Sinusitis: A Treatment Plan That Works
More Letters

We have continued to receive email and have chosen some of them for you to read:

From:C.
Subject: Colloidal silver

Dear Dr. Tichenor:
I have seen a number of websites on the internet which suggest the use of colloidal silver for treatment of sinusitis. What do you think about it?

There is evidence to suggest that silver has both antifungal and antibacterial properties, however I have a number of concerns about it. The FDA has not approved the use of colloidal silver as a drug. Taking silver in a high enough amount can cause poisoning called argyria. There are numerous websites which review the toxicity which you can find on one of the search engines. The primary manifestation of argyria is a silver-grey coloration of the skin. There is no treatment for this, since there is no known chelation agent which can be used for treatment. Just as with many other forms of treatment, patients can get much worse if the wrong treatment is used.

From: B.
Subject: drug interactions

Dear Dr. Tichenor,
Your website is extremely thorough; I was grateful to find it -- it has already been stimulating in my thinking about sinusitis and how I can improve my situation. The FAQ is fabulous!

I do have a question: I have been a sufferer for the last 7 years or so -- it began then with an infection (not visible on x-ray) but treated with antibiotics and nasal sprays which seemed to work at the time. When things are not as bad, it is still touch and go -- I will get bad headaches in clusters, with throbbing in my nose and pain in the cheeks. (I have also, by the way, not seen any mention of the particular symptom of nose throbbing, twitching -- do you come upon it? It's a very odd feeling -- sometimes I just want to strap my nose down!!)

For the past two months I have been taking antibiotics, first Zithromax (didn't help much), then Ceftin (which did). I am on Ceftin again, now for a 20 day period. For symptomatic relief, I am in a bind because I am also taking Imipramine (an antidepressant which can cause dryness) and a small amount of Xanax ( for anxiety relief) daily, and during the previous recent infection, I was using Nasacort, a lot of Tylenol Sinus, Fiorinal for pain, and Ceftin.

I had a drug toxicity reaction (very odd out of body sensations) and several psychiatrists suspected the pseudoephedrine combined with the other drugs to be a culprit. I'm reluctant to try nasal sprays again, and any over-the counter products, or for that matter, prescription decongestants.

I am using a HEPA air purifier. Acupuncture has been helpful, but not during acute stages. My physician has not ordered any further diagnostic testing.

There do seem to be some advances in drugs for sinusitis, but what about for people like myself who are using other prescription drugs which may interact negatively with those drugs?

(Incidentally, in the past I have used Vancenase, Nasalcrom, Cromalyn, and Tavist-D, but with little relief).

My acupuncturist wondered about the drying aspects of Imipramine..I have pain and pressure but no discharge.

I am most grateful for any time you could put to these issues.

Thanks so much!

B

The symptoms that you have can be difficult to treat because of the drying effects of the imipramine. Have you talked to your psychiatrist about a different antidepressant? Antihistamines can also cause dryness. Have you had a nasal endoscopy, and a CT scan - Regular X-Rays are not optimal for sinusitis? Have you been on guaifenesin?

It is common that patients will have side effects with medications and one of the things that we have to do is work with the side effects. There is also another decongestant called phenolpropanolamine which can sometimes be used.

From: l
Subject: sinusitis of my 3 yr old boy, B

I enjoyed your article from the Internet. My son was diagnosed with chronic sinusitis approximately two and one half years ago. The problems began as an infant not being able to breathe and running low grade fevers almost all of the time. From this scenario, B developed a periorbital cellulitis that abscessed behind his left eye and had to be surgically drained (May 1995).

His problems continued with almost nonstop antibiotic therapy. We had numerous CT scans and IV antibiotic therapy. The next step took us to allergy testing at ************ in ******** - the tests all were negative leaving the physician to refer us to their Otolaryngology Dept.

After months of antibiotic therapy, they felt the adenoids should be removed. The surgery was performed in ********* in September 1995. If anything, the sinus condition worsened over the next few months. Feeling exhausted, we went to another allergy/immunology clinic in *************. These physicians performed a battery of tests also. None with conclusive information. The sweat test (to check for cystic fibrosis) was given as well as a pneumovax vaccine with pre and post titers ( to check on the immune status). Again, no answers from this battery of tests other than negative to Cystic Fibrosis.

The immune studies weren't good but not too bad according to the immunologist. He suggested another ENT which we saw. FESS was performed in March 1996. B has been on an antibiotics 9 of the 10 months following this.

We have again been to an Immunologist who has ordered an additional round of immune studies. Presently, we are on IV antibiotics (Rocephin) and have been for 10 days with a 7 day extension. The physicians now want us to go back to an ENT for additional surgery because the CT scan shows no air pockets at all in the sinuses (especially maxillary). At the conclusion of the IV, our physician is wanting B to take 30 days of Biaxin along with liquid Claritin.

I would love to hear your response to this. I promise I have stumped the physicians in ********, especially our Pharm.D. I work for ******** which is a family practice residency training program. The physicians here have been intrigued by the round of events that have transpired and everyone is very hopeful that this last battery of tests will show something. Dr. B in ****** has mentioned trying the gammaglobulin infusions before any additional surgery is performed.

Please give me some type of feedback or suggestions. I am open for any and all of the help I can get.

Please e-mail me at ********

Thanks in advance for your help.

s.

We generally don't like to give gamma-globulin unless it is clear that there is an immunodeficiency. Once people are on gamma-globulin, it is difficult or impossible to get them off. That being said there are obviously circumstances when it is not clear whether there may be a immunodeficiency, and that can be difficult to decide whether it makes sense to use it.

Typically tests are done to determine whether the levels of gammaglobulins are normal in the blood. Sometimes the levels to specific antibodies are checked as you had done for Pneumovax. If patients don't respond to the Pneumovax by producing antibodies, then IV Gammaglobulin may be given. It is extremely expensive ( typically $25,000 - $50,000 per year), so we don't use it indiscriminantly.

Unless there is a good reason ( like severe allergy), we don't like to use antihistamines.

As for reoperating, most of the time with optimal medical treatment, patients don't need to be reoperated on, but there are obviously exceptions. The reoperation is more difficult, so if it is done, make sure it is someone with a lot of experience. (The ENT who I work with in New York does reoperations almost exclusively.)

From: J
Subject: sinusitis/osteomyelitis

I am Dr. J. I am not a doctor of medicine, but education. Please do not let this interfere with your finishing this letter. I have had some medical training . . .paramedic and respiratory therapist. My concern is that I have chronic sinusitis and have been treated for it for over three years. I have had surgery three times: to remove polyps twice and to debride the bone during the last. My symptoms are typical: pain in left maxillary region, tenderness in the cheek, profuse drainage (not clear). Note: I have completed allergy testing and the desensitization with injections.

My specialist is Dr. A of *******. He has performed the three surgeries and acknowledges that he is stumped. Previous CT scans (18 months ago) for the last surgery indicated the possibility of osteomyelitis.

Now with increased pain including pain around the mandible, he has ordered another series of CT and MRI films for tomorrow. The drainage is now foul smelling and I believe that indicates anaerobic bacteria. Please realize that I have also completed two series of IV antibiotics (one was gentamicin) for over 21 days each, I have taken more Cipro than you can imagine, I have seen an infectious disease specialist in ******* named Dr. N. I have taken steroids, Augmentin, I irrigate my sinuses, and have even sprayed saline with gentamicin into my sinuses.

Cultures often show a Pseudomonas; however, the cultures have waivered between the Pseudomonas to now Staph and back. My question is this: Who do you recommend in *******?

I have researched that in Germany beads are produced by the Merck company that have antibiotics. I understand that the beads are available in Canada. I would appreciate any information you can provide me.

Allergy shots typically may take 1-2 years to work, so please give the desensitization enough time to work.

The fact that you have had multiple infections and the drainage is foul smelling suggests the possibility that you may either have a fungal sinusitis or should have a workup for an immunodeficiency.

I am not familiar with the beads in treatment of sinusitis.

One thing I have noticed is that most people don't use enough of the irrigation solution. You have to get 1-2 tablespoons into the nose each time to irrigate it.

From: H
Subject: sinuses.com

Dr. Tichenor, I wanted to thank you for your web pages on sinus problems, allergies and asthma. I have been miserable for months and recently learned that it is due to chronic sinusitis. Your reference has been the most extensive and usable that I have been able to find. As a techie, I am praising the graphics and presentation format as well as the very informative content. The CT scan explanation was particularly useful. I expect to call upon this bookmark repeatedly as I continue with treatment.

I would be interested in a bit more detail about the surgery and recovery process:

What types of medications are used post-surgery?

What is experienced after surgery ? I've read elsewhere in less objective terms about continued headaches, bleeding and scarring, and the necessity of "packing".

According to my Dr., my lab test results included a low white blood cell count and iron levels and a very high ESR ( a test to measure inflammation). I don't see anything in your Laboratory Tests section to indicate that these are significant considerations in evaluating treatment of sinusitis.

I felt the greatest relief with prednisone. How does this help? What are guidelines for use of systemic steroids - how long and in what dosages are they helpful?

Is there any advantage to starting allergy shots now, or can I wait until this infection is under control and I'm feeling a bit more normal?

Regards,
H

Most people don't get scarring, and most of the time people don't need packing. Some people have pain after surgery, but many don't. There is a sensation of some stuffiness due to the crusting after surgery, but it is different than before, because the sinuses are open. It is important to have excellent post-operative care, including removing debris, and opening up any early scars so that they don't cause problems. Despite the best care, however, some people do get scarring which may need to be treated.

Typically most patients are placed on antibiotics after surgery, but often the mucus thinners, and steroid nasal sprays are not used, at least initially. You will typically be told not to do any heavy lifting, fly in a plane or blow your nose for a while.

The high ESR may be from infection. The white blood count I can't comment on. It may need to be investigated. The low iron count may not be related.

Steroids reduce inflammation. They must be used with caution, and in limited amounts. A typical regimen is the Medrol Dosepak which is used for 6 days, in tapering amounts.

Allergy shots take a long time to work, but should be started as soon as is reasonable

Subject: surgical skills
From: N

In your article you stress the importance of a doctors surgical skill and experience.

I'm set to have surgery and would like to check on the MD's qualifications. Where and how can I get that kind of information? I contacted one agency but they only could tell me if there was any complaint against the Dr.

Any suggestions?
Thanks,
N

It is very hard. You can check with the hospital, or medical school about how many complications he has had, and find out how many procedures he has done.

Ask what his complication rate is, and ask if he is a member of the American Rhinologic Society. You can also ask where he was trained, if he is board certified, and if he has done any research, lectured, or taught courses on the technique.

If it is a complicated procedure, or if you have had previous surgery, we will often suggest that people come to New York to see one of the surgeons that we suggest. Remember the complication rate is directly related to the skill of the surgeon, as well as the number of patients previously operated on.

From: N
Subject: sinus surgery recovery

I'm scheduled to have sinus surgery in Feb.

Does anyone who has had surgery know what the recovery time is? My Dr. says a week, a friend says much longer. What has been your experience?

I will be having the surgery on my nose as well as the sinus openings. Will I be able to fly to Florida in April?

N

It takes about 1-2 weeks before going back to work, 3-6 weeks before the crusting stops, and 6-12 months before the nose is much less sensitive to things like tobacco smoke, etc. Usually it takes 7-21 days before you can fly.

Another patient replied to the above question:

I had a particularly severe case, it's true. But it took me a good 2 weeks before I could function without pain-killers and feel anything close to "normal.' A month at least before I could stop feeling the inflammation from the surgery, and I am still having problems with my sinuses (polyps reformed at once).

My advice is to give yourself two solid weeks of bed rest if possible to get the best start -- I pushed myself and regretted it. A

It is highly unusual for recovery to take that long.

From:k
Subject: sinus surgery recovery

Dr. Tichenor,

Just an observation in regard to your response to "N" I don't know what your criteria for "back to normal" would be, but I wasn't anywhere near normal after a week. The packing, splints, and drainage tubes didn't even come out until after 5 days. I'm nearing the 6-month mark, and I still have some level of crusting occurring.

Perhaps a slightly more realistic estimate would be a kindness to fearful patients?

K

Most patients don't need packing or drainage tubes. You are obviously an exception. Most patients are back to work after a week. The statistics that I stated are typical for most patients, including my personal experience with surgery, but obviously given the variation in people's experience, you must be prepared for a longer recovery time that usual. Some people have an extended period of crusting, but it is unusual.

I am always concerned when people have that long a period of time for recovery as to whether there was something wrong with the original surgery, or if something may need to be done medically. unfortunately most doctors can't deal with medical treatment of sinusitis well.

From M
Subject: surgery and reoccurring problems

Great web page!

I had extensive sinus surgery in April '96. I was sent to an allergist and it was determined that I was allergic to most of the 33 allergens that I was tested for. I am currently on the allergy shot routine, just reaching maintenance (5 months). I have still been having some problems related to sinusitis, so my allergist tried a few different scenarios, lastly being a CT scan. It was determined that a few cysts and mucous thickening were present.

I have never had the 'typical' reaction to cats, pollen, etc (running eyes, wheezing, sneezing, etc). I never knew I even had sinus problems until I had bronchitis 12/95 and it never got better, resulting in the first CT scan in 3/96.

I had several sinuses with total opacification (complete blockage) and lots of cysts/polyps. I wouldn't have even gone to an allergist after the surgery if if wasn't for the insistance on my part. The surgeon didn't think I had an allergy problem -- nor did the allergist -- in the beginning-- I didn't have any of the classic symptoms.

I must admit that the allergy-proofing of my home was something that I had not done. (My most allergic culprits are cats & dust mites). I realized that I needed to do something. I have taken my bedroom and removed nicknacks, curtains, etc. I am washing everything in hot water, barring the cat from the bedroom at all times, and I purchased a Honeywell HEPA filter.

NOW, it is less that a year later and my CT scan is showing problems reoccurring. My concerns are how to treat my environment, it seems like the source causing the cysts is still present. I do spend a lot of time on a farm, living in an old farm house on the weekends, which is very dust oriented. I'm going to avoid the place for a few months to see what the effects.

My questions:

• Can cysts shrink if your environment is changed (i.e. there's trouble again up there in the ethmoid, maxillary, etc.)
• Can I get rid of the cysts without surgery?
• Does all the plastic bed cover stuff work?
• Is there anything that can be done to carpet, if you cannot remove it?
• Would tossing scatter rugs and comforters in the dryer for say 30 minutes intense heat kill dust mites?
• What effect can bathing my cat weekly have?
• Have you heard anything about a pill to give pets to alter the allergic aspect of the dander?

Any help would be appreciated!

Thanks,
M

Sometimes cysts and polyps can shrink by controlling sinusitis and the environment. Reducing the exposure to allergenic agents such as dust mites by using mattress and pillow covers does help. Washing the throw rugs, and bed linens in hot water once a week does help. If you are allergic to dust and mold, the farmhouse can be a problem.

There are products that can be put on rugs which kill the dust mites or destroy the allergenicity of the dust mite, but they are not my favorites to use. Discuss them with your allergist. They can be obtained from any of the supply companies on the bookmark page. The best thing to do is CLEAN UP YOUR ROOM.

Bathing the cats may help. It is controversial, however. I am not familiar with any pills that can be given to them.

Once people have had surgery, we like to try to manage their allergies first. Most people will get better without reoperating. Remember that it may take a year or two for the shots to work.

If with good treatment you don't improve, then it is possible you may need to be reoperated on, but remember what I said in the other part of the website. You have to get good treatment, and many patients don't. Repeat surgery is more difficult to do, however, so make sure that the person is well experienced. The ENT that I use primarily does reoperations.

From: M
Subject: sinusitis during pregnancy

I just found out that I am 4-5 weeks pregnant. The problem is that I felt a sore throat coming on initially and then it progressed to nasal dripping but most of all terrible "pressure" in my head.

I visited the doctor and she said that there was no ear or chest infection and that it was probably sinusitis and because of the pregnancy I could not take anything. I was hoping you could suggest some at home treatments to ease the head pain.

Is sinusitis part of pregnancy?

Any information would be greatly appreciated since I would love to celebrate my pregnancy instead of feeling miserable.

Thank you
M

All too often, we see patients who have been told by their obstetricians that they should avoid medications during pregnancy at all costs. There are circumstances when it is important to treat medical problems during pregnancy. One of those circumstances is sinusitis. You can use most of the medications that we suggest during pregnancy. Talk to your doctor about what can be used.

From g
Subject: chronic sinusitis and yeast infections

Thank you for the informative website!

I would like to add my feeling that some information on yeast-related infections would be helpful. I have had a near continual round of sinus infections, along with sinus surgery, and many (too many) courses of antibiotics. Like a previous writer, my symptoms--headaches, fatigue, groggy feeling--would persist even after CT scans showed "relatively" clear sinuses (mild thickening, etc).

I did take Diflucan for six weeks last Fall and had an amazing improvement--like a huge pressure lifted off my head. Over Christmas, I got another bad sinus infection (of course!) that I am still fighting--Augmentin, Cedax and now Lorabid. I am also preparing for another fight with my doctor to convince him to put me back on Diflucan.

What I would REALLY like is to quit getting these infections! This all started abruptly when we had a baby (and all the infections he brought and brings home) and I am starting to worry that all the antibiotics have diminished whatever was left of my obviously fragile immune system.

I am HIV negative and wondering if there are other immune system tests or issues I should wonder about.

Thanks again!

G

The yeast related (fungal) infections will sometimes occur in patients who have been on antibiotics for a long time. That is what happened to me. I got a fungal infection in my sinuses, which is what prompted me to have the surgery. Since then, I have been fine.

If you have developed a fungal sinusitis, and you consequently responded to Diflucan, I would be very concerned that it may happen again.

If that occurs, then it can be very difficult to treat. It usually makes sense to get a CT or MRI scan, and if possible do a culture from the sinuses.

Most people who have a fungal (yeast) infection in their sinuses need surgery. The antifungal agents just don't work as well as the antibiotics. Please see the section on fungal sinusitis on the Physicians Page.

You should also have other immune system tests done by allergist including gammaglobulin levels.

From: T
Subject: Irrigation

Please forgive me if this question has already been asked...I have been lurking (on a newsgroup), but not found the answer.

I have had sinus problems all my life. Been going to an ENT (the same one) since I was 4...I'm 23 now. I have had my sinuses X-rayed and CT scanned multiple times, all showing blockage and small sinus openings.

I was allergy tested (at my ENT's office) and it was determined that I have severe allergies...so I went on shots, Vancenase, Lorabid, Clor-Trimeton....etc. Point is I've done the whole 9 yards.

My question is...I am wondering why my doctor has not recommended surgery/irrigation. I have heard from friends (with less severe problems than me) that they have had surgery or that their Dr.s have recommended using a waterpik to "clean" the sinus cavities.

What's the story with this irrigation thing?

T

It is not generally accepted by most physicians that irrigation works if you have not had surgery. I, however, have seen many patients who are helped. Some patients find that using the Grossan irrigator with a Water Pik does help. The address is in the bookmarks section.

Concerning surgery: unfortunately many physicians don't recommend surgery, including ENT's. There are many possible reasons including the fact that your ENT may not due endoscopic surgery. Most of the time good medical treatment will control sinusitis, but if patients don't get better, surgery may be indicated.

We generally do not suggest using antihistamines such as Chlortrimeton unless allergies are severe, since antihistamines can dry out the mucus.

I think that because allergists specialize in allergy treatment, it makes sense to see an allergist when someone isn't doing well. Obviously, though, I am prejudiced about it because I am an allergist.

From: S
Subject: Thanks + question

I read your home page today and it meant a lot to me that you described your sinus travail, especially the part about not being taken seriously.

Years ago, I had a sinus infection in all 8 sinuses, but it took 2 years for me to find an ent specialist to diagnose it. (During those 2 years, doctors told me to get married, get a hobby, go to a shrink.)

I took dicloxacillin for a long time and recovered, but since then I have had to go back on antibiotic once or twice a year, always for longer than 2 weeks--and that has kept it under control. Unfortunately, the specialist retired, and I am having trouble finding a dr. who will prescribe diclox for me long enough, so now I have the worst case I've had in years.

I have 2 questions:

1. My current dr talked me into taking augmentin instead of diclox. She says the bacteria have become resistant to diclox. Could diclox still work on MY bacteria?
2. I apply a warm compress over my right maxillary sinus and eye, where the pressure is the worst. Is that better than an ice pack?

THANK YOU FOR SHARING YOUR EXPERIENCE!

Yes, Augmentin may work. Often, with repeated use, bacteria may become resistant to the antibiotics. You often have to try another drug and see if it works. But as you know from reading the website, usually it has to be treated for a long time.

If warm compresses work, I don't argue with success!

From: M
Subject: Internet House Call

Dr. Tichenor,

I have a question that I hope you will be able to answer (like you haven't heard that before).

My wife has been suffering from recurrent sinusitis for the last three years. After an ENT had allergy tests done (negative), a CT scan was scheduled. She was put on antibiotics (Amoxicillin 250mg and Augmentin 250mg, 3 times a day) for 21 days prior to the CT scan. During the treatment, her symptoms were gone.

After the CT scan came up clean, an endoscopic rhinoscopy was performed 4 days later with the same results. She stopped taking the antibiotics the day of the CT scan. Three days after the endoscopic rhinoscopy her symptoms returned.

Now to my question. Is it normal procedure to put someone on an antibiotic regimen for three weeks before a CT scan or endoscopic rhinoscopy is performed? She is now being referred to a neurologist because the CT scan was clean.

After reading through your WEB site, I feel like we are going in the wrong direction. Any help/advice that you can give would be greatly appreciated.

Thank you,
M

P.S. Your WEB site contains a wealth of information. Thank you very much for making it available to the public.

It is TYPICAL that symptoms will come back if antibiotics are not continued for a long enough time.

When the CT or rhinoscopy is done is up to the MD, but we will now typically do the endoscopy before starting antibiotics if it is not clear that a patient has sinusitis. If a CT is done later, it is sometimes hard to establish if there was a sinusitis in the first place.

An additional factor is that sometimes the CT scan is underinterpreted by the radiologist, i.e. there may be questionable disease on the CT which the radiologist doesn't think is significant. In addition, there are times when the CT scan just doesn't show disease which we may be able to see at the time of surgery.

From: "S
Subject: What is the "sinobronchial reflex?"

Could you explain what the sinobronchial reflex is. I have heard that it may be an explanation for why patients with sinusitis have asthma.

S

The sinobronchial reflex is a postulated connection from the sinuses to the lungs via the brain which is thought to cause inflammation in the lungs when the sinuses are inflamed. It has been shown in animals but not yet in humans.

Additionally because mucus and other inflammatory materials drip down the back of the throat, they can inflame the throat and lungs and can also be a cause of asthma .

From: t
Subject: sinusitis

First of all...great website. It was quite informative :>)

I am almost positive that I have had sinusitis, off and on, for about 10 years now and it seems to be reoccurring more frequently. I am a 36 years old, male, and I live in*******. I have a few questions.

1) What can be done to PREVENT sinusitis from reoccurring?

Live in a bubble:-) Seriously, you have to control all irritants from colds to allergens to smoke which is obviously difficult or impossible to do.

2) I exercise 2-4 hours a day. Could overexercising cause sinusitis?

Doubtful

If I exercise when I have symptoms of Sinusitis, the cold only gets worse.

You probably don't have enough energy when you have a severe sinusitis or cold, so it wouldn't make sense to push yourself then.

3) I surf in the ocean just south of San Francisco, once a week, usually for 3 hours. Could this cause sinusitis? If so what can I do, besides not surf, to prevent the condition.

Getting water in the nose can be a problem. You may want to use noseplugs.

4) I am a science teacher. Could I be getting sinusitis from my students (12-14 years old) or from my classroom. If so any ideas for prevention?

Irritating chemicals can cause problems. You may want to use an appropriate mask.

5) Will herbal remedies such as Echinachia or Goldenseal help prevent or treat Sinusitis?

There is no data, but some patients have said that they help.

6) What about being slightly chilled at night while sleeping? I sleep on a futon, could I be allergic to the mattress?

Yes, you could be allergic. See the section of the website on allergy.

7) Can "Breath Right Nasal Strips" help? Hurt?

Some people are helped, especially if they have a narrowing of the front part of their nose.

8) I am taking 60 mg of decongestant 4 times a day. Is that OK?

Ask your doctor, but most people can tolerate that amount.

Thanks for responding to my letter

T

We have had numerous inquiries recently about the Rhinotherm. Unfortunately we no longer have a source for either new or used Rhinotherm units, nor do we have a place to suggest for repair. If you have a source, please let us know.

I received this note recently about a chat group on allergy:

An allergy support group has just started on IRC (Internet Relay Chat). IRC gives you the opportunity to chat in real-time with others suffering from or in any way dealing with food and/or environmental allergies.

The IRC concept is simple and has been around for several years...

- get a Windows, Mac, or DOS based shareware program
- you connect to your internet provider
- you open the IRC program
- you pick a "nickname" for yourself
- you pick an IRC server to connect to
- you choose a channel (chatroom) to chat in (this one's called #Allergies) Following are detailed instructions for for connecting to #Allergies...

- connect to the internet and using any web browser download a good IRC client, my suggestion to anyone running Microsoft Windows would be to get a copy of mIRC 5.02 and let it step by step you through it's very user friendly self-install. You can find it at www.mirc.co.uk

- you'll have the option when you start up the mIRC program to connect to a wide variety of servers, pick the option to connect to a "Random DALnet Server" (DALnet is one of the more popular IRC networks comprised of many linked servers and thousands of chatrooms)

- the first time you use mIRC it prompts you to pick a nickname so just go straight to clicking the "Connect to IRC Server" button when you're finished

- once in the program, type the following line at any flashing prompt... /join #Allergies (note that IRC commands start with the / sign)

- A window will open and you simply type whatever you wish and press the "Enter" key... others will see what you say with at worst several seconds lag and respond, remember to wait patiently for others to respond as they have to read what you say and type a reply.

STUDENTS

Most universities can only provide IRC access via "Telnet". To connect using Telnet simply log in to the system as usual and type the following as separate lines hitting the "Enter" key after each line...

telnet
telnet.dal.net (at this point you'll be prompted to provide a nickname)
/join #Allergies

From: L
Subject: Sinusitis homepage

Dr. Tichenor, I followed your recommendation to check out your home page regarding sinusitis.

Congratulations on a really wonderful site, with answers to pretty much every question I could come up with.

I am a singer, and my chronic sinusitis is aggravated by concha bullosa. (Concha bullosa is an enlargement of the turbinates in the nose due to air pushing down from the ethmoid sinuses. Look at the CT scans elsewhere on this website for a better understanding.) They will be corrected by surgery this summer.

The chronic sinusitis has swollen my vocal folds to the point where I have been unable to sing since September, although in retrospect, I think I may well have had chronic sinusitis before then- just not as badly. I was told the concha bullosa is

a) congenital, and

b) wasn't as problematic while my face was still growing (I'm 20 now).

I saw an allergist early in my tackling of this problem; he did several prick tests all of which turned up the result "postinfection hypersensitivity", i.e. not really a positive allergy to any tested substance, but not completely negative. As I'm sure you know.

It would be interesting to see you deal with some of the ways sinusitis and sinus surgery affects the singing and speaking voice in your FAQs, e.g. the breathing tube which is put in your throat and used with general anesthetic to put you to sleep.

I'm glad to see from your discussion, however, that my ENTs have done as well by me as they could- my GP sort of flubbed in giving me a ten-day round of Ceftin a month or two into the condition, but she referred me on to one of the Otolaryngology profs at my university.

When he recommended surgery, I got a second opinion from the head of the oto. department. Both of them have considerable experience with FESS (i think that's the right acronym) and have taught it to their students for some time- they're probably the best guys I could ask for east of ******. This is comforting, as i am still a little scared of surgery-

I suppose you could call it an irrational fear, but then again I guess it's good to have a bit of wariness for any procedure involving remodelling the body we were born with- while I certainly have no problem with the idea of surgery, I don't think it should be taken lightly.

Thanks again for a very informative web page.

L

I agree that surgery shouldn't be taken lightly, but if other treatments don't work, it can work wonders.

I am not familiar with the term postinfection hypersensitivity. The allergist may have felt that you were not sensitive enough to the things to warrant treatment. I believe, however, that if a patient has chronic sinusitis and allergies, the allergies should be treated to attempt to reduce the likelihood of future sinusitis. The sinusitis can be made worse by the allergies. I have several patients who needed surgery, but we were able to avoid it by giving them allergy shots.

The post nasal drip commonly changes the voice by dripping down into the throat and then irritating the vocal cords. It also may reduce the vocal stamina and change the pitch and range of the voice. It can also cause hoarseness. The resonance of the voice changes because the sinuses usually contain air and if they become filled with mucus or polyps, the resonance changes.

If a general anesthetic is used, it is necessary to use a tube to put in the throat. Usually it doesn't do any damage, but that is something you should speak to the anesthesiologist about. It is possible, however, for the surgery to be done under "local" anesthesia, which means that you are asleep, but still able to breathe on your own, and they don't have to put a tube in your throat.

From: gls
Subject: sinusitis / Entertainer's Secret

Dr Tichenor -

We have a product which is called Entertainer's Secret Throat Relief which your patients may find useful for treatment of chronic sinusitis. Many patients find that it is soothing to the nose and throat. After you have had a chance to observe how this product works in your own patients, please get in touch.

gls

We have tried it in a number of patients and have found that it can be helpful. The website is listed in the Bookmarks section.

From: P
Subject: Chronic Sinus Problems

Thank you for the comprehensive and informative web site on sinusitis problems.

I had endoscopic nasal surgery to clear all of my sinuses (with the exception of the frontals) about a year and half ago. I have had ongoing problems since, primarily in my frontal sinuses, including facial pain and headaches, extreme chronic fatigue and general malaise.

After many rounds of antibiotics, my ENT finally did a follow-up CT scan which revealed significant disease in my frontal sinuses. He also did an immune system evaluation and determined that my IgG was low at 489 with an mildly decreased level of IgA. While we are further evaluating this "immunodeficiency", he has prepared me for the fact that I may need a frontal sinus obliteration with abdominal fat transplant. Do you have any information on this procedure?

It sounds so invasive and I am looking for alternatives. I have been on various antibiotics for the last seven weeks, with really no relief.

I am also using vitamin supplements, herbal teas, papaya enzyme, colloidal minerals and facial hot packs. If my immune system is truly immunodeficient I am also going to try a short term regimen of IV immune globin, prior to surgery. Do you have any suggestions?

Best regards,

P

Frontal sinus obliteration is a major procedure. It involves cutting into the scalp and creating a flap of skin which is folded down over the eyes exposing the bone over the forehead. The forehead bone is then removed, and fat is transplanted from the abdomen, and then the bone put back in. It is a major procedure and if you have it done, it should be done by someone who does it very frequently. Nowadays, it is usually possible to do frontal sinus surgery using image-guided surgery, which is discussed elsewhere in this website. With that technique it is possible to create a drainage area from the frontal sinuses the same way it is done for the rest of the sinuses.

The possible immunodeficiency should be fully evaluated before you have IV gammaglobulin. You should see an allergist/immunologist about that.

From: j
Subject: sinus surgery

Hi. I'm scheduled for sinus surgery tomorrow, so I won't see your reply until well after the surgery. I have TWO major concerns:

1) what to expect for recovery time.
2) recovery WITHOUT antibiotics

I have violent reactions (anaphylactic shock) from antibiotics and my surgeon is concerned about not using preventative and post-surgery treatment with antibiotics. I have had other surgeries without them.

My reactions to antibiotics (all types) has become more severe over the years until I went into shock 8 years ago from using them.

Here's what I'm scheduled to have done --

maxillary sinusotomy (making an opening into the maxillary sinus)
septoplasty (correcting a deviated septum)
turbinate reduction (reducing the size of the turbinates to breathe better)
and rhinoplasty to realign my nose (after deviated septum repair).

Any thoughts would be appreciated. Thanks for your website!

j

It is difficult to avoid using antibiotics in treatment of sinusitis, especially post surgery. As you have seen from the website, antibiotics are an important part of the treatment regimen. It is very possible that it may be possible to avoid surgery if an antibiotic is found that you can tolerate.

You should probably have an evaluation by an allergist as you are likely to need antibiotics at some point. Sometimes we can get away with just using an antibiotic solution to irrigate the nose after surgery is done.

From: r
Subject: Haller Cells and Chronic infection-bone

Could you please explain what Haller Cells in the sinuses are?

They are ethmoid sinus cells that are displaced downward into the maxillary sinuses ( see the diagram on the CT scan page).

How frequently does infection in chronic sinusitis effect bony structures of the face or spread to the brain

Very rare, but if it occurs, it can be serious.

From: j
Subject: chronic sinus disease

We would like to take the opportunity to tell you how amazing this website is. Have a question to ask though.

We would like it if you could give your opinion on a situation involving a surgery that was done by a doctor in my home town.. The patient had bone spurs removed and her sinuses were cleaned, and polyps extracted.

Since the surgery she has had infection after infection (staph). Also she has been on several courses of antibiotics which have lasted over the last 7 months. Was sent to a infectious disease doctor for a second opinion. Tests showed she has chronic sinus disease.

The doctors indicated she may possibly need a second surgery. Any thoughts, information, or comments would be greatly appreciated.!!

Thank You ,

Sincerely,

All stuffed up...:)

J

Once people have had surgery, it usually is possible to treat patients with medical therapy to get them better. Every once and a while, they do need to have revision surgery.

In addition, patients should have an immune system evaluation by an allergist/immunologist to determine if the immune system is working correctly, checking the gamma globulin levels and sometimes checking to see if the body can respond normally to bacteria such as tetanus, pneumococcus, etc. If there is an abnormality detected, then sometimes intravenous gammaglobulin must be given.

Have you had a repeat CT scan and endoscopy?

From: T
Subject: POST NASAL DRIP

My son is 3 years old. Six months ago, he got a maxillary sinusitis and had a nasal wash. Up till now, he doesn't have any other symptoms, just post nasal drip that made him cough. He looks good and his appetite is also good.

My question is that :

Every time, after the doctor prescribed the antibiotics for him, he is really cured. But after two weeks, the post nasal drip will come back again. Is it chronic sinusitis?

Maybe - it needs to be looked into. Two weeks of antibiotics is often not enough.

I wonder if the cilia are working in the sinus since it is always full of secretion. Will it become worse and bony erosion happen?

It can happen but bony erosion is unusual. The cilia often stop working in chronic sinusitis but, with treatment, usually come back.

Since January 1997, he has taken different kinds of antibiotics (e.g. Augmentin, amoxicillin, ) for 3 months (each course is two weeks). I'm afraid it will lowered his resistance. How serious will it be? Any possible complications?

Bacteria can become resistant, but usually it is possible to find an antibiotic that works. There are all kinds of possible complications, but usually they can be treated.

The secretion he produces is yellow in the morning but transparent during daytime. Is this a sign of infection? I visited another doctor who said that if my son just has post nasal drip (PND) and he didn't complain of headache or cheek pain, it's just allergic, and he is not going to prescribe antibiotics for him. Will allergies create PND? Why is the PND yellow in the morning?

The yellow mucus may indicate sinusitis, but sinusitis can occur with clear mucus. The post nasal drip tends to become thicker and therefore darker while sleeping because no fluids are drunk.

Is it OK for him to go to school?

Daycare in that age group can be a problem, and sometimes it is suggested that kids stay at home until they get older.

Is swimming OK?

No, there is too much risk of having pool water get into the sinuses and cause irritation, especially in a 3 year old.

I am trying my best to let him have exercise and a balanced diet. I feel very frustrated.

Is there anything I can do?

Thank you very much

Regards,

T

He needs to see a good sinus specialist.

From : C
Subject: allergic fungal disease

My 19 year old daughter C has had a total of seven sinus surgeries. Three this summer alone. Biopsies of bone and tissue show no infection there. However, now allergic fungal disease is suspected . How and with what drugs do you treat this condition?

Thank you so much.

C

As you may know, allergic fungal sinusitis is caused by many fungi and is caused by an allergic reaction to the fungus.

Talk with your doctor, but treatment typically includes Prednisone, surgery, and possibly allergy shots. See the section for physicians on fungal sinusitis.

I asked Dr. Grossan to contribute something about his Nasal irrigator, the website for which is in the Bookmarks section.

Nasal irrigation, using the Water Pik and the Grossan Sinus attachment is based on the Hindu technique of alternately sniffing and snorting, in and out. This is fine if:

the pressure stays low - below 5 PSI
the salt is mixed right
the rate of pulsation matches the normal nasal cilia - 16 pulses per second.

The idea of the Water Pik device, is that the pressure is just right, the rate of pulsation is just right, and the salt mixture is easy. Many 5 year olds do this procedure, so obviously it isn't hard.

Whether it goes out the other nostril or into the throat depends on how you hold your head. If your head is erect, it goes to the throat. If you bend your head it comes out the other side. However, it still is effective in either manner.

HOWEVER, the device is designed NOT to work if your nose is completely blocked. You don't want to force it and there is no value if the nose is totally plugged.

I have had someone ask if this is more pleasant than other methods: I really can't answer that myself, but would like to hear from others who have used other methods. Since many doctors are recommending this for their patients after surgery for patient comfort, I would think it would be satisfactory.

Murray Grossan, M. D.

Given the popularity of the irrigator, I would agree.

From: B
Subject: Polyps

I can't seem to find information on reoccurring polyps. I have had two sinus surgeries for this problem and am facing another one in August. The CT scan shows an area completely blocked by polyps.

Will this be an ongoing problem?
What is the prognosis here?

Only one sinus cavity has these polyps but it causes an infection that will not respond to antibiotics. Is there any effective maintenance?

B

Unfortunately, polyps tend to recur. They are often due to inflammation, either due to allergies, or sinusitis, so those problems must be controlled.

Treatment should include all of the things that I talk about on the website.

From: W
Subject: Chronic sinusitis w/ upcoming mountain climb..

Dear Sir:

I found your web site to be exceptionally informative. I have had recurring sinus infections complicated with allergies for the last 8 or 9 months. I am scheduled to go on a mountain climbing expedition to 14,000 feet and am in adequate physical condition to so. Am taking Entex, Duratuss 1200mg (guaifenesin) and am presently on Vantin, as well as Claritin.

I live in ****where the allergies (especially mold) are horrific. I anticipate going to Colorado and Wyoming to climb which will be some welcome allergic relief. My allergist will give me a cortisone injection to provide some relief before I go on my trip.

I am very concerned as to the cumulative effects of all these medications at altitude and welcome any advice you might have as to the effects of sinusitis at altitude especially.

I have been on antibiotics for most of the last 7 months and am suspecting surgery may be necessary after a CT scan or endoscopy. I am leaving in 7 days to go to the mountains, so I am desperate for information.

You seem to be very expert at what you do, so I would be interested in sending you a copy of my CT scan or travelling to see you if necessary for evaluation and/or surgery.

When given antibiotics, I get rid of the acute sinusitis, but still have congestion, drainage and otitis media (when infection worsens). Part of my problem may be due to inadequate treatment from the onset months ago when I was given 7 to 10 day doses of regular antibiotics instead of good ones for this (biaxin, etc.)

I am in despair, because I want to climb my mountain desperately and I need to make a decision very soon whether to go or not. Please help me.

Thank you very much. I hope to hear from you. Feel free to call me collect at ******* as well as email me *******

Sincerely,

B

The primary problems with sinusitis occurring at altitude include the dry air, and the fact that it is easy to get dehydrated, which is a major problem at that height. Claritin can also cause problems with dryness. Whenever I go skiing, I always take a vaporizer with me. It also helps to carry around a nasal spray to keep the nose from getting too dry. Steroid nasal sprays also help.

You also have to watch out for sunburn, as it alters immunological responses, and makes it easier to develop a sinusitis.

Unfortunately due to medicolegal restrictions, we can't evaluate CT scans at a distance, but we would be happy to see you if you can get to New York.

From:g
Subject: Sinus Aspergillosis

A fungal mass was removed from my maxillary sinus about three years ago. Though the next CT scan looked "clear" - the fungus remains and didn't respond to 100mg Sporanox ( an oral antifungal medication) - now on 200mg Sporanox twice a day. My question is this: if the fungus is now, or has always been, resident in the ethmoid sinus, should it show up on a CT scan, is an MRI better, or is there some other, or any way at all of figuring out it's site?

(I'm beginning to think I should have a zipper in my head!) My doctor is an infectious disease specialist, I think he's excellent - but this is evidently not something frequently seen.

I'd love to know I was "really" over it the next time I'm taken off medication.

Although I have a low IgM (gammaglobulin) and a right sinus area which shows the ravages of two surgeries and uncountable strep & staph infections, I'm essentially healthy - don't have AIDS and haven't had cancer therapy.

I'd love to "talk" to somebody who has treated this successfully - or a person who could say, "sure, I got over that."

Thanks for you time.

G

You need to see a sinusitis specialist as fungal sinusitis is difficult to treat. MRI is better than CT for fungal sinusitis. You should look at the section on the website for physicians about fungal sinusitis. I have numerous patients with fungal sinusitis. It is a very treatable problem.

The fact that you have a low IgM as well as Strep and Staph infections is also important and may indicate that you have an immunodeficiency which may need to be treated with IV gammaglobulin. You need to have a good immune system evaluation by an allergist/immunologist.

Although you may have a good ID specialist, they are not the specialists that typically treat sinusitis.

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