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Sinusitis Relief
By Harvey Plasse, Shelagh Ryan Masline Henry Holt and Company
Copyright © 2002 Harvey Plasse, M.D., and Shelagh Ryan Masline
All rights reserved.
ISBN: 978-1-4299-3976-8
CHAPTER 1
What Is Sinusitis?
If you're reading this book, you probably picked it up because you or someone you know suffers from sinus problems ... and you're looking for some answers. Sinusitis, which afflicts more than 30 million people in this country, is one of the most common health problems facing Americans today. Perhaps even more surprising, people who have this disease report more pain, depression, and fatigue in their lives than even those who have heart disease or chronic back pain. Yet because sinusitis is so poorly understood, people often suffer in silence, failing to receive proper diagnosis and treatment.
SINUSITIS: A PRIMER
The suffix "itis" means inflammation, and sinusitis is an inflammation of the mucous membranes lining one or more of the hollow sinus cavities in the skull. Sinusitis has grown increasingly common over the course of the last decade or so. Although no one knows exactly why, experts speculate that forces such as increased environmental pollution and immune impairment are at work. But whatever the explanation turns out to be, sinus sufferers in this country are making more than 10 million visits to the doctor each year. As a result, physicians write over 13 million antibiotic prescriptions — adding up to a staggering annual tab of more than $3 billion, and literally millions of days lost yearly from work and school. Still more cases of sinusitis go undiagnosed. People mistakenly believe that their symptoms are due to recurrent allergies or colds when, in fact, they have a common condition that responds extremely well to appropriate treatment.
AN OVERLOOKED AND MISUNDERSTOOD DISEASE
While in some cases it is just a minor nuisance, often sinusitis can make life miserable. Particularly frustrating is the fact that because the chronic variety usually presents no obvious symptoms — no fever, no rash — little credibility is given to its sufferers. Consequently, people cope with symptoms such as headaches, nasal congestion, a reduced sense of smell, and facial pain for years, sometimes decades, without finding a solution. The fact is, sinusitis is more than just a runny nose or a stuffed-up head. Chronic or recurrent cases carry a significant risk of complications that can be dangerous and, particularly in people with compromised immune systems, even fatal. Though rare, these complications include blindness and infections of the brain. But even when serious complications do not develop, sinusitis can have a severely negative impact on one's overall quality of life. (Read more about sinusitis and quality-of-life issues later in this chapter.)
Overall, sinusitis is shaping up to be one of the most common and yet, simultaneously, one of the most misunderstood diseases of our era. It is misdiagnosed, overdiagnosed, and underdiagnosed, subject alike to both over- and undertreatment. Even when medical attention is sought, not all doctors know how to make the right diagnosis or appropriately treat sinusitis. Some people undergo unnecessary surgical procedures, while others can't seem to obtain the simple prescription that would rid them of painful symptoms. But once you arm yourself with the proper information about sinusitis — the warning signs to watch for, the right people to turn to, the treatment to expect, and more — you can successfully prevent or control the many serious consequences of this disease.
WHAT CAUSES SINUSITIS?
Infection and inflammation that block the sinus openings (ostia) are the direct causes of sinusitis. Given these circumstances, it comes as no surprise that sinus infection most often follows a common cold. But the chances of developing sinus problems are greatly enhanced by a whole host of other factors, including allergies, immune system problems, polyps, and swollen adenoids. An overall rise in immune impairment is a major contributing factor to the epidemic of sinusitis in recent years, as is the increase in urban air pollution. It is now generally accepted that diseases that are related to or increase the risk for sinusitis are on the rise worldwide and are associated with increased pollution. Another aspect that scientists are focusing on is the role of fungi, which appear to be nearly ubiquitous in the sinuses. Your chances of developing sinus disease may also be greater if you are a smoker, or even if you are exposed to secondhand smoke. Changes in ambient pressure — as during air travel or scuba diving — also contribute to the problem. Some of these factors can be avoided while others are inevitable, for the anatomy of the nasal passages and sinuses themselves plays an occasional role in sinusitis. To further complicate matters, explanations for sinus infection and pain can usually be attributed to a combination of some or all of these elements. (Read more about the causes of sinusitis in chapters 3 and 4.)
THE ANATOMY OF A SINUS INFECTION
Not everyone who has a cold or an allergic reaction develops sinusitis. You are most likely to develop sinusitis when the following three factors are all present:
• You have sinus blockage. This can be the result of inflammation, or of mechanical obstruction such as enlarged adenoids or nasal polyps.
• You are experiencing some kind of immune system impairment.
• Infection-causing microorganisms are present.
Ostial Obstruction
When you experience an inflammatory problem such as an upper respiratory infection or allergic reaction, the diameter of a sinus opening shrinks. Doctors refer to this condition as ostial obstruction. The osteomeatal unit, or OMU, is considered the seat of sinus disease, since the majority of the sinuses drain into this area around the nose. Sinusitis is usually initiated with obstruction of this final common pathway.
The Inflammatory Response
Inflammation is most commonly due to viral infection or allergies. The resulting redness, swelling, heat, and pain are local tissue reactions to an abnormal stimulus (such as infection, allergy, injury, or irritation). The inflammatory response is actually a protective move on the part of your body to isolate the affected area and rush in blood packed with disease-fighting antibodies to neutralize any hostile invaders. Yet inflammation leads to acute rhinitis: a sudden swelling of the mucous membrane that lines the nose. As the swelling extends to the sinus membranes, it increasingly interferes with airflow and normal mucous drainage, eventually narrowing the ostia or even closing them altogether.
The Role of Colds and Allergies
Colds and allergies are the most common culprits responsible for inflammation and obstructed drainage. If these are ruled out, your physician will examine your nose and sinuses for signs of anatomic or mechanical obstruction. For example, small grapelike growths called nasal polyps can interfere with the normal drainage of your sinuses. Other possible causes of obstruction include unusually small drainage openings, a significantly deviated septum, and tumors. Adequate mucociliary clearance — the sweeping of mucus through sinus chambers by microscopic hairs called cilia — is also essential to proper drainage and the normal functioning of the sinuses. Finally, a change in the nature or amount of secretions within the nasal cavities may lead to inadequate drainage. Sinusitis develops when inflammation is strong enough to impair local immune defenses as well as contribute to ostial obstruction.
Immune Impairment
The immune system is the body's natural defense against infection. In the nose and sinuses — indeed, throughout the respiratory system — mucous secretions are rich in substances that destroy or inhibit disease-causing microorganisms. Among the most important of these are proteins known as immunoglobulins. These vital antibodies work to eradicate infectious organisms that play a significant role in sinusitis. Other protective substances in mucus are T cells, which are best known for their ability to combat HIV infection. In addition, there are enzymes that attack Candida and other fungi and kill bacteria by invading and digesting their walls. Current research supports a greater emphasis on the role of weakened immune defenses in chronic sinusitis, shifting away somewhat from the traditional focus on infection. It may be that the presence of disease-causing organisms is less significant than the weakened immune system that makes a person susceptible to them.
A Greater Susceptibility to Disease
When your immune system is functioning at peak efficiency, disease-fighting substances band together to help keep you healthy. But if your body no longer produces an adequate number of antibodies, you become more susceptible to a whole panoply of disorders — and featuring prominently among these is sinusitis. Immune impairment can have any number of different causes. For example, if you are undergoing aggressive chemotherapy for cancer or are taking cortisone for a chronic condition such as colitis, your immune system is weakened. This makes you more likely to come down with a cold or flu that can be a precursor to sinusitis. Sinus disease is also especially common in people with weakened immune systems due to HIV infection. In recent years, the overuse of broad-spectrum antibiotics has contributed to impaired immunity by encouraging the emergence of drug-resistant strains of bacteria. Along with the increases in air pollution and the corresponding increase in allergic rhinitis, this practice is believed to be a major contributing factor to the soaring incidence of sinusitis.
The Overuse of Antibiotics
Over the course of the last decade or two, there has been an explosion of so-called supergerms or superbugs, bacteria that cause infections that are difficult and sometimes impossible to treat with the antibiotics we have available today. Supergerms are a direct consequence of the overuse of antibiotics. To set the record straight, antibiotics are only effective in curing bacterial infections; they have no effect whatsoever on viruses. Nevertheless, patients frequently ask for and doctors often continue to prescribe these drugs for viral infections such as colds and flu. Incredibly, the Centers for Disease Control and Prevention (CDC) estimate that one-third of the 150 million outpatient prescriptions written for antibiotics in the United States each year is unnecessary. To further complicate matters, livestock on farms are routinely fed antibiotics to prevent infection and promote growth. Scientists are concerned that this practice will eventually lead to drug-resistant bacteria that can reach us through the food chain.
Inside your body, bacteria adapt to the onslaught of repeated antibiotic attacks by morphing into ever newer, tougher, and harderto-treat strains. Antibiotics may also destroy the friendly bacteria that normally reside in your digestive tract, thus opening the door to the growth of the more destructive Candida fungus. The irony is that treatment with the same antibiotics that miraculously cure many dangerous bacterial infections can also lead to the generation of virulent supergerms. Indeed, these are often the very bacteria responsible for serious and persistent cases of chronic sinusitis that fail to respond to regular antibiotic treatment. The answer? According to organizations such as the CDC and the American Medical Association (AMA), it lies in reducing the number of unnecessary antibiotic prescriptions and educating the public about the differences between viral and bacterial infections. As an individual, you can protect yourself and your family by talking to your own physician and making certain that he or she prescribes antibiotics only when absolutely necessary. Even though they are more expensive, you might also consider buying freerange, antibiotic-free chicken and beef.
Bacteria and Other Disease-Causing Microorganisms
The third critical element in the initiation of sinusitis is the presence of bacteria or other disease-causing microorganisms. Sinusitis is an infection, frequently brought on by a virus such as a cold or flu, but usually perpetuated by bacteria, and occasionally by a fungus. Bacteria are opportunistic invaders that take advantage of other weakened conditions of the body — in this case, sinus obstruction and immune impairment. Most often, inflammation due to viral infection or allergy is a key component in this process; blocking the ostia, it leads to poor sinus drainage. But whether blockage is due to inflammation or mechanical problems (such as polyps or adenoids), once the sinuses can no longer drain properly, pus, mucus, and other secretions begin to accumulate in cavities. This creates a fertile breeding ground for infectious microorganisms such as bacteria and fungi. The vicious cycle of sinusitis is thus begun, as inflammation that blocks airflow and drainage opens the door to infection, which in turn causes further inflammation and blockage, and so on until the cycle is finally broken by the body's own immune defenses or through medical intervention.
THE DIFFERENT TYPES OF SINUSITIS
To clarify some of the confusion and misperceptions that persist concerning sinusitis, doctors make careful distinctions among the different types of this disease. Specifically, they categorize sinusitis according to which cavities are affected and how long symptoms last. There are four pairs of sinuses: the maxillary, frontal, ethmoid, and sphenoid. (Read more about the anatomy of the sinuses in chapter 2.) The location of sinus pain and swelling depends upon which sinuses are affected. For example, if you have a maxillary infection, your teeth and upper jaw may ache. In contrast, an infection of the frontal sinuses in the forehead causes pain when this area is touched.
Perhaps even more important, physicians make a careful distinction between two major categories of sinusitis: acute and chronic. Both forms of sinusitis can be confusing to diagnose and treat. Acute sinusitis most commonly occurs as a complication of a common cold, but may also be linked with allergies, anatomic abnormalities, or even dental infection. Because they are similar and often overlap, acute sinusitis is often confused with a cold, and thus can be neglected by affected individuals or incorrectly treated by doctors. When this happens, the result can be chronic sinusitis, the symptoms of which are far more subtle and even trickier to diagnose.
By definition, acute sinusitis lasts up to four weeks. Within that time, there is a complete resolution of symptoms such as congestion, postnasal drip, and headache. However, if symptoms linger longer than this, you may have or be at risk of developing chronic sinusitis. In the long run, chronic disease exacts a much deadlier toll on the sinuses. Chronic sinusitis occurs when symptoms persist for twelve weeks or longer. People who suffer from chronic sinusitis may never feel completely right. They always have what seems like a slight cold or nasal congestion, which occasionally flares up into full-blown sinus infection.
There are also two further subdivisions of sinusitis. Subacute sinusitis occurs when symptoms last longer than four but less than twelve weeks. It is especially important to correctly diagnose and treat this type of problem, before it becomes chronic and causes permanent scarring and narrowing of the sinuses. Recurrent acute sinusitis consists of four or more acute episodes in one year. Between these attacks, there are no symptoms. Although sinusitis — no matter what type — is most commonly due to bacterial infection, it may also be caused by a fungus or virus. In the case of recurrent sinusitis, you may be infected by different microorganisms at different times.
Most cases of sinus disease are acute sinusitis. That is, they either respond to treatment or clear up on their own within four weeks. Say you've developed a cold that lasts longer than usual. You have trouble breathing through your nose, and at night a persistent cough disturbs your sleep. To make matters even worse, your sinuses are achy and tender to the touch. In fact, the problem may not be a cold at all — you probably have acute sinusitis.
(Continues...)
Excerpted from Sinusitis Relief by Harvey Plasse, Shelagh Ryan Masline. Copyright © 2002 Harvey Plasse, M.D., and Shelagh Ryan Masline. Excerpted by permission of Henry Holt and Company.
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