Understanding Sinusitis and Allergy: The Asthma Center Education and Research Fund Manual Written by: Marc F. Goldstein, M.D. Donald J. Dvorin, M.D. George A. Belecanech, M.D. Irene C. Haralabatos, M.D. Nancy D.Gordon, M.D. Raquel B. Empedrad, M.D. David F. LaRosa, M.D. Edward A. Fernandez 2nd Edition We wish to acknowledge Gaille Woodlyn for her expertise in editing and preparing this manual for publication. We’d also like to recognize the contributions of all staff mem- bers of The Asthma Center who reviewed this manuscript. The Asthma Center Education and Research Fund Professional Arts Building Suite 300 • 205 North Broad Street • Philadelphia, PA 19107 • (215) 569-1111 ii The Asthma Center Education and Research Fund Sinusitis and Allergy Manual ©2017 The Asthma Center Education and Research Fund Understanding Sinusitis and Allergy: The Asthma Center Education and Re- search Fund Manual is the sole property of The Asthma Center Education and Research Fund and cannot be reproduced, used commercially, or redistributed for any reason without written permission from The Asthma Center Education and Research Fund. The Asthma Center Education and Research Fund Sinusitis and Allergy Manual iii Table of Contents PART ONE Sinusitis Chapter 1. Anatomy and Function....................................................................................................................................... 5 What are the Sinuses and How Do They Work?.............................................................................................. 5 Maxillary Sinuses .......................................................................................................................................... 6 Ethmoid Sinuses............................................................................................................................................. 7 Frontal Sinuses .............................................................................................................................................. 7 Sphenoid Sinuses............................................................................................................................................ 8 Nasal Turbinates.................................................................................................................................................... 8 Respiratory Mucous Membranes........................................................................................................................ 10 Mucociliary Clearance......................................................................................................................................... 11 How Do You Test for Mucociliary Clearance?................................................................................................. 13 Chapter 2. Sinusitis: Types, Diagnosis, and Treatment...................................................................................................... 15 Acute Sinusitis....................................................................................................................................................... 15 Symptoms of Acute Sinusitis....................................................................................................................... 17 Diagnosing Acute Sinusitis.......................................................................................................................... 17 Nasal Cytology (examination of nasal secretions) and Biopsy ..................................................... 19 CT Scan of Sinuses ............................................................................................................................... 20 MRI of Sinuses....................................................................................................................................... 21 Conventional X-ray, Ultrasound and PET Scans of Sinuses ......................................................... 22 Causes of Acute Sinusitis............................................................................................................................... 22 Viral Infections...................................................................................................................................... 22 Bacterial Sinusitis ................................................................................................................................. 24 Cultures.......................................................................................................................................................... 25 Natural Course and Complications of Acute Sinusitis............................................................................. 25 Antibiotic Treatment Guidelines for Acute Bacterial Sinusitis................................................................ 26 Chronic Sinusitis................................................................................................................................................... 28 Symptoms of Chronic Sinusitis .................................................................................................................. 29 Diagnosing Chronic Sinusitis...................................................................................................................... 29 Sinus Imaging for Chronic Sinusitis .................................................................................................. 29 Causes of Chronic Sinusitis.......................................................................................................................... 30 Nasal and Nebulized Antibiotics for Treatment of Chronic Sinusitis .................................................. 30 Intravenous Antibiotics for Chronic Sinusitis.......................................................................................... 31 Immununoglobulin Replacement Treatment for Chronic Sinusitis....................................................... 31 Noninfectious Chronic Sinus Disease......................................................................................................... 32 Chapter 3. Acute and Chronic Sinusitis Risk Factors.......................................................................................................... 33 Medical Risk Factors............................................................................................................................................. 33 Air Pollution.......................................................................................................................................................... 34 Post Nasal Drip...................................................................................................................................................... 35 Fungal Sinus Disease............................................................................................................................................ 35 Nasal Polyps and Sinus Disease............................................................................................................................ 37 Aspirin Hypersensitivity , Nasal Polyps and Sinus Disease............................................................................. 38 Sinus Headaches and Migraines......................................................................................................................... 39 Other Causes of Facial Headache....................................................................................................................... 41 Asthma and Sinus Disease.................................................................................................................................... 42 Chapter 4. Surgical Treatments for Sinusitis........................................................................................................................ 43 Functional Endoscopic Sinus Surgery................................................................................................................. 43 Other Types of Sinus Care................................................................................................................................... 44 Post Operative Care.............................................................................................................................................. 44 What Happens if Surgery Fails............................................................................................................................ 45 PART TWO Upper Respiratory Allergies............................................................................................................................... 46 Chapter 5. Mechanism of Allergic Reactions........................................................................................................ 47 Chapter 6. Environmental Airborne Allergens..................................................................................................... 48 Outdoor Allegens.................................................................................................................................... 48 Tree Pollen....................................................................................................................................... 49 Grass Pollen ................................................................................................................................... 49 Weed Pollen..................................................................................................................................... 50 Molds............................................................................................................................................... 50 Indoor Allergens..................................................................................................................................... 50 Dust Mite Allergens ...................................................................................................................... 50 Cat and Dog Allergens.................................................................................................................. 51 Cockroach Allergens ................................................................................................................... 51 Indoor Mold Allergens................................................................................................................. 51 Chapter 7. Seasonal Allergic Rhinitis (SAR)...................................................................................................... 52 Definition/Causes.................................................................................................................................. 52 Signs and Symptoms of Seasonal Allergic Rhinitis........................................................................... 52 Diagnostic Studies................................................................................................................................. 53 Diagnosis................................................................................................................................................ 54 Chapter 8. Perennial Allergic Rhinitis (PAR)...................................................................................................... 55 Definition/Causes.................................................................................................................................. 55 Signs and Symptoms of Perennial Allergic Rhinitis.......................................................................... 55 Diagnostic Studies.................................................................................................................................. 55 Diagnosis................................................................................................................................................ 55 Chapter 9. Allergy Injections/Immunotherapy and Sublingual Immunotherapy............................................ 56 Chapter 10. Environmental Avoidance of Allergens and Irritants..................................................................... 58 Avoidance Measures ............................................................................................................................. 59 House Dust Mites................................................................................................................. 60 Relative Humidity................................................................................................................... 60 Cockroaches............................................................................................................................. 61 Chemical Fumes .................................................................................................................... 61 Furniture.................................................................................................................................. 61 Pets........................................................................................................................................... 61 Air Conditioning................................................................................................................... 62 The Bedroom.......................................................................................................................... 62 Bedroom Suggestions for Allergy and Sinus Sufferers...................................................... 63 Air Cleaners............................................................................................................................. 63 Air Duct Cleaning ................................................................................................................ 66 Water Sources ........................................................................................................................ 68 Bathrooms......................................................................................................................... 68 Sinks................................................................................................................................... 68 Toilets................................................................................................................................ 68 Showers and Tubs............................................................................................................ 68 Chapter 11. Nonallergic Nasal Conditions........................................................................................................... 69 Nonallergic Rhinitis............................................................................................................................... 69 Vasomotor Rhinitis................................................................................................................................ 69 Gustatory Rhinitis.................................................................................................................................. 69 Nonallergic Rhinitis with Eosinophilia Syndrome.......................................................................... 69 Atrophic Rhinitis.................................................................................................................................... 70 Rhinitis Associated with Systemic Disease......................................................................................... 70 Nasal and Sinus Tumors........................................................................................................................ 70 Rhinitis Associated with Pregnancy.................................................................................................... 71 PART THREE Treatments for Sinusitis and Upper Respiratory Allergies........................................................................ 72 Chapter 12. Medical Treatment for Allergies and Sinusitis............................................................................... 73 Decongestants........................................................................................................................................ 74 Mucolytics/Expectorants..................................................................................................................... 75 Oral Corticosteroids............................................................................................................................. 76 Nasal Corticosteroids........................................................................................................................... 76 Anticholinergics.................................................................................................................................... 78 Antihistamines....................................................................................................................................... 79 Leukotriene Modifiers.......................................................................................................................... 80 Xolair- (Anti-lgE Therapy).................................................................................................................. 81 Mucolytics............................................................................................................................................. 82 Analgesics.............................................................................................................................................. 82 Immunizations and Sinusitis.............................................................................................................. 82 Chapter 13. Complementary and Alternative Medicine Treatments for Sinusitis and Allergic Rhinitis..... 83 Acupuncture/Acupressure.................................................................................................................. 83 Reflexology............................................................................................................................................ 83 Massage................................................................................................................................................. 85 Chiropractic Therapy........................................................................................................................... 85 Relaxation Techniques......................................................................................................................... 85 Biofeedback.......................................................................................................................................... 85 Breathing Exercises and Meditation.................................................................................................. 86 Yoga....................................................................................................................................................... 86 Hydrotherapy......................................................................................................................................... 86 Aromatherapy........................................................................................................................................ 87 Homeopathy.......................................................................................................................................... 87 Nasal Saline Irrigation......................................................................................................................... 89 Moist Heat............................................................................................................................................. 94 Drinking Water..................................................................................................................................... 94 Herbal Remedies ................................................................................................................................. 95 Nutritional/Dietary Supplements....................................................................................................... 96 Antioxidants......................................................................................................................................... 97 PART FOUR Allergic Eye Disease........................................................................................................................................... 98 Chapter 14. Allergic Conjunctivitis..................................................................................................................... 100 Chapter 15. Atopic Keratoconjunctivitis............................................................................................................. 103 Chapter 16. Vernal Conjunctivitis....................................................................................................................... 104 Chapter 17. Giant Papillary Conjunctivitis........................................................................................................ 105 Chapter 18. General Approach to the Treatment of Allergic Eye Disease........................................................ 105 Antihistamines....................................................................................................................................... 107 Vasoconstrictors/Decongestants........................................................................................................ 107 Mast Cell Stabilizers............................................................................................................................. 107 NSAlDs (nonsteroidal anti·inflammatory drugs)............................................................................ 107 Corticosteroids...................................................................................................................................... 107 PART FIVE Special Topics...................................................................................................................................................... 108 Chapter 19. Airline Travel, Sinus Disease and Upper Respiratory Allergies................................................. 109 Chapter 20. Scuba Diving, Sinus Disease and Upper Respiratory Allergies................................................... 111 Chapter 21. Sinusitis in Children......................................................................................................................... 112 Chapter 22. Home Care for Sinus Disease and Upper Respiratory Allergy.................................................... 113 PART SIX Frequently Asked Questions................................................................................................................................... 116 1. What is sinusitis?................................................................................................................................................. 117 2. Who is affected by sinusitis?............................................................................................................................... 117 3. What causes sinusitis?......................................................................................................................................... 117 4. What are the different types of sinusitis?........................................................................................................... 117 5. What increases the risk of developing sinusitis?.............................................................................................. 117 6. What are the symptoms of sinusitis?.................................................................................................................. 117 7. How can you distinguish among sinusitis, colds and allergies?.................................................................... 117 8. When should you see a specialist? Which specialist should you see?.......................................................... 119 9. How are sinusitis and allergic rhinitis medically treated?............................................................................. 119 10. What medications or treatments can you use at home to treat your sinusitis and allergic rhinitis?........ 119 11. What are the complications from sinusitis?...................................................................................................... 120 12. What can you do to prevent another episode of sinusitis?............................................................................. 120 13. What are the complications of allergic rhinitis? ............................................................................................. 120 Glossary...................................................................................................................................................................... 121 Clinical Research...................................................................................................................................................... 132 The Asthma Center Education and Research Fund........................................................................................... 132 The Authors............................................................................................................................................................... 134 Introduction 1 Please read Sinusitis and Allergy Introduction this introduction What is sinusitis, what are allergies, and what is the relationship between sinusitis and allergy? before using The term “sinusitis” is often used by individuals and the media to indicate symptoms of pressure the manual. It or discomfort over parts of the face, symptoms typical of a “bad cold,” significant nasal conges- tion, persistent post nasal drip, chronic throat clearing, headaches or severe “allergy symptoms.” will help you understand From a medical point of view, sinusitis simply means inflammation of the sinuses or, more pre- the cisely, inflammation of the mucosal tissues lining the sinuses. Sinus inflammation can be caused importance by infection, allergy or other factors. Allergic inflammation can cause swelling of the sinus mu- cosa, interfering with the normal cleansing movement of mucus through the sinus passageways. behind Allergies are caused by an abnormal immune response to allergen exposures such as pollen, treatment for foods and animal danders. Allergic inflammation can occur in the nose and sinuses. Allergic in- sinusitis and flammation of the sinus tissue can interfere with the normal clearing of bacteria within the sinus cavities leading to infection. Under these circumstances respiratory allergy can play a major role respiratory in repeated sinus infections. allergies. Since chronic sinusitis can be the result of both allergy and infection, both underlying causes often need to be evaluated and effectively managed if the problem of chronic sinusitis is to be resolved. Allergy induced chronic sinusitis associated with repeated sinus infections can lead to significant alteration of the sinus mucosa and surrounding structures. Once damage occurs, restoration of full normal function of the sinus cavities may not be possible. Therefore, any delay in identifying and treating an underlying allergic component of chronic sinus disease can lead to years of unnecessary suffering. Allergists often see sinus suffers who have undergone repeated treatments with antibiotics for symptoms of sinusitis or even after sinus surgery. Sinus symptoms often persist until the allergic component is finally identified and treated. Comprehensive management of the allergic compo- nent earlier in the disease process may prevent some cases of refractory sinusitis in which the sinus cavities are no longer capable of removing bacteria and are filled with scar tissue, bacteria and inflammation. In addition, nonallergic factors should also be evaluated in those with per- sistent sinus symptoms. This manual will inform you of the diagnostic and treatment options for acute, recurrent and chronic sinus disease as well as upper respiratory allergies. Therefore, if you have recurrent or chronic sinus disease with symptoms persisting in spite of multiple antibiotics directed against bacterial infections, you should undergo an in-depth allergy and immunology evaluation. This evaluation will help to determine whether or not allergy and immunologic problems contribute to or cause your symptoms. If allergy and immunologic problems do play a role in your sinus symptoms, then several different treatment options be- yond antibiotics may be available to you. All of these treatment options are extensively reviewed in this manual. 2 Introduction Sinusitis Introduction Are you one of the millions of individuals affected by repeated bouts of sinusitis? Do you have symptoms of recurrent headaches, facial pressure, nasal and/or sinus congestion, post nasal drip, constant throat clearing, throat irritation, hoarseness, decreased sense of smell, coughing, or other symptoms typical of sinus disease and/or allergies? Did you know that sinus disease may also cause you to feel tired, irritable, suffer from poor concentration, low energy, or just feel sick all the time? The discomfort associated with sinus disease can be so great that it keeps you from functioning well at work, school, or home. Recurrent or persistent symptoms of sinusitis may make you feel ill or just plain miserable much of the time. If you suffer from chronic sinusitis, it is likely you feel unable to find relief and that you are no longer in control of your symptoms. Furthermore, complications from poorly treated sinusitis can lead to severe life threatening diseases including generalized infection (septicemia), infections of the sinus bones (osteomy- elitis) and infections of the tissues around the eyes or in the brain. Sinus disorders can also trigger asthma. So what is sinusitis? Who gets sinusitis? How is it treated? How do you reduce your risk? How do you prevent recurrences and complications? If you want to learn the answers to these questions and more, this manual is for you. Sinusitis Facts • 24-31 million Americans are affected with sinusitis annually • Annual average loss of work time for sinusitis is 4 days per year per case • Most occurrences of sinusitis begin as common colds • Close to $11 billion per year is spent on treatments of sinusitis • Surprisingly, the quality of life of individuals with chronic sinusitis is worse than those with heart failure Respiratory In the United States, close to $11 billion dollars is spent on sinus care each year. The cost of antibiotics, x-rays, doctor visits and even surgery can be a great burden for you, not to men- allergy tion time lost from school and work and associated suffering. With such great costs in deal- can play a ing with sinusitis, it makes sense to learn how to get the best care. Parts 1 and 3 of this manu- al will help you ask the right questions, find the right solutions and be active and informed in major role getting the care that you need. in repeated sinus Since allergies can play such a significant role in causing and/or promoting sinusitis, you will also learn how to detect and manage allergies. Allergy of the nose affects more than 20% of infections. Americans. If you have allergies, symptoms may exist year round (perennial) and/or at the change of seasons like fall and spring. If you suffer from sneezing or itching of the eyes, nose, throat, ears and roof of the mouth and/or get congested frequently, you may be experi- encing telltale symptoms of upper respiratory allergies. Part 2 (Upper Respiratory Allergies) of this manual will help you understand the triggers of allergies, how best to control symp- toms with medications and allergy shots and how to prevent complications like sinusitis and asthma. Introduction 3 Allergy Facts • 60 million Americans suffer from upper respiratory allergies annually • Allergies account for over 6 million lost school days annually • Allergies account for over 10.7 million lost work days annually • Close to $18 billion dollars per year are spent on treatment of allergies Parts 1 (Sinusitis) and 3 (Treatments for Sinusitis and Upper Respiratory Allergies) of this manual are dedicated to the medical treatment of sinus disease and upper respiratory aller- gies. These sections are dedicated to conventional and well accepted treatments used at The Asthma Center and other institutions and practices. It is recognized that many people with upper respiratory allergies and sinus disease resort to use of complementary and alternative treatments, these treatments are also discussed (Part 3, Chapter 13). In general, many of these treatments are not scientifically proven and are not endorsed by most experts, but some may benefit some individuals. Part 4 (Allergic Eye Disorders) of this manual discusses eye allergies, commonly connect- ed with upper respiratory allergies. Special topics relating to sinusitis and upper respiratory allergies are located in Part 5. Topics such as air travel, scuba diving, sinus disease in children and home care for sinusitis and upper respiratory allergies are discussed. Frequently asked questions and a glossary of terms used in the manual are included in Part 6. PART ONE Sinusitis