OH MY ACHING HEAD

Nasal congestion, stuffiness, or obstruction of nasal breathing is one of man’s oldest and most common complaints. Affecting nearly 32 million people, it is also America’s Number One medical complaint. Over 16 million people went to physicians in 1989 for their sinus or nasal problems.
 
During an average year, more than $1.5 billion dollars is spent on “sinus” medication. Stuffy noses, congestion, headache, postnasal drip and runny nose may be considered a nuisance to some, but for others it is a considerable source of discomfort and detracts from their quality of life.

WHAT ARE SINUSES?

Before birth sinuses start as "pea-size" pouches that extend from the inside of the nose into the bones of the face and skull. They expand from childhood until young adult hood. The two largest sinuses the maxillary sinuses, lie behind the cheeks. The frontal sinuses are over the forehead. The ethmoid sinuses lie between the eyes, and behind them near the center of the skull are the sphenoid sinuses. Small openings, about the size of a pencil lead, connect the sinuses inside the nose.

Each sinus is lined with the same kind of mucous membrane that lines the nose. This membrane contains little hairs (cilia) that sweep mucus, dust particles, bacteria, and other air pollutants out of the sinuses and through the natural openings (ostia). The mucus then travels into the back of the nose and finally to the throat where it is swallowed. In the stomach, acids destroy any dangerous bacteria that may have been contained in the mucus. This mucus flow, commonly called "postnasal drip, is a normal bodily function.

Several other important structures are inside the nose. The nasal septum is a partition made of cartilage and bone that separates both sides of the nose. The turbinates are three paired structures on the walls of the nose that act as baffles that swell and decongest. A multitude of factors cause that response including: temperature, exercise, menstrual cycle, pregnancy, allergy, infection, and even a daily "nasal cycle." When the nasal passages are irritated by allergies, air pollution, or smoke, the nose and sinus membranes secrete more than the normal amount of mucus. The most common type of "postnasal drip" is a clear, watery mucus which is supposed to wash away any irritation or allergy. Another form is thick and sticky mucus. This occurs when the air is too dry for the nasal membranes to produce enough moisture for easy flowing mucus. Bacterial infections may be another cause of thick, sticky mucus mixed with pus which turns to a yellow or green color.

Nasal congestion, stuffiness, or obstruction have three common causes: structural, infectious and allergic. It is not unusual to have more than one factor involved.

STRUCTURAL PROBLEMS

Structural abnormalities within the sinuses can narrow the already small openings into the sinuses. These abnormalities can develop through trauma, growth, and aging. If the natural openings of the sinuses are blocked, or if the mucous membranes touch each other, then the mucus flow stops, causing a buildup of secretions, more swelling, and possible infection.

Deformities in the nose and nasal septum are fairly common problems. Approximately 7% of newborns suffer significant nasal injuries from birth trauma. It is almost impossible to go through life without getting hit on the nose at least once. These injuries, forgotten by the mind, are not forgotten by the nose, which remains deformed and blocked.

One of the most common causes of nasal obstruction in children is enlargement of the adenoids- tonsil like tissue that fills the back of the nose. Children with enlarged adenoids may have wide open nasal passages and complain of nasal obstruction because the air cannot flow from the nose to the throat. Children with enlarged adenoids breathe noisily at night and may snore. They may also be chronic, mouth-breathers who develop a "sad-sack" looking face and sometimes, dental deformities. Surgery to remove the adenoids and occasionally the tonsils may be advisable. Children are prone to inserting various objects (such as peas, beans, cherry pits, buttons, safety pins, and bits of plastic toys) into their noses, which can cause nasal obstruction. If foul smelling nasal drainage is noticed, a foreign body could be the cause. In this case, a physician should be consulted.

INFECTIONS

Sinusitis

We often see medical terms ending in......itis." This terminology indicates infection or inflammation. "Sinusitis" is an infection or inflammation of the sinuses. A typical case of acute sinusitis begins with a cold, the "flu, or an allergy attack that causes swelling of the nasal membranes, and an increased production of watery mucus. Membranes can become so swollen that the tiny openings to the sinuses become blocked. Then the mucus and air cannot flow easily between the nose and the sinuses and abnormal pressures occur in the sinuses causing mucus to build-up. This, in turn, causes pain or pressure in the forehead or face, between and behind the eyes, and in the cheeks and upper teeth, depending on which sinuses are involved. A blocked sinus cavity filled with mucus becomes the perfect place for bacteria to grow. When a cold lasts more than a week and the mucus turns yellow/green or develops a bad odor or taste, then a bacterial infection has probably taken over. In acute bacterial sinusitis, the pressure and pain in the face and forehead can be quite severe.

Chronic Sinusitis

Chronic sinusitis occurs when a sinus opening is blocked for an extended period of time. Although chronic sinus infections may or may not cause pain, nasal obstruction, or an offensive, postnasal drip is often present. Some people develop fleshy growths in the nose (polyps) from sinus infections. These infections can spread into the lower airways and lead to chronic cough, bronchitis, or a worsening of asthma symptoms.

Medical treatment of nasal polyps includes control of allergies, steroids, and sometimes antibiotics. Massive polyps that obstruct the nose may not respond to medical therapy and require surgical removal. One week prior to surgery, these patients are usually given oral corticosteriods to help decrease the polyp size and reduce bleeding during surgery. As a general rule, acute sinus infections respond to antibiotic treatment, whereas chronic sinusitis usually requires surgery.

Most cases of sinusitis respond promptly to medical treatment and are not serious. However, because an infection in the sinuses is very close to the eyes and brain, an extension of that infection into these areas, although rare, is extremely serious. Furthermore, it is not healthy for the lungs to have infected mucus dripping down from infected sinuses. Bronchitis, chronic cough and asthma are often aggravated and even brought on by sinusitis. A combination of antibiotics and decongestants are used for approximately three weeks to treat the infection. Direct culture obtained in the office or during surgery helps to determine the type of antibiotic used. In some particularly resistant cases, a combination of antibiotics or intravenous antibiotics can be used. In some cases of chronic sinusitis, in addition to antibiotic therapy, surgery to open the blocked sinuses or drainage passages may be required.

ALLERGIES

Allergic rhinitis, otherwise known as hay fever or summertime cold, is an exaggerated, inflammatory response to a foreign substance. Stuffy nose is usually caused by pollen, mold, animal dander, or some element of household dust. In springtime, pollens from trees and grasses, or in late summer, ragweed may cause problems, but household dust and mold can be a year-round problem. Also, food allergies may cause a problem. Ideally, the best treatment, although not always the most practical, is to avoid these substances.

Antihistamines and decongestants

In the allergic patient, allergens stimulate the release of the chemical "histamine, which causes congestion and excess watery mucus production much like a common cold. Antihistamine drugs help prevent these symptoms by blocking the effect of the histamines. Decongestants help to shrink the swollen nasal tissues and open the breathing passages. A side effect of most antihistamines is sleepiness; in decongestants it is stimulation. Therefore, a combination of these two drugs is often the best solution, since the side effects cancel each other out, and the desired effects complement each other.

WARNING!

Patients who get sleepy from antihistamines should not drive an automobile or operate dangerous equipment after taking the medication. Patients who have high blood pressure, irregular heart beats, glaucoma, or difficulty with urination should avoid decongestants, as they stimulate the heart and raise the blood pressure. Pregnant women should consult their obstetrician before taking any medications.

Steroids

Steroids are very effective for allergic patients, but because of the potential side effects from long-term use, these patients should obtain advice and monitoring from a physician. Steroids given over a one-week period have a minimal risk of side-effects. Nasal spray steroids are much safer and still very effective, however, it may take several weeks to obtain a positive effect. Nasal sprays that can be purchased without a prescription usually contain decongestants for direct application to the nasal membranes. Although they give prompt relief from congestion by constricting the blood vessels, they create a much stronger stimulation than an oral decongestant. The circulation in the nose is somewhat impaired and after a few hours, the vessels will again dilate or expand to improve the blood flow. This results in a "rebound" or "bounce-back" effect and the congestion returns. The patient then feels the need to use the spray again and, in so doing, starts a vicious cycle: congestion spray - decongestion - rebound - more congestion. For this reason, nasal spray decongestants should not be used for more than three days at a time.

Desensitization injections

Allergy shots (desensitization injections) are highly successful in allergic patients and are the most specific treatment available for inhalant allergic problems. In our office, to determine which substances cause allergies, a computerized blood test called Enzyme Linked lmmuno-Sorbent Assay (ELISA) is used. The initial blood screen of common items helps us determine if the patient is allergic to inhalants. If a test is positive, or if the patient is known to be allergic, another 22 antigens are tested using the original blood sample. Blocking antibodies are formed in the patient’s blood stream, which then interfere with the allergic reaction. From this test, we prepare a vaccine and begin desensitization injections. Many patients prefer allergy shots; however, others may need to take medication along with the injections.

Patients with allergies have an increased tendency to develop sinus infections and may also have asthma, nasal polyps, and aspirin allergy. Aggressive medical and surgical management may be used to obtain relief.

“A thing of beauty is a joy forever: Its loveliness increases; it will never pass into nothingness; but still will keep a bower quiet for us, and a sleep full of sweet dreams, and health, and quiet breathing.” (ENDYMION, John Keats)

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