Nasal Sinus Problems Vary by Individual But Collectively Are Surprisingly Common and Very Energy-Draining
Does it sometime appear that a rather small organ or appendage, namely, your nose, seems to take near-complete control of your life?
A constantly runny nose that must be blown frequently, turns many of us red-nosed in appearance, not unlike Rudolph the Reindeer or a fairly severe alcoholic you might meet on the street.
Conversely, nasal congestion or stuffiness changes the pitch and timbre of our voices so that we sound like those people in B- grade movies or on low budget cable TV crime reenactment stories trying to phone in a ransom demand with a voice vaguely disguised by putting a handkerchief over the mouthpiece.
It is not unusual for many patients to have sinus headaches, where the nasal blockage or inflammation is caused by abnormal build-ups of pressure in one or more of the several sinus cavities.
Of course, one of the ways the body attempts to resolve blockages or react defensively to an irritating situation, is the socially awkward mechanism of sneezing. Which curiously enough, if repeated several times, tends to become self-sustaining since the attempt to discharge an irritating substance or break through a log-jam of sorts, eventually further irritates the linings of the nose, throat, and back of one’s mouth, perpetuating the cycle.
And there can be the infamous post-nasal drip where phlegm and mucus seem to be redirected in unnatural amounts and colors down the back of own’s throat, prompting all manner of coughing.
What all have in common, if they last long enough, is the patient’s exhaustion.
This is not caused because you’ve been chopping wood. It’s just that you cannot be well-oxygenated if you can’t breathe freely.
While this can be somewhat consciously offset through the awkward but manageable practice of mouth-breathing for daytime hours, significantly increased snoring and even apneic episodes can occur due to blocked nasal passageways.
This impedes refreshing sleep and oxygenation that is vital for you continue to function optimally. Instead, with unremedied nasal sinus symptoms, you just keep increasing your sleep deficit and O-2 desaturation levels.
And in many cases, one loses his or her sense of smell.
Or worse, gets a distorted sense of smell. Things that are supposed to be smell appetizing, have no interest, and worse yet, things that smell bad (coming from you or from somewhere in the environment around you) do not offend you enough to take corrective or evasive actions.
All of these conditions are manifestations of sinusitis, an inflammation of the nasal and facial cavities (sinuses).
These can be caused by infection, allergy, or pollution, and are mostly commonly encountered by most Americans in conjunction with a “head cold” or the “flu.”
According to the National Institute of Allergy & Infectious Diseases’ website , www3.niaid.noh.gov/topics/sinusitis/ , there are 37,000,000 new cases of acute sinusitis reported every year, with symptoms lasting from days to a few weeks.
In addition, there appears to be a deep reservoir of 32,000,0000 chronic rhinosinusitis patients who suffer from months to years with limited relief, if any.
Particularly affected are asthma sufferers, and devastatingly affected are children with cystic fibrosis.
Conservative Over-the-Counter Medical Regimes
Work for Many Patients in the Short Run
Symptomatic relief from sinusitis for many people comes from over-the-counter pills or capsules. These typically contain pseudoephedrine or phenylephrine. They reduce inflammation by shrinking the blood vessels in your nose. This, in turn, cause the swollen membranes to shrink back, allowing freer breathing, and coincidentally helps promote a return to normal mucus production (neither too much nor too solidified).
Antihistamines, which are frequently combined with decongestants, work to reduce inflammation by modulating the cellular immune response that increases swelling and mucus production.
A wide variety of antihistamines are available, with generic names like chlorpheniramine, bromopheniramine, diphenhydramine, and loratadine.
Decongestant/antihistamine-like compounds are also available in spray bottles for instilling into the nose.
A saline solution is often the base of the contained fluid, as this has its own antiseptic and mucus-managing properties.
Many such sprays give prompt relief, but if used for more than three days, the nose actually becomes dependent on them. Ultimately over-use can cause its own “rebound” problems, some as bad or worse than the original condition.
Outright flushing or irrigation of the nasal cavities is gaining a fair amount of attention, and, as in more widely and conventionally used nasal sprays, a saline solution is the base as a low-grade mucus solvent and flusher of allergens or hardened debris.
Intriguingly, the use of solutions including baby shampoo have been reported as successful, although the patients involved had been those who had already had a surgical procedure performed.
One or more of these previous over-the-counter steps is likely to have resolved the short-term nasal sinusitis problems for at least 90% of sufferers.
Prescription Treatments Can Often Help Those for Whom Over-the-Counter Preparations Were Insufficient
The most common step up from any of these over-the-counter treatments, for the remaining 10%, is the prescription of antibiotics, on the assumption that the sinusitis is caused by a bacterial infection, or that the build-up of mucus provided a home for unwanted bacteria, so that the infection was actually secondary to the initial complaint.
Unfortunately, there is a substantial amount of doubt that most of these bouts of sinusitis are initially bacterially caused (most often they are viral or allergic responses). Over-prescription of these drugs in the event of colds and flu is now generally regarded as inappropriate, because it builds up drug resistance.
There is somewhat greater success in reducing opportunistic fungal infections, which actually occur more often, through prescriptions.
Genuine nasal bacterial infection, either primary or secondary to the sinusitis, is encountered in a minority of cases. Unfortunately, it increasingly involves MRSA: methicillin-resistant Staphylococcus aureus.
MRSA is singularly difficult to eliminate in the nose, this type of staph seems to populate the membrane system of the sinus cavities in a particularly well-defended location.
MRSA appears to construct ---- or at the very least densely populate ----a kind of an envelope of protection: a biofilm.
Biofilms are the result of a collective action on the part of some communities of micro-organisms, sometimes including fungi, that allows them to build a thin, polymeric protective barrier out of their own metabolic waste-products or uses apoptotic layers ----essentially a lining of dead bacterial cells, kind of like a callus of dead skin-----as a shield.
The biofilm is semi-permeable. It not only provides the bacteria with shelter, but allows enough nutrient influx, to subsist to some degree upon on the nasal mucus and quite possibly receives metabolic gas exchange through the capillary system of the nose.
In essence, nasal populations of MRSA not only seize the dwelling, but hijack the ongoing deliveries of what are literally vital supplies.
Permanence of any bacterial infection in the nasal sinuses is a problem . Given that the nose drains at least partly into the upper respiratory system, which connects to the lower one, the chances for vastly more serious MRSA infections as seen in pneumonia, and even sepsis are very real.
A key step in MRSA control, ironically whether or not the antibacterial medications worked well through direct action in any particular patient, would be the elimination of the inflamed nasal sinus lining substrate that makes this sort of malevolently populated biofilm possible.
One way this is done is to use nasal sprays that contain light doses of steroids or steroid-like compounds.
The theory is that a topically applied spray of liquid, leads to a localized reduction of chronic inflammation. This in turn leads to a sharp reduction in the favorability of the nasal sinus environment that could support opportunistic hostile infections. Essentially this is an antimicrobial effect, even if the steroids themselves are not antimicrobial by direct action.
It is clear than sprays of this type have the potential to reduce inflammation effectively for an intermediate amount of time, sometimes months, and perhaps a year. But, just like the milder over-the-counter nasal sprays, their longer run use may evolve into a kind of habituation and dependency on the spray to govern the nasal sinus equilibrium on its own.
In other words, if it does not work right away, the steroid does not so much set the stage for a return to a more natural equilibrium: The equilibrium cannot be maintained without the steroid.
This leaves the physician with the option of systemically delivered steroids, most often given in pill form.
Often even more problematic is the long term taking of oral steroids like prednisone. These do calm inflammation responses effectively, particularly at first , even at low doses.
But ultimately, their effectiveness at low doses wanes and higher doses are required. Moreover they actually reduce natural resistance to infection, and have a host of other potential problems with long term use.
These include stomach irritation, “ fattening of the face” effect, osteoporosis, and in some cases, mood swings, and even psychosis.
Nonetheless, by the time various prescriptions have been tried, as high a proportion as 96% will have been satisfactorily treated.
Unfortunately, the remaining small percentage simply does not get any better. They get worse. They don’t die off quickly. It seems as if their lives are dying in little steps: time lost from work, opportunities for good sleep gone, inability to participate in customary physical activities, and no ability to actually appreciate good tastes and pleasant scents.
Essentially, every year, several hundred thousand of nasal sinusitis patients move from the ranks of the 37,000,000 acute cases, the vast majority of which will be effectively cured, to the sad growing accumulation of 35,000,000 for whom no medical cure seems to have worked.
Is The Last Line of Defense, Surgery, a Drastic Step?
What then is left? Two surgical approaches, with the second really a variant of the first.
The first is traditional Functional Endoscopic Sinus Surgery, FESS.
FESS is done with an emphasis on enlarging nasal sinus ducts, cutting both soft and bony tissue. It enlarges the “holes in the bones” so that patent airways can be re-established, much as a traffic-clogged underground tunnel could be enlarged through gouging into the surrounding rock walls to make way for extra traffic lanes.
But this is by no means a crude procedure. Conventional x-rays, CAT scans, MRIs, and even SPECT imaging helps guide the surgical plan of attack, so that airways are re-established in the most severely occluded situations, particularly if there is bony debris from past disease processes (or the concomitant problem in some patients of nasal polyps).
FESS has an absolutely solid record of providing a great deal of relief, and scores well in post-operative exams of patients that verify the continuing presence, and physically measure the extent of the cleared airway, weeks and then months later.
Once the nasal sinus passages have healed and firmed up (particularly toughened up), the sinuses seem to be less welcoming of foreign microbial invaders probably by becoming less conducive to the forming of biofilms.
Gratifyingly, post-operative Quality-Of-Life, QOL surveys disclose high ratings from the vast majority (well over 90%) of patients who were previously recalcitrant to medical interventions. They feel much better and generally experience an overall brightening of mood. They are less fatigued, and most, if not all their sinus pain is gone.
What is the second approach?
Minimally Invasive Sinus Technique: MIST.
MIST abandons the idea of working intentionally on the bony material, and instead focuses on the soft tissue at sinus drainage “choke-points” as it were.
The idea is to go thoroughly through all of these choke points successively during the same procedure.
This has two obvious advantages.
First, healing times, and blood loss is minimized. Dealing only with soft tissue is far less traumatic or dramatic surgery. A 15 minute procedure is not unusual.
Second, because it involves a standardized, systemic clearing process of the whole system of check-points, including both obviously major and less-obviously minor choke-points that could eventually become major, the procedure appears to be at least as preventative as curative.
And, as a practical matter for ENT surgical training, MIST allows for consistency of treatment ( and often consistency of results ) in both very experienced and less-experienced hands, because what gets done is the same for every patient.
How does MIST compare with FESS?
Very favorably thus far, with roughly equal post-surgically measured patency of drainage-ways, and perhaps even greater QOL scores, because the procedure was less frightening, involved less loss of work time, and relatively minimal blood loss and shorter times or minimal use of uncomfortable nasal packing.
The choice of which surgical procedure is best for a particular patient is, of course, best resolved between an oto-laryngologist and his or her patient. The amount of data supporting FESS is still greater, because more ENT surgeons have been using it longer, and there may be some situations where it is going to remain superior to MIST.
But in an increasing number of oto-laryngologic practices , the point is moot. Today, a great many surgeons in this field can perform both types of procedures.
Is surgery then, an infallible last resort? Does it work equally well for all types of patients.
No, there will be a small percentage of patients, perhaps less than 5%, who will need continued combination medical therapy (often irrigations or sprays) and and perhaps surgical revision (doing the procedure over again.)
Which groups do less well with these surgeries? Women, people with aspirin intolerance, people who are chronically depressed, smokers, some asthmatics, and people who have had previous surgical procedure in this area, do somewhat less well.
But even so, most of these patients, in their QOLs report a great improvement, and given the choice would do it again.
Tony Stankus, tstankus@uark.edu , Life Sciences Librarian & Professor
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