Sinus Article

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Doctors Rethinking Treatments for Sick Sinuses

New York Times

December 17, 2002

By GABRIELLE GLASER

Over the last 10 years, many doctors have become convinced that the

answer

to chronic sinusitis, which afflicts millions and costs the United States

an estimated $6 billion a year, could be successfully treated with

surgery.

The introduction of fiber optic surgery, involving tiny scopes with

cameras

attached to a monitor, has become common, giving doctors access to the

cramped, convoluted sinus passageways. Before the new technique was

developed, doctors cut through the roof of the mouth or made incisions in

the eyebrows to clear away scarred tissue or polyps.

Many physicians said they thought the new tools could help cure the

disease. But now, as many of those who have had the procedure return to

their doctors' offices sick once again, the early hopes for surgery have

been dashed. Researchers are shifting their focus to inflammation and the

immune system.

" The medical community thought endoscopic surgery was the be-all and

end-all, " said Dr. S. Benninger, chairman of the otolaryngology

department at Henry Ford Hospital in Detroit. " Surgery still has a role

for

some problems. But it's certainly not the solution for everyone. "

Dr. H. Krouse, a professor and the director of rhinology and

otolaryngic allergy at the Wayne State University School of Medicine in

Detroit, agreed. For years, Dr. Krouse said, ear, nose, and throat

surgeons

were puzzled when patients returned to their offices just months or weeks

after having surgery. Some patients had six operations, Dr. Krouse said.

Physicians, he added, began asking, " What are we doing? " and " What

exactly

are we treating? "

The disillusionment with surgery occurs as recognition is increasing that

other common remedies for chronic sinus disease like antibiotics,

steroids,

antihistamines and decongestants also are falling short of expectations.

Researchers say they are beginning to suspect that they have to rethink

the

underlying causes. Instead of allergies and infections, long considered

the

primary culprits, doctors are asking why sinuses become sick in the first

place. Increasingly, they are looking at inflammation or the responses of

the immune system.

At this point, researchers are struggling even to define sinusitis, which

affects an estimated 37 million Americans, or 13 percent of the

population.

The symptoms include repeated infections, persistent congestion,

headaches,

facial pain and malaise that can last for years.

According to the Centers for Disease Control and Prevention, chronic

sinusitis is the most common long-term illness in the United States,

affecting more Americans than asthma, arthritis and congestive heart

disease. It strikes women more than men and is most common in the

Southeast.

Sinusitis is also expensive and time consuming. It is responsible for

nearly 14 million visits a year to doctors' offices, according to the

National Institute for Allergy and Infectious Diseases.

The sinuses, hollow spaces surrounding the nose like grape clusters, are

something of a mystery. Anthropologists theorize that they originated

from

evolution, allowing the head to be held upright. They also warm, cool and

humidify air entering the lungs, equalize barometric pressure and provide

resonance for the voice.

Each sinus has a duct no bigger than the lead of a pencil for the free

exchange of air and mucus and is joined with the nasal passages by a

continuous mucous membrane that, when healthy, resembles the lining of

the

inside of the mouth.

The membrane produces a pint to a quart of mucus a day, which is flushed

out of the sinuses by tiny cilia, or hairlike filaments. They help pass

pollen, bacteria and viruses from the nose to the back of the throat,

where

they are swallowed and then dissolved by stomach acids.

For reasons that are not entirely clear, the sinuses of people with

chronic

sinusitis are often mottled with inflammation. The ducts swell, trapping

mucus, viruses and bacteria inside.

The dark moist hollows become ideal breeding grounds for infection.

Frequently, the chronic swelling and infections cause polyps.

" No one is really sure what sets off the cascade of inflammation that

makes

some people sick, " Dr. Krouse said. " We don't know why some respond to

one

treatment while others don't or why some symptoms bother some patients to

distraction but are not noticeable to others. We are struggling to make

sense of it. We're not even sure what this disease really is. "

For years, doctors expanded the sinus openings with surgery, stripped

away

membranes and removed bony structures, known as turbinates, which are

responsible for humidifying inspired air. Sometimes, the procedures

created

more problems than they solved. Turbinates, it turns out, are essential

to

the health of the chambers and are primary defenders against disease.

Still, some problems like polyps or anatomical blockages may call for

surgery. Surgeons are finding that when procedures are necessary, a less

aggressive approach often yields better results than the radical

designing

of the sinuses that was done in years past.

Nonsurgical treatments have included oral and intravenous antibiotics,

antihistamines and decongestants, as well as oral and topical steroids.

Steroids work to calm inflammation, and some doctors find them effective.

Often the only relief many patients receive is from prednisone, a

powerful

steroid.

" We began to see that we were not going to solve this puzzle with a

better

antibiotic, or a better procedure, " Dr. Krouse said. " That points to

inflammatory and immunologic processes, not surgical or infectious ones. "

Researchers at the Mayo Clinic achieved a breakthrough in 1999, when they

found that some inflammation was caused by an immune response to fungi in

the nose. Patients and control subjects had many different species of

fungi

in the nose. But just those with chronic sinusitis have white blood

cells,

known as eosinophils, that are activated by the immune system, the

researchers found.

Led by Dr. Jens Ponikau, they discovered that the immune system sends

eosinophils to attack fungi. The eosinophils release a protein that

irritates the membranes in the nose. The irritation remains as long as

the

fungi are present.

A paper on their findings will be published in a peer-reviewed journal

next

month.

The Mayo team is treating patients with antifungal solutions. Clinical

trials are continuing, and patients who have been treated have given

encouraging reports. " But we have to settle in for the long haul, " Dr.

Ponikau said. " It's a paradigm shift, a different way of looking at the

disease. "

Some doctors have succeeded with a class of asthma drug called

leukotriene

receptor antagonists. They works by blocking leukotrienes, substances

that

the immune system secretes in asthma and allergy attacks and that inflame

the respiratory tract. Patients with sinus disease often have asthma, as

well.

" Asthma patients who used these drugs found that their sinus symptoms

were

eased,, " said Dr. Setzen, who has a practice in Manhasset, N.Y.,

and is an assistant clinical professor of otolaryngology at the New York

University School of Medicine. " If it works, patients know it right

away. "

An asthma medication, Singulair, the trade name for montelukast, is

awaiting approval from the Food and Drug Administration for allergy

symptoms. Many doctors, however, prescribe it for sinus problems.

Dr. C. Chester, an internist in Washington, treats hundreds of

patients with sinusitis. He recommends cutting dairy products from the

diet. Eliminating milk was popular advice some years ago, but lost

currency

because the benefits could not be verified, Dr. Chester said.

In 10 percent of his patients, he said, eliminating milk products

substantially improves sinusitis and all its symptoms. It is possible

that

less milk means less mucus, but researchers are unsure exactly why

reducing

milk in the diet is effective.

Dr. Chester and other experts also urge common sense. Patients with

sinusitis should be evaluated for anatomical obstructions (in those

cases,

surgery can help), allergies and strength of the immune system, Dr.

Krouse

said, adding, " We need as much information on a patient-by-patient basis

as

we can get. "

Dr. Benninger of Detroit asks patients to complete a questionnaire about

physical, emotional and social difficulties. Routinely, patients report

high levels of fatigue, depression and sexual dysfunction. " This disease

is

so much more than just its symptoms, " he said.

Many doctors encourage patients to avoid wine and beer, which can cause

passageways to swell. Smoking and tobacco smoke should also be avoided.

The doctors agree that patients should exercise, drink enough water and

irrigate their noses with a homemade saline solution. Many

over-the-counter

solutions have a preservative, benzalkonium chloride, that can be

irritating and may paralyze cilia.

Some doctors also find promise in an over-the-counter nasal saline spray

made with xylitol, a natural sweetener used in

chewing gum and mints since the 1960's. Xylitol is also produced in small

amounts in the human body in normal metabolism.

A recent study in Finland found that xylitol, a natural antimicrobial,

was

effective in reducing the ability of common respiratory bacteria,

including

Streptococcus pneumoniae and Hemophilus influenzae, to adhere to the

mucous

membrane.

The doctors who treat patients with chronic sinusitis are frustrated,

too.

" We're not even close to having all the answers, " Dr.  Setzen said. " Our

big hope is that we can help these people who are nasal cripples. A

functioning nose is essential to the quality of one's life. "

http://www.nytimes.com/2002/12/17/health/anatomy/17SINU.html?ex=104125587

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