After over three decades of delivering primary healthcare as a family nurse practitioner, diagnosing and successfully treating hundreds of patients – a majority of whom presented with sinusitis, no experience or patient encounter had been as heart wrenching or as rewarding as the situation I am about to share with a patient I will call “Susan.”
Nineteen-year-old Susan presented tearfully, holding her head in her hands. She had undergone sinus stripping several months prior (a surgical procedure to remove parts of the sinus mucosa to relieve pressure and help drainage). I reviewed her chart, noticing she had been treated repeatedly with several courses of antibiotics within the past 2 year period by another provider. She developed allergies to three antibiotics, had been prescribed decongestants and cough medicine, and self-medicated with over-the-counter preparations. When asked if she used salt water to irrigate her sinuses, she said she never heard of it.
The National Health Interview Survey (from 1997-2006) provided 1-year prevalence data for several disease conditions. Patients with sinusitis were significantly more likely to visit the emergency room, spend greater than $500/year on health care, and see a medical specialist than those without sinusitis. Interestingly, according to the National Health Statistics Reports (2008) complementary and alternative approaches used for treating head or chest colds showed a marked decrease from 2002 to 2007 (9.5% to 2.0%) which may suggest that people were not receiving education about the benefits of these interventions.
According to more recent reports by the CDC (2014), “the number of non-institutionalized adults with diagnosed sinusitis was recorded to be approximately 28.5 million” [http://www.cdc.gov/nchs/fastats/sinuses.htm]. Clearly, sinusitis continues to represent a significant disease burden. When we check recent NHI surveys and CDC reports for comparisons, we discover that the disease burden of this preventable, treatable condition has historically exceeded that of other conditions commonly thought to be more serious. When we consider that statistics revealed that patients with sinusitis missed an average of 6 workdays per year while patients with illnesses unrelated to sinusitis missed, on average, 4 workdays per year, we ask, “Is it possible to reduce the dramatic negative impact sinusitis has on our society?” The answer is, of course: “Yes” and the intervention is very affordable. There is no reason why the number of workdays lost by sinusitis sufferers needs to be similar to that of acute asthma, and no excuse for us to permit health care spending on sinusitis to be so significantly greater than that of ulcer disease, acute asthma, and hay fever.
If there is still any question about the importance of paying greater respect to the prudent use of antibiotics for upper respiratory infections, please consider the 2016 report by the CDC (click here) which concludes from an evidence-based perspective that sinus infections, bronchitis, coughs and the like should NOT be treated with antibiotics.
In recognizing what your body is telling you, ‘itchy eyes’ most often represents an allergic component. Coughing may represent a tickle in the throat related to allergies OR to post nasal drip. Once ‘sinusitis’ is the diagnosis, the next step is to determine the cause of sinus inflammation. (Sinusitis means “inflammation of the sinuses” and flags the body that there is an irritation to which the sinuses are responding).
There are different types of sinusitis. The first seven days of any sinus symptoms are attributed mostly to viral infection. Antibiotics do not fight viruses. If sinus congestion can be alleviated before it becomes a secondary bacterial infection, antibiotics are not needed. Failure to cure sinusitis in its early stages complicates the infection, resulting in prescription antibiotics and often other complex and expensive interventions. Antibiotics are over prescribed (click here for a video interview sharing the latest CDC news) and can be harmful. Inappropriate use of antibiotic therapy can complicate fungal sinusitis and increase chances that bacterial organisms become resistant. Repeated exposure to antibiotics may increase chances that the patient will develop an allergy to that antibiotic.
Saline sinus irrigation remains the treatment of choice for early onset sinusitis (symptoms < 7 days duration). It targets bacterial and viral sinusitis, and is effective when used by sinus sufferers who must be treated with antibiotics. Before using any over-the-counter treatments, it is prudent to consult with your primary health care provider, especially if you have a history of high blood pressure, congestive heart failure or any chronic illness for which you are under advanced nursing or medical care. For sinus sufferers who are otherwise healthy, and have not been diagnosed with high blood pressure or congestive heart failure, a mild salt water solution (bring 8-10 ounces [about a cup] of water to a rolling boil, permit to cool, add 1/4 tsp salt, 1/8 tsp baking soda) may be used to shrink swelling of sinus tissue, creating an environment to help the body fight infection.
Some people prefer to use a Neti pot. If the Neti pot is used, all cleaning instructions must be carefully followed in order to avoid growth of fungal organisms. In addition, it is usually recommended that the water used for the solution is “distilled” or “filtered” and then boiled. If you do not have a Neti pot, you may use a tall cup and fresh, unused straw (this permits excellent irrigation of the sinus cavity). Your primary health care provider can assist you in perfecting your technique; however, if you wish to try this at home, you can follow a few easy steps in the privacy of your own bathroom.
1) After salt water cools, place straw into cup, stir gently, tapping bottom of cup with straw
2) Lift straw out of cup, then place it back into cup until bottom of straw touches bottom of cup; cover opening of straw at top end with tip of index finger
3) Lift straw out of cup, keeping finger at top so that solution remains in straw
4) Tilt head back, insert bottom of straw about 1/8 inch into one nostril
5) Permit solution to escape into nostril by lifting finger off top of straw
6) Once all solution is in nostril, keeping head tilted back, gently pinch both nostrils and tilt head to the side solution went into (put straw down)
7) Then tilt head forward (chin to chest) and bend at waist so that solution flows into sinus cavity (when successful, you will feel tingling inside cheek, under that eye)
8) Hold this position for about 10 seconds, breathing through your mouth
9) Bending over sink, release pinched nostrils and gently blow into a tissue. Spit salt water that escaped down back of throat.
10) Repeat steps for other nostril. Then, repeat irrigation in each nostril two more times. Do this 3 to 4 times a day: upon waking, before bedtime, and once or twice during the day.
In order to avoid developing bacterial sinusitis, saline sinus irrigation is the least expensive, most cost effective intervention to treat both the first signs of sinus congestion and the first few days of any sinusitis. When used as a first line treatment for nasal congestion, saline sinus irrigation relieves painful swelling, may reduce the need to take time off work, and is affordable for those without health insurance. This intervention works best in conjunction with a healthful diet, 7 to 9 hours a night of restful sleep, and avoiding sugar-rich foods.
One does not need a medical or nursing professional to teach this procedure although, if uncertain or uncomfortable about it, individuals should ask a trusted primary health care provider for guidance.
Susan’s surgeon encouraged me to teach her how to irrigate her sinuses with this saline preparation and she learned quickly. After practicing in my office, she announced with delight, “Something cleared!”
Pharmaceutical companies vested in selling antibiotics and over-the-counter treatments might object to any alternatives to their products; however, preparations that include steroids may, if used incorrectly, contribute to rebound swelling, and antibiotics do not address viral or fungal infections, nor do they clear congestion caused by swelling or blockage related to accumulation of scabs, blood or mucus.
At the very least, saline irrigation should be used in conjunction with antibiotic therapy. It is the responsibility of every patient, business and primary health care provider to consider how many sick days and how much suffering could be avoided by using such a simple, inexpensive, and easy preparation. Preventive health care and treatment must become the focus of primary health care providers, and consumers must demand it.
It behooves the Centers for Disease Control and Prevention to begin to list saline sinus irrigation as a valuable intervention. Further, the United States Department of Health and Human Services, medical schools, nursing schools, community health care institutions, as well as elementary, middle and high school nurses need to begin to offer preventive health education, at the very least, focusing on this low cost, easily available, and highly effective intervention. All primary health care providers should be aware of the value of saline sinus irrigation and should educate patients who present with sinus infections. As educated consumers of primary health care services, it is incumbent upon every individual to insist that all primary health care providers offer interventions that are safe, effective and affordable.
Dr. Nancy Iankowitz DNP, RN, FNP-BC 