• History of acute viral respiratory infection, dental infection, or nasal allergy
• Nasal congestion and thick mucus discharge
• Fever, chills, and frontal headache
• Pain, tenderness, redness, and swelling over the involved sinus
• In chronic infection, often no symptoms other than mild postnasal discharge, a musty odor, or a nonproductive cough
Sinus infection, or sinusitis, is a bacterial infection of the sinus passages—it may be either acute or chronic. The most common predisposing factor in acute bacterial sinusitis is viral upper respiratory infection (the common cold). Nasal allergies and other factors that interfere with normal protective mechanisms may precede the viral infection and therefore are the more likely predisposing factors. The key point is that any factor that induces swelling or inflammation of the mucous membranes that line the nasal and sinus passages will predispose a person to bacterial sinusitis, as the environment that is produced serves as a suitable medium for bacterial overgrowth, with streptococci, pneumococci, staphylococci, and Haemophilus influenzae being the most commonly cultured bacteria.
In chronic bacterial sinusitis an allergy is the most common cause; in 25% of cases there is an underlying dental infection.
Although antibiotic therapy is the dominant treatment of acute and chronic bacterial sinusitis, it is of limited value.1 A detailed analysis of clinical trials with adults concluded that there was insufficient evidence to say that antibiotic treatment was effective in acute sinusitis.2 Nonetheless, in severe or unresponsive cases, antibiotics may be appropriate. In a Cochrane review it was shown that although 80% of participants treated without antibiotics improve within two weeks, antibiotics have a small effect in patients with uncomplicated acute sinusitis who have symptoms for more than seven days. Newer, more potent antibiotics (e.g., cephalosporins) appear to be more effective than penicillin, amoxicillin, and other less potent antibiotics.3
In children, there is even less evidence that antimicrobial therapy is of significant benefit.4 Overuse of antibiotics for children with sinusitis or otitis media is a growing concern, as it is leading to antibiotic-resistant strains of bacteria.
In chronic sinusitis, antibiotics are also usually of little or no benefit.5 Clearly the most rational approach seems to be to address the underlying cause of chronic sinusitis (respiratory or food allergens) along with providing supportive therapy (saline nasal rinse, immune-enhancing herbs, natural decongestants).
Studies indicate that among most patients with chronic sinusitis, perhaps as many as 84%, have allergies.6,7 Environmental control requires the elimination of dust mites (washing at a temperature of at least 136°F), use of air-filtering vacuum cleaners, installation of an air cleaner with a high-efficiency particulate air filter, and whatever methods are necessary to maintain the humidity under 50%. Some particularly sensitive patients may need to have all pets removed, along with carpeting and featherbedding.8 Other recommendations are in the chapter “Hay Fever.”
The ability to clear particulate matter and microorganisms from the sinuses depends on the properties and volume of secreted mucus and the hairlike appendages (cilia) of the cells that line the sinuses. In chronic sinusitis, the mucus is usually thicker and sticker. Guaifenesin (also known as glycerol guiacolate) is a derivative of a compound originally isolated from beech wood that has expectorant and mucolytic properties and is available in many over-the-counter preparations. The goal with a mucolytic is to reduce the thickness and stickiness of the mucus to help promote effective clearance.9
Alternative mucolytics include N-acetylcysteine (NAC) and proteolytic enzymes. NAC is very effective in this role, interacting with the protein bonds of mucus to break it down into less viscous strands. NAC has been shown to be effective for chronic bronchitis.10 These same properties make it useful for sinusitis. Proteolytic (protein-digesting) enzymes may break down complex proteins at the site of inflammation, exert some antimicrobial effects, or act directly on mucus proteins. Trypsin, chymotrypsin, Serratia peptidase, and bromelain are the proteolytic enzymes that can break down mucus proteins and other proteins when they are administered topically. Of these enzymes, Serratia peptidase may be the most effective, while bromelain is probably the most popular and readily available. Serratia peptidase is an enzyme derived from bacteria that reside in the intestines of silkworms. It is also called “silkworm enzyme,” as it is the enzyme used to break down the cocoon of the silkworm. It is more powerful and has broader pH stability than the pancreatic enzymes chymotrypsin and trypsin. It has been used in Europe and Japan for over 25 years as a mucolytic and natural anti-inflammatory. When Serratia peptidase was given at a dose of 30 mg per day for four weeks to patients with chronic sinusitis, it significantly reduced the thickness of nasal mucus.11When Serratia peptidase was administered at the same dose to patients with chronic bronchitis, it significantly increased mucus clearance.12 In a double-blind, placebo-controlled study of 193 subjects suffering from various acute or chronic ear, nose, or throat disorders, including sinusitis, Serratia peptidase demonstrated greater efficacy and more rapid action against all the symptoms examined.13 Orally administered bromelain has also shown benefit in the treatment of chronic sinusitis.14
Many herbs have been shown to have antibacterial, antiviral, and immune-enhancing effects that would be appropriate for bacterial sinusitis. The most popular herbal medicines historically used in the United States for sinusitis are goldenseal (Hydrastis canadensis) and echinacea (Echinacea species); see the information on echinacea in the chapter “Common Cold,” as it may be more useful than goldenseal in viral infections. The discussion below includes goldenseal and other berberine-containing plants as well as South African geranium (Pelargonium sidoides). Extracts from the rhizomes and tubers of South African geranium have been shown to exert a number of effects beneficial in upper respiratory tract infections, particularly acute bronchitis, for which it is an approved drug in Germany (see the chapter “Bronchitis and Pneumonia”).
Goldenseal and Other Berberine-Containing Plants
Goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), Oregon grape (Berberis aquifolium), and coptis or goldthread (Coptis chinensis) are valued for their high content of alkaloids, of which berberine has been the most widely studied. Berberine has demonstrated significant antibiotic and immune-enhancing effects in both experimental and clinical settings. Berberine has also been shown to inhibit the adherence of bacteria to human cells, so they cannot infect the cells.
The primary immune-enhancing action of berberine is the activation of white blood cells known as macrophages. These cells are responsible for engulfing and destroying bacteria, viruses, tumor cells, and other particulate matter. Historically, berberine-containing plants have also been used to bring down fevers. In animal studies, berberine has produced a fever-lowering effect three times as potent as that of aspirin. However, while aspirin suppresses fever through its action on hormone-like compounds known as prostaglandins, berberine appears to lower fever by enhancing the immune system’s ability to handle fever-producing compounds produced by bacteria and other microorganisms.
South African Geranium
South African geranium (Pelargonium sidoides) has demonstrated immune-enhancing effects as well as antibacterial and antiviral effects and the ability to prevent adhesion of bacteria to epithelial cells.15 In one double-blind, placebo-controlled trial, 103 patients with acute sinusitis of presumably bacterial origin were given an extract of P. sidoides (EPs 7630, sold under the name Umcka) for a maximum of 22 days.16 The average decrease in symptom severity score was 5.5 points in the EPs 7630 group compared with 2.5 points in the placebo group. Patients in the EPs 7630 group also had a faster rate of recovery.
Use of a neti pot to deliver a saline wash is also recommended. A neti pot is a ceramic pot that looks like a cross between a small teapot and Aladdin’s magic lamp. The neti pot originally comes from the ayurvedic/yoga medical tradition but has been used worldwide for centuries. Typically, to use the neti pot or another nasal irrigation device you would mix about 16 fl oz lukewarm water with 1 tsp salt. Once you’ve filled the neti pot, tilt your head over the sink at about a 45-degree angle. Put the spout into your top nostril and gently pour the saline solution into that nostril. The fluid will flow through your nasal cavity and out the other nostril. It may also run into your throat. If this occurs, just spit it out. Blow your nose to get rid of any remaining liquid, then refill the neti pot and repeat the process on the other side. Use the neti pot once per day when symptoms are present. A more convenient way of doing nasal rinsing is with a plastic squeeze bottle filled with the lukewarm saline solution. It is available commercially as NeilMed Sinus Rinse.
• Any factor that causes swelling of the lining of the sinuses may result in obstruction of drainage and subsequent infection.
• Antibiotic therapy is of limited value.
• Addressing the underlying cause of chronic sinusitis along with supportive therapy appears to be the most rational approach.
• A daily nasal rinse with a saline wash is recommended during active infection.
In acute sinusitis, the immediate therapeutic goals are to reestablish drainage and clear the acute infection. Various measures can be used: local application of saline through the use of a neti pot, botanicals with antibacterial and immune-enhancing properties, and basic immune system support (see the chapter “Immune System Support”).
Because chronic bacterial sinusitis is often secondary to allergy, long-term control depends on isolation and elimination of the food or airborne allergens and correction of the underlying problem that allowed the allergy to develop. During the acute phase, elimination of common food allergens (milk, wheat, eggs, citrus, corn, and peanuts) is indicated until a more definitive diagnosis can be made.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin A: 5,000 international units per day
Vitamin C: 500 to 1,000 mg every two hours
• One of the following:
Bioflavonoids (mixed citrus): 1,000 mg per day
Grape seed extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 150 to 300 mg per day.
• Zinc: 20 to 30 mg per day
• N-acetylcysteine: 200 mg three times per day
• One of the following:
Bromelain (1,200 to 1,800 MCU): 250 to 500 mg three times per day between meals
Serratia peptidase (enteric-coated): 30 to 50 mg three times per day between meals
• Goldenseal (Hydrastis canadensis) or another berberine-containing plant (standardized extracts recommended):
Dried root or as infusion (tea): 2 to 4 g three times per day
Tincture (1: 5): 6 to 12 ml (1.5 to 3 tsp) three times per day
Fluid extract (1: 1): 2 to 4 ml (0.5 to 1 tsp) three times per day
Solid (powdered dry) extract (4:1 or 8 to 12% alkaloid content): 250 to 500 mg three times per day
• Echinacea species:
Fluid extract of the fresh aerial portion of E. purpurea (1:1): 2 to 4 ml (1/2 to 1 tsp) three times per day (preferred form)
Juice of aerial portion of E. purpurea stabilized in 22% ethanol: 2 to 4 ml (1/2 to 1 tsp) three times per day (preferred form)
Dried root (or as tea): 1 to 2 g three times per day
Freeze-dried plant: 325 to 650 mg three times per day
Tincture (1:5): 2 to 4 ml (1/2 to 1 tsp) three times per day
Fluid extract (1:1): 2 to 4 ml (1/2 to 1 tsp) three times per day
Solid (dry powdered) extract (6.5:1 or 3.5% echinacoside): 150 to 300 mg three times per day
• South African geranium (Pelargonium sidoides, EPs 7630 or equivalent preparation): adults, 3 ml three times per day or two 20-mg tablets three times per day for up to 14 days; children ages 7 through 12, 30 drops (1.5 ml) three times per day; age 6 years or less, 10 drops (0.5 ml) three times per day
• Nasal rinse with warm saline solution once per day, increasing to several times a day during acute attacks