Sinusitis Book Review

"What your doctor may not tell you about sinusitis"

I bought this $15 paperback book with high expectations and read it on a flight from Dallas to Gatwick a few days ago. The author, Doctor Hirsch, is a noted Chicago neurologist and ENT specialist, with an interest in smells, who has appeared on Oprah.

The chapter on types of headaches is great, but those with asthma who also suffer from sinusitis will be disappointed by the relative paucity of treatment tips. The author believes that the majority of folks who think that they have sinusitis do not, but instead, have headaches due to lingering colds (rhinitis), migraine headaches, allergic rhinitis, or GERD.

He correctly states that "abnormalities" on sinus x-rays and CT scans have little relationship to the cause of symptoms. He rightly recommends avoiding all sources of smoke, children (who are virus vectors, especially when school starts in September), cold, dry air, noxious chemicals and fumes, sugar, caffeine, and codeine. The best treatment is to drink 8-16 cups of water every day, to maintain the flow of thin mucus from the sinuses, through the nasal passages, and down to the stomach. Natural decongestants, which may be helpful, include inhaling steam and eating spicy foods (pepper and garlic).

Dr. Hirsch says that OTC drugs and supplements have no proven benefits, including zinc (Zicam nasal goo and lozenges), which may permanently impair the sense of smell, vitamins, homeopathic nostrums, and herbs, but he does like massages and other stress reducing therapy.

After reading most of the books on this topic, I think that "The Sinus Cure" remains the best.

Related Topics: Cold or flu?, HOw to Short Circuit a Cold

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Sinus Headaches for 2006?

There are many reasons for a headache during the holidays, but mine was due to sinusitis. Like many other folks, for as long as I can remember, I've had hay fever, also called allergic rhinitis. A couple of times a year, I get sinusitis, which usually causes a toothache, apparently located at the base of an upper incisor. I also get a feeling of pressure at my cheeks, and a sinus headache.

I've learned that sinusitis is caused by rhinitis, specifically swelling of the nasal mucosa at the areas deep in the nose where the sinuses normally drain. The fancy term for this area is the osteo-meatal complex, or OMC for short. Your doctor would need a fiberoptic scope to view this area, a $1000 instrument that only ENT docs have in their office. However, the symptoms of rhinosinusitis are distinct enough that viewing the OMCs is not necessary to confirm this very common disease before treating it.

When I've got an exacerbation of my allergic rhinosinusitis, I use Sinus Rinse twice-a-day, followed by a nasal decongestant, then a nasal corticosteroid spray. Washing out the nasal passages with salt water is a treatment used successfully for hundreds of years.

If you like metaphysics and alternative medicine, you can dribble a cup of salt water into each nostril from a $20 ceramic Neti pot. If you are rich, you can put the salt water in a $120 nebulizer and spend ten minutes sitting while it produces a salt water mist. All pharmacies carry a $15 bottle of saline nasal spray with preservatives, but it only has 4 ounces of salt water, not even enough to rinse out one side of your nose once. I've tried all of these over the years, but have happily settled on a plastic squeeze bottle that holds a cup of warm water. This Sinus Rinse bottle costs less than ten dollars, lasts for a year or more, and comes with packets of salt, the size of fake sugar packets.

I simply tear open a salt packet and pour it into the bottle. I then fill the bottle from the warm shower or the bathroom sink and shake it. Sometimes I've filled it with cold water and nuked it for 30 seconds in the microwave. I then lean over the sink and push the smooth black tip of the bottle against one nostril, then gently squeeze the bottle, sending the salt water through one side of my nose and out of the other side, washing away the gunk. I then repeat the squeeze on the other side.

If I was really poor, I would just buy the bottle and measure out a teaspoon of salt from a shaker or container of salt, but the Sinus Rinse packets don't cost much and are very convenient, especially since I travel a lot. If you don't mix the correct amount of salt with the water, it will sting your nose. If the water is too cold or too hot, it's also uncomfortable. The correct temperature and salt concentration makes the nasal lavage (rinse or douche) soothing, although the sight of snot is not appetizing. Just remember, if you don't wash this icky material -- mucus, pollens, smoke particles, and pus cells (neutrophils and eosinophils) out of your nose, you will unknowingly swallow it, up to a quart every day. (The concentrated hydrochloric acid in your stomach digests it quickly.)

I wait for more than 15 minutes after the Sinus Rinse (enough for the remainder of the salt water to drain away), and then use a long-acting nasal decongestant spray (like Afrin). The exact technique of using a nasal spray is very important, since the usual technique doesn't get the medication around the sinus drainage openings, where it is needed the most. If you haven't used the spray for more than 24 hours, check the level of fluid in the bottle and prime it by spraying it once into the room air. Ensure that it produced a nice plume of mist.

Stand next to your bed (or someone else's bed!). Look downwards. Insert the tip of the bottle about a half an inch into your nostril and then tilt it so that it is pointed towards the back of your neck (NOT towards your eyebrows). Squeeze it. Don't inhale while you are squeezing the bottle. Do the same for the other nostril. Now quickly lie down on your back with your head extending over the edge of the bed, and stay there for 3 minutes! This strange maneuver causes the solution to drain downwards to bathe your sinus openings (the OMC areas), which have become closed due to inflammation of the nasal mucus membranes.

If your doctor has also prescribed for you a nasal corticosteroid spray (like Flonase, Rhinocort, or many others), administer that spray a few minutes after the nasal decongestant spray, using the same technique.

The decongestant nasal spray will begin to work within a few minutes, but the corticosteroid spray takes several days of daily use to fully suppress your nasal inflammation (rhinitis).

Use the Sinus Rinse first because that removes all of the mucus in the nose, which would prevent the medications from getting to where they are needed (the OMC areas). Use the nasal decongestant spray before the nasal corticosteroid spray because the decongestant will quickly shrink the nasal passages, allowing better distribution of the corticosteroid solution thoughout the nasal cavity.

I'm aware of the old worry that the use of nasal decongestant sprays for more than 3 days may cause rebound nasal congestion (rhinitis medicamentosa or Afrin Addiction), so, I try not to use it for more than a week. By then, the nasal corticosteroid spray has reduced my nasal inflammation, preventing the rebound nasal congestion, and the original cause of the rhinosinusitis exacerbation is gone.

I noticed that a company is now selling online a new $30 "system" for Afrin Addiction. It works by slowly tapering (diluting) the daily dose of nasal decongestant. I prefer to use a nasal decongestant instead of an oral decongestant (like Sudafed), because of the many side-effects of oral decongestants (such as nervous system stimulation and increased blood pressure).

Related Topics: Headache, Nasal Sprays: More Than Meets the Nose?

Tags: sinusitis,headache,webmd

Death by Inhaler

Should your doctor inform you about the risk of death when prescribing some popular asthma inhalers?

The January 2006 issue of the most prestigious allergy journal (JACI) contains articles and editorials regarding the FDA's new "black box" warning for very popular inhalers used by patients with asthma. Serevent (salmeterol), Advair (salmeterol and fluticasone), and Foradil (formoterol). Salmeterol and formoterol are long-acting bronchodilators.

The black box quotes data from the "SMART" study of 26,000 adults with asthma randomly given Serevent or placebo for six months (in addition to their usual asthma medications). This "postmarketing surveillance" (phase IV) study was begun ten years ago, and the four times higher asthma-related death rate in the Serevent group (13 deaths versus 3 deaths in the placebo group) was first known in September, 2002, but the study results won't be formally published for a few more months (in the journal CHEST). Put another way, the excess risk of death for those taking Serevent was about one extra death for every 700 patients taking the drug for one year.

Should your doctor tell you this if you are taking one of these three inhalers? Does your doctor even know this? Does she carefully weigh the benefits of adding a long-acting bronchodilator to your other asthma medications against this risk of death? Once your asthma is well-controlled using Advair or Symbicort, does she consider stepping down your therapy by discontinuing the long-acting bronchodilator?

Editors of the journal wondered if the FDA warning is a "wake-up call or just an over-reaction," stating that "physicians have mixed feelings about the discolsure of black box warning information to patients." They recommend that each medical society inform their members about the black box and how to convey this information to their patients. However, there are many medical societies and not all physicians who treat patients with asthma belong to one of these professional organizations. Furthermore, JACI is the publication of the largest professional society of allergists (the AAAAI), and this society has not yet provided such information. One editorial suggests that every patient with asthma should be given both a verbal and written warning by their doctor before such inhalers are prescribed, and they should sign that disclosure statement in order to protect the doctor from legal liability.

Many pulmonary specialists feel that long-acting bronchodilators are safe when inhaled corticosteroids are given at the same time, and the widely accepted NAEPP guidelines for asthma say that. However, the FDA advisory panel must not have been fully convinced by the data, thus they also required the black box warning for Advair (and will probably do so for Symbicort, which includes formoterol, if and when it is approved for marketing in the United States). Amazingly, the SMART study did not ask about the use of inhaled corticosteroid medications in the 27,000 participants during the study of Serevent, so a large new study will have to be done to know if combination inhalers are truly safe.

Sadly, it's hard for me to know who to believe. Certainly not the drug companies who make these inhalers -- that's like asking the fox to guard the chickens. The FDA's voluntary, minimalist system of post-marketing surveillance for drug side-effects (MedWatch) is woefully underutilized by doctors and patients alike, and it's unlikely that the same agency that's responsible for approval of new drugs can also be highly committed to proving itself wrong.

The professional societies receive tens of millions of dollars in "unrestricted" educational grants from drug companies each year; the journals receive millions of dollars from the drug companies for glossy advertising as well as reprints of articles about their drugs; many of the journal editors and manuscript reviewers have received tens of thousands of dollars each year from the drug companies for consulting, speaking, and research; and the drug companies themselves now design and fund the majority of the research on new pulmonary drugs. The investigators are overpaid for recruiting their patients into new drug studies. Your doctor probably has no idea about these many layers of conflicts of interest (unless she is a recipient of the generosity and has time to reflect on its influence).

Related Topics:FDA Panel: 3 Asthma Drugs Can Stay, Understanding Asthma: Treatment

Tags: asthma, inhaler, FDAwarning, ethics, JACI, webmd

Asthma: Long-Acting Bronchodilators

What's the place of long-acting bronchodilators in treating asthma? Here's an interesting discussion about whether the risks outweigh the benefits.

Serevent was one one of the five dangerous drugs mentioned by an FDA division director last year when he testified to Congress, and it subsequently got a "black box warning" on the label.

There are now three long-acting bronchodilator (LAB) inhalers available by prescription in the United States: Serevent (salmeterol), Foradil (formoterol), and Spiriva (tiotropium). Since inhaled corticosteroids (ICSs) are also frequently prescribed for patients with asthma and COPD, the combination of a LAB and ICS makes treatment more convenient for patients who need both types of medications (and faster for the doctor to write a prescription for one drug instead of two), so more than 6 billion dollars of Advair (a combination of salmeterol and fluticasone) was sold world-wide last year, and Symbicort (a combination of formoterol and budesonide) is pending approval in the United States, but meanwhile very popular in other countries. Due to the massive market for these drugs, other "me-too" ICS+LAB combination inhalers have been developed and are undergoing clinical trials.

A couple of decades ago, it became clear that trying to treat asthma with short-acting bronchodilators alone was dangerous, as dozens of patients with asthma died "clutching their inhaler." It took a few years to confirm that the reason was that their underlying airway inflammation was not treated by the bronchodilators and they developed a tolerance to them. A malignant cardiac arrhythmia caused by the low oxygen levels in their blood (caused by the severe airway edema), low intracellular potassium levels (caused by the beta-agonists), and cardiac stimulant effects of the bronchodilator was a likely "coup de grace" causing an out-of-hospital demise (usually officially attributed to various other causes). It's a shame that it took a decade of use (in one country or another) before it finally became apparent that the new long-acting bronchodilators (LABs) also increased the risk of similar deaths (probably with similar mechanisms). Most doctors now know that they should not prescribe a LAB unless the patient is also taking an ICS every day.

When asthma is poorly controlled in patients faithfully taking an ICS twice-a-day, the addition of a LAB does result in better control for many of them, thus there is a good place for ICS+LAB combo inhalers in the treatment of asthma. But I'd call this step-up in treatment evolutionary, not "revolutionary."

The largest remaining problem with LABs in patients with asthma is that they are often unnecessary after the asthma exacerbation for which they were prescribed has subsided. Thus the patient suffers from unnecessary expense and sometimes LAB side-effects, which include muscle cramps or pain, nervous stimulation, and cardiac arrhythmias. Patients see doctors during exacerbations, but follow-up appointments are much less likely to be scheduled or completed. There is also lots of pressure to "just keep using the inhaler that obviously worked."

A footnote: The companies which make and market Spiriva are obviously unhappy when their ultra-long-acting bronchodilator is placed in the same group as the black-boxed Serevent. They will say that it's an entirely different drug with an entirely different mechanism of action. Indeed, Spiriva is an anti-cholinergic instead of a beta-agonist (like Serevent and Foradil); but all three are bronchodilators designed to relax bronchial smooth muscle. No bronchodilator reduces airway inflammation (although considerable effort is spent to find just a smidgen of some type of anti-inflammatory effect). This "misunderstanding" probably causes less harm because very few folks with asthma respond well to anticholinergic bronchodilators, so Spiriva and Atrovent are prescribed primarily to relieve shortness-of breath in smokers with severe COPD. However, an increased risk of severe cardiac side-effects as a result of anticholinergic inhaler treatment has been found in such patients. (I was a coauthor of one such study.)

Related Topics: Stress and Asthma, Use a Peak Flow Meter to Manage Asthma

Tags: bronchodilator,serevent,advair,,asthma,webmd