Posts Tagged ‘chronic sinusitis’

Many countries have special schools for children with severe asthma and other allergies. Italian children are sent to one in the Italian Alps, where there is no trace of pollen, house-dust mite, or animal allergens. After nine months these children are a great deal healthier and more active - all their lung function tests are vastly improved. Blood tests show that they are actually less allergic to common allergens than before.
You may not be able to do quite this well at home, but all allergens and irritants can be avoided to some extent. Even if you can’t eliminate them completely, you can certainly reduce your exposure.
Before you start, it is important to be clear about exactly what affects you, otherwise you will be wasting a lot of effort. For example, people who are allergic to dust mite often think that a dusty house will necessarily be worse for them than an apparently clean house, but this is not so (see p. 115). Or they may say ‘Oh, I got asthma on holiday, because the roads were so dusty and I’m allergic to dust,’ forgetting that only house dust contains dust mites. The road dust may have acted as an irritant, and helped to spark the asthma attacks, or it may have contained pollen or mould spores - but it does not contain dust mites or their allergens. Blaming the wrong thing for the asthma attack means that the real culprit is not identified.
If you are not absolutely sure what causes your allergies, skin-prick tests (see p. 91) can identify the allergen. These are especially recommended if your reactions to the presumed allergen are inconsistent, or you don’t respond to the anti-allergen programmes described here. For example, a few people who react to house dust are not allergic to dust mites, but to something else in the dust such as wool fibres or mould spores, or particles from cockroaches, house
flies, carpet beetles or a long-departed cat. Even pollen that has accumulated in house dust can provoke allergic reactions - if you are not an over-keen duster, it can still be there long after the pollen season.
If you have hayfever, knowing which pollens cause your symptoms (and learning to recognise the plants concerned) is useful. You will probably need skin-prick tests to be sure. ‘Hayfever’ can even be a seasonal mould allergy in some people (see p. 27).
Tackling allergens is now big business. There are a lot of people out there competing for your money and false claims are common, especially for anti-mite products. Only a few manufacturers are deliberately misleading, and most false claims probably stem from ignorance or wishful thinking, but be very sure you know the facts about your allergen before you buy.
Air cleaners are a good example. A really good quality air cleaner (which uses a HEPA filter - a High Efficiency Particulate Air filter) is an expensive purchase and, as the advertising tells you, it takes out very small particles with staggering efficiency. But this is entirely irrelevant if the source of those particles is no distance at all from your nose - your mite-infested pillow, for example, or the cat on your lap.
Something else that advertisements for air cleaners rarely mention is that unless you reduce allergen production - tackling mould growth in the house, for example, or keeping the dog outside - the filter can’t help much. In short, air cleaners do have their uses for some allergens, but they can’t work miracles.
The products mentioned here, if not available in your locality, can be bought mail-order from specialist suppliers of anti-allergy products (see p. 255). Note that some offer both very good products and distinctly doubtful products, so judge each item on its individual merits. Ask to see scientific evidence that it works.
Don’t be taken in by vague statements such as anti-allergenic’ - get the facts. This label is often used on pillows with synthetic filling, for example, and people assume that it refers to dust-mite allergy, whereas it simply means that the pillow does not contain feathers. But unless you are allergic to feathers, there is no reason to avoid feather pillows. (In fact, if not covered with mite-proof covers, synthetic pillows collect more dust-mites than feather pillows, because the fabric used for the cover is less tightly woven and the mites and skin particles get in more easily.)
Bad advice is also a hazard. Some of it just wastes your time and effort, but some could actually increase your exposure to the allergen. Advice to vacuum floors daily, or to vacuum beds, is commonplace but this achieves little and it means breathing much more allergen unless you have the right kind of vacuum cleaner. One health magazine even advised its readers with dust-mite allergy to ‘air mattresses by regularly turning them’. This will not affect mite numbers at all, but it will shoot massive amounts of mite allergen out of the mattress and into the nose and lungs.
Ridding your house of allergens and irritants is, in itself, a hazardous procedure because more of the offending substances will be released into the air during the work. If you take up carpets or remove mattresses, dust-mite allergens and mould spores will be churned up in their millions. Just bundling up a duvet will produce invisible clouds of dust mite allergen - and cat allergen, if your pet once slept on the bed.
Ideally, the allergic individual should not do the work, nor be in the house until it is 100% complete and the house has been very thoroughly aired. This is particularly important for those with chronic sinusitis and mould growth in the house, because of the risk of fungal infections in the sinuses (see p. 32).
If you are an allergy sufferer and have absolutely no choice but to do the work yourself, or to be present, then you should get a good quality dust mask and wear it throughout - only take it off when you go outdoors. Those with atopic eczema and sensitivity to airborne allergens should cover their skin carefully -with clothing, not barrier cream.
An ordinary hardware-shop dust mask is not adequate for most allergens - it only takes out really big particles and lets through all the common airborne allergens except pollen. You need a more serious sort of mask, designed for workplace use and conforming to official standards. Before buying one, ask what is the smallest size of particle that it filters out (at 90% efficiency, or better). Compare this with the particle size of your allergen (given in the articles that follow).
You must be able to breathe well through the mask when physically active, and it must fit tightly against your face, forming a seal at all edges. Beards and moustaches tend to prevent this - as does stubble.
Masks that combine an activated carbon filter with a dust filter will take out gases and chemical vapours as well as particles. Cycle shops now sell such masks -or try an industrial supplier. Such a mask can be useful if you are affected by traffic exhaust or industrial pollution as well as an allergen, for example, or if you are exposed temporarily to wet paint or other fumes at home. Activated carbon masks should also filter out the irritant substances from oil-seed rape plants.
Some people who try the anti-allergen programmes feel much better quite fast. But generally these are long-term strategies - you may not reap any benefits for a few weeks, and the improvement may be small at first. Sometimes it takes several months for the full effects to be felt, so be persistent.

Tony had suffered from hayfever since childhood but rarely took any medicines. Outside the grass-pollen season, he was fine, free of allergies and very fit. Then, when he was 35 he bought a run-down cottage in the country. The cottage was very damp and dirty.
The previous owner of the cottage, an elderly man, had died, and everything was much as he had left it. Tony moved in with his wife in late summer, and they began pulling out all the old carpets and furniture. Many of the windows would not open and there were dank musty cupboards and attics to be cleared. Dust filled the air – and Tony’s nose. He began to sneeze a little and within a few days he had a strange and unfamiliar feeling of tightness in his chest. During the following weeks, harvesting began in the surrounding fields, with several huge combine-harvesters working away all day and night. Tony noticed that, when out of doors, his eyes began to stream and the tightness in his chest became more noticeable. A few more days passed, and Tony found it harder to breathe, so he reluctantly went to see the doctor. The diagnosis was asthma. Skin-prick tests showed that Tony had allergic reactions to house-dust mite and moulds.
Tony’s case shows how someone who is already sensitised to an allergen – pollen in this case – may be vulnerable to developing new sensitivities, and new symptoms. It was almost certainly the dust mite and mould spores in the cottage that sparked off the trouble, followed by the mould spores from the cereal leaves, dispersed during harvesting.
For people with a tendency to allergies, the dangers of heavy exposure to potential allergens are something to bear in mind. It is surprising how many people with asthma had their first major attack while away from home, sleeping on an old sofa or in a friend’s dusty spare room. The dose of dust-mite allergen that you get from an ancient mattress or eiderdown can be massive.
Managing your allergy symptoms
As well as avoiding the development of new allergies, you need to manage your existing symptoms, and make sure that they interfere with your life as little as possible. For this you need good information and advice, support from your doctor, optimal drug treatment, and careful avoidance of your allergens.
Quite often people have all the information and drug treatment they need, but they still don’t stay on top of their health problems. There can be two distinct reasons for this: either they are not wholehearted about wanting to be well (ambivalence) – or they have never really accepted that they are ill (denial).
Ambivalence
Sometimes being ill has certain benefits – or being entirely well has certain disadvantages. Our state of health determines how people treat us, especially within the family, and the expectations people have of us. It may be comforting to be ill because others are more supportive then, or it may be less risky, because we are not forced to try things (such as sports or other physical activities) at which we might fail or look foolish. Being ill as a child often sets up a pattern for how we interact with the world, which revolves around caution, the comforts of familiarity, and holding back from new situations.
These habitual patterns can survive in the mind long after any real advantages have evaporated. Many people become stuck with a way of thinking and living where ill-health is a cornerstone of their existence. Doctors at the Chelsea and Westminster Hospital in London, who have developed a radical programme for treating atopic eczema (see pp. 46-8), have noticed this in their patients. ‘Old habits die hard and living with a little bit of eczema is a very tempting prospect for many patients, rather than clearing the skin completely…. As atopic skin disease begins for many in the first year of life, causing sometimes understandable alarm and despondency in the parents, the child learns how relevant their condition can be in their relationship with the external world, and with their parents in particular. Before they are able to speak, they have a powerful means of gaining parental attention which can have long-standing effects in the development of their personality. For some, to live without eczema is understandably a daunting prospect. This can be consciously appreciated and spontaneous-y referred to by some patients, while for others the issue will be buried from view, deep in their unconscious.’
If any of this rings bells with you, try to tackle the problem at source. Such mental blocks are not immovable. Indeed, simply recognising that the block is there can start to change things for some people.
Others may need professional help to overcome these longstanding habits of mind. Counselling or cognitive therapy can be very valuable, and your doctor may be able to help in locating a suitably qualified person for this.
Denial
At the opposite end of the spectrum are those who want to deny that they have any kind of health problem. Often these people cannot quite accept that they have a long-term disease, such as eczema or asthma, so they forget to take their drugs, apply creams to their skin, or carry their inhalers. Ironically, these people frequently wind up having far more trouble with their allergies than they need to, and a very poor quality of life, simply because they neglect preventive treatments.
To be really well, you first have to admit that you do have allergies, and then sort out your conflicting feelings about what this means. Again, counselling, cognitive therapy or some other kind of psychotherapy can be helpful.
Dealing with doctors
The decisions that your doctor makes about your treatment are ones in which you should be fully involved. Quite a few allergy patients don’t feel happy about their doctor’s treatment plan, but they never say so to the doctor’s face.
The usual pattern is to accept what the doctor prescribes without any argument, but then halve the dose of tablets, or only put the cream on once a day instead of twice, or not use the Inhaler at all. Some people stop and start their drugs in a random way because they never quite make up their minds about whether drugs are a good thing or not.
This approach to allergies invariably leads to worsening symptoms. The risks are greatest with complex problems such as
atopic eczema or chronic sinusitis, where a vicious circle can easily be set up if the disease is not brought under control, and for those with a life-threatening condition such as asthma. In the case of asthma, neglecting preventative treatment can be fatal.
It is far better to say what you think in the surgery, and discuss any misgivings you may have about drugs with the doctor. That way you can agree on a treatment regime that you are prepared to stick to – which may or may not involve drugs. Most doctors would far prefer a little plain speaking at the outset to having a patient who is half-hearted about following the treatment plan and never really improves.
A more serious form of communication breakdown occurs when a doctor stops believing what a particular patient says. This usually occurs because the doctor has decided that some or all of a patient’s symptoms are due to psychological rather than physical causes. (This is far more likely to happen to those with intolerance or unusual forms of allergic reaction than to those with classical allergic diseases.) Sometimes doctors say what they think, but often they don’t – they just start treating the symptoms in a different way, or acting impatiently, or saying rather puzzling things that leave the patient trying to guess what is going on.
If you find yourself in such a situation, the main thing to do is stay very calm and be very rational. Getting upset, or challenging the doctor’s opinion in a manner that seems at all aggressive, instantly confirms the ‘psychological’ diagnosis. Unfortunately, insisting firmly that the symptoms are not psychological also confirms the diagnosis as far as many doctors are concerned (see p. 237) which can be extremely frustrating. To begin with, deal with the situation by informing yourself about your illness. Be tactful and patient but persistent with the doctor, trying all the time to keep the relationship pleasant and the channels of communication open. If, after giving it a fair try for some weeks or months, this approach isn’t working, you should look into the possibility of changing doctors (see p. 88).
Emergency alerts
An emergency alert bracelet or pendant should be worn by anyone who:
• is allergic to latex rubber, or to drugs such as penicillin
• has a severe allergy to insect stings
• suffers from exercise-induced anaphylaxis, or anaphylactic shock as a result of food allergy
• has very severe asthma attacks.
Key information is engraved on the bracelet, along with a telephone number which gives medical staff access to a computer database containing vital medical data about you. This valuable service is provided by a non-profit-making company called Medic Alert.
As everyone knows, a little knowledge is a dangerous thing. You can use the information in this book to help yourself, but it’s important to remember that there is no substitute for the comprehensive understanding of the human body that your doctor gained during many long years at medical school. Always check with your doctor before changing your diet, stopping your drugs, practising breathing exercises, taking a non-prescription medicine or trying any other experimental treatment.
The information about disease, diagnosis and treatment in this book falls into four categories:
• basic information about the disease that no doctor would disagree with
• the findings of new research, or research that has not become widely known, but which falls within the accepted medical model of the disease concerned. Your doctor may not know about some of this research (there is a terrifying amount of new information bombarding doctors every week, and no one can keep up with it all) but he or she won’t find it unbelievable.
• evidence from research that is entirely valid, but which is widely ignored or dismissed because it falls outside the accepted medical model of the disease concerned (see pp. 86-7)
• information based on the repeated observations of doctors, or of patients – this does not amount to scientifically valid evidence, but it’s included here if it seems plausible and if it could be useful to some readers.
You should be able to tell, from the context in which it is presented, which category any item of information falls into. When talking to your doctor about items that belong in the last two categories above, be prepared for a certain amount of scepticism or possibly outright dismissal.
The important thing to ask the doctor is if there is good reason why you should not try the suggested measures, in addition to your usual treatment – is there any risk involved, given your particular state of health? Make it clear that you want to try the additional treatment with an open mind and will drop it if it is not helping. Ask for the doctor’s help in assessing the effects of the treatment objectively.
Managing asthma
Of all the diseases described in this book, asthma is among the most difficult to live with, especially severe asthma. Learn to recognise asthma symptoms before they get out of hand, and take immediate action.
Studies of patients who die from asthma attacks find that the deaths could, in almost all cases, have been prevented. Factors contributing to fatal attacks include:
• heavy exposure to allergens just before the asthma attack
• cigarette smoking
• failure to use preventer drugs
• repeat prescriptions for inhalers being given without the patient seeing a doctor
• delays in seeing an asthma specialist
• depression in the asthmatic leading to neglect of treatment.
For the day-to-day management of asthma, you should have a written management plan prepared by your doctor or asthma nurse.
This should tell you how often to take your drugs under normal circumstances, and what to do if your symptoms change or you develop a cold or chest infection. The actual brand names of your drugs (or the colour of the inhaler) should be included on the management plan. Assuming you have a peak-flow meter – and you really should have one –specific peak-flow values should be included on your management plan, with instructions for how to respond if your peak flow falls to these levels.
Your plan should tell you how to recognise a severe attack coming on, and what to do at the various stages of the attack. (This personal management plan is specifically geared to you or your child. Although pp. 100-101 give generalised advice, your own plan is invaluable.)
Be sure that you know exactly how the advice in the plan relates to the sort of real-life situations you experience. No matter how good your plan, real life can sometimes be far more complex than anyone anticipates, so there may be times when it is difficult to know what to do. When this occurs, make a note of the situation, and the reasons why you are unsure how to implement the plan. Call your doctor immediately if your asthma is getting worse, and get the asthma attack under control. Save your notes and, at the next opportunity, check with the doctor what you should have done in those circumstances. This will help you to build up your detailed knowledge of how to manage your asthma, or that of your child.
Research shows that asthmatics can, with training, develop a greater awareness of how narrow their airways are – this helps you to detect worsening asthma before things get too serious. You can train yourself in this art by guessing what your peak flow will be and writing your guess down before you use your peak-flow meter (see right) each day. Over a period of weeks, you should find your guesses getting closer to the true value.
A key part of asthma control is having everything with you that you need in case of an attack. It’s tedious, but you have to do it. You should take your reliever inhaler with you wherever you go. Those with severe asthma can also benefit from carrying a collapsible spacer (ask your pharmacist or see p. 255 for contact details of suppliers).
For a long day out, or a stay away from home, check that you also have:
• your management plan
• your peak-flow meter
• your preventer inhaler
• steroid tablets, if you sometimes need these
• your doctor’s phone number.
A little lateral thinking may be needed regarding the problem of carrying all this kit around. One asthmatic friend of mine carries his inhalers in a trendy-looking camera bag that goes everywhere with him. Mothers of asthmatic children have solved the problem by making an ‘inhaler pouch’ from a sunglasses case and attaching it to a favourite belt or by enlarging the pocket in a teenager’s jacket to accommodate inhalers.
Anyone with severe allergies to food or insect stings should take similar steps, so that carrying their auto-injector everywhere is a simple matter.
Peak-flow meters
A peak-flow meter can detect narrowing of your airways – the beginnings of an asthma attack – before there are any obvious symptoms. It measures the maximum speed at which you can force air out of your lungs. The signs of worsening asthma include:
• a morning reading which is less than 75% of the evening reading
• average readings less than 75% of your best-ever reading. (If they get to less than 50% of your best reading, this is a severe and possibly life-threatening attack.)
To use a peak-flow meter:
• push the pointer to zero and hold the meter horizontally
• keep your fingers away from the scale and the pointer
• breathe normally before you start
• stand up and take a deep breath, but don’t puff your cheeks out and don’t hold your breath before you blow
• seal your lips tightly around the mouthpiece
• blow hard into the meter, as if blowing out candles on a birthday cake; don’t move your tongue while doing this
• repeat three times, and record the highest reading of the three.
You must learn how to use a peak-flow meter from your doctor or asthma nurse, who should also check your technique regularly – it is very easy to get into bad habits.

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.