Hello Bryan,
Nice to see a question from you!
Nasal polyps and sinusitis are sort of like the chicken and the egg
story. Which came first? Infection/Allergy can cause inflammation
which can cause polyps to grow. The polyps themselves can harbor
organisms, leading to a vicious circle. After polyps are removed,
another sinus infection, prompted by allergens, pollutants, or an
upper respiratory infection can trigger polyps to re-grow in about 50%
of folks who have had this surgery! People with an aspirin allergy
(many times an unknown allergy) are more prone to sinusitis and
polyps.
?Some patients suffer from aspirin allergy, nasal polyps and asthma, a
condition known as the aspirin triad. This can develop later in life.
Even though these patients are allergic to aspirin, most can be made
to tolerate high doses by starting off at a very low dose of aspirin
initially (and increasing it day by day. Once a higher dose is
reached, aspirin desensitisation can reduce asthma severity, the rate
of polyp regrowth, and the severity of sinusitis. The decision to
undertake aspirin desensitisation is best made by an allergy
specialist. Sometimes, you may need to do a deliberate aspirin
challenge to find out whether or not you are allergic to aspirin.?
http://www.allergycapital.com.au/Pages/polyps.html
?Nasal polyposis is an inflammatory condition of unknown etiology.
Nasal polyps are the most common tumors of the nasal cavity.
Approximately 30% of patients with nasal polyps test positive for
environmental allergies. Incidence of nasal polyps is higher in
children with cystic fibrosis and persons with known aspirin
hypersensitivity.?
?The typical patient with massive nasal polyposis presents with
increasing nasal congestion, hyposmia to anosmia, changes in sense of
taste, and persistent postnasal drainage. Headaches and facial pain
and discomfort are not uncommon and are found in the periorbital and
maxillary regions. Occasionally, a patient with completely obstructing
nasal polyposis presents with symptoms of obstructive sleep apnea.
Patients with solitary polyps frequently present only with nasal
obstructive symptoms that may change with a change in position. For
example, while lying supine, the polyp may swing posteriorly, opening
up the nasal cavity. In an upright position, the polyp has a more
obstructive effect.
Whether one or more polyps are present, patients may have symptoms of
acute, recurrent, or chronic rhinosinusitis if the polyps obstruct the
sinus ostia?
Do you have any known food allergies? ?Dietary modifications should be
considered in patients with food allergy and nasal polyposis.
Controlling allergy in these patients is very important, and recording
a food diary or undergoing tests for food allergy may help control
symptoms and may slow polyp growth.?
Your doctor may also prescribe steroid nasal sprays. These have proven
very efficacious and have little to no side effects. Long term use is
safe, as this form of corticosteroids are not absorbed into the
system. You can see some brands of nasal sprays on this site, in the
aqua colored column.
http://www.emedicine.com/ent/topic334.htm
?Normally, the nose and sinuses produce between a pint and a quart of
mucus secretions per day. This passes into and through the nose,
picking up dust particles, bacteria and other air pollutants along the
way. The mucus is swept to the back of the throat by millions of tiny
hairlike structures (cilia), which line the nasal cavity; and is
swallowed. In the stomach acids destroy any dangerous bacteria. Most
people do not notice this mucus flow because it is just a normal
bodily function.?
In some people, the cartilage and bone in the center of the nose
(called the septum) can be shifted to one side through injury while
others may be born that way. If this shift is severe, sinus drainage
on that side of the nose can he affected. This can lead to complete
closure of one or several of the sinus channels. Mucus then builds up
behind these obstructions and causes sinus infection. If the swelling
becomes severe, the lining of the sinuses can grow excessively. These
growths are called polyps, which can cause further blockage of the
sinus channels. Trapped or stagnant mucus provides a breeding ground
for bacteria.?
http://www.nasal.net/sinuspain.htm
Often, a lingering sinusitis occurs after a viral infection of the
upper respiratory system. It happens this way:
One gets a viral infection, often triggered by allergens and pollutants.
The virus causes cellular damage to the sinus lining.
The cellular damage leads to inflammation and swelling(edema).
The inflammation causes the sinus lining to thicken and fill with fluid.
The thickened lining and fluid causes an obstruction to the process that
normally removes bacteria and other organisms.
Organisms multiply and invade the sinus lining, causing sinus infection
symptoms.
Allergens and irritants in the air can cause the same thing.
?Mechanical obstruction at the osteomeatal complex secondary to
anatomic factors or mucosal edema arising from various etiologies (eg,
acute viral or allergic rhinitis) triggers the stasis of secretions
inside the sinuses. Mucous stagnation in the sinus forms a rich medium
for the growth of various pathogens. Initially, resulting acute
sinusitis involves only one type of aerobic bacteria. With persistence
of the infection, mixed flora, anaerobic organisms, and, occasionally,
fungus contribute to the pathogenesis. Most cases of chronic sinusitis
develop in patients with acute sinusitis that does not respond to
treatment or in those who have not received treatment.?
?The role of viruses in the etiology of acute sinusitis has also been
documented. In one study, sinus cavity abnormality occurred in 87% of
patients with early common viral rhinitis. Bacterial sinusitis
complicated up to 2% of viral rhinitis cases.
While the microbiology of acute sinusitis has been well established,
various researchers disagree on the microbial etiology of chronic
sinusitis. Some studies have documented anaerobes as the prominent
pathogens in chronic sinusitis, while others have failed to
demonstrate this. The reasons for the variable growth of microbes in
the samples obtained from chronic sinusitis may be due to prior
exposure of patients with chronic sinusitis to various broad-spectrum
antibiotics as well to a difference in sample collection techniques.
The exact role of these microbes in the pathogenesis of chronic
sinusitis is another unresolved issue.
Increasing attention is currently being focused on osteomeatal
obstruction, allergies, polyps, occult and subtle immunodeficiency
states, and dental diseases, while the role of bacteria is being
reduced to that of opportunistic colonizer.?
http://www.emedicine.com/med/topic2556.htm
Organisms that commonly causes sinusitis are Haemophilus influenzae,
Streptococcus pneumoniae, Moraxella catarrhalis and Staphylococcus
aureus, and assorted fungi,particularly household molds
?Sinusitis occurs when there is an undrained collection of pus in one
or more of the sinuses. Disorders that cause swelling of the membranes
of the nose, such as allergic rhinitis or viral respiratory
infections, are the most common cause because the swelling prevents
fluid from draining out of the sinus normally. A deviated nasal septum
or other obstruction of the nose may also trap fluid in a sinus.
Occasionally, swimming or immersion of the head in water may allow
water and bacteria to enter the sinus, causing irritation and
infection. The fluid trapped in the sinus may then become infected
with bacteria, viruses, or fungi. Dental infections such as tooth
abscess may spread into the sinus and infect it directly. Acute
sinusitis is most commonly the result of a bacterial infection.
Chronic sinusitis is much less common than acute sinusitis. When
sinusitis recurs frequently, or lasts for a prolonged time, it is
classified as chronic.
The pain of sinusitis results from the inflammation itself or from
pressure within the sinus from accumulation of undrained fluid.?
http://www.healthcentral.com/mhc/top/000647.cfm
Antibiotics:
------------
Antibiotics may clear your sinusitis briefly because you may have a
resistant strain of bacteria. When resistant strains of an organism
are present, the weaker forms of bacteria will die when taking
antibiotics, alleviating some symptoms. In the meantime, the stronger
ones are reproducing, and you get a relapse. Antibiotics will not
clear an infection caused by a virus, but often, you can have a
bacterial AND a viral infection, concurrently. Nor will antibiotics
clear a fungal infection.
?Antibiotics have little or no effect against most acute sinus
infections in children, despite guidelines that recommend their use
when symptoms linger, a study found.
The study comes amid growing concern that the overuse of antibiotics
is creating drug-resistant germs.?
http://www.canoe.ca/Health0104/03_sinus-ap.html
?Antibiotic resistance means that some infection-causing bacteria are
immune to the effects of certain antibiotics prescribed by your
doctor. Antibiotic resistance is making even common infections, such
as sinusitis, challenging to treat. You can help prevent antibiotic
resistance. If the doctor prescribes an antibiotic, it is important
that you take all of the medication just as your doctor instructs,
even if your symptoms are gone before the medicine runs out.?
http://www.entnet.org/healthinfo/sinus/sinusitis.cfm
Keeping sinusitis at bay:
?? using an oral decongestant or a short course of nasal spray decongestant
? gently blowing your nose, blocking one nostril while blowing through the other
? drinking plenty of fluids to keep nasal discharge thin
? avoiding air travel. If you must fly, use a nasal spray
decongestant before take-off to prevent blockage of the sinuses
allowing mucus to drain
? If you have allergies, try to avoid contact with things that
trigger attacks. If you cannot, use over-the-counter or prescription
antihistamines and/or a prescription nasal spray to control allergy
attacks?
http://www.entnet.org/healthinfo/sinus/sinusitis.cfm
This is why a GOOD culture and sensitivity must be run. The culture
will identify the offending organism, and the sensitivity can identify
which antibiotic is the most effective for YOUR bacteria! Without the
sensitivity, it can be trial and error in finding the best antibiotic
for you.
?Resistance a major health threat
Antibiotic resistance has emerged as a major public health threat,
prompting the US Centers for Disease Control and Prevention and the US
Food and Drug Administration to campaign against overuse of the
medications.
"Because sinus infections are so prevalent and it is the fifth most
common diagnosis for which antibiotics are prescribed, our patients
are a key area of concern," lead author Dr Neil Bhattacharyya, an
otolaryngologist at Brigham and Women's Hospital in Boston, said in a
prepared statement. "Our research shows that patients suffering from
chronic sinus infections may be able to lower their rate and
likelihood of antibiotic resistance if a careful and strict approach
to care is followed."
?Our findings add more evidence that antibiotics should be used, as
long as they are used carefully," Bhattacharyya said. "This begins
with procedures that help guide accurate prescribing."
http://www.health24.com/news/Ear_nose_and_throat/1-905,29788.asp
Reasons a swab may not have shown an infection:
-----------------------------------------------
To properly swab a nasal passage, one needs a smaller swab than the
usual swab used for a sore throat. Throat swabs, being too large, will
collect epithelial cells and do not reach far enough to collect a
proper specimen.
Not to disparage anyone in the health care field, but sometimes the
person collecting the sample is ignorant of technique. The swab *MUST*
be kept moist, and at the proper temperature before reaching the lab.
Some swabs may be stored improperly, or allowed to dry out before
reaching the lab. Most nasal swabs have a small ampoule at the bottom
of the collection tube, that must be crushed after inserting the
specimen. This ampoule contains transport media ? nutrients and
moisture to keep the organisms viable. Many times this is not crushed.
I have even seen a swab with specimen on it, dragged across the face,
or dropped on the table and still inserted into into the transport
tube, and forwarded to the lab. In these instances, contaminants can
overgrow the actual pathogen, causing a negative or false report.
Not only size is important, but swab tip material matters too! It
all depends of course, on which methods the performing lab uses for
testing; direct culture, antigen-antibody testing, enzymatic, etc. If
the lab requires a Dacron swab and the collector uses a cotton tipped
swab, this can affect results, if the lab even accepts the specimen.
Some doctor?s offices may not have prompt pick up or delivery of
specimens. If a swab is collected on Friday and it sits till Monday
before reaching the lab, organisms can die, and results can be
affected.
Some offices may utilize nothing more than a simple Gram stain to
preliminarily identify organisms. A swab can be collected, rolled on a
glass slide, dried, and stained. Using a microscope, the doctor can
look for offending organisms. Many doctors are good at this, but it?s
been my experience that microscopy is not a forte of most. For some
unknown reason, most medical staff seem to be unaware of how delicate
organisms are, destroying bacteria as the use the ?stir and smash?
technique, rather than gently rolling the swab, to place he sample on
the slide. Bacterial cells are often mixed with epithelial cells this
way, and are beyond recognition using this technique.
?Chronic sinusitis patients usually must be treated with an
appropriate oral antibiotic for a minimum of 4 to 6 weeks to optimize
a response. There are oral antibiotics that are reserved for suspected
chronic infections that can be very effective. Again, one should
always complete the prescribed medication for the length provided.
For a minority of patients, an appropriately selected and dosed oral
antibiotic taken for lengthy periods of time may not fully resolve a
chronic sinus infection. A CT scan of the sinus will be used to
identify physical and I or anatomic changes and help define extent of
disease. The physician may perform an in- office endoscopic
examination of the sinus utilizing a special lighted scope inserted
through the nose.?
?Some patients with CS have significant anatomic problems that must be
corrected surgically - resistant or large polyps, outlet obstruction
and anatomic variants - to insure long term success. Functional
endoscopic sinus surgery (FESS) is a minimally invasive procedure
designed to restore natural aeration and drainage of the sinuses.
Although not designed to remove deeply set bacteria from surrounding
tissue, these procedures may allow medications to have their intended
curative effect. Surgical procedures also repair and, remove
anatomical structures that may be a source for continued sinus
symptoms. For CS sufferers, IV antibiotic care can complement FESS and
other surgical care initiatives improving long term outcomes.
All patients are evaluated for allergy. More than 50% of CS patients
have allergies to a varying degree. Allergies must be controlled long
term if CS is not to recur. Additionally, a small subset of CS
patients may have more complex immunologic problems that are addressed
through our allergist / immunologist affiliates.?
http://www.sinucare.com/content.php?PAGE=SINUSITISAW
Fungal Sinusitis:
-----------------
?The most common pathogens are from Aspergillus and Mucor species.
Aspergillosis can cause noninvasive or invasive infections, which are
characterized by dark thick greasy material found in the sinuses.
Noninvasive infections cause symptoms of sinusitis, and the sinus
involved is opacified on radiographic studies. Cultures from the
sinuses rarely demonstrate the fungus. However, the fungus usually is
suspected upon reviewing the CT scan and is detected on removal of the
secretions from the sinus.
Invasive infections cause tissue invasion and destruction of adjacent
structures (eg, orbit, CNS).
Problem: Fungal infections of the paranasal sinus can manifest as 2
distinct entities.
The more serious infection occurs in patients with diabetes or in
individuals who are immunocompromised and is characterized by its
invasiveness, tissue destruction, and rapid onset. Early detection and
treatment are vital for these infections due to the high mortality
rate.
Noninvasive infections are chronic and usually are treated for
extended periods as chronic sinusitis before the condition is
recognized.?
A favorite fungus of mine is Aspergillus fumigatus, and it is thought
to be the only organism to cause chronic invasive sinusitis. ?A
fumigatus is the only fungus associated with chronic invasive fungal
sinusitis.?
http://www.emedicine.com/ent/topic639.htm
?When the body's immune system is suppressed, fungi find an
opportunity to invade the body and a number of side effects occur.
Because these organisms do not require light for food production, they
can live in a damp and dark environment. The sinuses, consisting of
moist, dark cavities, are a natural home to the invading fungi. When
this occurs, fungal sinusitis results.? There?s plenty of good
information on this site, which I am unable to post in full, due
copyright restrictions.
http://www.entnet.org/healthinfo/sinus/fungal_sinusitis.cfm
GERD (Gastro-Esophageal Reflux Disease):
----------------------------------------
?A review of studies by Medical College of Wisconsin physicians
suggests that gastric acid refluxed up the esophagus may damage
structures other than the esophagus and result in various health
conditions including sinus infections and eroded teeth and gums.?
?While acid reflux probably does not reach all the way to the sinuses,
it could induce inflammation of nasal mucous, blocking the sinuses.
The exact cause-and-effect mechanism of acid reflux and sinusitis has
not yet been established.?
http://healthlink.mcw.edu/article/968784529.html
?Some individuals have chronic sinusitis which is resistant to
resolution with antibiotic treatment. Di Blaise et al of the
University of Nebraska Medical Center in Omaha have found a high
prevalence of GERD (8 of 11) in such "resistant sinusitis" patients.
The GERD in the resistant sinusitis group was similar to that in GERD
patients without sinusitis except that the former had more abnormal
nasal endoscopic findings and less likely signs of laryngeal
irritation. Anti reflux therapy led to a modest improvement in
sinusitis symptoms in this group.?
http://www.aaaai.org/aadmc/currentliterature/selectedarticles/2002archive/gerd.html
Rhinitis (Common Cold)
----------------------
?Technically, every cold is also a case of viral sinusitis. However,
when doctors use the term sinusitis they are usually referring to a
bacterial infection in the sinuses.
Acute bacterial sinusitis has been present for less than three or four
weeks; subacute bacterial sinusitis has been present for up to about
ten weeks; and chronic bacterial sinusitis has been present for about
ten weeks or more. The three may have different causes and treatments.
Who gets it?
Anyone can get a sinus infection. Colds or nasal allergies are usually
present first. Sinus infections are also more common when there is
exposure to cigarette smoke.
Children who have ear infections, GE reflux, cystic fibrosis, immune
problems, deviated nasal septa, or poorly functioning cilia are more
likely to develop sinus infections. Asthma and sinus infections often
go together.
In addition, swimming, breathing cold dry air, or attending day care
can predispose a child to sinusitis.
Boys get more sinus infections than girls.?
http://www.drgreene.com/21_1188.html
?Viral Rhinitis:
----------------
Acute viral rhinitis (the common cold) can be caused by a variety of
viruses. Symptoms consist of runny nose, congestion, post-nasal drip,
cough, and a low-grade fever. Stuffiness can be relieved by taking
phenylephrine, or
NEO-SYNEPHRINE as a nasal spray or pseudoephedrine by mouth. Some
Trade Names are AFRINOL and SUDAFED. These drugs, available over the
counter, cause the blood vessels of the nasal mucous membrane to
narrow (constrict). Nasal sprays should be used for only 3 or 4 days
because after that period of time, when the effects of the drugs wear
off, the mucous membrane often swells even more than before. This
phenomenon is called rebound congestion. Antihistamines help control
runny nose but cause drowsiness and other problems, especially in
older people (see Some Drugs With Increased Risk for Older People ).
Antibiotics are not effective for acute viral rhinitis.
Vasomotor Rhinitis: Vasomotor rhinitis is a form of chronic rhinitis.
Nasal stuffiness, sneezing, and a runny nose?common allergic
symptoms?occur when allergies do not appear to be present. In some
people, the nose reacts strongly to irritants (such as dust and
pollen), perfumes, and pollution. The disorder comes and goes but is
worsened by dry air. The swollen mucous membrane varies from bright
red to purple. Sometimes, people also have slight inflammation of the
sinuses. When persistent, endoscopy of the nose or computed tomography
(CT) of the sinuses may be needed. If inflammation of the sinus is not
significant, treatment is aimed at relieving symptoms. Avoiding smoke
and irritants and using a humidified central heating system or
vaporizer to increase humidity may be beneficial.?
http://www.merck.com/mmhe/sec19/ch221/ch221g.html
?Irritants such as tobacco smoke, air pollutants, and perfumes may
cause nonallergic responses that mimic allergic disease. Other factors
include pregnancy, ingestion of spicy foods, emotional stress, changes
in temperature, and exercise.
Excoriations of the skin of the external nasal margin may be evident.
Shiners can occur in allergic and nonallergic rhinitis and
occasionally in sinusitis. A high-arched palate and dental overbite
develop from a lack of normal facial modeling during persistent mouth
breathing. The presence of middle ear effusion, recurrent wheezing, or
eczema points to an allergic cause.
Prominent nasal congestion is common in patients with hypothyroidism
and myxedema. A careful review of systems is important to exclude
hypothyroidism as a cause. In patients with uremia and diabetes,
ischemia may cause rhinitis. In addition, rhinitis can be associated
with immunologic diseases (eg, Wegener's granulomatosis, sarcoidosis,
relapsing polychondritis, lethal midline granuloma).?
http://www.postgradmed.com/issues/2002/06_02/chrostowski.htm
Illustrations
=========
Notice how far the nasal swab is inserted. Swabbing just the outer
nasal passages is insufficient for an effective culture. The swab
needs to reach the posterior nares to collect a good sample. This
often causes the patient to cough.
http://www.dsf.health.state.pa.us/Health/Lib/Health/old_DIR/labs%5Cdcm%5Cnpswab.gif
http://www.cdhb.govt.nz/chlabs/protocol/prot76.htm
Not as good an illustration, but?
http://pcchu.peterborough.on.ca/OBswab2.jpg
Method of collection depends on several factors; which organism is the
physician hoping to find, and which collection method is preferred by
the performing laboratory? A nasal wash may be performed, or a swab
alone.
http://pcchu.peterborough.on.ca/OBappen10.htm
Nasal swabs are not completely effective in diagnosing infection,
unless actual drainage is obtained, using a thin wire swab.
http://www.rcpa.edu.au/pathman/nasal_sw.htm
http://www.show.scot.nhs.uk/monklands/ClinicalServices/LabServices/Microbiology/NtoT.asp
Additional information:
-----------------------
Symptoms and locations of sinus infections
http://www.emedicinehealth.com/articles/14139-3.asp
You mentioned being interested in alternative remedies:
http://www.pulsemed.org/sinusitis.htm
You might consider discussing the efficacy if an HIB vaccine
(Hemophilus pneumoniae) and/or a Pneumovax vaccine (Streptococcus
pneumoniae) in your case.
http://www.whale.to/vaccines/pneumococcal.html
http://www.enh.org/healthandwellness/encyclopedia/wellconnected/000062.asp
So, Bryan, you can see there are many reasons for your sinusitis to
return and linger. One of the following may be causing your;
Antibiotic resistance
Fungal infection
Poor culture results
Incorrect antibiotic
Insufficient length of treatment
Allergies, including food, aspirin, and environmental allergens
Pollutants/Irritants
Smoking (You don?t smoke do you?)
Excessive Humidity/Dryness
GERD ? Gastro-Esophageal Reflux Disease
Conditions causing immunosuppression
Periodontal disease
If this has not satisfactorily answered your question, please utilize
the Answer Clarification process,before rating, and I will be glad to
respond!
Here?s to healthy nasal passages to you!
Sincerely, Crabcakes
Search Terms:
Nasal polyposis
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fungal sinusitis
nasopharyngeal swab culture infection
sinus infection + nasal polyps
sinus infection +antibiotics + relapse
GERD + sinusitis
Chronic nasal discharge
viral sinusitis
pneumovax vaccine adults sinusitis
HIB vaccine |
