Sinusitis:
America’s number one headache.
In my medical practice, more people suffered sinusitis than
suffered any other medical condition.
Sinusitis kept them from work, school, and
play. Sinusitis kept them from normal
functioning. It affected their thinking,
behavior, activities, and mood. It put their
life on hold when they could ill afford it.
When I began practice in 1969 a case a month of sinusitis was
likely. In my later years, five to ten cases
a day was more the rule. I believe this
logarithmic increase results from our
worsening air quality. More people, more
vehicles, more buildings, more crowding,
more spraying, more nasty viruses, more
antibiotic resistance, more pollen, mold,
and indoor pets, coupled with the lack of
know how to maintain or afford clean air.
The sinuses are hollow air spaces in the head. They are there
to serve us. They cushion the brain, lighten
the head, maintain our balance, and keep us
erect.
They too come in pairs. There are the sphenoids - located
behind and above the nose, the frontals -
over the eyes, the maxillary - inside the
cheekbone, and the ethmoids -alongside the
nose and between the eyes.
There is an aphorism,
“God made the body beautiful; Satan made the sinuses.”
The trouble is in the engineering. Drainage must proceed
uphill and the openings of the sinuses into
the nose are too small. Thus easy drainage
of mucus secretions is limited at best and
impossible at worst.
Sinusitis mainly develops from simple respiratory colds,
allergies, and breathing foul air. That’s it
in the proverbial nutshell. Each of these
conditions leads to nasal inflammation. With
inflammation there is local tissue swelling.
The swelling results from the damage. There
is an outpouring of white blood cells,
enzymes, tissue fluid, mucus secretion, and
a breakdown of the membranes lining the
nasal cavity. The result is a blockage of
the small sinus openings opening into the
nose.
The sinuses are actually extensions of the nasal cavity. When
the nose is injured from pollution,
allergies, viruses and bacteria, the sinuses
are also.
This compounds the problem for the patient. Now instead of
having one continuous thoroughfare, there
are instead multiple closed compartments,
each filled with residue and blocked off.
Pain and suffering are the natural
consequences.
Most commonly the diagnosis of sinusitis is elusive. Symptoms
vary among patients. Mostly it appears as a
cold which doesn’t quit – or that once a
year bad head cold. More often than not the
symptoms start out subtly – a postnasal drip
with excessive clearing of the throat. The
nose is stuffy and is clogged. The head
feels full. There is a cough. The cough
generally is mild but both frustrating and
unpredictable. Just when relief appears
within reach, the cough reappears in
earnest. The victim becomes torn. Not
feeling so ill to visit the doctor, he
becomes his own diagnostician.
“It’s an allergy. It’s something I’m eating. Maybe I’m just
rundown. I probably need more food
supplements -or cough drops or perhaps some
of the antibiotics left over from last
time. If only I could get more rest, more
sleep,” etc.
Complications set in when the condition festers, when
management is delayed. The sinuses become
further inflamed, swollen, blocked, and
hyperirritable. Pain now is more evident -
Pain about the nose, deep in the cheeks, the
face and forehead.
Inflammation drops down into the chest and distress mounts.
The cough becomes wet and more frequent.
This complicating bronchitis is thought to
be more a consequence of a sinus reflex than
a direct spread. At this point the patient
is sick. No longer is it thought to be a
simple cold. The cough is persistent
throughout the day and much worse at night.
To lie down is to cough. To fall asleep is
difficult.
Thoughts of tuberculosis, cancer, and double pneumonia cross
your mind. Now a doctor is consulted. You
pray he can attend you right away - if not
sooner. He hears some wheezes, and you learn
that asthma is now a consideration.
A work up is ordered. With sinusitis, the chest X-ray, blood
tests, throat culture, and tuberculin skin
test tend to be normal. Regular sinus x-rays
typically are within normal limits too,
while a C-T scan generally finds the
pathology – the ethmoids being cloudy and
the maxillary sinuses showing fluid
densities and thickened membranes.
Laboratory tests are an option. Mostly they are not necessary
in milder illness nor even in more advanced
episodes unless an imposed course of
treatment has failed.
It is important to know what condition one is treating. How
apparent this claim. Yet until one rules out
the cold, allergy, pneumonia, tuberculosis,
and asthma, management of the inciting
sinusitis may be too little and too late.
Furthermore it is critical to note sinusitis is more of an
inflammation than an infection. Sinusitis is
a blockage. Antibiotic treatment is not the
first consideration. It may be of no
consideration. Relief of the obstruction is
paramount. Until the sinuses are unblocked
and drainage is promoted, relief will be
delayed. Antibiotic therapy is at most an
adjunct to naso-sinus irrigations. My
preference is to initially withhold
antibiotics in mild infections but to employ
them when the episode continues for three or
more weeks.
Mainly our patients were well pleased irrigating with a water
pik. We modified it with an adapter which
fits snugly in first one nostril followed by
the other. The patient bends over,
applicator in hand, the tip inserted into
the nostril. Then the water pik is turned on
and blows out the circulating fluid through
the open nostril at roughly 3 the patient
blows out at about 3 second intervals.
The water pik bowl contains tepid water with one teaspoon of
saline. The process is repeated as often as
there is drainage. Comfort is immediate. A
clear liquid drainage is to be expected for
the next half hour or so following the
irrigation.
When antibiotics are used my suggestion is the Quinolones,
Augmentin, or the newer Macrolides.
Nasal decongestants for up to three or four days appear
helpful. Antihistamines and oral
decongestants do not. Cough medicine is a
personal option.
A steroid nasal spray may be prescribed; their main use is in
allergy. Sometimes in patients with a
tendency to develop one sinus attack after
another, these steroid sprays might be taken
on a daily basis for prophylaxis.
I do use prefer pulses of oral corticosteroids for all but
the mildest of attacks. I find these of
major assistance in this inflammatory
condition. When the patient becomes adept in
self care I have no qualms in supplying both
the prednisone and antibiotic so they may
get a jump on initiating treatment prior to
their follow up visit with me the next day.
Bill Ziering
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