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.
Here’s my response below to a NY Times article on chronic sinusitis. They talk about cutting edge research in diagnosing and treating sinusitis, but completely miss an important point. Please read my post below to see what I mean, and feel free to comment on anything that I’ve said.
Biofilms are the pathology de jour in chronic sinusitis research right now. A few years ago, it was our immune system’s response to funguses. Before that, it was allergies, and before that, bacteria. As long as we’re convinced that it’s a bad organism or agent that’s attacking our body (sinus) cavities, you may get rid of the infection, but you’re doing nothing to treat what’s actually causing the inflammation that leads to blockage of the sinuses. The same analogy can be made for anti-reflux medications. None of the proton pump inhibitors (like Prilosec or Nexium) or H2 blockers (like Zantac) actually do anything to prevent reflux. It only lowers acid production, without doing anything to prevent regurgitation of stomach juices into the esophagus or throat.
Interestingly, a recent large scale study showed that the vast majority of people who suffer from recurrent sinus infections, pain and headaches are actually suffering from migraines. This is a neurologic form of inflammation in the sinuses, which over-reacts to weather changes, chemicals, scents, or odors. Chronic inflammation can lead to swelling, leading to blockage of sinuses, which can predispose to infections by bacteria that normally live in your nose.
Saline is also commonly recommended for chronic sinus sufferers, but it’s a double edged sword: A recent study showed that people who used nasal saline irrigation frequently had more episodes of infection than those who didn’t. Yes, saline irrigation flushes out pollutants and bacteria, but it can also cause paralysis of the cilia, which are finger-like projections that move nasal mucous back into your throat. Saline is like a mild version of Afrin – it’s still a decongestant. This is why some people have to use saline every day, sometimes 3-5 times per day. They’re addicted, just like with Afrin.
Sinus problems are much more common these days due to underdevelopment of our facial bones, which also include our jaws. Over the past few hundred years, due to a radical shift in our diets, as well as our eating habits (soft, mushy foods, bottle feeding, etc.), our jaws are not expanding to their full potential. If your facial skeletons don’t grow as much, the natural nasal and sinus passageways will be more narrow, becoming more predisposed to obstruction with colds, allergies, or any kind of inflammation.
This is why most people with chronic sinusitis can’t (or prefer not to) sleep on their backs. Due to smaller oral cavity volume, the tongue takes up relatively too much space, which leads to more frequent obstruction while breathing at night. Breathing pauses (apneas) then can suction up your normal stomach juices into your throat, lungs and nose, causing more inflammation. Most people with chronic sinusitis will also have sleep-difficulty and one or both parents will be heavy snorers with typically undiagnosed sleep apnea.
I presented a poster many years ago looking at the incidence of obstructive sleep apnea in people who had persistent or recurrent symptoms after nasal or sinus surgery. Almost 80% were found to have significant obstructive sleep apnea. Now that I look for and treat sleep-breathing problems before considering surgery, the need to go on to sinus surgery has plummeted. Plus they sleep better.
One of the more common complaints from CPAP users is that they are prone to sinus infections. Typically, they deal with it using saline irrigation, decongestants, and sometimes even go to their doctor for antibiotics. As a result, people suspect contamination or infection from their equipment, especially the mask, tubing or even the machine itself. Other suspects include molds, allergies or even sensitivity to their masks.
I had an experience today with a patient that makes me rethink how CPAP may aggravate nasal or sinus infections. This patient was unable to use CPAP after 4-5 days because his nose and sinuses would burn. He interpreted this as an infection. His numbers and other compliance parameters were perfect. While performing nasal endoscopy (placing a thin flexible camera in his nose) he commented that the sensation was identical to the feeling that he experienced when he used CPAP.
That got me thinking about how most cases of sinus headaches and pain have been shown to be a variation of a migraine. This is a neurologic reaction to any sort of irritation or stimulation. If you were to undergo a CAT scan during an episode, you’ll see that in most cases, it’ll be completely normal. Unfortunately, too many people end up being given oral antibiotics.
What can you do about this if you’re susceptible to these problems? Unfortunately, it’s a catch-22. In theory, the best way of handling this is to treat the underlying obstructive sleep apnea, but in this case, the treatment itself can cause nasal inflammation that can worsen sleep apnea. Many people benefit significantly by using CPAP, but there will always be a few people who absolutely can’t tolerate CPAP, no matter how hard they try to use it (different machines, settings, masks, medications, or other gadgets.)
Do you get recurrent sinus “infections” when you use your CPAP?