What Your Doctor May Not Tell You About(TM): Sinusitis

DR. ALAN HIRSCH SEPARATES
SINUSITIS FACT FROM FICTION!

My cold has lasted more that one week. It must be a sinus infection.

In up to 25 percent of the cases, a cold lasts two weeks or more. . . . In other words, if you visit a doctor with a long-lasting cold (more than ten days) you may leave with a prescription for antibiotics for a diagnosed sinus infection. Unfortunately, that diagnosis and treatment could be wrong at least 25 percent of the time!

I snore every night and I have nasal congestion, so I probably have chronic sinusitis.

Snoring may indicate sinusitis, but the nasal congestion could be caused by asthma, allergies, or nasal obstruction associated with polyps or deviated septum.

I took a decongestant for my headache and it got better, so my pain must have been caused by a sinus headache.

This is generally not true. Nasal symptoms associated with colds and sinusitis generally do not resolve with decongestants and antihistamines that are designed to relieve symptoms only. However, these same medications usually relieve migraine pain.

BEFORE YOU POP THE PENICILLIN, PUT YOUR
ASSUMPTIONS ASIDE AND CONSIDER . . .

WHAT YOUR DOCTOR MAY NOT TELL
YOU ABOUT^™ SINUSITIS

For my beloved family:
Marissa, Jack, Camryn, Noah, and Debra

Acknowledgments

I could not have accomplished this book without the assistance of and help from many others.

Without the editorial style of my longtime friend, Virginia McCullough, and that of my editor at Time Warner, John Aherne, this book would have been, at best, incomprehensible. Thanks also to Noah Lukeman, of Lukeman Literary Agency, who conceived this project. Thanks to Dr. Jordan Pritikin of the Chicago Nasal and Sinus Center, and to my mentor, Dr. Joel Saper of the Michigan Head-Pain and Neurological Institute of Ann Arbor, Michigan, for their most valued input.

Thanks also to Dr. Jacob Fox, chairman of the Department of Neurology at Rush-Presbyterian-St.Luke's Medical Center in Chicago for his mentorship and steadfast support.

For her many years of devotion and effort, I wish to acknowledge Denise Fahey, practice administrator of the Smell and Taste Treatment and Research Foundation, Chicago.

Special thanks and love to my wife, Debra, and my children, Marissa, Jack, Camryn, and Noah, who generously sacrificed their time with me so that this book could be completed.

Alan R. Hirsch, M.D., F.A.C.P.

Neurological Director

Smell & Taste Treatment and Research Foundation

Chicago, Illinois

Foreword

The diagnosis and treatment of chronic sinusitis can at times be a daunting task. As a sinus specialist, I spend a large portion of my time seeing both patients who have been incorrectly diagnosed with chronic sinusitis, and patients with very subtle symptoms but with rather severe sinusitis. In fact, almost inexplicably, sinusitis appears to be at the same time both the most common chronic disease state and the most commonly misdiagnosed disease. These misdiagnoses occur at the hands of both patients and physicians alike.

Dr. Hirsch is highly respected in his field for work that sits at the crossroads of several specialties: neurology, psychiatry and otolaryngology (ears, nose, and throat). He has been an invaluable resource for a number of my patients, and I utilize his expertise for my patients who have refractory smell and headache problems. While it is true that Dr. Hirsch has published hundreds of articles in medical journals, it is his clinical acumen rather than his notable academic record that has continued to impress me.

In this text, Dr. Hirsch has done an outstanding job of explaining sinusitis and other disorders that may mimic sinusitis, including such common maladies as the common cold, allergies, migraine, and tension headaches. He does a wonderful job laying the foundation for these disease states, including their root causes, presenting symptoms and treatment options. This current text serves as an excellent resource for patients suffering from all of these disorders.

Jay M. Dutton, M.D.

Assistant Professor

Department of Otolaryngology

Rush University Medical Center

Chicago, IL

Introduction

Sinusitis—A Diagnosis in Search of a Disease

In the late summer of 2002, a nineteen-year-old man living in Virginia went to see his family doctor complaining of fever, chills, fatigue, muscle aches, and sinus pain. He was diagnosed with acute sinusitis and given an antibiotic and another medication used to treat symptoms of sinus infections. The young man returned four days later with the same symptoms plus dizziness and nausea, along with a temperature of 103.5°F. On this visit the doctor performed some blood tests and after receiving the results, he changed the diagnosis to malaria. At that point, the treatment the young man received matched the diagnosis and he got well.

It is easy to see how a misdiagnosis, or a missed diagnosis, could occur. When the young man first went to his doctor no reason existed to believe he could have a disease like malaria. It's relatively rare in the United States and none of the risk factors—international travel, blood transfusions, and needle sharing—applied to him. No one among his immediate neighbors had developed the disease, although it was later discovered that he lived a half mile from another person who contracted malaria. This man lived within ten miles of the Washington-Dulles International Airport, which has nonstop flights from countries in which P-vivax malaria is endemic. After his diagnosis, mosquitoes were captured and tested within a few miles of his home and a small number (which is all that's needed to spread the disease) tested positive.

Am I saying that if you develop symptoms of sinusitis you should immediately consider malaria as a possibility and perhaps be tested for it prior to other treatment? No. Well, not exactly. You see, malaria represents only one, and fortunately rare, variation on the symptoms that can lead to a misdiagnosis of sinusitis. In 1992, malaria was considered eradicated from the United States, but since that time outbreaks have occurred and between 1,000 and 1,500 cases are reported every year, and it is likely many more have gone undiagnosed and unreported (or mistreated as sinusitis). So, yes, malaria is relatively rare, but because its symptoms mimic those of sinusitis, the initial misdiagnosis of the nineteen-year-old was considered important enough that JAMA (Journal of the American Medical Association) reported the case in November 2002. In other words, malaria, like many other common and much less esoteric diseases discussed in this book, cannot be taken off the list of possible conditions that produce the varied symptoms we associate with sinusitis.

I call sinusitis "a diagnosis in search of a disease" because much of the time, individuals develop a cluster of symptoms, some of which fit the criteria for a diagnosis of sinusitis. In the majority of cases, however, a diagnosis of sinusitis does not necessarily mean the person has sinusitis. Put another way, patients may leave their doctors' offices believing that the symptoms "add up" to sinusitis and they're relieved to have the label because most people tend to link a diagnosis with treatment whereby the condition will be cured. Unfortunately, the true cause of the symptoms could be allergic responses, common colds, headache syndromes, asthma, dental problems, nasal tumors, and even AIDS. The diagnostic line is blurry, especially when we attempt to differentiate a viral infection (the common cold) from a bacterial infection (that may be acute sinusitis), and distinguish sinusitis from migraine headaches.

A PICTURE OF CONFUSION

You can barely breathe, you can't smell the rolls in the bakery, and your face aches. You have sinusitis. Or do you? Given your symptoms, it is likely that sinusitis will be high on the list of possible diagnoses, should you see a doctor. Maybe this is not the first time you've had these symptoms and taken many trips to your doctor looking for an effective, lasting treatment. You may have seen several doctors in your quest for help.

Or maybe you have a history of frequent headaches. You also have nasal congestion, impaired ability to smell, and pain in your face, but you do not believe sinusitis is the cause of your symptoms. In fact, you never even thought about sinusitis and are not even sure what that means. To you, the symptoms are a sign that a migraine is on the way.

Or perhaps you have a cold that has lasted for two weeks and is draining your energy. You blow your nose all day, you cough, and your ears feel "stuffy." Although normally you don't go to the doctor with what you assume is a common cold, this time it's lasted so long that you make an appointment. What you may be told is that your viral infection (viral rhinitis) has become a bacterial sinus infection. You go home with an antibiotic and within a few days your symptoms may or may not begin to disappear. It seems logical to expect a cause-and-effect relationship between the antibiotic and the disappearance of the symptoms, but that expectation is not always scientifically sound.

Same symptoms, different cause, different treatments, and, perhaps most important, different "labels" may follow a patient around and start a cycle of incorrect treatments for a cluster of symptoms. Once a syndrome or a pattern of symptoms and diagnoses become part of a patient's medical history, this attached label often means that subsequent diagnoses will fall into similar patterns. Although many patients attempt to "start fresh," they find it a difficult task to accomplish.

Difficulty in achieving an accurate diagnosis is not an unusual situation in every branch of medicine. Unfortunately, some conditions lend themselves to confusion, and sinusitis is one of them. On the one hand, reported incidence of sinusitis is on the rise, but on the other hand, it is clear that this label could be incorrectly assigned to a group of symptoms not directly connected to the sinuses. The onset of a migraine headache can mimic some sinusitis symptoms, as can a long-lasting cold caused by a virus. Because so many symptoms overlap and treatments may be quite similar for a variety of conditions, medical professionals and patients end up confused.

Sadly, sinusitis symptoms don't involve just some isolated cases or a handful of situations in which an initial problem was misdiagnosed. Consider that between thirty-five and fifty million individuals (depending on what literature you read) are labeled as suffering from "sinus problems." Somewhere in the neighborhood of twenty million visits to doctors' offices take place annually because of sinus symptoms and most of these millions of patients leave with a prescription of some kind. It's a problem with huge dimensions and implications. Every day in my particular medical practice I see evidence that this is indeed an extremely confusing diagnostic situation.

THE DELICATE NOSE

The Smell & Taste Treatment and Research Foundation in Chicago sees more patients with smell and taste disorders (chemosensory impairment) than anywhere else in North America. About half the patients come from states outside Illinois, and approximately 25 percent come from other countries. On a daily basis patients are referred to the foundation with a diagnosis of sinusitis-induced smell loss. However, upon evaluation, this is almost never the case. The smell loss and headaches that are being attributed to sinusitis are instead due to other conditions that mimic sinusitis, a syndrome I call "pseudo-sinusitis." Studies have even suggested that if a patient comes to the doctor with a self-diagnosis of sinusitis, the diagnosis is incorrect about 98 percent of the time, and when a doctor diagnoses sinusitis, the diagnosis is incorrect about 90 percent of the time.

Clearly, the way to help relieve sinusitis-like symptoms is to treat the real problem. The word sinusitis literally means "inflammation of the sinuses." Though the term is used throughout this book, instead of sinusitis I probably should use the phrase "symptoms usually attributed to sinusitis but aren't really due to sinusitis." To clarify, I often use the terms pseudo-sinusitis and/or sinusitis-like symptoms.

Most of the time, the patients I see are motivated to seek help because of persistent sinusitis-like symptoms such as diminished, distorted, or (occasionally) increased ability to smell and taste. Almost always, I find other non-sinusitis conditions that result in these sinusitis symptoms, including headache syndromes—particularly migraines. Some of the same medications may work, at least temporarily, to relieve the symptoms of both sinusitis and non- or pseudo-sinusitis, but obviously an accurate diagnosis is in the patient's best interests.

It is unfortunate that loss of smell and taste are not considered major symptoms in the diagnosis of colds, allergies, nasal polyps, and sinusitis. I often see patients who have undergone years of treatment for sinus-related symptoms, and they may come to the Smell & Taste Treatment and Research Foundation because they have developed chemosensory impairment. Unfortunately, they frequently have lost the ability to smell and taste as a result of the treatments for the presumed sinusitis, and not necessarily because of the underlying disease.

Common prescription and over-the-counter medications such as nasal sprays and antihistamines may impair smell; in addition, surgery almost always affects this delicate sense. Surgery was once considered a valid and beneficial treatment, although smell loss often resulted, and quite often the loss was permanent. However, new thinking about the cause of sinus symptoms and sinusitis are radically changing attitudes toward surgery. In chapter 10 you will gain a better understanding of old and new thinking about sinus surgery.

This diagnosis-treatment confusion becomes more complex when we consider that the reported incidence of sinusitis is on the rise, but because it is likely overdiagnosed, it may not be on the rise at all. If we misuse the term in the first place, more clusters of symptoms are likely to land under that diagnostic label.

Given the confusion about the matrix of symptoms that may be called "sinusitis," I've come to the conclusion that if you think you have sinusitis, you probably don't. About forty-five million cases of sinusitis are diagnosed each year; therefore, if even half of those diagnoses are incorrect it may result, at the very least, in massive amounts of unnecessary antibiotics. In actuality, the incidence of misdiagnosis is probably much higher. However, that doesn't mean you don't have nasal congestion, facial pain, and so forth. That just means you have some other condition that needs medical attention.

The reason it is important to read this book is to help you find treatment for the condition that is causing your sinusitis-like symptoms. The goal here is to understand sinusitis and to begin the process of determining if you truly have it or another condition, or a more complex combination of problems. In these pages, we will look at all the components of sinus disease, and we'll start by explaining the anatomy and physiology of the sinuses. The drawings should help you understand the origin of some symptoms, but may also help you to form relevant questions for your doctor. Equally important, this book can help you provide accurate answers to your doctor's questions. Accurate information can help guide diagnostic testing or correct previous misdiagnoses.

A WORD ABOUT "COST-EFFECTIVE TREATMENT"

The health care industry is greatly concerned about overall cost, and some treatment regimens are studied for cost in relation to treatment results for most of the patients most of the time. An article published in a medical journal in 2001 discussed treatment for acute sinusitis based on what is typically used in office-based medical practice. The article analyzed what treatments were cost effective on a national basis for the three million or so cases of acute bacterial sinusitis seen annually. For example, the study found that using X rays or CT scans to diagnose sinusitis has never been cost effective; on the other hand, antibiotics were. This means that based on presenting symptoms alone, diagnosing a sinus infection and giving the patient a prescription for an antibiotic is cost effective most of the time. However, the authors of the study point out that this inevitably leads to overuse of antibiotics, which as we now realize causes bacterial resistance and renders certain antibiotics ineffective over time. Antibiotics are becoming more expensive because of increased bacterial resistance—a growing global problem. Antibiotics also have side effects, which include vaginitis caused by overgrowth of yeast, gastrointestinal distress, and skin rashes.

Treating bacterial infections effectively with antibiotics means matching the drug with the bacteria causing the infection, which is why taking a culture is considered the "gold standard" method to diagnose a sinus infection. Culturing the sinuses is not considered cost effective, however, so the average patient is given one of the broad-spectrum antibiotics without a culture. Much of the time this works, insofar as the symptoms go away after the antibiotic is taken. However, just because symptoms disappear does not mean that an infection was present in the first place, nor does it mean the antibiotic helped the symptoms to go away.

An additional argument for treating virtually all patients who have what are widely believed to be symptoms of sinusitis is that acute sinusitis can have very rare but extremely serious complications. As the reasoning goes, if everyone with the symptoms of sinusitis is treated with antibiotics these complications will be largely avoided. At least half the prescriptions are given in error, however, which means millions of dollars of added cost, hardly cost-effective. And do we really want well over a million unnecessary antibiotic prescriptions written for just this one issue? Furthermore, there is no evidence that oral antibiotics actually prevent the progression of true sinusitis from the sinuses to the eyes or the brain. Again, the treatment is based on broad general diagnostic criteria, not on the diagnosis of individuals.

When you are ill you seek treatment as an individual and are not thinking about what is cost effective for society as a whole. In fact, as patients, we all have a responsibility to ask questions about the kind of medical advice we're given, precisely because we want to avoid such unnecessary medications as antibiotics. In addition, if the emphasis is on cost effectiveness, tests and procedures that might hasten the diagnostic process could be overlooked and a major problem could continue unnoticed.

I had a brush with erroneous cost-benefit analysis when as a new attending physician I suggested a complete battery of tests to narrow down the possible causes of the serious neurological symptoms of a particular patient. Rather than performing the tests, the intern tried different approaches that on the surface looked more compatible with the probable cause. Tragically, this resulted in months of unsuccessful treatment and incredible suffering, plus seven hospitalizations. Ultimately, one of the first tests I suggested was done and the diagnosis was finally made: arsenic poisoning. (It turned out a family member was poisoning the patient!) Not only was the piecemeal approach not cost effective in the long run, it extended the patient's suffering, which led to long-term problems. Of course, it also meant that the criminal in the family came close to getting away with murder. This goes to show why you have every right to insist on a complete diagnostic picture to avoid a one-size-fits-all sinusitis prescription.

The prescription for antibiotics given to treat your acute sinus infection may be based on statistics, presumed diagnosis, and treatment cost effectiveness, but not on your individual situation. We can always look at statistics for cost effectiveness, but we can't treat individual patients based on these numbers. It's like playing Russian roulette.

At this point I hope you can consider your condition with an open mind about the label that seems to fit but may not. Simply shifting your thinking away from the term sinusitis and to the term "sinusitis-like symptoms" opens the door to the possibility of a new way to view your condition.

P a r t   I

DIAGNOSIS

C h a p t e r   1

The Anatomy of Your Sinuses

Quite literally, sinuses are the holes—the cavities—inside the skull, specifically the air spaces around the nose and eyes. Sinuses exist in symmetrical sets or pairs. If you think of the center of your face as a square, the frontal sinuses are located in the upper two corners over the eyes in the forehead. The maxillary sinuses are located in the lower two corners next to your nose and extend down the upper cheeks and above the teeth. The ethmoid sinus cavities run along the side and back of your nose. (See figure 1.1.) This group of sinuses makes up the paranasal sinuses, so named because of their proximity to the nose. When we think of "stuffy" sinuses or sinus pain, these paranasal areas are most commonly involved, although as you will see, the pain itself does not necessarily originate in the sinuses. In addition, we have a pair of sphenoid sinuses located behind the eyes; these are the most deeply placed of the sinus cavities. Medical practitioners group the sinuses by pairs and think of eight separate structures. But these main sinus cavities contain other smaller ones, so we have approximately thirty sinus cavities that drain into the nose and form part of an efficient "drainage" system designed to help maintain health.

Figure 1.1 The septum.

Each of these sinus pairs is connected to the nose through small openings called the ostia (the singular is ostium or "os"). The sinuses grow along with us; each sinus cavity is about the size of a pea in newborns, and will reach roughly walnut size by the time we're adults. A few people are born with one sinus cavity missing in a pair, and occasionally the frontal sinuses will not appear symmetrical. However, these abnormalities are not considered a cause of later sinus problems.

In addition to their role in helping to protect the body from potentially harmful invaders—viruses, fungi, and bacteria— sinuses also serve to lighten the skull. Some believe they act as mini shock absorbers, a mechanism designed to minimize damage from trauma to the face and head. The sinuses probably play a role in regulating pressure inside the nose and they may regulate the resonance of the voice. From an evolutionary point of view, the fact that the sinuses make the skull lighter may contribute to humans' ability to walk erect.

We cannot separate the nose and the sinuses because they are both covered by a membrane of mucus that resembles one long piece of plastic wrap. The nose is one end of the "wrap" and the sinuses form the other end. When we have a severe cold, the nose and sinuses are affected at the same time, so we should call a common cold rhinosinusitis, rather than simply viral rhinitis, as it is medically known.

FLOWING RIVERS AND DRAINAGE CANALS

The nose and sinuses work together to form one of the most important functions in the body, and while you may not think of your nose as a primary organ of the immune system, that's exactly what it is. When healthy, the sinuses are lined with mucus, a clear fluid that adds moisture to the air and warms it as you inhale. The mucosal lining is also part of the mechanism that processes odorant molecules and helps us detect scents in the air.

The sinuses contain cilia, tiny hair cells that propel or sweep mucus toward the openings (ostia) of the sinus cavities and into the nose. These cilia are always on the move as they cleanse the sinuses. Anything that slows or stops the sweeping motion of the cilia can cause stagnation and blockage in the sinuses, which then may develop into a sinus infection. (However, as discussed later, a "stuffy" nose is not necessarily a sign of an infection or a cold.) Unlike the clear, thin mucous discharge, yellow or green thickened discharge from the nose is a sign of sinus blockage, which makes the sinuses vulnerable to infections caused by viruses, bacteria, or fungi trapped in the sinus tissues. In addition, fluid buildup in the sinuses may cause pressure and pain. On the other hand, mildly blocked sinuses do not necessarily indicate the presence of a sinus infection.

In the maxillary sinuses, the ostium is located near the roof of the sinus and the cilia must work against gravity as they sweep upward to keep the river flowing. In a sense, the cilia have a tougher job—an "uphill battle"—and frequently are implicated in sinus infections. Inflammation tends to narrow the ostia and less oxygen reaches the sinuses and less foreign matter is cleared. This situation predisposes the sinuses to infection.

As an infection progresses, the mucosa (the lining) swells and the cavity may fill with pus. Over time, the chemistry of infected sinus cavities and the structure and chemistry of the cilia may change and when inflammation is chronic, irreversible scarring can occur. This situation also sets the stage for polyps to form. (Polyps are benign tissues that arise from the mucous membranes in the nose.) In addition, a sinus infection on one side can eventually spread to the opposing set of sinuses. In more than 40 percent of patients receiving a diagnosis of sinusitis, sinuses on both sides are affected. (This number would likely change if we were to weed out the cases of misdiagnosed sinusitis.)

The structures within the sinuses and nose are important because they form an "apparatus" that regulates the pathways for mucus to drain. Figure 1.1 shows the septum, which is made up of cartilage and bone, and is the structure that separates the two sides of the nose. We also have three bones, called turbinates