Sinusitis

The facial sinuses, formed within the skull bones and located around the nose, consist of 4 pairs of cavities which are interconnected and mucous membrane-lined, that drain into the nasal cavity. Each of the sinus cavities are named after the particular facial bone(s) that shape(s) them, including:

1. Fontal sinuses, are located above the eyes in the brow area.
2. Maxillary sinuses, are located on either side of the face inside each cheek bone.
3. Ethmoid sinuses, are located behind the bridge of the nose, and between the eyes
4. Sphenoid sinuses, are located deeper, behind the ethmoids, above the nose and behind the eyes.

The main function of the sinuses are to circulate air. For this purpose they are lined with specialized cells that produce mucus and cells that possess tiny hairs, known as 'cilia'. Further, the sinuses contain a thin layer of watery mucus that traps and filters out pathogens and other harmful particles from inhaled air. Simultaneously, the cilia pulsate rhythmically so they are able to sweep the stagnant mucus out of the sinuses and into the nasal cavity for final excretion through the nose.

The sinuses not only catch unwanted material before it reaches the lungs causing further damage in other respiratory areas, the mucus and cilia also work together to warm and humidify the sinuses and nasal cavities so they remain moist and do not dry out during breathing. The sinuses also generate high concentrations of nitric oxide, a free radical and immune-mediator, which may serve to maintain sterility, strengthen immune defense against viruses and bacteria, and enhance the efficiency of cilia in clearing excess mucus (DeMuri 2009; Keir 2009).

Sinusitis can be acute, subacute, chronic, or recurrent acute; categorization is dependent upon duration and frequency of the experienced symptoms.

• Acute – Symptoms have a sudden onset, and last less than 4 weeks
• Subacute – Symptoms last from 4 to 8 weeks
• Chronic – Symptoms last longer than 8 weeks
• Recurrent acute – Symptoms occur 3 or more times per year and last less than 2 weeks.

Symptoms of sinusitis, associated with any of the four categories include (to varying intensity):

1. Throbbing facial pain or pressure in one or all of the sinus cavities. This symptom is present in the same location as the affected sinus (eg, in the forehead, cheeks, nose, or between the eyes). The pain experienced is the result of increased pressure caused by trapped air and mucus. This pressure build up pushes on the affected sinus mucous membrane and bony wall behind it. Another contributing factor to sinus pain can be negative pressure within the sinuses, this normally occurs due to blocked sinus openings that do not allow air to enter creating a vacuum space.
2. Sinusitis is also often marked by a change in the characteristics of nasal secretions. Normal mucus change from healthy clear and watery to thick and opaque (presenting in various colors such as white, yellowish, greenish, or blood-tinged) indicating infection. Once healthy mucus loses water it becomes thick and trapped within the sinus cavity. Because it can't be excreted the mucus becomes saturated with inflammatory mediators and appears discolored as it mixes white blood cell.
3. Other symptoms that may be experienced with sinusitis include:

• Headache
• Postnasal drip
• Sore throat
• Reduced sense of smell and taste
• Halitosis (bad breath)
• Ear pain/pressure
• Nasal congestion and runny nose
• Cough (which may be worse at night)
• Fever
• Fatigue
• Aching teeth

When symptoms of the common cold or viral sinusitis do not improve after 10 days or worsen after 5 days, bacterial sinusitis may be suspected (Balkissoon 2010; DeMuri 2009).

The focus of conventional pharmaceutical options is to reduce inflammation in the sinuses and nasal passages. One option is to prescribe using corticosteroids and decongestants, though unfortunately some people receive only limited, or minimal, symptom relief through this treatment option.

Alternatively, antibiotics are often needlessly over-prescribed since most cases of acute sinusitis are caused by viruses, which do not respond to antibiotics, and chronic sinusitis can be caused by chronic inflammation or anatomic irregularities. The danger with inappropriate use of antibiotics is the possible lead to antibiotic-resistant organisms and an unnecessary increase in antibiotic-related adverse events such as diarrhea.

The nasal passages are usually heavily colonized with bacteria, but the paranasal sinuses are generally free from bacteria and other potentially harmful organisms. However, the ostia (drainage openings) that allow the sinuses to empty into the nasal cavity are relatively small, and are thus vulnerable to becoming blocked. When this drainage system through the ostia becomes blocked, the stagnant mucus begins to accumulate thus allowing bacteria and other pathogens to colonize in the sinus cavity. This build-up of infected mucus results in inflammation and infection - known as sinusitis.

The blockage of the ostia is usually caused by two leading contributing factors: mechanical obstruction, various swelling contributors, such as:

Swelling Factors

• Viral upper respiratory tract infection (i.e., common cold)
  
• Allergies (i.e., hay fever, allergens, irritation)
• Cystic fibrosis
• Chemical inhalation (i.e., tobacco smoke, pollution)
• Immune disorders
• Facial injury (i.e. broken nose)
• Changes in atmospheric pressure (i.e., flying, scuba diving)
• Overusing nasal decongestant sprays

Mechanical & Anatomical Obstructions

• Deviated septum
  
• Nasal polyps
• Foreign body
• Congenital deformity
• Tumor
• Nasal bone spur

Although there are multiple risk factors that can contribute to ostia obstruction, allergic inflammation and viral upper respiratory infections (URIs) are the most significant causes. Since the function of cilia is largely dependent on the quality and quantity of the surrounding mucosal fluid, diseases that dry out the mucosal layer or affect its viscosity (eg, cystic fibrosis) may also contribute to sinusitis (DeMuri 2009; NIH 2012). Ostia blockage is also associated with an increase in mucosal viscosity because the trapped mucus begins to lose its water content. In rare cases, fungi can cause sinusitis (NIAID 2012). People with abnormal sinus structures or those with weakened immune systems are more vulnerable to fungal sinusitis (NIAID 2012; Mayo Clinic 2012b; Riechelmann 2011

Sinusitis is usually diagnosed based upon a physician’s assessment of a patient’s symptoms and medical history. In some cases, when a patient presents with a history of upper respiratory infection and symptoms lasting from 7 to 10 days, a bacterial culture may be obtained.

The majority of sinusitis cases are caused by viral infection, and antibiotics are generally not needed in these cases as it will not make any difference in recovery time. Since the symptoms of viral sinusitis are mild-to-moderate and typically resolve on their own within 10 days or less, they can often be managed via self-care techniques and/or home remedies such as steam inhalation, herbal teas and supplements.

• Ensure you get adequate rest. This will help the body fight infection and speed-up the recovery process.
• Elevate your head while sleeping by using an extra pillow to reduce congestion and keep the sinuses draining properly - this will also assist in easier breathing, take care not to strain your neck.
• Stay hydrated with clean, fresh water. This helps flushing out toxins and to thin out mucus secretions and promote drainage of the nasal cavities. Sipping hot beverages may also help, since they can dilate blood vessels and promote drainage - add some lemon and honey for taste and positive benefits.
• Avoid alcohol and caffeine consumption, since they can cause dehydration and contribute to nasal and sinus swelling. The milk may also aggravate mucus formation.
• Eat a healthy, well-balanced diet, which includes plenty of fruits and vegetables (organic where possible); a diet rich in antioxidants may boost immune function and help fight infection.
• Try steam inhalation (with a few drops of eucalyptus and/or tea tree essential oil) 3-4 times daily to open sinus passages. This can help reduce pain and help clear mucus. Steam inhalation can be done by draping a towel over the head and inhaling rising steam from a bowl of hot water. Breathing in the warm, moist air of a hot shower or use of a humidifier may also be beneficial - especially in winter when the air is cold and dry; and if you are often in air conditioned areas.
• Apply a warm, damp towel to painful sinus areas several times a day, this has a soothing effect.
• Rinse out nasal passages with a saline nasal spray several times a day, this also known as nasal irrigation and can be done with clean salain water, or a sea salt solution. This helps to reduce congestion by loosening mucus and cleaning out sinuses and nasal passages. This technique may also have a moisturizing effect, which can reduce the crusting of nasal secretions.

Decongestants – Also known as α-adrenergic agonists, decongestants cause blood vessel constriction, thereby reducing airway resistance by increasing the size of the airway lumen. Oral decongestants are less potent than topical nasal decongestants, therefore topical nasal decongestants are often preferred, but their use should be limited to 3-5 consecutive days. This is because they quickly induce tolerance, which means that higher and higher doses will be needed to achieve the same effect as before(Balkissoon 2010). Furthermore, if a nasal decongestant spray is overused and then abruptly stopped, an extreme increase in nasal congestion (ie, rebound congestion) may be experienced (Mayo Clinic 2012b; Balkissoon 2010).

Mild analgesics – Over-the-counter pain relievers such as aspirin, Tylenol™, or ibuprofen may be helpful for temporarily relieving sinus pain and headache (Mayo Clinic 2012b; AAFP 2008). Intranasal corticosteroids – Although nasal steroids may decrease the inflammatory response associated with sinusitis, clinical trials have shown conflicting results (DeMuri 2009). However, nasal steroids may still be of benefit, since they are able to decrease swelling of the sinus passages associated with allergies and allow the sinuses to drain (NIAID 2012). As a result, nasal steroids may be of benefit to individuals whose nasal allergies (eg, hay fever) predispose them to developing sinusitis (DeMuri 2009).

Antibiotics – Although bacterial sinusitis is less common and more severe than viral sinusitis, it may resolve without the need for antibiotics (Mayo Clinic 2012b). As a result, sinusitis treatment guidelines do not recommend taking antibiotics within the first week of illness, unless the symptoms are particularly severe (eg, high fever or extreme pain). A typical course of antibiotic treatment for severe bacterial sinusitis will last for 10-14 days, and should not be discontinued early just because the symptoms have resolved (Balkissoon 2010).

Surgical intervention - this is usually a last resort, and thus reserved for cases of chronic sinusitis that have not responded to drug therapy (DeMuri 2009; NIAID 2012). The goal of surgery is to improve drainage by removing or reducing sinus obstruction (NIAID 2012). Surgery can be performed to enlarge sinus openings, remove nasal polyps, and correct anatomical abnormalities (eg, deviated septum) (DeMuri 2009; NIAID 2012; NIH 2012). For most patients, surgery results in lasting symptom improvement and an increased quality of life (DeMuri 2009; NIAID 2012); however, symptoms may reoccur (NIAID 2012).

• Lactoferrin – Lactoferrin and its active metabolite, lactoferricin, are multifunctional proteins known to possess antibacterial, antifungal, and antiviral activities, as well as immune regulatory and anti-inflammatory actions (Psaltis 2008). Lactoferrin is produced and stored within the cells of the nasal mucosa and is presumed important as a first line of defense against invading pathogens (Acioglu 2012). Lactoferrin production is reduced in people with sinus conditions compared to healthy subjects. Moreover, lactoferrin levels are particularly low in sinusitis patients with nasal polyps. The low levels of lactoferrin associated with sinusitis are due to both its decreased expression/down-regulation as well as its increased utilization to fight infection (Acioglu 2012).
• Vitamin C (available at Health Renewal) - Since the human body cannot synthesize vitamin C, it must be acquired from the diet (Hemavathi 2010). Research shows a sufficient daily intake of ascorbic acid is required for the immune system to defend the body against infections (especially viral infections) (Ely 2007). Evidence suggests that supplementation with 1000 mg daily of vitamin C can decrease the risk of catching a cold (Holt 2010). When given in doses greater than 200 mg daily, vitamin C has been shown to reduce the duration of cold symptoms by 1-4 days (Khalid 2011). Individuals with sinusitis typically exhibit decreased serum levels of vitamin C (Cho 2009; Unal 2004).
• Zinc (available at Health Renewal)– Zinc is an essential trace element required for a variety of metabolic processes (Classen 2011), including the maintenance of a healthy immune function (Roxas 2007). Zinc deficiency, which is common among the elderly and the young, is linked to the impairment of many components of the immune response, including T- and B-lymphocyte function, natural killer cell activity, macrophage phagocytosis, and antibody formation (Maggini 2012; Pae 2012; Nriagu 2007). As a result, zinc deficiency is associated with an increased risk of infection (Maggini 2012; Pae 2012). Zinc supplementation has long been considered an effective therapy for reducing theduration of the common cold (Roxas 2007; Nriagu 2007). In a 2012 study, researchers found that the combination of zinc plus vitamin C was more efficacious than placebo at reducing runny nose, and it also appeared to accelerate recovery in common cold patients (Maggini 2012).
• N-acetyl cysteine (available at Health Renewal)– N-acetyl cysteine (NAC) may reduce the viscosity and improve the clearance of mucus. NAC has antioxidant properties, which can help protect against free radical damage. It may also help restore healthy sinus conditions that have deteriorated due to sinusitis (Clinical Pharmacology 2012). A 2010 study found that NAC is capable of fighting infections, such as those that cause sinusitis, through its ability to break down biofilms. Biofilms are essentially a community of bacteria that adhere to surfaces, including moist mucus membranes. These biofilms are known to produce resistant communities of bacteria and are estimated to be involved in at least 60% of all chronic and/or recurrent infections. NAC has been shown to reduce the adhesion of biofilms to mucus membranes (eg, antibiotics or nasal steroids) (Pintucci 2010).
• Vitamin E (available at Health Renewal) – Numerous studies have demonstrated that vitamin E may have a positive effect on the human immune system. A 2011 study found that topical vitamin E (in combination with other antioxidant oils) was able to persistently reverse oxidative stress and nasal inflammation, similar to that by viral infections, chronic sinusitis, and allergic disease (Gao 2011).
• Bromelain – Bromelain, which is a proteolytic enzyme complex found in pineapple, is frequently used to treat sinusitis because it reduces inflammation and loosens mucus. Among sinusitis patients, bromelain has been shown to hasten symptom recovery and resolve inflammation better than standard treatment or placebo. Typical oral doses of bromelain are between 500-2000 mg daily (Helms 2006).
• Eucalyptus – Cineole is the main ingredient of eucalyptus oil. It has anti-inflammatory and antimicrobial properties, and it also affects ciliary beat frequency (Tesche 2008). Studies have confirmed that cineole can thin, drain, and reduce mucus secretions(Kehrl 2004).
• Herbal combination formula – A combination of Gentian root, Primula flower, Elder flower, Sorrel herb, and Verbena herb is frequently used in the treatment of acute and chronic rhinosinusitis (Glatthaar-Saalmuller 2011; Rossi 2012). Results from a 2011 laboratory study demonstrated that this formula shows a broad spectrum of antiviral activity against viruses commonly known to cause respiratory infections (Glatthaar-Saalmuller 2011). A more concentrated version of the formula (ie, dry extract) reduced exudate volume and leukocyte numbers in an animal study. Since inflammation of the mucosa can often lead to a loss of smell, researchers theorize that this combination of herbs may be useful for this indication as well (Reden 2011).
• Xylitol nasal irrigation – Xylitol is a sugar alcohol that appears to enhance the body’s natural defense against bacterial pathogens. Nasal irrigation with the xylitol solution was associated with a significant improvement on a standardized assessment of sinusitis symptoms (Weissman 2011).
• Black cumin seed oil – Nigella sativa, also known as black cumin, is a flowering plant that grows in Eastern Europe, the Middle East, and Western Asia. The small black seeds of nigella sativa have a rich history of medical use in the Middle East and Asian countries. In an animal model of rhinosinusitis, an active constituent derived from black cumin seed was found to be as effective as antibiotic therapy in reducing manifestations of sinusitis such as vascular congestion, inflammation, and epithelial injury in sinus tissue (Cingi 2011).