May 25, 2011
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.
November 12, 2010
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?