Sinusitis

Sinusitis is the inflammation of one or more of the paranasal sinuses (frontal, sphenoid and maxillary sinuses), often as a complication of rhinitis. With the inflammation of the nasal mucus membranes the openings from the sinuses may be obstructed promoting the accumulation of sinus secretions, causing pain, pressure, headache, fever and local tenderness. Sinusitis can be either acute or chronic, but it can be difficult to distinguish between the two, and as both are attributed to bacterial infection they are treated identically with antibiotics. (Berkow 1992; Rubin and Farber 1990, 690-91; Govan et al 1991, 290-91)

It is estimated that 37 million people in the United States suffer from chronic sinusitis, making it one of the most commonly experienced conditions. Similar to acute sinusitis, chronic sinusitis is thought to be bacterial in origin, and is typically treated with antibiotic therapy. Most patients however, while obtaining some temporary benefit, find that their symptoms return with a matter of a few weeks. In a recent study of chronic sinusitis patients, researchers at the Mayo clinic found that 93% of 210 consecutive patients diagnosed with chronic rhinosinusitis were found to be suffering from fungal infections, and that all cases were characterized by the presence of eosinophils in the nasal tissue and mucus. Thus the routine use of antibiotics may be contraindicated in chronic sinusitis, and may end up making the problem worse by tipping ecological factors in favour of the fungi (Ponikau et al 1999).

The most important component in sinusitis is the outflow tracts (ostia) of all of the sinuses into the nose, but most importantly, those of the maxillary and ethmoid sinuses. Within the sinuses the cilia move mucus toward these channels, and when the function of the cilia are impaired in some way, such as in exposure to tobacco smoke, the result is the stagnation of mucus. In situations where the ostia are obstructed, such as paranasal inflammation caused by an infection or allergy, or from the presence of foreign bodies or polyps, the activity of the cilia will be impaired. As the mucus stagnates it becomes a breeding ground for bacteria – the more chronic the obstruction the greater the chance of secondary infection. Typical pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes and Staphylococcus aureus. Fungal pathogens have also been identified in acute sinusitis in immunocompromised patients, or in patients that have been treated for extended periods of time with antibiotics. Allergic fungal sinusitis (AFS) is commonly caused by Aspergillus, as well as Fusarium, Curvularia, Candida and other fungi. It is the changes in air pressure within the sinuses caused by the obstruction that promotes the pain of sinusitis (Berkow 1992; Ponikau et al 1999).

Medical treatment

Medications used in the treatment of sinusitis consists of topical steroids, decongestants, antihistamines, antibiotics, antifungals and surgery. The most commonly used medications for chronic sinusitis are steroids (e.g. fluticasone propionate), applied as a nasal mist, or in the form of injections into the turbinates. Steroids often improve symptoms dramatically for the first few days after usage, but overtime can cease to be effective and promote ecological changes in the nasal and sinus mucosa that can make the condition worse. (Berkow 1992)

Topical decongestants include ephedrine hydrochloride, ipratropium bromide, phenylephrine, oxymetazoline, and xylometazoline hydrochloride. Oral decongestants include pseudoephedrine, and up until relatively recently phenylpropanolamine (PPA), which has since been taken off the market due to concerns over hemorrhagic stroke. Both oral and topical decongestants act as adrenergic agonists, promoting vasoconstriction in the capillary mucosa, thereby decreasing blood flow and mucus secretion. Although OTC and prescription decongestants are widely applied their usage for even more than one week may cause rebound sinusitis (‘rhinitis redicamentosa’). Antihistamines are sometimes resorted to as well, particularly in allergic sinusitis, but as they tend to dry secretions and inhibit the flow of mucus through the ostia they should be avoided. (Berkow 1992)

Oral antibiotics are considered the mainstay of the medical treatment of sinusitis and in practice are often prescribed without the necessary tests to determine the pathogen. The challenge in diagnosis is to obtain a sample of sinus secretions, which may be different from nasal secretions. Antibiotics penetrate into the sinuses rather poorly, and as a result treatment is usually at least two weeks and can extend to 6-8 weeks in particularly recalcitrant cases. Broad spectrum antibiotics such as amoxicillin and clarithromycin are typically used during the initial treatment, but the presence of antibiotic resistant organisms may call for the usage of newer classes of antibiotics including ciprofloxacin, levofloxacin and moxifloxacin. Needless to say perhaps, but the usage of antibiotics can dramatically worsen fungal sinusitis, damage the bacterial ecology of the body, and when used chronically (as is often the case) contribute to antibiotic resistance. (Berkow 1992)

The relatively recent discovery of the prevalence of fungal sinusitis in chronic sinusitis has stimulated the usage of topical antifungals such as amphotericin B, but because of the drug’s sensitivity (i.e. it must be protected from light and refrigerated) it is inconvenient to use. (Berkow 1992; Ponikau et al 1999)

Surgical methods in the treatment of sinusitis are typically resorted to only after topical and oral medications have failed. Surgeons will attempt to improve sinus drainage by making the ostia wider or puncturing new holes in the sinus bones, although the development of scar tissue may reverse this latter procedure (Berkow 1992). In some cases surgeons may trim the turbinates, but the excessive loss of tissue may create an increase in nasal congestion similar to the phantom limb syndrome, and is called the ‘empty nose syndrome (Wang et al 2001). Depending upon the patient, the anterior and/or posterior ethmoid sinuses may also need to be removed, either partially or in total. The success rate and operative complications are dramatically related to the skill of the surgeon, and professionals note that there is a very long and steep learning curve. (Berkow 1992)

 

Holistic treatment

The holistic treatment of sinusitis is a comprehensive approach based upon the causative factors. In Ayurvedic medicine sinusitis is discussed under the classification of pratishyaya and related conditions including pinasa. According to the Madhava nidanam pratishyaya is caused by several factors, including the suppression of natural urges, ingestion of uncooked foods, exposure to smoke, dust and pollen, abnormal climate, injury to the head, excessive talking, anger, insomnia, sleeping during the day, drinking very cold water and exposure to cold weather. Symptoms that include a dry throat, scanty mucus, excessive sneezing, hoarseness, and pain in the temples is associated with vata, especially if other vata symptoms are present, including constipation, anxiety, and exhaustion are present. Pitta variants of pratishyaya are manifest as sinus inflammation, a yellowish to red discharge, fever, and burning sensations. Kaphaja pratishyaya is identified by symptoms such as a thick whitish discharge, itching of the throat, palate, lips and head, facial swelling and sleepiness. Symptoms of pratishyaya that appear and reappear are caused by all three doshas. The Madhava nidanam further states that when pratishyaya is not treated at the proper time the result may be an incurable form.

Chinese medicine differentiates sinusitis based upon specific afflictions of organ dysfunction, including Wind-Heat of the Lungs (usually caused by changes in weather), Damp-Heat of the Gallbladder (often caused by emotional problems), Damp-Heat of the Spleen and Stomach (typically caused by eating greasy and spicy foods), a Deficiency and Cold of Lung Qi (more often found often in chronic illness) and a Deficiency of Spleen Qi (caused by an improper diet). Treatment is directed to the specific pattern presented.

In Western herbal medicine sinusitis is similarly seen as the result of an improper diet and exposure to food allergens, depressed immunity, climactic factors, smoking and environmental toxins, nutrient deficiency and autotoxicity.

Taken as a whole, the holistic treatment of sinusitis consists of the following

1. Remove causes.

• quit smoking
• limit exposure to environmental toxins, especially in air-conditioned indoor environments where viral, bacterial and fungal pathogens are continuously re-circulated. Personal air filters in such environments are recommended.
• address the issue of dietary intolerances and food allergens by implementing a elimination-challenge diet. Generally speaking heavy and sticky foods such as dairy, sweets and flour products should be avoided.
• assess patient for air-borne allergens

2. Clear the body of toxins

• Cholagogues and hepatotrophorestoratives to enhance liver detoxification with cholagogues and supportive nutrients, e.g. Barberry (Berberis vulgaris), Boldo (Peumus boldo), Milk Thistle (Silybum marianum), Haridra (Curcuma longa), Bhumyamalaki (Phyllanthus amarus), Katuka (Picrorrhiza kurroa), Huang Qin (Scutellaria baicalensis), Guduchi (Tinospora cordifolia).
• Diuretics: Priest and Priest state that in addition to liver detoxification the kidneys maintain a special relationship with the lungs, and thus an increase in respiratory catarrh can indicate a relative insufficiency of renal function (1982, 10-11), e.g. Celery seed (Apium graveolens), Cleavers (Galium aparine), Nettle (Urtica dioica), Goldenrod (Solidago virgaurea), Horsetail (Equisetum arvense)
• Lymphagogues: Pokeroot (Phytolacca spp.), Red Cedar (Thuja plicata), Cleavers (Galium spp.), Redroot (Ceanothus americanus)

3. Re-establish a healthy body ecology.

• Antibacterials: Purple Coneflower (Echinacea angustifolia), Wild Indigo (Baptisia tinctoria), Goldenseal (Hydrastis canadensis), Garlic (Allium sativum), Guggulu (Commiphora mukul), Huang Lian (Coptis chinense), Lian Qiao (Forsythia suspens), Jin Yin Hua (Lonicera japonica), Ban Lan Gen (Isatis tinctoria), Huang Qin (Scutellaria baicalensis)
• Antifungals: Garlic (Allium sativum), Sweet Annie (Artemisia annua), Pau D’arco (Tabebiua spp.), Barberry (Berberis vulgaris), Purple Coneflower (Echinacea angustifolia), Toothache plant (Spilanthes spp.), Neem (Azadirachta indica), Huang Lian (Coptis chinense), Tulasi (Ocimum sanctum), Bhringaraj (Eclipta alba), Haritaki (Terminalia chebula), Hingu (Ferula foetida), Bibhitaki (Terminalia bellerica)
• Probiotics: e.g. lactobacilli, bifidobacterium; live culture foods
• Prebiotics: e.g. fructo-oligosaccharides, inulin (e.g. found in Inula and Taraxacum root)

4. Check mucus production and restore tone to respiratory tract.

• Mucolytics: Bayberry (Myrica cerifera), Goldenseal (Hydrastis canadensis), Horseradish (Armoracia rusticana), Witch Hazel (Hamamelis virginiana), Mullein (Verbascum thapsus), Goldenrod (Solidago virgaurea), Eyebright (Euphrasia spp.), Ginger (Zingiber), Cang Er Zhi (Xanthium sibiricum), Xin Yi Hua (Magnolia liliflora), Ma Huang (Ephedra sinica), Pippali (Piper longum), Ela (Elettaria cardamomum)
• Expectorants: Mullein (Verbascum thapsus), Elecampane (Inula helenium), Grindelia (Grindelia spp.)

5. Modulate inflammatory and immune processes.

• Immunomodulants: Ganoderma, Huang qi (Astragalus membranaceus), Amalaki (Emblica officinalis), Wu Wei Zi (Schizandra chinense)
• Antiinflammatories: Licorice (Glycyrrhiza glabra), Neem (Azadirachta indica), Bhunimba (Andrographis paniculata), Guduchi (Tinospora cordifolia), Ju Hua (Chrysanthemum moriflora), Amla (Phyllantus emblica), Haridra (Curcuma longa), Sheng Di Huang (Rehmannia glutinosa), Shi Hu (Dendrobium nobile), Mai Men Dong (Ophiopogon japonicus), Yin Chai Hu (Stellaria dichotoma), Shi Hu (Dendrobium nobile)
• EPA/DHA, 1000-2000 mg each daily, to down-regulate inflammatory mechanisms
• Quercetin and bioflavonoids, 5 g daily, to stabilize mast cells and histamine release
• Immunosupportive nutrients, including vitamins A (25,000 IU daily), B complex (50 mg daily), C (to bowel tolerance) and E (800 IU daily), as well as zinc (50 mg daily)

6. Hydrate nasal and sinus mucosa.

• Neti, with isotonic water, twice daily
• Humidification, especially at night, with essential oils (e.g. Spruce, Eucaplytus, Rosemary, Cedar, Pine, etc.)
• Nasya, 2-3 gtt of sesame oil instilled and inhaled into each nostril, once daily on an empty stomach

7. Dietary changes.

• Mucus-producing foods must be eliminated, including dairy, flour, and sugar.
• Avoid all yeasted foods, e.g. bread, wine, beer, balsamic vinegar

8. Additional formulae:

• Trikatu churna, 2-3 g bid-tid with honey and water
• Shiva gutika, 12 g bid-tid with water or soup
• Chitraka Haritaki churna, 6-12 g bid-tid with water
• Bi Yan Pian (for Wind-Cold and Wind Heat), 6 pills bid-tid
• Bi Tong Pian (Wind Heat, Phlegm, Liver Heat), 4 pills bid-tid
• Long Dan Xie Gan Wan (Aristolochia-free) (Damp Heat in Gall Bladder), 4-6 pills bid-tid