Sinusitis in Allergy.
Sinus cavities are something that most people just don’t know they have. It’s only when they start to
hurt that you find out where they are. ‘There is this terrible throbbing pain above and around my eyes,
and in my cheeks. It’s the most unpleasant feeling, but it’s hard to describe to anyone who hasn’t felt
it,’ says Gina, who suffers from chronic sinusitis (long-term inflammation of the sinus cavities).
There are no figures, but chronic sinusitis seems to be increasingly common.
A sinus cavity has no function, it is just empty space without which our skulls would be much heavier.
In other words, these airy spaces seem to have evolved simply to help us feel more ‘light-headed’. If
you have sinusitis, unfortunately, you feel just the opposite. ‘I had sinusitis for years,’ says Dr
Wellington S. Tichenor, a New York allergist who now specialises in treating chronic sinusitis. ‘I kept
working but felt like I wanted to die.’
Sinus cavities are lined with a membrane which is essentially similar to that lining the nose. It
contains immune cells and can produce mucus when necessary. Most of the time it doesn’t need to produce
much, because relatively few microbes or foreign particles get into the sinus cavities.
Any mucus that is produced should escape from the sinus cavities through narrow drainage channels,
called Ostia, leading to the nose. Unfortunately, the Ostia are very narrow – the diameter of a
pin-head – and U-shaped, making them prone to blockage. And that is not the only problem. These
drainage channels are situated at the top rather than the bottom of the main sinus cavities – this
arrangement was fine for our ancestors who walked on all fours, and therefore did not have to fight
gravity when clearing their sinuses. Sadly for
us, natural selection has not got around to reorganising things yet. It would be a completely hopeless
arrangement if not for the tiny hairs known as cilia, which lie like a carpet across the membranes
lining the sinus cavities. The cilia beat rhythmically. 18 times a second, to waft the mucus upwards to
the top of the sinus cavity.
This is a far-from-perfect system, and it is hardly surprising that it sometimes goes wrong. Chronic
sinusitis can begin in at least three different ways:
• The sinus membranes become inflamed due to an allergic reaction – 28 for likely airborne
allergens.
• The drainage channels from the sinus cavities become blocked due to events in the nose
(infection or allergy) or due to the growth of polyps (non-cancerous jelly-like lumps that can block
the drainage channels). When mucus cannot drain away, it stagnates in the sinus cavities encouraging
infection by bacteria or fungi. These infections cause inflammation.
• A bout of acute sinusitis (see box on p. 31), due to bacterial infection, never really goes
away and the persistent infection causes longterm inflammation. Note that this is unlikely: it is rare
for acute sinusitis not to clear up.
Whether the problem begins through allergy or blockage or infection, once it has begun a vicious circle
can be set up all too easily. Mucus output increases when there is inflammation, blocking the drainage
channels even more, so the sinus cavities become clogged up and increasingly uncomfortable. More mucus
pooling in the sinus cavities perpetuates any existing infections and fosters new ones.
All this infection results in more severe inflammation, causing the membranes which line the sinus
cavities to swell up. Inflammation also makes polyp growth more likely. The cilia may be lost or
severely depleted, and the mucus gets thicker. All this means yet more blockage. To cap it all, there
can be allergic reactions to some of the microbes involved (see right), fuelling the inflammation
further.
The body’s own attempts to clear the sinuses are defeated, and the problem is also very resistant to
medical treatment. This may make depressing reading, if you have chronic sinusitis, but don’t despair.
Understanding the complexities of the problem is a large part of the battle. Chronic sinusitis is not
invincible, if you have a good doctor to help you - that means a doctor who also understands these
complexities.
The symptoms of sinusitis are:
• pain and a sense of swelling or unpleasant fullness around the cheeks, or over and between the
eyes
• earache or headache; pain around the teeth
• reduction in the senses of smell and taste
• sore throat
• coughing, particularly at night
• post-nasal drip (mucus from the back of the nose running into the throat and airways)
• bad-smelling breath
• feverishness
• for some people, severe fatigue, poor concentration and even (but very rarely) psychiatric
symptoms
• irritability, especially in children.
Note that any of these symptoms can be caused in other ways, and even if you have several of them, you
may not necessarily have sinusitis. On the other hand, sinusitis can go unrecognised - to some people
it may seem like nothing more than a lingering cold.
Acute or chronic?
In medical terms, ‘acute’ means short-lived, while ‘chronic’ means long-lasting.
Acute sinusitis — a short, sharp dose of it, lasting less than 3-4 weeks - usually follows on from a
cold. Colds are caused by viruses, but a bacterial infection can follow, and it is the bacteria that
move into the sinus cavities and cause trouble. Some people are far more susceptible than others and
have an attack of sinusitis after every cold.
Chronic sinusitis means symptoms lasting more than three months, according to some authorities, but the
time point is a little arbitrary. This article deals with chronic sinusitis.
If your sinusitis has been going on for between four weeks and three months you will obviously be
asking ‘Is this acute or chronic?’ At this point, no one can say, but you would certainly be wise to
seek some expert medical treatment now, on the basis that it could be the start of chronic sinusitis.
Tackling chronic sinusitis before the problem becomes
entrenched and complex is a good plan.
Allergy and chronic sinusitis
Chronic sinusitis is not necessarily an allergic disease, but it can be connected with allergies (or
other forms of immune sensitivity) in various ways:
• Allergic reactions can occur in the sinuses, usually in conjunction with allergic reactions in
the nose.
• Even if the allergic reaction does not affect the sinuses directly, allergic reactions in the
nose can block the drainage channels from the sinuses, causing an accumulation of mucus there. This may
lead to sinus infections.
• Once sinusitis has begun, infectious fungi (moulds) in the sinuses may provoke allergic
reactions, or other forms of immune sensitivity. This allergy to ‘the enemy within’ fuels more
inflammation and more mucus production. Right now, allergic fungal sinusitis (as it is known) is a
source of heated debate - 32. Allergic reactions to some of the bacteria that are present may also
occur.
• Chronic sinusitis - however caused - can contribute to asthma. Research on children with both
sinusitis and asthma found that 80% no longer needed asthma drugs once their sinusitis had been
treated, and 85% no longer wheezed. The link may be due to post-nasal drip, increased mouth-breathing,
or to a nerve-connection between the sinuses and the airways (the sinobronchial reflex) which can
stimulate airway inflammation. Alternatively, the sinusitis may simply fire up the immune system with
messenger chemicals in the bloodstream, resulting in more powerful responses throughout the body.
• Chronic sinusitis can also be the root cause of long-standing nettle rash (chronic urticaria),
and treating the sinusitis can result in a prompt and remarkable clearance of the skin symptoms.
• Some people who have chronic sinusitis are sensitive to aspirin (see box on p. 28) - a
sensitivity which is also linked with asthma, nasal polyps, rhinitis and chronic urticaria. Avoiding
aspirin and all other aspirin-like drugs (151) may substantially improve the sinusitis.
Diagnosis
Because so many different factors can play a part in chronic sinusitis, diagnosis should, ideally,
consider the problem from several different angles:
• The sinuses are viewed using X-rays and CT scans (computed tomographic scans - they use X-rays
but give a much more precise picture). These reveal how badly swollen the sinus membranes are, which
sinus cavities are blocked, and how much mucus has collected in the sinuses.
• Endoscopy (92) may be used to look inside the sinus cavities. Polyps are best located by this
method.
• Where allergies seem to be part of the picture, the doctor may employ skin-prick tests (91) to
identify allergies to airborne allergens (from house-dust mites, moulds, pets, pollen, cockroaches,
etc.)
• Laboratory tests on samples taken from your sinus cavities will be used to show which bacteria
and/or fungi have set up home there. There may also be a hunt for the immune cells known as eosinophils
(19) or the typical debris which they generate. The presence of large numbers of eosinophils is one
indication of allergic fungal sinusitis (see below).
• Skin testing with fungi (moulds) found growing in the sinus cavities may also be tried if
allergic fungal sinusitis is suspected.
• In severe cases, there may be tests of immune function, to see whether this is depressed in any
way.
• Children may be tested for an inherited disorder affecting the cilia, or for cystic fibrosis -
mild forms may escape detection, and can produce both chronic sinusitis and wheezing.
The enemy within
The biggest controversy in sinusitis research at the moment concerns allergic fungal sinusitis. The
orthodox view of this condition is that:
• It affects a small minority of chronic sinusitis patients -fewer than 10%.
• There is a true IgE-mediated allergic reaction to the fungus (mould) growing in the sinus
cavities. This allergic reaction is detectable with a skin-prick test (91). Immune cells known as
eosinophils (19) are also key players in the inflammatory reaction to the fungus, but it is an
IgE-response to the fungus that draws the eosinophils into the sinuses.
• There is clear evidence of fungal infection in the mem- banes of the sinus cavities.
• There may also be ‘fungus balls’ - a solid mass of fungus inside the sinus cavity. Or there may
be ‘allergic mucin’, a dark sticky mucus containing fragments of the fungus.
A rare complication
In rare cases, the fungi involved in allergic fungal sinusitis can be invasive, spreading from the
sinuses to the surrounding bone. This problem needs prompt and thorough treatment with anti-fungal
drugs.
In 1996, researchers at the Mayo Clinic in Rochester, Minnesota, USA, caused a rumpus by claiming to
have identified a different form of allergic fungal sinusitis which is overlooked by standard
diagnostic techniques, and which affects 96% of patients with chronic sinusitis.
This is a staggering figure - 96% means, in effect, that they are claiming to have found the
fundamental cause of virtually all chronic sinusitis. ‘Up to now, the cause of chronic sinusitis has
not been known. Our studies indicate that, in fact, fungus is the likely cause of nearly all of these
problems,’ states Dr David Sherris, one of the researchers.
According to the Mayo Clinic team:
• The fungi (moulds) are growing in the mucus of the sinus cavities, not generally in the
membrane itself. They are not detected by normal diagnostic methods which tend to ignore the mucus. A
special method of collecting the mucus is required to detect the fungi.
• The immune reaction to the fungi is not usually an IgEmediated reaction, so skin-prick tests
are often negative.
• Finding evidence of unusual numbers of eosinophils is adequate for diagnosis of allergic fungal
sinusitis because the eosinophils are the prime movers in this sensitivity reaction to the fungi, as in
several other diseases (19).
‘We can now begin to treat the cause of the problem instead of the symptoms,’ says Dr Eugene Kern, head
of the research team. There is a lot of scepticism about these claims among other sinusitis
specialists, and so far no new treatment for chronic sinusitis has emerged.
The Mayo Clinic researchers say that they are in the process of developing a drug treatment, but that
it will take several more years before it is generally available. Existing anti-fungal drugs (taken in
capsule form) could not work on this particular form of allergic fungal sinusitis (if it exists)
because the drug does not get into the mucus. Any new treatment would probably involve inserting an
anti-fungal drug directly into the sinus cavities, which is far from easy.
All we can do for now is wait and see what emerges from the ongoing research. The current treatment for
allergic fungal sinusitis involves all the usual methods (see right) with special emphasis on steroids
to calm the inflammation, plus anti-fungal drugs where fungal infection is detectable in the membrane.
In some countries, immunotherapy is also used to reduce the immune reaction to the fungus, but this is
difficult to obtain in Britain (164).
Clearing moulds from your home may help (34). So may reducing the humidity in the house (119), as humid
conditions seem to be linked with allergic fungal sinusitis.
Treatment
Sinusitis can be very hard to treat, particularly if it has been going on for a long time. You need a
really committed attitude if treatment is to be successful.
All these treatments should be given at the same time:
1 Antibiotics for 2-3 weeks minimum (it takes this long because the antibiotic has such trouble getting
into the sinus cavities – if you are offered a shorter course, this suggests that the doctor does not
have enough expertise with chronic sinusitis, so you might be better off with someone else). It must be
the right antibiotic – commonly used ones such as penicillin, tetracycline and erythromycin are
unlikely to work because the bacteria are usually resistant to them.
2 Steroid drops in the nose to combat the inflammation. It is important to put these in correctly, so
that they have maximum effect (144) especially if you have polyps.
3 Irrigating the nose and sinus cavities daily with sterile salt water (saline). Your doctor will show
you how to do this.
4 Tablets that reduce the congestion in the nose.
5 Nose drops that reduce congestion, but for three days only (29).
6 Steam inhalations to loosen the mucus. There are special steam vaporisers on sale (ask at a
pharmacy), but you can just inhale steam from a bowl of boiling water, with a towel over your head to
keep the steam in. Adding eucalyptus oil to the water may help. For a quick-and-easy version, warm up a
damp flannel in the microwave and place it over your nose. Some doctors recommend having a steam
vaporiser beside the bed at night, when nasal blockage is most likely to occur, but if you have
allergies to house-dust mite or moulds this is not a good idea in the long term, as a damp bedroom will
favour both (and could encourage allergic fungal sinusitis).
7 A drug called guaifenesin which thins the mucus is used in some countries but rarely in Britain.
Alpha-methyl-cysteine is another drug that breaks up mucus. It is mainly used in chronic bronchitis but
some doctors also find it valuable in chronic sinusitis. If steam inhalations didn’t work – suggesting
that the mucus is too solid to be shifted – these drugs may be worth trying.
8 Anti-fungal drugs (taken by mouth) if allergic fungal sinusfis is suspected. Sometimes these have a
dramatic effect on chronic sinusitis that has previously resisted treatment.
You may also be given other drugs, such as steroid tablets. The new anti-leukotriene drugs (149) are
also being tried, with some success. As well as being taken by mouth, they can be applied directly to
the nose in an irrigation fluid, and may be helpful for those with nasal polyps.
Problems with nose drops
Nasal drops and washes contain preservatives and other non-drug ingredients. Some of these may act as
irritants – or the pH (acidity or alkalinity) of the preparation might cause problems. If you
experience burning or irritation after inserting drops or irrigating the sinuses, ask your doctor or
pharmacist about trying a different preparation.
Antibiotic resistance
Bacteria are becoming resistant to the effects of antibiotics: it is probably the biggest headache
facing modern medicine.
This is emerging as a particular problem in chronic sinusitis because many patients have been dosed
very regularly with antibiotics. Although most of the bacteria have been killed each time, the fact
that the sinus cavity is so clogged up with mucus, and so badly accessed by the bloodstream anyway,
means there is always some nook or cranny where a few bacteria survive because they have not been
exposed to the full lethal dose of the antibiotic. As you might expect, these survivors tend to be the
‘tough ones’ – those bacteria that are not just well hidden but also the least sensitive to the
antibiotic.
Repeat this process many times, with frequent courses of antibiotics (separated by intervals during
which the hard-to-kill bacteria multiply in numbers) and what happens? Eventually you breed a race of
bacteria that are completely resistant to one or more of the antibiotics taken.
If you ever get to this point with your sinusitis, treatment is going to be extremely difficult. That’s
why it is so important to treat infections really thoroughly, and get rid of them completely. Expert
medical help is essential for this treatment campaign.
Too many people with chronic sinusitis are careless about taking their antibiotics regularly, or feel
ambivalent about them and stop the course before it’s complete, or don’t see the doctor again when the
tablets are used up. This is courting disaster.
Don’t start antibiotic treatment for chronic sinusitis until you are sure you can see it through. If
you have doubts about taking antibiotics, try all the other treatments and self-help measures first.
They may be sufficient, especially if you find you have an allergy underlying the chronic sinusitis and
can tackle this successfully.
Should there be no improvement, you could then go on to the antibiotic programme: delaying this
treatment for a few months will do no harm. What is hazardous is starting the antibiotic programme and
then stopping, or not taking the drugs consistently.
Antihistamines may be prescribed to treat any allergic reactions, but some specialists feel that they
can also aggravate the problems. In their experience, antihistamines dry out the mucus so that it
sticks to the walls of the sinus cavities, rather than being ushered out by the cilia. Drying out the
mucus may make you feel better initially, by reducing the pressure inside the sinus cavities, but it
makes matters worse in the long run.
Anti-chollnergic drugs (156) are sometimes prescribed for chronic sinusitis, but they too can dry up
the mucus and should be used cautiously.
After three weeks, if the sinusitis has not improved substantially, a different antibiotic is given. If
there are any bacteria resistant to the first antibiotic infesting your sinus cavities, the new
antibiotic is intended to kill them off.
Should you still have sinusitis after another three weeks, you will be given yet another antibiotic.
Changing the antibiotic, and taking prolonged courses, is the best way of exterminating the bacteria
completely, which prevents the development of antibiotic-resistant bacteria (see box at left).
It is crucial that you always see the doctor promptly at the end of each course, so that there is no
gap between the courses – do not give the bacteria any opportunity to build up their numbers again. The
last antibiotic treatment should continue for at least a week after symptoms clear up.
Dealing with allergic reactions is also important:
• If you cannot get allergy tests, try to work out for yourself if an allergen is playing a part.
Ask yourself if there were any changes in your life before the sinusitis began, such as getting a new
pet, moving house, increased exposure to moulds or house-dust mite, or starting a new job with exposure
to allergens. When thinking about this, remember that allergies to newly encountered allergens do not
develop immediately – it may take up to two years. Try avoiding the allergen concerned and seeing if
you improve.
• Should you discover that an allergen is at the root of the problem, but have difficulty
reducing your exposure to the offending item, try to obtain immunotherapy (164) or another form of
desensitisation treatment (210).
• If you suspect allergic fungal sinusitis (32), it is well worth eliminating any mould growth in
your home (120). One research study showed that the moulds growing in a patient’s sinus cavities were
often the same as those growing in the patient’s house. It is possible that, by inhaling the mould
spores from moulds in their houses, sinusitis sufferers are continually reinfecting their sinuses.
Various other self-help measures can be valuable during this medical treatment:
• Reduce your exposure to cigarette smoke (including other people’s) to an absolute minimum.
Cigarette smoke acts as an irritant to the nose and sinuses, but, more importantly, it paralyses the
cilia, preventing them from shifting mucus out of the sinus cavities.
• Avoid breathing other irritants, especially ozone (130). Think about the chemicals you use both
at work and at home – could any of these be irritants that are aggravating your sinusitis?
• Don’t drink too much alcohol – it dries out the sinus membranes and makes matters worse.
• Drink plenty of water, to keep your mucus from becoming too dry and therefore hard to shift.
• Try to breathe through your nose as much as possible. The amount of oxygen in your sinus
cavities drops drastically if you breathe through your mouth, and the low oxygen level probably fosters
the growth of certain bacteria. Devices, such as nose clips, that help keep the nose open at night may
be worth trying.
• Spicy food can help to clear nasal and sinus congestion, so try eating chilli or hot curry
regularly.
• Some people find that garlic helps – either eaten or sniffed.
• If you suspect that your sinusitis might be related to food sensitivity (68) consider trying an
elimination diet to identify the culprit food.
• Observe your reactions immediately after eating – some foods, such as yeast and red wine, can
cause an immediate swelling of the nasal membranes in certain people. So can sulphite food additives.
Avoid such items if you are affected.
• Treating gastro-oesophageal reflux (acid regurgitation from the stomach after meals) can
improve sinusitis.
• See an osteopath. By gently manipulating parts of your face, a good osteopath may be able to
improve the drainage from the sinus cavities.
• Some patients experience good effects from acupuncture although there are no observable changes
on CT scans. Other alternative therapies, such as homeopathy or Chinese herbal medicines, have not been
investigated scientifically, but some patients report good results.
Prolonged courses of antibiotics destroy many of the beneficial bacteria in the intestine, and may
cause long-term bowel problems. It makes sense to take a bacterial replacer (205).
Surgery for sinusitis
Chronic sinusitis sufferers may be offered surgery to remove polyps, or to correct anatomical problems
such as a deviated septum (the central division of the nose).
These operations can be very useful, but if you have asthma try all other options first, because
surgery to the nose can sometimes make asthma much worse.
Surgery on the sinus cavities themselves is also a possibility, when sinusitis does not respond to
medical treatment. The operation enlarges the natural drainage channels, so that mucus drains away more
easily. This rarely cures chronic sinusitis completely, but it usually makes it much easier to manage.
Once the drainage channels are larger, antibiotics can be put directly into the sinus cavities, for
example, avoiding the need for antibiotic tablets.
Don’t agree to surgery unless other forms of treatment, such as allergen avoidance or immunotherapy,
have been tried to the full. Patients for whom surgery seemed to be the only answer have sometimes
found they did not need an operation once their allergies were treated.
If you decide on having an operation, make sure your surgeon has a proven track-record with this type
of surgery. Don’t be afraid to ask searching questions about how many operations of this kind the
surgeon has done, how many he or she carries out per year, and the complication rates (how often things
go wrong). It’s a delicate job, and you want a real expert.