The healthcare industry has been obsessed with finding a better allergy medicine and the “right antibiotic” to finally cure chronic nasal and sinus problems. Patients caught in a seemingly endless cycle of short-term relief followed by a return to stuffy heads and sinus pressure remain skeptical about the promise of new treatment options. One thing is clear. Based on advancements in our understanding of chronic and recurring sinus infections, there is no one-step cure for this bothersome condition. However, in the care of an ear, nose and throat specialist, a detailed assessment of the root causes of each individual patient’s problems can lead to a lifetime of relief in most cases.

For most patients, chronic sinus-related symptoms are not the result of a single condition, but rather a chronic, multi-factorial breakdown in the normal filtering and cleansing function of the nose and sinuses. While some medical treatments do help in the short run by temporarily decreasing swelling or killing bacteria, lasting relief is usually only achieved when all of the persistent issues and their underlying causes are addressed.

Clinical Definitions

When examining the pathway to lasting nasal and sinus health, an understanding of a few critical terms can be very helpful:

Chronic – a term which describes any condition lasting more than 12 weeks.

Recurrent – this means something happens at least 3-4 times a year for several years in a row.

Mucosa – the moist lining of the nasal and sinus passages. Under the microscope mucosa is a microscopically thin lining coated with small, hair-like structures (cilia).

Mucociliary Clearance – the healthy flow of thin, watery mucus pushed along continuously by the cilia, or microscopic hairs that line the nasal and sinus passages. This is a very efficient system that has essentially broken down in patients with chronic nasal and sinus problems. Just as tears sweep across the eye to clean it every time we blink, mucociliary clearance is vital to keeping the nasal and sinus passages clear of debris, allergens, viruses, bacteria, and fungi. This flow can be halted by viral infection and inflammation, which cause an increase in mucus secretion and an inability to clear it from the nose and sinuses (rhinosinusitis). This buildup of mucus creates a protein-rich medium in a warm, dark, moist environment that is just perfect for growing bacteria!

Sinuses – these are air-filled chambers or hollow parts of the skull. They are lined with mucosa, which keep the sinuses sterile by mucociliary clearance through very narrow passages into the nasal passage.

Nasal Passage – the breathing passage from the tip of the nose to the back of the throat (nasopharynx).

Septum – the midline partition between the right and left nasal passages.

Turbinates – these scroll shaped bones in the nasal passage are overlaid with blood-enriched mucosa and serve to filter and humidify air passing into the lungs. When “congested” or filled with blood, they swell and cause a stuffy nose. Decongestants can decrease the amount of blood in the turbinates offering temporary relief of a stuffy nose. However, these medications do nothing to halt the underlying inflammation causing the stuff nose. Decongestants should not be used daily for more than a few days. If used long term, they can create a false dependency on their effects and result in serious damage to the lining of the nose.

The Primary Components Of Nasal And Sinus Problems

With the fundamental knowledge of anatomy and nasal function outlined above, it is easier to understand why patients with sinus and nasal problems are often frustrated with the lack of lasting relief. Most people suffering from chronic nasal and sinus disorder have problems with obstruction, inflammation, and infection each separately playing a role in their condition. Treating any one of these conditions alone will not fully resolve the problem and often leads to relapses and frustration for the patient.

Obstruction

The term obstruction refers to the frequent or chronic blockage of the nasal passage or sinus drainage passages due to structural narrowing. This condition can be temporarily improved with medicine, but by definition the narrowing does not stay open nor is the problem resolved once the medicine is gone. An example of this condition is a deviated septum where the septum partition is too far over to one side of the nasal passage or the other creating a barrier to both airflow and mucus. Additional examples are polyps, which are growths that form in some patients as a result of inflammation, and hypertrophied (chronically-swollen) turbinates, which block the nasal passage. Also, some patients are just born with very narrow or underdeveloped sinus outflow tracts. The key point about obstruction problems is that medicine never fundamentally changes them. The only way to permanently enlarge these passages is with some type of procedure.

Inflammation
The term inflammation refers to a body’s reaction to injury or irritation from environmental exposure such as cigarette smoke and pollution, allergens, toxins, and viruses. In the upper respiratory tract, inflammation causes chemicals to be released into the body that cause swelling of tissue, a halt to normal cilia clearance of mucus, swelling and further obstruction of outflow tracts, excess secretion of mucus, thick mucus, and in the case of allergic inflammation, itching and sneezing.

There are three types of inflammation: infectious (viruses, fungi, and bacteria), allergic, and non-allergic. Unlike obstruction issues, inflammation is always a medical problem. As and example, even after a perfect procedure that clears all obstruction and opens the nose and sinuses physically, there is no way to completely eliminate the daily causes of inflammation. Therefore, patients with chronic and recurrent nasal and sinus inflammation (chronic or recurrent rhinosinusitis) often still require daily topical medicines applied directly to the nasal passages to address inflammation.

Infection (Bacterial, Fungal & Viral)

Bacterial and fungal infections are the direct result of obstruction and inflammation because of the hospitable environment they produce for these organisms. There are very strong medicines that can successfully kill off bacterial and fungal organisms. However, if the obstruction and inflammation issues are permanently corrected, mucociliary clearance can sweep the debris and bacteria out of the sinuses and eliminate the environment for bacteria and fungi to grow. This prevents infections and the need for potentially toxic medications.

Viral infections are related to incidental acute bacterial sinusitis, but typically are not a source of chronic nasal and sinus problems.

Other Factors


There are other clinical situations that can cause nasal and sinus problems and each patient needs an individual assessment to determine the best plan for treatment. Specific challenges such as polyps, scar tissue from previous sinus or nasal surgery, diabetes, and even poor immune systems must all be considered when planning treatment. It is also true that some patients clearly have only one of the three major problems (obstruction, inflammation and infection) as their predominant issue. Such patients often do well just with focused treatment to that one problem.

A Systematic Approach To Lasting Treatment

The majority of chronic nasal and sinus sufferers would benefit from a thorough review of their medical history, as well as a careful examination with endoscopy and/or CT scan to identify any sources of obstruction. Once obstruction problems are corrected, through the most gentle process possible, proper airflow can then be restored through the nasal passage and allow continuous mucociliary clearance from the sinuses. This process also creates access to the sinuses and nasal mucosa so that ongoing topical medications can be applied to safely control inflammation. This method is well grounded in scientific research and is fully consistent with the positions and recommendations of the American Academy of Otolaryngology. Best of all, it results in ongoing, lasting relief for most patients.

We hope you now have a better understanding of the underlying causes of chronic nasal and sinus problems and can use this knowledge to find your path to a lasting solution.

CornerStone Ear Nose & Throat has offices in Charlotte, NC, Monroe, NC, and Indian Land, SC. Call 704-752-7575 for an appointment.