Is your cold not going away? You may have sinusitis, a chronic sinus condition that strikes more than 35 million Americans each year. Find out how it’s diagnosed and what treatment options are available.

Our guest is Dr. Ralph Metson, an ear, nose and throat specialist in practice at the Massachusetts Eye and Ear Infirmary. He’s a clinical professor at Harvard Medical School and author of the book, “The Harvard Medical School Guide to Healing Your Sinuses.”

Dr. Metson answers questions from the audience.

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Judy Foreman:

Hello and welcome to HealthTalk Live [HealthTalk Live has been renamed [HealthTalk Live has been renamed Health Now with Judy Foreman] Health Now with Judy Foreman]. I'm your host, Judy Foreman. Is your cold not going away? You could have sinusitis, a chronic condition that strikes more than 35 million Americans every year. Tonight we'll talk to a sinus expert about how it's diagnosed and what treatment options are available. I'm very pleased to welcome tonight Dr. Ralph Metson, an otolaryngologist – that's an ear, nose and throat specialist – in practice at the Massachusetts Eye and Ear Infirmary. He's a sinus surgeon and a clinical professor at Harvard Medical School. He's also author of the book, "The Harvard Medical School Guide to Healing Your Sinuses."

Dr. Ralph Metson, thank you so much for joining us tonight.

Dr. Ralph Metson:

My pleasure, Judy. Nice to be here.

Judy:

Good. And I can call you Ralph?

Dr. Metson:

You certainly may.

Judy:

Okay. Well, actually I'd like to start by asking you what attracted you as a younger doctor to sinuses in the first place?

Dr. Metson:

Well, let me say that the specialty to ear, nose and throat is in my blood. My father is a retired ear, nose and throat doctor. He was in practice in Los Angeles for over 50 years, in his specialty. And my grandfather's brother, my great uncle, was also an ear, nose and throat doctor. So I kind of followed in their footsteps, so to speak, and it led me into this specialty.

At the time that I came in about the mid 1980s, when I was finishing my training, sinus surgery was undergoing a revolution. The whole theory as to the cause and treatment of sinusitis was changing radically with new ideas coming out of Europe at the time. So I was poised to take advantage of these, gave it new techniques to try and followed the end of my nose, both literally and figuratively, and here we are.

Judy:

Okay. Well, what are the sinuses, and why would we humans and other mammals have developed them over evolutionary time? Because to people like me, who have sinus problems, sinuses could easily count as one of evolution's big mistakes. Why do we have them?

Dr. Metson:

Well, that's a good question. Nobody knows for sure. Some people say it's just so surgeons have something to operate on, just like the appendix. But the truth is the sinuses are air containing spaces or cavities in the bones of the skull and the face. They surround the eyes. And these cavities are lined with a membrane that secretes mucus. And this mucus drains through very small pinpoint openings into the nose called ostia. And if the ostia become blocked when the nose swells for some reason, then the mucus builds up inside the sinuses, bacteria can overgrow, and you can develop a sinus infection or sinusitis.

The reason we have these sinuses remains unknown, although there are theories as to the fact that perhaps they help to make the skull lighter. Man in a more upright position, going from on all fours to standing on two legs, perhaps the air in the sinuses and the fact the skull and facial bones are not solid may make them lighter so that man can maneuver more easily. Another thought is that the sinuses help with resonance of the voice. Others say they help with the sense of smell to make it more refined. Others feel that these air containing cavities around the eye and the brain help to protect the eye and the brain from trauma, so it adds to survival. Lots of theories, but again, we don't really know the exact reason.

Judy:

Well, did the Neanderthals have sinuses?

Dr. Metson:

They sure did have sinuses.

Judy:

And the Cro-Magnons too?

Dr. Metson:

Well, if you look at a skull or you just look at a picture of what a caveman looks like, you'll notice there is a flat forehead. Above the eyes there's not much of a frontal lobe. And in the same respect there's not much of a frontal sinus, so cavemen had sinuses, but they were smaller. Particularly the ones above the eyes, the frontal sinuses, were almost absent in Neanderthal and a little larger in Cro-Magnon. And again larger in Homo sapiens, modern man. But still to this day about 10 percent of people are born without frontal sinuses and never developed them.

Judy:

Are they the lucky ones?

Dr. Metson:

Well, it depends on how you look at it. I'll simply say they don't miss not having those sinuses.

Judy:

I bet they don't. Well, sinuses are kind of like empty spaces, I guess, but what is the structure of them? And how many pairs of them do we all have?

Dr. Metson:

We have four pairs of sinuses. The ones above the eyes are called the frontal sinuses. The ones between the eyes are called the ethmoid sinuses – they're little, honeycomb shaped. They have lots of little compartments called air cells. Again, they look like a little honeycomb partition.

And then the ones below the eyes, those are the ones when they become blocked that you get facial pain or cheek pressure, those are called the maxillary sinuses.

Then finally the deepest sinus, the ones behind the nose, are called the sphenoid sinuses - sphenoid meaning wedge, if you will, in Greek. In other words, it's wedged in the very deepest part of the skull. So you have those four pairs of sinuses.

Judy:

And then what are turbinates? Are they sinuses too, or are they something else?

Dr. Metson:

They are something else. So these sinuses drain through these little pinpoint openings I mentioned earlier into the nose. The nose has some other structures as well as the draining sinuses. The nose has three scroll shaped bones, very thin, rounded bones on either side, six total, that are covered with a membrane. These bones and the membrane together serve as the air conditioning system, if you will, for the nasal cavity. They help to condition the air that we breathe in to prepare it for the lungs.

The turbinates increase the surface area of the nasal cavity, so the air we inhale as it passes over these turbinates and around these scroll shaped objects are warmed and humidified and moisturized before the air particles get into the lungs. Without turbinates, we'd be basically putting dry air right into the lungs instead of the warm, moist and humidified air that we breathe. Without turbinates, pneumonia and bronchitis would be much more common.

Judy:

So basically when you breathe through your mouth you're getting that unwarmed, unhumidified air, right?

Dr. Metson:

That's right. There is still a little bit of that because the nasal membranes are moist and warm, but not nearly the surface area you have when you breathe through your nose. Man is meant to breathe through his nose in resting state and during most of the day.

Judy:

Okay. And then one more anatomical thing to just sort of set the stage for what we're going to get to.

Dr. Metson:

Sure.

Judy:

What is this thing called the meatus or the osteomeatus? What's that and why do we have that?

Dr. Metson:

I refer to the osteomeatus – let's call it the OMC, osteomeatal complex, OMC for short. I call it the turnstile of the nose. All the sinuses eventually drain past this one common, final pathway, the OMC. When that very narrow area inside the nose becomes blocked – thickened by swelling, a cold, allergies, whatever – the sinus is blocked. The most common cause of sinusitis is blockage or swelling in the area of the OMC, the final common pathway for drainage of all the sinuses into the nose.

Judy:

Okay. And in your book I think you mentioned that babies are not born with all their sinuses already made, which seems a little funny to me. And if they don't have all their sinuses, then why do little kids get so many colds and runny noses?

Dr. Metson:

Well, little kids get so many colds and runny noses because they're exposed to other little kids with colds and runny noses, particularly in a daycare center. Kids don't have quite the hygiene that adults might, so they're exchanging secretions with other kids in the same room, and what happens is they're exposed to a lot more viruses. Their immune systems are more immature. They haven't seen so many viruses in their lifetime. So they have these upper respiratory infections, viral infections or just the common cold, and that's why they have the runny noses all the time.

But children do have sinuses when they're born, but they're primarily just the ethmoid sinuses between the eyes and small maxillary sinuses in the cheek. Ethmoid – the frontal and sphenoid sinuses develop as they get older and all the sinuses grow.

Judy:

That's interesting.

Dr. Metson:

Yeah. The reason they're thought to grow is because, if you think about it, a child's skull has to grow to accommodate an enlarging brain, from childhood into adulthood. So to keep in proportion to that enlarging skull, the facial bones also have to enlarge or grow proportionately. And one way to do that is by just laying down pure bone, if you will. But a more efficient way that uses fewer calories, less energy, might be to enlarge sinuses or air containing spaces within the bones so the body does not have to produce so much bony material. Instead, it can produce less bone surrounding these air containing sinuses. It's an efficient way to grow the facial bones in proportion to the skull as it grows with the enlarging brain. At least that's a theory.

Judy:

Yeah. Well, what is the quote-unquote "nasal cycle?" I gather there's a natural back and forth in which we breathe through one nostril while the other is blocked and then we switch. All of this is unconscious. Is there some evolutionary reason why there would be a nasal cycle?

Dr. Metson:

Yes, there is. A lot of your listeners might feel that one side of their nose is blocked during the day, and then the other side becomes blocked. It goes back and forth. If you pay attention to your breathing, that's true for most people. About every six hours, the predominant side through which air passes through our nose as we breathe in and out changes from the right side to the left side and back and forth again. So every six hours it changes from one side to the other.

Judy:

Why?

Dr. Metson:

Well, the thought is there that one side is giving a rest to the other side. In other words, rather than both sides working all day long to help warm and humidify the air, one side is doing the majority of the work while the other rests.

The blood vessels have to dilate and become engorged in order to warm and humidify and cleanse the air we breathe in. There's a certain chemical process going on - increased metabolism, if you will - and that's the side that we might be breathing predominantly through. Then that side rests, the waste products are taken away, the cells have time to regenerate and recoup, take a breath, breathe if you will, sleep if you will, while the other side is working.

So it goes back and forth so that one side is not always working. If you just had both sides working full steam ahead all day long the nasal membranes would tend to dry out. The mucus would tend to become thicker, more sticky and not flow so readily. So the nasal cycle is a really ingenious way, a natural way, to keep that air conditioned as it goes to the nose and into the lungs without overdoing it, so to speak, without drying out the nasal membranes.

Judy:

But it's kind of weird because we don't give one lung a rest while the other one does the work. It's just the sinuses that get a break, right?

Dr. Metson:

I guess some guys have all the luck.

Judy:

Well, how many people or Americans do have sinus problems? In your book you cite figures from the Federal Centers for Disease Control and Prevention showing that sinusitis affects more than 35 million Americans. That's a whole lot of people. Is it really that many people?

Dr. Metson:

It's amazing how many. It depends on your definition of sinusitis. It depends on whether you're talking about acute sinusitis, that is, just a brief sinus episode that may only last a couple weeks, or chronic sinusitis, where you're continually getting one infection after another. But the latest estimates are about 17 percent of the United States population suffers from sinusitis in one way or another, either acutely or chronically. And again that number – there have been different studies that have looked at it, and these are official U.S. statistics sources, but they're all about the same. They're all around 30 million plus or minus two million are felt to have sinusitis in this country.

Judy:

That's huge.

Dr. Metson:

And again, it just seems like an amazingly high number. I won't say it's not. It could be an overestimate, because a lot of doctors might circle the diagnosis sinusitis when a patient just has an upper respiratory cold, let's say. So it could be an an overestimate, but the statistics are just the ones that you mentioned, about 30 million people a year.

Judy:

I'm talking to my friends – lot of people have it. So what is your definition of sinusitis or rhinosinusitis?

Dr. Metson:

Well, literally, sinusitis means an "itis" of the sinuses, and "itis" means inflammation. So an inflammation of the sinuses, particularly a bacterial infection, although it can be viral as well. It causes the lining of the sinus to become inflamed. That is the definition of sinusitis. And then we now often refer to it as rhinosinusitis, "rhino" referring to nose. The nasal membranes usually swell when the sinus membranes do at the same time.

Judy:

I see. Okay. And do sinus problems tend to run in families or is it just random who gets it?

Dr. Metson:

Well, it certainly can run in families. There's more and more evidence now that sinusitis may have a genetic underpinning, genetic predisposition, if you will. So if allergies run in the family, so can sinusitis.

Judy:

Would the genetic predisposition be something like sinuses that are too small, these little drainage holes being too small?

Dr. Metson:

That's one possibility. Why does one person get it and another person doesn't?

Judy:

Yeah.

Dr. Metson:

Perhaps the sinus drainage openings, the ostia that we referred to earlier to which the sinuses drain, are just congenitally small in some people. It could be, on the other hand, something to do with inflammatory factors that are inherited. Certain genes that are overactive or underactive in your father and your grandfather are also in you, which combined with environmental factors would predispose you to sinusitis, to developing it. So probably some genetic factors, some physical and anatomic factors as well, all could be inherited.

Judy:

So tell us in a little detail what are the symptoms of sinusitis and how it's diagnosed. And how do you tell if you've got sinusitis or just a bad cold?

Dr. Metson:

Alright. Let's first start with the symptoms of sinusitis.

Judy:

Okay.

Dr. Metson:

Three primary ones: first is headache or facial pressure. The second is congestion or difficulty breathing through the nose. And the third is mucus drainage or when it goes down the back of the throat – we call it postnasal drip. Those are the three hallmarks of sinusitis. There are lesser symptoms like teeth pain and bad breath, halitosis. So there are some others you can get, but the three primary ones are those I alluded to: the pain and pressure, the congestion difficulty breathing through the nose, and the nasal drainage or postnasal drip.

Now, a lot of those can be the same with colds, but with colds the drainage would tend to be clearer. With a chronic sinusitis, you're going to start to see yellow or discolored, greenish drainage. Cold symptoms typically, you're going to have, because they're caused by a virus for three days, five days, the longest a week. But if your symptoms persist for a week, ten days, two weeks, and your drainage comes from clear to discolored, well, then you start to think, "Wow, maybe I have sinusitis not just a run of the mill cold." A cold precedes lots of sinus infections.

Judy:

And then a cold is by definition a viral infection, but somehow the fact that everything gets clogged up allows bacteria to grow, and then it becomes a real sinusitis with a bacterial infection.

Dr. Metson:

You are absolutely right, because the cold causes the initial swelling of the nose. When the sinuses then become blocked and fill with mucus, that mucus acts as a culture media, if you will. It's a perfect environment for bacteria to overgrow, and so you get a secondary bacterial infection, and you develop sinusitis in those cases.

Judy:

So what role do X rays or more specifically CAT scan, CT scans play in diagnosing sinusitis? Do you have to have those to diagnose it?

Dr. Metson:

No, you don't have to, although they can be helpful. You see, for most patients when they are having a sinus infection, it doesn't go away on their own, they would tend to call their doctor, and they'll be treated for that with antibiotics or some other sinus medication. If symptoms keep coming back, they'll often be referred to a specialist. And the specialist, an ear, nose and throat doctor would diagnose sinusitis by two means: The first is a physical exam using an endoscope. An endoscope is a small, skinny telescope that can be passed through the nostrils to examine and visualize the areas of the nose through which the sinus is draining.

Judy:

And does that hurt?

Dr. Metson:

Well, we try to make it as painless as possible by first spraying the nose with a decongestant that opens up the passages and also a topical anesthetic so that there's no pain whatsoever. But there can be a little bit of discomfort, but hopefully there is none.

Judy:

Okay.

Dr. Metson:

So that examination alone, that nasal endoscopy as we call it, is often all you need to make the diagnosis. If the doctor sees pus draining out of the sinuses or sees polyps or inflammation or something strongly suggestive of a sinus infection, well, the diagnosis is made, and you can treat accordingly. But other times you need to actually see deeper into the sinuses. To do that - see the interior of the sinuses themselves - a CAT scan has to be ordered. A CAT scan, a fancy X ray which looks and slices through the sinuses in three different dimensions, and that shows you: Is there fluid trapped in the sinuses, are there cysts or polyps in the sinuses, is the lining of the sinus inflamed? And it looks at that with little pinpoint openings in great detail, at high resolution, so a definitive diagnosis of sinusitis can be made.

Judy:

Okay. And you just mentioned polyps. I forgot to ask you about that earlier. What are polyps, and are they part of sinusitis?

Dr. Metson:

Yes, they certainly can be. Polyps are seen in the more advanced forms of sinusitis. They look like little peas or little grapes hanging on stalks from the walls of the sinuses in the nasal cavity. They are caused by inflammation. If you have chronic inflammation of the lining in the nose and sinuses, eventually polyps will develop. These polyps will continue to increase in size with ongoing inflammation, repeated infection and eventually become so large that they block breathing. They block sense of smell. They actually physically block the sinuses as well, so the sinuses again cannot drain and become even more infected.

Judy:

Several times you've mentioned this chronic inflammation of sinuses. Why wouldn't just taking ibuprofen or one of the other nonsteroidal anti-inflammatories help with this? Or does it?

Dr. Metson:

Well, it certain can. An anti-inflammatory agent can help with pain. It can help with the inflammation – it can help decrease sinus inflammation. But most of the inflammation from sinusitis is due to bacterial infections, so an anti-inflammatory does not go to the root cause, which is that bacteria that's producing all these noxious substances that are causing inflammation. So the way to treat inflammation for most patients of sinusitis is to treat them with antibiotic. That kills the bacteria, the pus drains, the sinuses open up, and the inflammation goes away that way. An antibiotic actually helps the inflammation more than an anti-inflammatory agent because infection is the underlying cause in many cases.

Judy:

Okay. I have kind of a gross question.

Dr. Metson:

That's okay. I'm used to those as an ear, nose and throat doctor.

Judy:

You talk in your book about why infected mucus is green, and I actually was fascinated, and I must say I had never actually wondered about that. But since you do write about it, why is the mucus in a sinusitis infection green?

Dr. Metson:

You know, mucus is normally clear in a healthy individual. And it tends to become discolored, yellow or particularly green, during a sinus infection because white blood cells - a particular type of blood cell in the body which is used to fight infections - even though it has the name "white" because it looks white under a microscope compared to the normal blood cell, which is a red colored or red blood cell, white blood cells actually are green if you just look with your naked eye at them. In a test tube or in a bottle they'd be green.

So when this mucus becomes infected, these infection fighting white blood cells grow in increasing numbers and reproduce in this mucus and flow to this mucus to fight the bacteria, and so the mucus becomes green because of the large number of white blood cells within.

Judy:

So it's actually a sign that your body is trying to fight the infection.

Dr. Metson:

It sure is. It's a good sign. It's not a bad sign. It shows you have an active immune system. Also bacterial breakdown products can also be green as bacteria are being destroyed, and that can contribute also to the greenish and yellowish discoloration of mucus.

Judy:

How colorful.

Dr. Metson:

Well, there you go. You take the good with the bad.

Judy:

Does green mucus automatically mean you have a sinus infection, or could you have the green mucus even with a simple cold? Because I think a lot of people kind of think, "Well, I'm not going to call my doctor unless everything turns green."

Dr. Metson:

Yes. Green in and of itself is not an absolute sign of infection.

Judy:

Okay.

Dr. Metson:

Again, it is a sign of mucus that contains white blood cells in most cases, but that does not necessarily mean you're having a sinus infection. It could be white blood cells there because of a viral infection. It could be white blood cells there because of ongoing allergy where the white blood cells are activated. So green or discolored mucus in and of itself is not a definite sign of a sinus infection. There are many people who have green mucus, and it will clear on its own after a few days and it's fine. In fact, often just simple home remedies, like saltwater irrigations, can take care of a lot of that problem, be it green or just thick, clear mucus.

Judy:

Well, you're providing perfect segues here from one question to the next. I wanted to get you to talk about the nitty gritty of all this besides the evolutionary, interesting stuff and talk about the various treatments for sinusitis. In your book, you actually have a little chart of the steps of treatment from the simplest, which is this nasal lavage or irrigation, to decongestants or antihistamines to nasal steroid sprays to antibiotics to oral steroids and finally to surgery. I'd like to have you take a few minutes and walk us through some of these and tell us how a person would do it and what is the evidence that these various treatments are any good.

So why don't you start with the nasal lavage.

Dr. Metson:

My pleasure. I'm a strong believer in nasal lavages, also known as saltwater irrigation or saline irrigations. I've had my patients do these for many years, and they're getting more popular with each passing year because they have virtually no side effects, and they help so many patients.

The concept is to take saltwater – for instance, you could start with just a glass of warm water and a teaspoon of salt. The exact amount of salt you add is not critical, just so it's salty to taste. You want to take that saltwater and put it into the nose in some way where it will flush out mucus. So a simple way might be just to use a bulb syringe similar to what you would use to clean an infant's nose. It looks like a little light bulb with a tapered tip or a small turkey baster.

Judy:

Yeah. One of those blue things?

Dr. Metson:

Those blue things – so you take one of those blue things, those bulb syringes, you fill it up with that warm saltwater you made at home, lean over the sink and put that soft rubber tapered tip into the nostril, not far in, just the opening, and squeeze gently. The water runs right up into the nose, out the same nostril and brings with it that mucus that's blocking your breathing and blocking your sinuses and at the same time, washes away those allergy particles or bacteria and other offending particles. You repeat the same thing, lean over sink, flushing, the opposite side of the nose. And I say to my patients: Do it twice a day, like right after brushing your teeth. You brush, then you flush.

Judy:

And then you floss.

Dr. Metson:

That's right. Why not?

Judy:

And what's the recipe? How much salt for how much water?

Dr. Metson:

Normally, again, it's about eight ounces of water with one teaspoon of salt. And some people even put a little bit of a pinch or half a teaspoon of baking soda in there also to buffer it a little, get the pH just right so it's really soothing to the nasal cavity. But let me say there's a simpler, more convenient technique. In the last couple of years, virtually every local drugstore now, you can walk into and get a sinus irrigation bottle or kit of some type which comes with a plastic squeeze bottle and pre-packed salts. You just take one of these little packets of buffered salt, put it in the bottle, add the warm water. And again, it has a top with a little hole in it so that you just lean over sink, squeeze this bottle filled with saltwater, and it goes right up the nose and runs right out.

Each side, again, twice a day, brush and flush. So these bottles are really becoming quite popular, quite readily available and quite inexpensive. You can also get them on the Internet. They're in catalogs. They're all over, and they've just become so convenient and so useful.

Judy:

Well, I have to say I do this all the time myself, and I think it does help.

We have an e mail question right on this topic from Anita, and she writes, "I have had a horrible time this season with sinus issues. I have allergies and I use the prescription nose sprays, and I don't have issue so much with typical allergy symptoms. But, oh, my gosh, THE HEADACHES and the feeling of being all backed up in my sinus cavities is unbearable at times. I read somewhere about using a nasal wash with pepper of some sort. I'd try anything at this point."

I've never heard of using pepper, but what do you know about all this?

Dr. Metson:

Well, I think she's probably referring to capsaicin, which is an ingredient of chili peppers. And there were a few studies in the medical literature that looked into the use of this capsaicin for sinusitis, because you think about it, if you take and bite into something that's really hot, like a red hot chili pepper, you get that feeling that rushes through your entire head, and it's one that actually tends to open up the passages and gives you a sense that your nose is opening up. Your sinuses are opening up. They might be burning at the same time, but it leaves you with the sense of, "Wow, everything opened up." And so doctors thought maybe there is something to this, and we could put it in pill form or we could put it in irrigation form or something in the nose and sinuses and see if it really works to open up the passages that are otherwise closed and become infected.

So some early studies suggested it might be a benefit, but the truth is if it worked well, we'd all be recommending it to all of our patients. So there's a little talk about it, and some people seem to think it helps, but overall it's kind of fallen by the wayside – that's the pepper treatment for sinusitis. Just like there was an article once - a doctor wrote about his grandmother's horseradish chicken soup, the idea that horseradish will do the same thing. It tends to open up your nose and sinuses. When you're done with that hot, spicy chicken soup, just like other hot, spicy foods or peppers, you can breathe better.

Judy:

Temporarily.

Dr. Metson:

Temporarily.

Judy:

Just to go back to the baking soda thing for a minute. In my own experiences, but I'm more interested in yours, adding a little baking soda really helps the salt not burn on the way in.

Dr. Metson:

It sure does in some patients. Now, we don't recommend it for everybody because it's so much simpler to just take a teaspoon of salt and not have to worry about the baking soda, but for most patients just the regular saltwater, eight ounces of warm water, teaspoon of salt is all they need, and it's very soothing. But a certain percentage of those patients - maybe about 10 to 20 percent find there's burning when they irrigate. It kind of feels like when you're swimming in a pool and water goes up your nose, that uncomfortable burning feeling.

Judy:

Yeah.

Dr. Metson:

And that's because the pH is not right. Saltwater is a little bit too acidic, and the nasal lining and the mucus in our nose is a little bit more basic. Instead of a pH of seven, by adding like a half teaspoon of baking soda to that eight ounces of warm water, you're able to increase the pH more to about 7.5 or eight. And that makes it very soothing, so it takes away the burning if you happen to have burning when you irrigate with just saltwater. These new over the counter sinus irrigation kits that are available with the prepackaged salt, those packages already have a little bit of baking soda added to it. So they are buffered. They are the right pH, the right osmolality, if you will, so they're all set to be soothing when you mix it with saltwater.

Judy:

We have a couple of e mails that have come in. The first one is from Beverly who writes, "I have both chronic sinusitis and a deviated septum. Would it help the sinusitis to have the deviated septum fixed?"

Dr. Metson:

That depends, Beverly, on how deviated your septum is. First, let me clarify. The septum is the wall or partition that separates the right from the left nasal cavity. Often, rather than being perfectly straight, it's pushed to one side or another. That may have been from trauma, such as breaking the nose, or many people are born with a deviated septum. If the septum is badly deviated, it can block breathing. It can also block the sinus outflow drainage passages.

So that's a decision, Beverly, for your doctor to make with you. But again it's not unusual for a badly deviated nasal septum to cause sinusitis. And if you're going to have surgery to fix those blocked sinuses, straightening the septum at the same time, a procedure called a septoplasty, may be necessary.

Judy:

We have another e mail question. This is from Louise, and she writes, "I do have chronic sinus problems, and my family doctor informs me that this is a side effect of Rebif." For our listeners who may not know, Rebif is a drug that is used for multiple sclerosis. "Is it true that a side effect of Rebif is a potential for a chronic sinus problem?"

Dr. Metson:

I'm afraid, Louise, I'm going to have to pass on that one. I just am not familiar enough with the side effects of Rebif to know.

Judy:

Okay.

Let me go back to asking you about some of these other basic treatments for sinusitis – decongestants and antihistamines. First of all, I always get them confused. What is the difference between these drugs? And do they really help with sinusitis?

Dr. Metson:

Well, it's easy to confuse them because so commonly they're packaged together as combination ingredient for colds and sinuses. But simply, decongestant, as the name sounds, it decongests. It opens up the nasal passages, reduces swelling so that you can breathe better through your nose, and the sinuses can drain better. And the most common decongestant is Sudafed, or pseudoephedrine is the chemical or generic name.

Antihistamines come in a large variety of classes and families and names. Antihistamines, as the name implies, go against histamine. Histamine is one of the activating agents for allergies. Histamine is released during an allergy flare up like hay fever or caused by pollen. So the decongestant opens up the passages to breathe better and drain better.

Antihistamine blocks the release of histamine, and they can be very effective in patients with allergies. So antihistamines do work for sinusitis if allergy is underlying cause. Otherwise, they're generally not that useful. Decongestant is going to help with patients with sinusitis if congestion is a big problem, difficulty breathing through the nose. That symptom can be helped by a decongestant.

So final answer is yes, they help in some patients with sinusitis, but not all. There are side effects. If you can tolerate them, these medications are so readily available over the counter they're usually worth a try on that step wise approach to treat sinusitis.

Judy:

Sudafed is less readily available than it used to be. Don't you have to get permission from the person behind the counter of the drugstore?

Dr. Metson:

That is right. That is right. You've got to feel guilty if you're going to buy it because it's used in so many methamphetamine labs to make illicit drugs. The idea is that you have to ask for many Sudafed containing products now which are kept behind the counter by the pharmacy. You don't need a prescription, but you need to ask for them.

Judy:

Yeah, it's kind of a pain for the people who don't abuse drugs to have to go through that extra hassle because of the people who do.

Dr. Metson:

This is true.

Judy:

But anyway, steroid sprays, I guess that would count things like Flonase. How do they work? And are they addictive? And do they really help or not that much or what?

Dr. Metson:

Well, they do really help, but again they help block inflammation and usually inflammation due to allergy. Flonase is the most common one because it's available over the counter. You do not need a prescription. There are lots of others like Nasacort and Rhinocort and Nasonex, and all of these steroid sprays work the same way. They're all anti-inflammatory, they block inflammation, but the beauty is they don't have the side effects of taking steroids by mouth or by injection. They just basically coat the nose, and they're not absorbed in the bloodstream to any large extent, so you can take them long term with minimal side effects. So they are very useful.

So, again, the next step on that step wise approach of treatment of sinusitis would be a nasal steroid spray, and I do recommend it for patients with recurrent sinus infections. They work so well and the side effects are so minimal. Give it a try, and a lot of patients, they get better relief. They can breathe better. Their sinus infections aren't so bad.

Judy:

And just to make sure people are not confused, these steroids are not to be confused with the steroids that baseball players use and other athletes.

Dr. Metson:

That's right. They will not build big muscles on you. These are corticosteroids, not anabolic steroids that athletes take.

Judy:

Okay. Just wanted to make sure we got that straight.

Dr. Metson:

I just want to clarify one thing.

Judy:

Sure.

Dr. Metson:

You asked me about the other nasal sprays. Don't confuse these with decongestant nasal sprays, like Afrin or Dristan or Neo Synephrine. Once you get hooked on one of these over the counter decongestant sprays, it can be very hard to get off. There's something called the rebound effect. You use it for more than a few days, when you stop using this the nose swells up more than it ever did before you started using the medications, so you just have to keep taking them in order to breathe well and sleep well. And patients just get hooked so badly on Afrin and Dristan, so please do not take them for more than a few days, if at all.

Judy:

Why does that happen?

Dr. Metson:

Well, again it has to do with the fact that when you spray them in, the blood vessels contract. And when they contract they have to stay contracted, because the metabolism is such that the smooth muscles that line those blood vessels have to contract, and so they're always firing, and they're always working. And they're working overtime. And finally, you can imagine, they're so tired, they're so exhausted, they have expended so much energy that when the medication wears off, they just not only go back to their normal way they were set before, their normal threshold, but they relax completely.

Judy:

Oh, I see.

Dr. Metson:

So the blood vessels just get massively engorged.

Judy:

They get dilated.

Dr. Metson:

Dilated, and that's why you can't breathe.

Judy:

I see. Okay.

Dr. Metson:

Overworked blood vessel muscle fibers.

Judy:

So that's not addictive in the real sense of addiction. It's just people get in a vicious cycle with it.

Dr. Metson:

That's right. They can't sleep without it. They'll take it two, three, four times a day. They'll take it every few hours. They'll be hooked on it for months, and they just need it. But you're right. It's not a physical addiction with a physical withdrawal the way a narcotic or heroin might be, but it's an addiction because you can't breathe without it. So you really want to take it in order to sleep well and function well.

Judy:

What I do – not that I'm a doctor – but I just take it at nighttime if I've got a cold and sort of muddle through during the day and then get some sleep at night.

Dr. Metson:

And it's okay just during that cold, but only during a brief cold that's a few days. If you keep doing it at night for a week or two, it may be very hard to stop that.

Judy:

Yeah. What about antibiotics for sinusitis? Who should and who shouldn't take these? We hear so much these days about antibiotic overuse and then the subsequent problem of resistance. Are we overusing antibiotics for sinus infections?

Dr. Metson:

That's a really good question, Judy. The way they're overused is they're given for too many colds, too many viral infections that really aren't sinusitis. But if your symptoms persist, if they persist for longer than a week, if it's ten days, 14 days and your symptoms are not gone, your mucus has become discolored, you have facial pain or headache, your doctor diagnoses sinusitis, or X ray or CAT scan shows sinuses that are blocked or filled with fluid, then antibiotics are by all means indicated. They will work well. They'll give you relief and solve the problem.

So for the right diagnoses and real cases of bacterial sinusitis they should be prescribed, but not for shorter viral infections, especially the common cold. There, they're worthless and should not be used.

Judy:

There's one thing I wonder about every time I get a cold or sinusitis, and that is why isn't there some easy test just like sticking your Q tip up your nose or something to tell whether you've got a bacterial infection or a viral infection.

Dr. Metson:

Well, you could do that if you knew exactly where to stick that Q tip: right into the depth of the sinus. But the problem, Judy, is all of our noses have bacteria in them all of the time. Our noses are loaded with lots of variety of different bacteria. So if you just put a Q tip up there and then swab that on a culture plate, you're going to grow out five or six different types of bacteria off it. In fact, one of the more common one will be staph, staph aureus. About a third of the population has their nose colonized with staph aureus.

Judy:

Well, is it a different kind of bacteria that causes sinusitis, then?

Dr. Metson:

It's the exact same one. It just lives in the base of the hair follicles inside the nose. So a nasal swab tells you nothing because all of our noses are filled with bacteria.

Judy:

Could you do a quantitative thing? I mean, if you're really loaded with the stuff that would be a sign of sinusitis, and if it's not above a certain threshold, you don't have sinusitis?

Dr. Metson:

It's not really the load that causes it. It's that it should not be inside the sinuses.

Judy:

I see.

Dr. Metson:

So if you could put that swab right inside the sinus. Or what a doctor does, he'll take a very small Q tip, put an endoscope in the nose, see pus draining through the opening from the sinus into the nose and put the Q tip right into that drainage, into that pus, if you will, and that gives a pure sampling of what's coming out of the sinuses. If that comes back positive, then we know: Yes, you have bacterial sinusitis. We know what antibiotic to treat it with. But just a simple swab of the nose is really worthless because there's too much bacteria that grow in the nose all the time and the same bacteria often that cause sinusitis.

Judy:

We have an e mail question related to this topic from a woman named Rita. She says, "I have just been put on Avelox, an antibiotic for my sinus infection, and now I feel so heavy in my chest, and I can't stop coughing. Is this normal? I've generally been put on amoxicillin in the past and didn't have these side effects."

Dr. Metson:

Well, amoxicillin is a much more common medication to be used for sinusitis, and it's a good first line drug for sinusitis. Then we go to our second line drugs like Augmentin or Biaxin. Avelox is a little stronger, a little more broad spectrum and not prescribed too commonly for sinusitis. Again, you hold back and use it for the more resistant organisms and the ones called gram negative bacteria.

So Avelox can work for sinusitis, but you may be having a side effect from that, Rita. If you've never taken that drug before, it does have side effects. I'm not sure if you're having one or not. I strongly recommend you give your doctor a call to find out what he or she thinks. But Avelox can be used for sinusitis, but it's not the first or second choice. It's usually the third choice. And again, because it does have side effects is one of the reasons why.

Judy:

Why would it cause the heaviness in the chest and the inability to stop coughing?

Dr. Metson:

Yeah, I can't really say for sure. I don't know if Avelox specifically has that as a side effect. What it does is, it's so broad spectrum that it starts killing the normal bacteria that live in the gut and the upper respiratory track, and again the less common bacteria and fungi start to overgrow.

Another problem she might be having is bacteria – now that she's on the Avelox, her sinuses could be draining for the first time. So she could be having thick postnasal drip that's running down the back of her throat into the lungs and causing a cough reflex. So it's hard to know over the phone.

Judy:

So it might be a sign that it's working.

Dr. Metson:

It might be a sign that it's working.

Judy:

Okay. Well, how well do antibiotics really work for sinusitis? There was one study that I read recently that showed antibiotics really aren't that effective because the blood flow to the sinuses is so poor that the antibiotics can't get to where they're needed. Is that true?

Dr. Metson:

Well, that is true to a certain extent. When a sinus cavity becomes filled with mucus and pus, it's like an abscess. There's very poor blood supply or none whatsoever in the center of that fluid collection, in the center of the sinuses. So no matter how much antibiotic you give, there's a low concentration of it in the center of the sinus where the bacteria lives. So that's why sometimes just three, four, five days of antibiotic is not enough for sinusitis. You've got to give at least ten days and sometimes two weeks of an antibiotic to really have it be effective for sinusitis.

Judy:

You would think that with all the great brains in modern medicine, they would think of a better way of getting the antibiotics to the sinuses. I've heard of people putting antibiotic ointment like Bactroban or something on a Q tip and putting that up your nose.

Dr. Metson:

Sure, there's applying that. What I think you're going to see in the next two years is going to be antibiotic sprays for the nasal passages.

Judy:

Why don't we have them already? My god, 35 million people suffer from this. It would seem to be there's a huge market.

Dr. Metson:

I think they're long overdue. I couldn't agree with you more. I've spoken with some drug companies about that, and all I can say is drug companies are big, and they have a lot of inertia. I think eventually, the demand is there and there's the need, so antibiotic sprays for the nasal cavity and sinuses I think is something, again, we will be seeing in the not too distant future.

Judy:

I'd like to get to the topic of sinus surgery because when all else fails, that seems to be the last resort for a lot of people. Tell us what is done in sinus surgery. And actually how many people have it every year?

Dr. Metson:

Well, somewhere between 4 and 500,000 sinus surgeries are performed each year in the United States alone. That makes it one of the most commonly performed surgeries in this country. It's generally performed under general anesthesia, so the patient is asleep in the operating room, does not remember or feel anything. And a small, thin, narrow telescope, called an endoscope is passed into the nose, and there's a miniature video camera attached to that endoscope. And alongside the endoscope goes small endoscopic or microscopic instruments. Little tiny scalpels, little tiny forceps, little tiny curettes.

And under direct visualization, the surgeon removes the swollen, abnormal tissue that's blocking the sinuses, that could include a little bit of the thin bone that forms the sinus walls, and takes a pinpoint opening that is blocked and makes it a large opening, let's say a quarter of an inch in diameter that can drain normally in the future. And this is done often by looking at a video monitor. And the surgeon actually looks at the monitor rather than the patient and does this surgery and often again under the direction of computer assistance as well.

Judy:

So there's a little camera on the end of the telescope, and then that sends an image to the screen that you're looking at when you're doing the surgery. Is that the normal thing or is there some extra thing that's called image-guided, or is it all one thing?

Dr. Metson:

Well, there is something extra called image guidance. Within the last five to ten years, something revolutionary has come into the sinus operating room, and that is an image guidance system, which is also called navigational surgery. This is like a GPS system, a global positioning system for the operating room. The same GPS system that helps you find your destination when you're driving in the city, that helps pinpoint missiles to their targets, also helps direct the surgical instruments in your nose and sinuses during the surgical procedure.

Basically there's an infrared camera in the operating room. And that camera as it monitors the movement or tracks the position of that instrument in your nose or sinuses shows the surgeon a real time location of the tip of his instrument on a three dimensional video monitor. This video monitor has on it your sinuses, your CAT scan performed before surgery. So the surgeon knows where the tip of the instrument is exactly in the sinuses, and therefore can remove the diseased tissue, can preserve the normal adjacent surrounding tissue, and the surgeon can avoid the complications of injuring the eye or the brain, which again are very near to the sinuses. So it makes surgery more thorough and safer using an image guidance system in many cases.

Judy:

So you're actually using two visual aids? You're using this old video monitor plus this new GPS thing?

Dr. Metson:

That is right. They are complementary aids. There are actually two video monitors in the operating room.

Judy:

I get it. Well, I was just going to ask you about the risks, but first I want to ask you about the effectiveness. How well does sinus surgery really work? If you talk to people who have had it, some absolutely rave about it and wish they'd done it 20 years ago, and some say it's different but not really better.

Dr. Metson:

Yeah, the exact number that we found in our clinical outcome studies following over a hundred patients for several years was 82 percent success rate for surgery. Now, success means reduced frequency and duration of infections, which also translates to improved qualify of life. About 48 percent reduction in medication usage and costs with antihistamines, decongestants, antibiotics, nasal steroid sprays we've been talking about go way down the year after surgery compared to the year before surgery.

Judy:

And what are the risks? You mentioned hurting someone's eye or brain. I mean, that's kind of scary.

Dr. Metson:

Yeah, they're very rare. The common risks – when I say "common," they still happen in less than five percent of patients – but would be bleeding and infection. So patients, if there's a lot of oozing at the end of the surgery, the surgeon may put some packing in the nose that will stay there for a few hours or overnight.

Judy:

Packing, like just cotton or gauze or something?

Dr. Metson:

Yeah, like a piece of gauze, or some packings are absorbable. There are all different varieties, depending on what's needed just to control the bleeding so that there's not that risk right after surgery, or it's greatly reduced.

Also, the risk of infection is treated by giving patients antibiotics, oral antibiotics to take for a week or so after surgery. So those are the two common risks, infection and bleeding, which are easily controlled and usually avoided.

Judy:

Infection is easily controlled even with all this sort of "new ish" news about MRSA bacteria?

Dr. Metson:

Well, MRSA is that methicillin resistant Staph aureus.

Judy:

Right. And that can be controlled too?

Dr. Metson:

Well, the idea being that once you've done surgery, you really don't need antibiotics in the sense that the sinuses that were blocked and infected can now drain normally, so they're much healthier after surgery than they were the day before surgery. So we're only giving antibiotics to prevent a new infection, not to treat an old one that might have been caused by MRSA or something else. And almost all postoperative infections are caused by a bacteria which is not MRSA. Postoperative infections for MRSA are incredibly rare. They're unusually seen in patients that had a preoperative infection from MRSA, and so they're not really a major issue for us at all following sinus surgery.

Judy:

There was a very interesting study recently, a couple of weeks ago, showing that sinus surgery seems to reduce the symptoms of chronic fatigue. Is this true, and why would it be true?

Dr. Metson:

That is absolutely true. One of my colleagues, Dr. Neil Bhattacharyya at Harvard Medical School did that study, and it's simply that patients who have sinusitis are fighting a chronic, low grade infection, and often every single day their body is using extra energy and calorie reserves to fight this infection in their nose and sinuses that otherwise goes towards normal daily function. They're always feeling run down and don't have that vitality. Once you clear up the infection, lo and behold, they have more energy. They're sleeping better. They feel better. Their quality of life is improved. And that is what that study and several others have shown and what millions of patients who have had sinus surgery can corroborate.

Judy:

So a couple more questions. Does smoking increase a person's risk for sinusitis?

Dr. Metson:

Yes, it does. The sinuses are lined by cells which contain little hairs called cilia. These cilia are constantly sweeping a blanket of mucus out of the sinuses. With that blanket of mucus goes dirt and debris and bacteria and whatever else shouldn't be inside those sinuses. When you smoke, lo and behold, the cilia stop working. They become paralyzed, if you will, from the toxins in the smoke. And this is true in the lungs as well as in the nose and sinuses. So people who smoke have an increased incidence of sinus infections.

Judy:

I'm afraid we're going to have to wrap up because we're just about out of time. This is fascinating, and I have pages more questions, but we're not going to be able to get to them. Dr. Ralph Metson, the author of "Healing Your Sinuses," any final thoughts you'd like to leave us with?

Dr. Metson:

Well, all I can say to you and to your guests is: May your sinuses remain healthy and don't forget those saltwater irrigations. They can work wonders.

Judy:

Okay. I'd like to thank my guest, Dr. Ralph Metson. And I'd like to thank you, the listeners, for joining us. Until next week, I'm Judy Foreman. Good night.