Maxine was fed up. Month after month, she suffered excruciating sinus pain and pressure. She initially went to her primary care doctor, who prescribed multiple course of antibiotics, but this stopped working after a while. She was then referred to an ENT surgeon, who prescribed a cocktail of stronger antibiotics, allergy medications and decongestants, only with temporary relief.
By the time she came to see me, she was desperate. In addition to her sinus problems, she told me that she also had the following:
- always chronically tired
- daily headaches
- increasing anxiety attacks
- frequent nighttime urination.
She requested stronger medications or antibiotics, but I was reluctant. A CAT scan of her sinuses came back as completely normal.
Rethinking sinus infections
This is a common scenario that I see all too often in my practice. Patients have been on multiple courses of antibiotics for what sounds like a classic textbook diagnosis. Along with a history of stuffy nose and yellow nasal discharge, all her symptoms may be interpreted as chronic sinusitis. Her doctors practiced textbook medicine. So then why was her CAT scan completely normal?
Modern medicine has made amazing advancements in treating infectious diseases. The development of antibiotics revolutionized modern healthcare and likely has saved millions of lives. Most of the recent research has been focused on the body’s response to infectious agents, with drug development aimed towards lessening inflammation. A more recent development is the discovery of biofilms, where bacteria can clump together, forming a barrier that can resist antibiotics. The current recommendation for chronic sinusitis is to consider sinus surgery if aggressive medical treatment (including multiple courses of appropriate antibiotics) don’t help.
However, not all sinusitis is related to bacterial infections. Here are three things to consider before undergoing routine treatment for sinusitis.
1. Sinusitis may be linked to obstructive sleep apnea and reflux
Early in my career as an ENT surgeon, I noticed an interesting phenomenon: Patients with persistent or recurrent symptoms after sinus surgery had a very high rate of obstructive sleep apnea. In fact, about 80% were found to have obstructive sleep apnea based on formal sleep studies. The vast majority of these patients had snoring and sleep problems long before their sinus problems developed.
Around this time, I began to see the link between obstructive sleep apnea and acid reflux, and the vicious cycle of upper airway inflammation that can potentially aggravate sinus symptoms. There are studies showing that treating acid reflux can help obstructive sleep apnea and vice versa.
When I began to look for obstructive sleep apnea and reflux for all my patients with chronic sinusitis and treating them appropriately, they were less likely to need sinus surgery.
2. Reflux and sinusitis
Sinusitis implies inflammation or infection, and not only due to bacteria. Other sources of inflammation can be caused by allergies, viruses, molds, and even stomach juice reflux.
One of the basic tenets of my sleep-breathing paradigm (which I describe in Sleep, Interrupted) is that obstructed breathing can aggravate reflux. Tremendous vacuum forces are created in the chest and throat which suctions up your normal stomach juices into the throat. This can cause chronic low-grade inflammation and swelling, hoarseness, coughing, post-nasal drip, or throat clearing. Even if you take anti-reflux medications, less acidic juices still reflux into the throat, causing more swelling, leading to more obstructed breathing. If you have tonsils, then they can become bigger, leading to more obstructed breathing, leading to more reflux.
Think about sucking water from a cup through a flimsy straw. As you suck through the straw (during an apnea due to palate, tongue or tonsils blocking your airway), tremendous negative pressure is created inside, not only causing the sidewalls of the straw to cave in, but also suctioning up water into your mouth (the throat).
What comes up from your stomach is not only acid, but also includes bile, digestive enzymes (such as pepsin), and bacteria. It’s been shown that pepsin can be found in the middle ear in patients with chronic ear disease. In patients with chronic lung disease, the vast majority were found to have pepsin and lipid-laden macrophages in lung washings.
It’s not surprising that connections have been made between reflux and chronic sinusitis. There’s even a study showing that treating chronic sinusitis with long-term reflux medications can resolve sinusitis in a significant number of patients.
3. A sinus migraine?
It’s now been shown that the vast majority of patients with sinus headaches are actually having a migraine of the sinuses. Many of the symptoms of sinus migraine can overlap with symptoms of sinusitis: facial pain, nasal congestion, post-nasal drip, etc. After reading this article on sinus migraines in 2007, I applied what I learned to the patient described above by trying her on sumatriptan (Imitrex), a commonly prescribed medication for migraine. The patient was extremely doubtful, but reported back later that her headaches and facial pain were completely gone. She was placed on migraine precautions and with good sleep hygiene and stress reduction, her symptoms became more manageable.
In his book, Heal Your Headache, Dr. David Buchholz expands the definition of migraine to areas other than the head. Any time the nerve endings in any part of your body become overly sensitive, you’ll get symptoms that are common to that part of the body. For example, an inner ear migraine can result in dizziness, balance problems, ringing and hearing loss. In your stomach, bloating, pain, constipation or diarrhea.
Lack of sleep or low sleep quality for any reason can lead to a physiologic stress response which can make your nervous system over-react to your environment. Most commonly, you’ll over-react to weather changes (pressure, humidity, or temperature), chemical , scents, smoke, or odors). Notice that these are also classic migraine triggers, in addition to the classic food triggers (red wine, aged cheeses, and MSG).
Given that obstructive sleep apnea and upper airway resistance syndrome patients are more likely to suffer from headaches, migraines, acid reflux and sinusitis, it’s not surprising that you can have all three of the above conditions co-exist together. As you can see, there’s a lot more going on with sinusitis that just a bacterial infection. It’s important to treat or at least consider these 3 important issues (apneas, migraines, reflux) if you have symptoms of sinusitis. Oftentimes, it’s not really sinusitis. Ultimately, you’ll have to deal with your breathing problem during sleep, which can aggregate all of the above.