsules of Benadryl
in one ounce of saline solution.
Antihistamines 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.
ALTERNATIVE MEDICINE
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 and as Clear Ease from Hydro Med, at
http://www.hydromedonline.com/ or 800-560-9007. Unlike some other
products, Clear Ease is made without sugar and will thus not promote
tooth decay. It costs considerably more than similar products,
however, 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. The Mayo doctors contend that it's not the fungi
itself in the sinuses that causes problems but the allergic response
to it by some individuals.
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).
You can read more about Candida at
http://dmoz.org/Health/Conditions_and_Diseases/Infectious_Diseases/Fun
gal/Candida/.
PREVENTION
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, saline nose spray (with or without Alkalol or
Alkalol-type ingredients), steam inhalation, using a hot compress on
the nose and cheeks, nose/cheek massage, drinking lots of liquids,
eating hot chicken broth with garlic, using a vaporizer at night,
gentle (as opposed to forceful) nose blowing, 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 dioxide
and bacterial and fungus 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 exacerbate 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 exacerbate sinusitis symptoms.
SURGERY
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. Although some ENTs still perform this
type of surgery, 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.
WEB SITES AND BOOKS
A number of doctors and medical organizations have created useful Web
sites where you can find more information about managing your
sinusitis. The top sinusitis and allergy Web sites include:
Sinusitis: A Treatment Plan That Works
http://www.sinuses.com/
From a New York City allergist named Wellington S. Tichenor who
occasionally participates in alt.support.sinusitis. Has helpful
internal search tool.
Dr. Grossan
http://www.ent-consult.com/
From an ENT from Los Angeles named Dr. Murray Grossan, inventor of the
Grossan Irrigator and a frequent participant in alt.support.sinusitis.
Handbook of Nasal Disease
http://www.surgery.ucsd.edu/ent/davidson/NASHAND/nasal.htm
From a California M.D. named Terence M. Davidson.
Rhinology/Allergy Pages
http://www.geocities.com/shouser144/
From an ENT trained in rhinology/allergy named Steven M. Houser.
Sinus Survival
http://www.sinussurvival.com/
From Robert Ivker, D.O., author of the book Sinus Survival and
president of the American Holistic Medical Association.
American Academy of Otolaryngology
http://www.entnet.org/index2.cfm
Patient-education material from an ENT organization.
American Academy of Allergy, Asthma and Immunology Sinusitis
http://www.aaaai.org/patients/publicedmat/sinusitis/
Allergy, Asthma, and Sinusitis Tips
http://www.aaaai.org/patients/publicedmat/tips/
Sinusitis Glossary
http://www.aaaai.org/patients/publicedmat/sinusitis/sinusterminology.s
tm
Patient-education material from an allergist organization.
Indoor Air Pollution
http://www.epa.gov/iaq/pubs/hpguide.html
From the U.S. Environmental Protection Agency (EPA)
Residential Air Cleaning Devices: Types, Effectiveness and Health
Impact
http://www.lungusa.org/site/apps/lk/links.asp?c=dvLUK9O0E&b=35700
From the American Lung Association
Recommended books about sinusitis include:
Sinus Survival: The Holistic Medical Treatment for Allergies, Asthma,
Bronchitis, Colds, and Sinusitus
By Robert Ivker, D.O.
This book covers both conventional medical and alternative medical
approaches and is very accepting of the latter.
The Sinusitis Help Book: A Comprehensive Guide to a Common Problem
By M. Lee Williams, M.D.
This book isn't quite comprehensive, however, not mentioning
irrigation.
Sources of products for environmental control of allergies include:
AllergyBuyersClub.com
http://www.allergybuyersclub.com/
Allergy Clean Environments
http://www.allergyclean.com/
National Allergy Supply
http://www.natlallergy.com/
This FAQ was written by Reid Goldsborough <reid...@netaxs.com>.