However, there have been two neti pot-associated deaths in Louisiana recently, both of which were caused by infection with the “brain-eating amoeba,” Naegleria fowleri. Naegleria itself isn’t particularly rare, but infections are, because the amoeba doesn’t cause harm if it’s ingested through contaminated drinking water, according to the U.S. Centers for Disease Control and Prevention (CDC) [3]. Instead, most Naegleria infections result from swimming in warm water — generally in the Southern or Southwestern U.S. states — which allows the amoeba to enter the nose. From there, Naegleria makes its way into the brain. Symptoms of Naegleria infection begin anywhere from a day to a week after exposure, and are similar to meningitis. They include nausea, headache, and vomiting. The symptoms progress into seizures and hallucinations, and the resulting meningoencephalitis, or inflammation of the brain and its membranes, causes death within days.

Drinking water (i.e. tap water), generally speaking, shouldn’t contain Naegleria, as it’s killed by chlorination. However, small quantities of Naegleria may survive the chlorination process, meaning that tap water in Southern and Southwestern U.S. states could potentially contain the amoeba. While this doesn’t make the water unsafe to drink, it does pose a small risk if tap water is used in a nasal irrigation device.

The CDC acknowledges that there’s a risk, albeit a very small one, of Naegleria infection associated with neti pot use, though there is no risk at all if sterile water is used for irrigation purposes. The State of Louisiana Department of Health and Hospitals warns that it’s best to use distilled water in neti pots, or to boil (sterilize) tap water before use.

The neti pot originated in India, though when it was first used is a matter of debate. A neti pot looks a bit like a teapot or genie’s lamp, with a reservoir and long spout. It is filled with warm saline (water and table salt). The spout is put up against one nostril, and by tipping the neti pot, the user pours water into the nostril. The solution flows through the sinuses and back out the other nostril. This procedure is repeated on the other side. This flushes excess mucus, dust, and allergy-causing particles from the nasal passages and sinuses.

Nasal irrigation can help to reduce sinus congestion. Although saline sprays are also available, a recent study found that saline nasal irrigation is more effective thn spray for chronic sinus symptoms.

References

1. Tomooka et al. Clinical Study and Literature Review of Nasal Irrigation. Laryngoscope. 2000 Jul;110(7):1189-93.
   View abstract
2. Rabago et al. Saline Nasal Irrigation for Upper Respiratory Conditions. Am Fam Physician. 2009 Nov 15;80(10):1117-9.
   View abstract
3. Naeglieria – Frequently Asked Questions (FAQs). Centers for Disease Control and Prevention. Accessed 2011 Dec 22.

Asthma is a chronic inflammatory disease that affects 24 million people in the United States and roughly 300 million people worldwide [2]. The disease affects the lungs, causing repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing. A number of factors can influence how severely the disease affects people and how well they respond to treatments. In addition to avoiding the triggers that can cause an attack, asthma can also be controlled by taking medication. However, the response to treatment is characterized by high interindividual variability. Poor response to inhaled corticosteroids often runs in families, suggesting that genetics plays a role in how people respond to the treatment.

To identify a gene variant, researchers from Brigham and Women’s Hospital and Harvard Medical School analyzed the genetic information from over 1,000 people enrolled in five separate clinical trials evaluating different steroid treatments for asthma. Investigators first conducted a genome-wide scan of the DNA of children and their parents enrolled in the Childhood Asthma Management Program, a multicenter, randomized, double-masked clinical trial designed to determine the long-term effects of three inhaled treatments for mild to moderate childhood asthma: budesonide (a glucocorticoid used daily) and albuterol (a short-acting beta-agonist bronchodilator used as needed); nedocromil (a nonsteroid anti-inflammatory agent used daily) and albuterol; and placebo and albuterol [3]. The scan identified 13 single nucleotide polymorphisms (SNPs) encompassing eight genes, including a variant in a gene called glucocorticoid induced transcript 1 (GLCCI1), which appeared to be associated with poor response to inhaled corticosteroids.

Researchers then verified the association in three additional studies on people with asthma, both children and adults. Due to the small numbers of subjects in other racial groups, the analyses were restricted to white participants.

The scientists found that people carrying two copies of the GLCCI1 variant were more than twice as likely to respond poorly to inhaled corticosteroid treatment as individuals with two copies of the normal GLCCI1 gene. Those who responded poorly had an average of one-third the level of lung improvement following inhaler treatment as did people with two normal copies of the gene.

Approximately 1-in-6 study participants had two copies of the GLCCI1 variant, which is thought to work together with other genetic and environmental factors to affect response to inhaled corticosteroids. Additional studies are needed to understand how GLCCI1 functions in the lungs and to explore whether it contributes to therapeutic response in patients of other ethnic groups.

Dr. Jeffrey Drazen, NEJM Editor-in-Chief, said in an editorial that the study brings researchers closer to being able to identify which patients are most likely to respond to treatment from inhaled steroids but that clinical trials are necessary to determine whether knowledge of this information leads to better clinical outcomes [4].

Susan Shurin, M.D., acting director of the National Heart, Lung, and Blood Institute (NHLBI), a component of the National Institutes of Health (NIH) that plans, conducts, and supports research related to the causes, prevention, diagnosis and treatment of heart, blood vessel, lung, and blood diseases, said [5]:

This finding helps to explain the genetic basis for the long-standing observation that some people do not respond well to what is a common asthma treatment. The study illustrates the importance of research examining the relationship between genetic makeup and response to therapy for asthma, and underscores the need for personalized treatment for those who have it.

Asthma affects people of all ages, but it most often starts during childhood. In the United States, more than 24 million people have asthma; 7 million of these people are children [2]. For more information on asthma — what it is, its effects and how it is diagnosed and treated — check out the CDC’s You Can Control Your Asthma brochure.

References

1. Tantisira et al. Genomewide Association between GLCCI1 and Response to Glucocorticoid Therapy in Asthma. Epub 2011 Sept 26.
2. FASTSTATS — Asthma. Centers for Disease Control and Prevention. Accessed 2011 Sep 26.
3. The Childhood Asthma Management Program (CAMP): design, rationale, and methods. Childhood Asthma Management Program Research Group. Control Clin Trials. 1999 Feb;20(1):91-120.
   View abstract
4. Drazen, JM. A Step toward Personalized Asthma Treatment. Epub 2011 Sept 26.
5. NIH-funded study connects gene variant to response to asthma drugs. NIH News press release. 2011 Sep 26.

World Asthma Day is an annual event organized by the Global Initiative for Asthma (GINA). The event raises awareness about asthma and works to improve asthma care around the world. This year’s theme is “You Can Control Your Asthma”. It aims to continue the focus on asthma control described in the latest version of the GINA guidelines [1]. These guidelines present a strategy for achieving and maintaining asthma control across five interrelated components of therapy:

1. Develop the patient/doctor partnership
2. Identify and reduce exposure to risk factors
3. Assess, treat, and monitor asthma
4. Manage asthma exacerbations

5. Special considerations in relation to various health conditions such as pregnancy, obesity, surgery, sinusitis, etc.

Today, GINA is also launching the next phase in a five-year Asthma Control Challenge that began last year on World Asthma Day 2010 [2]. GINA has challenged healthcare providers around the world to cut asthma-related hospitalizations in half by 2015 by improving asthma control. The new phase of the challenge includes an online data collection system that will be a powerful tool for countries around the world to track their progress in reducing hospitalizations.

Although World Asthma Day only runs one day, May is also National Asthma and Allergy Awareness Month. It’s a peak season for asthma and allergy sufferers, and a perfect time to educate everyone about these diseases.

Asthma Facts

Asthma is a chronic inflammatory disorder of the airways characterized by mild to life-threatening episodes of airway narrowing and obstruction, which causes wheezing, coughing, chest tightness and shortness of breath. It affects more than 17 million American adults and 7 million children under 18 years of age. According to WHO estimates, 235 million people worldwide suffer from asthma [3].

Asthma is the most common chronic disease among children. Rates of asthma have risen sharply over the past thirty years, particularly among children ages 5 to 14. Asthma disproportionately affects minorities, people with lower incomes, females, and children.

The strongest risk factors for developing asthma are exposure to indoor allergens such as house dust mites in bedding, carpets and stuffed furniture; pollution and pet dander; outdoor allergens such as pollens and moulds; tobacco smoke and chemical irritants in the workplace. Asthma triggers can include cold air, extreme emotional arousal such as anger or fear, and physical exercise.

Asthma is often under-diagnosed and under-treated, creating a substantial burden to individuals and families and possibly restricting individuals’ activities for a lifetime. Although there is no cure for asthma, daily preventive treatment plans according to individual symptoms can enable people to manage their symptoms and lead active lives.

Asthma research

The National Institute of Environmental Health Sciences (NIEHS), the National Heart, Lung, and Blood Institute (NHLBI), and the National Institute of Allergy and Infectious Diseases (NIAID) all work to advance studies that will help improve asthma prevention, diagnosis and management. Although each institute focuses on a fundamentally different aspect of asthma, they work closely together to coordinate research programs and provide a critical foundation for improving outcomes for patients with asthma.

The National Institute of Environmental Health Sciences (NIEHS)

As the lead NIH institute focusing on how environmental factors impact human health, the National Institute of Environmental Health Sciences (NIEHS) is working to understand how exposures to environmental agents trigger diseases such as asthma, and these diseases can be prevented, diagnosed and treated. Additionally, the NIEHS is developing and testing new technologies to help determine environmental triggers and reduce asthma symptoms. The NIEHS is also supporting research to find improved asthma interventions. By working closely with other NIH-funded researchers and international collaborators to conduct genome-wide association studies, NIEHS researchers continue to learn more about genetic susceptibility to asthma. The studies are aimed at identifying genetic risk factors and their interactions with environmental risk factors to characterize how they may influence susceptibility to the disease.

NIEHS Asthma Web Page

The National Heart, Lung, and Blood Institute (NHLBI)

The National Heart, Lung, and Blood Institute (NHLBI) supports a broad asthma research program that spans basic research, genomics, proteomics, epidemiology, clinical trials and demonstration projects. This support has advanced our understanding of the mechanisms of asthma and improved patient care. Several current NHLBI research programs are addressing the problem of recurrent asthma flare-ups in people with otherwise good day-to-day asthma control, including a study of new treatment approaches for flare-ups in infants and school-age children, as well as genome-wide association studies investigating the genetic factors that make some patients prone to worsening of asthma symptoms. The NHLBI will soon launch a network of six clinical centers that will integrate molecular, cellular and clinical studies of severe asthma to better predict when serious complications of asthma will occur and identify new targets for therapy.

NHLBI Diseases and Conditions: Asthma

National Asthma Control Initiative (NACI)

National Institute of Allergy and Infectious Diseases (NIAID)

The National Institute of Allergy and Infectious Diseases (NIAID) program in asthma research focuses on understanding how allergens, pollutants, infections and genetics interact with the immune system to cause and aggravate asthma. It also centers on developing strategies to treat and prevent the disease. NIAID funds three multi-site asthma clinical research programs and many individual grants in support of these efforts.

NIAID-funded researchers have greatly increased our understanding of asthma by studying inner-city children, who are at a disproportionately high risk for the disease. Major efforts are under way to understand how viral infections can worsen asthma, and how obesity may affect the disease. In the area of treatment, a recent NIAID-sponsored clinical trial found that augmenting NIH asthma guidelines-based therapy with a drug that targets immunoglobulin E, an antibody that plays a key role in allergy, nearly eliminated seasonal increases in asthma attacks and significantly decreased asthma symptoms among inner-city youth.

NIAID Asthma Web Page

The NIAID, NHLBI, and several other NIH institutes, together with the Agency for Healthcare Research and Quality and the Merck Childhood Asthma Network, co-sponsored the Asthma Outcomes Workshop in March 2010 to develop standardized definitions and data collection methods for asthma clinical studies. These standards will enable investigators to better compare results across studies and better inform the direction of future research. The March 2010 workshop participants reached consensus on seven key outcome measures that will be required in future NIH-sponsored asthma clinical trials and observational studies: symptoms, exacerbations, biomarkers, lung function, quality of life, asthma control questionnaire results and healthcare utilization and cost. The workshop report will be published in the Journal of Allergy and Clinical Immunology in fall 2011.

Resources

Here’s some additional resources on asthma:

The The World Asthma Foundation is dedicated to educational resources for the asthma treatment and asthma management including what causes asthma, asthma symptoms, astham attacks and asthma treatment options.

The Asthma and Allergy Foundation of America provides free information and resources for people with allergies and asthma.

The Centers for Disease Control and Prevention (CDC) asthma site covers asthma facts, asthma triggers and control of asthma, and includes information for specific groups, data & surveillance, and the CDC’s National Asthma Control Program.

Asthma at the U.S. Environmental Protection Agency (EPA) offers information on the EPA’s asthma program, basic information on asthma, community outreach and supporting science.

The AsthmaCommunityNetwork.org is designed for community-based asthma programs and organizations that sponsor them, including representatives of health plans and providers, government health and environmental agencies, nonprofits, coalitions, schools and more.

References

1. GINA Report, Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA). Updated 2010.
2. Asthma Control Challenge Backgrounder 2011. Global Initiative for Asthma (GINA). Accessed 2011 May 3.
3. 10 facts on asthma. World Health Organization. May 2011.

It has long been known that peanut allergies are heritable, but the gene responsible for this heritability was unknown. Filaggrin is a protein that is expressed primarily in the skin, where it binds to keratin and plays an important role in forming the protective and impenetrable barrier that makes skin such a vital organ. Mutations in the filaggrin gene have already been identified as risk factors for eczma, asthma and other allergies, which is what prompted Drs. Sara Brown at the University of Dundee in the UK and Yuka Asai at McGill University Health Centre in Montreal, Quebec, Canada, and colleagues to consider it as a candidate gene for peanut allergies.

The researchers analyzed blood or saliva from 71 white English, Dutch, and Irish people known to have peanut allergies based on an oral challenge and 1000 healthy English controls. To confirm their results, they repeated the study with 390 white Canadians who had peanut allergies and 891 white Canadian healthy controls. They looked for loss-of-function mutations — those that completely inactivate the protein — in the filaggrin gene (FLG) that are most prevalent in the European population. They found that these mutations are “strongly and significantly associated with peanut allergy.” Twenty percent of the people with peanut allergies harbored a loss-of-function mutation in the filaggrin gene in both the European and Canadian populations, compared to 5 – 10% of the control populations.

It is still unclear how nonfunctional filaggrin might allow peanut allergies to arise. Eczma is a hypersensitivity reaction in the skin that results in inflammation, and is thus very much like an allergy. It has been suggested that impairment of the epidermal barrier — as would occur if filaggrin function is disrupted — could allow allergens to penetrate into the body, causing a local inflammatory response like eczma as well as a more systemic response like asthma. Studies performed in mouse models support this hypothesis. This explains tactile peanut allergies, and to make the story even neater, eczma is a known risk factor for peanut allergies. In fact, eczma is a stronger risk factor than these loss-of-function mutations in the filaggrin gene. As for oral exposure to peanuts, some patients with eczma have increase intestinal permeability … but it is not yet known if filaggrin plays a role here. Filaggrin has not been found in the gastrointestinal tract, but it is present in the oral mucosa and possibly as far down as the esophagus.

The authors suggest that these mutations might be associated with other food allergies. As the “most significant genetic risk for peanut allergy that has been identified to date,” looking into that possibility certainly seems warranted.

Researchers at the North Carolina Agricultural and Technical State University have recently developed an enzymatic treatment that reduces two of the most potent peanut allergens in roasted peanut kernels, Ara h 1 and Ara h 2 [2]. Ninety percent of those with peanut allergies react to these two proteins. Jainmei Yu, who has been working on developing hypo-allergenic peanuts since 2005, plans to begin clinical trials as a first step of getting them. Hopefully they will be successful, and peanut butter and jelly sandwiches will become a school lunchroom staple once again.

References

1. Brown et al. Loss-of-function variants in the filaggrin gene are a significant risk factor for peanut allergy. J Allergy Clin Immunol. 2011 Mar;127(3):661-7.
   View abstract
2. Yua et al. Enzymatic treatment of peanut kernels to reduce allergen levels. Food Chemistry. 2011 Aug;127(3):1014-22.

EoE is characterized by inflammation and accumulation of a specific type of immune cell, called an eosinophil, in the esophagus. Symptoms of EoE vary with age: In young children a major symptom is spitting up food, while in older children and adults, the condition may cause food to become stuck in the esophagus. These symptoms may improve when a person with EoE is restricted to a liquid formula diet that contains no protein allergens or is placed on a diet that lacks six highly allergenic foods (milk, soy, eggs, wheat, peanut and seafood). EoE is not the same as more common food allergies, which also have serious consequences. Little is known about what causes EoE, but the disease runs in families suggesting that specific genes may be involved.

Investigators led by Marc Rothenberg, M.D., Ph.D., at Cincinnati Children’s Medical Center Hospital, and supported by the National Institute of Allergy and Infectious Diseases and the National Institute of Diabetes and Digestive and Kidney Diseases, both part of the National Institutes of Health, performed a genome-wide association analysis in children with EoE and healthy children. This type of study detects markers of genetic variation across the entire human genome and allows researchers to zero in on a region of a chromosome to identify genes that influence health and the development of disease.

The study was designed to provide needed evidence for selecting step-up care for such children and was supported by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health. Researchers also identified patient characteristics, such as race, that can help predict which step-up therapy is more likely to be the most effective for a child with persistent asthma.

The study found that almost all of its participants had a different response to the three different treatments. Although adding the long acting beta-agonist step-up was one and one-half times more likely to be the best treatment for most of the study group, many children responded best to other two treatments instead.

The results were presented March 2 at the American Academy of Asthma, Allergy and Immunology 2010 Annual Meeting in New Orleans and are published online in the New England Journal of Medicine.

In the United States, 29.5 million people 18 years of age and older are affected by sinusitis [1]. Millions more are affected by other types of allergic and non-allergic rhinitis (meaning irritation and inflammation of the mucosal membrane of the nose). Some people can reduce symptom severity using medication, including antihistamines and anti-inflammatory drugs. Antibiotics are frequently prescribed for acute and chronic sinusitis. However, their use far outweighs the predicted incidence of bacterial infection, suggesting that antibiotics are overprescribed for sinus infections. Regardless of the medication used however, for many patients, symptoms persist.

Nasal irrigation – the flooding of the sinus cavity with warm saline solution – can help to reduce sinus congestion and is often recommended by otolaryngologists (ear, nose and throat physicians) for a variety of sinus conditions. The goal of nasal irrigation is to clear excess mucus and foreign debris out of the sinuses, and to moisturize the mucosal membrane. The practice has been subjected to clinical testing and has been found to be safe and beneficial with no apparent side effects (for reviews of clinical evidence, see [2-3]). The practice is simple and inexpensive, and has been shown to decrease the symptoms of a variety of nasal and sinus conditions. As an alternative to irrigation, saline spray is often used because it is thought to be similar to and better tolerated than irrigation. However, the effectiveness of nasal saline spray has not been proven in clinical trials.

A new study from researchers at the University of Michigan Health System concludes that nasal irrigation is more effective that commonly used saline sprays for treating chronic nasal and sinus symptoms. Participants in the study, 127 adults with chronic nasal and sinus symptoms, were randomly assigned to irrigation or spray for 8 weeks. Those using nasal irrigation showed a statistically significant change in symptom severity as early as 2 weeks into the study. After 8 weeks, only 40% of participants in the irrigation group reported frequent (defined as “often or always”) nasal and sinus symptoms compared with 61% in the spray group [4].

Both groups experienced adverse effects. More were reported in the irrigation group. However, most adverse effects were minor and none required that treatment be stopped. The most commonly reported adverse effect was post-irrigation drainage, which occurs when saline in the upper sinuses isn’t expelled and later drains.

The study is the first of it’s kind to show greater efficacy of saline irrigation treatments versus saline spray for providing short-term relief of chronic nasal symptoms. According to lead author Melissa A. Pynnonen, M.D., clinical assistant professor in the University of Michigan Department of Otolaryngology [5]:

The irrigation group achieved a clinically significant improvement in quality of life in terms of the severity of their symptoms, whereas the spray group did not. Strikingly, they also experienced 50 percent lower odds of frequent nasal symptoms compared with the spray group.

An interview-based study assessing the attitudes regarding use of nasal irrigation for frequent rhinosinusitis as well as chronic sinus and nasal symptoms published last year found that [6]:

• Nasal irrigation produced rapid and long-term improvement in the quality of life.
• Users felt empowered.
• Barriers to use included discomfort, time and mild side effects.
• Instruction and at-home use can overcome the fore-mentioned barriers.

The take-home message? If you’re using saline spray to treat chronic sinus symptoms, you will experience a much greater benefit in terms of both symptom severity and frequency with saline nasal irrigation.

References

1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2005. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. 2006 Dec.
2. Papsin and McTavish. Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician. 2003 Feb;49:168-73.
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3. Harvey et al. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006394.
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4. Pynnonen et al. Nasal saline for chronic sinonasal symptoms: a randomized controlled trial. Arch Otolaryngol Head Neck Surg. 2007 Nov;133(11):1115-20.
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5. Sinus problems are treated well with safe, inexpensive treatment, UMHS study finds. Department of Public Relations and Marketing Communications Newsroom. University of Michigan Health System. 2007 Nov 19.
6. Rabago et al. Qualitative aspects of nasal irrigation use by patients with chronic sinus disease in a multimethod study. Ann Fam Med. 2006 Jul-Aug;4(4):295-301.
   View abstract

Antibiotics are only effective against bacterial infection. Many sinus infections are due to viral infection, allergies or hormonal changes. Physicians try to avoid antibiotic use to reduce the emergence of dangerous resistant bacterial strains, such as methicillin-resistant Staphylococcus aureus. However, most patients with sinus congestion want immediate relief and, because more effective drugs for chronic sinusitis are lacking, demand antibiotics.

The four-year prospective study found Americans made on average 4.25 million visits to healthcare facilities per year for sinus infection between 1999 and 2002. At least one antibiotic was prescribed in nearly 83% of cases of acute sinusitis and 70% of cases of chronic sinusitis. Antibiotics were prescribed more often than antihistamines, nasal decongestants, corticosteroids, and antitussive, expectorant, and mucolytic agents (order reflects the frequency of recommended medication).

The penicillins amoxicillin and amoxicillin-clavulanate potassium (brand name Augmentin) were the most commonly used antibiotics for both chronic and acute bacterial sinusitis. According to the Sinus and Allergy Health Partnership, the next most frequently used antibiotics should be erythromycins, lincosamides, and macrolides. However, the authors found cephalosporins, sulfonamides, trimethoprim, and tetracyclines were more commonly used.

Corticosteroids are used to reduce or prevent inflammation of the sinus mucous membranes. They do this by altering the actions of various cells of the immune system. Corticosteroids may be applied topically as a nasal spray or orally. Oral corticosteroids are rarely used to treat sinusitis. Prolonged use of oral corticosteroid treatments can cause serious side effects, including thinning of the bones, diabetes and increased risk of infection. Corticosteroid nasal sprays generally don’t cause these side effects. In addition, discontinuing use of corticosteroids does not lead to rebound congestion like topical nasal decongestants, frequently used to reduce sinus inflammation and congestion.

The use of corticosteroids was found in 15-16% of visits for acute and chronic cases of sinusitis. The authors maintain the rate of corticosteroid use is higher than published studies imply is necessary for acute sinusitis, while the rate may actually be lower than indicated for chronic sinusitis. Several studies suggest that intranasal corticosteroid use in conjunction with antibiotics are effective for improving the symptoms of acute sinusitis compared with antibiotic therapy alone [2-4]. Recent promising results from a study in patients with acute, uncomplicated sinusitis found that mometasone furoate (brand name Nasonex) nasal spray used twice daily produced significant symptom improvements versus amoxicillin and placebo, without predisposing the patient to disease recurrence or bacterial infection [5]. However, further studies may be needed to better clarify the role and proper dosage of corticosteroids when used alone or in combination with antibiotic therapy in the management of acute and chronic sinusitis.

The authors of the study express concern regarding the problems surrounding antibiotic overuse and conclude:

When two-thirds of patients with sinus symptoms expect or receive an antibiotic and as many as one-fifth of antibiotic prescriptions for adults are written for a drug to treat rhinosinusitis, these disorders hold special pertinence on the topic.

Increasing antibiotic resistance

Children average six to eight colds per year. Of those, only 0.5 to 5 percent will develop a sinus infection [7]. Nevertheless, sinusitis is the fifth most common diagnosis for which an antibiotic is prescribed [6]. There are a number of methods to determine whether a sinus infection is bacterial, including:

• Nasal cytology – examining a swab from the lining of the nose.
• Nasal endoscopy – running a tube into the nose to obtain a sample of mucus from the sinus cavity.
• X-ray, computer tomography, magnetic resonance imaging (MRI) or ultrasound
• Sinus puncture and bacterial culture — usually only performed if a reasonable diagnosis cannot be made using noninvasive techniques.

Unfortunately, all these methods are expensive and time-consuming.

A recent study found that 28% of Haemophilus influenzae strains cultured from patients with an acute exacerbation of chronic or acute sinusitis were resistant to ampicllin; 79% of Streptococcus pneumoniae strains were found to be penicillin-intermediate resistant [8]. An earlier study in 2001 in children with sinusitis found that 44% of Haemophilus influenzae cultures isolated were ampicillin resistant (41% having high-grade resistance) and 64% of Streptococcus pneumoniae isolates were resistant to penicillin (24% having high-grade resistance) [9].

Antibiotic resistance is an emerging public health crisis. Today, virtually all important bacterial infections in the United States and throughout the world are becoming resistant. The Centers for Disease Control and Prevention calls antibiotic resistance one of the world’s most pressing public health problems.

Remember

Taking antibiotics for viral infections will increase the risk of antibiotic resistance. Millions of antibiotics prescribed in doctors’ offices each year are for viral infections, which cannot effectively be treated with antibiotics. An alternative therapy for sinus infection is nasal irrigation, which can relieve symptoms, reduce inflammation and remove stagnant mucus in the nasal passages, making it difficult for infections to develop. The spread of viral infections can be reduced through frequent hand washing and by avoiding close contact with others.

References

1. Sharp et al. Treatment of acute and chronic rhinosinusitis in the United States, 1999-2002. Arch Otolaryngol Head Neck Surg. 2007 Mar;133(3):260-5.
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2. Meltzer et al. Intranasal flunisolide spray as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol. 1993 Dec;92(6):812-23.
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3. Barlan et al. Intranasal budesonide spray as an adjunct to oral antibiotic therapy for acute sinusitis in children. Ann Allergy Asthma Immunol. 1997 Jun;78(6):598-601.
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4. Dolor et al. Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA. 2001 Dec 26;286(24):3097-105.
   View abstract
5. Meltzer et al. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. 2005 Dec;116(6):1289-95. Epub 2005 Oct 24.
   View abstract
6. Anon et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2004 Jan;130(1 Suppl):1-45.
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7. Ramadan, HH. Pediatric sinusitis: update. J Otolaryngol. 2005 Jun;34 Suppl 1:S14-7.
   View abstract
8. Tellez et al. Microbiology of acute sinusitis in Mexican patients. Arch Med Res. 2006 Apr;37(3):395-8.
   View abstract
9. Slack et al. Antibiotic-resistant bacteria in pediatric chronic sinusitis. Pediatr Infect Dis J. 2001 Mar;20(3):247-50.
   View abstract

Sinus congestion is the blockage of one or more of the nasal passageways as a result of inflammation and swelling of the sinus tissues, secretion of mucus or a deviated septum (meaning obstruction of the nasal passage by the membranous ridge of cartilage in the nose that separates the nasal cavity into the two nostrils). Sinus congestion leads to impaired flow of mucus out of the sinuses. The build up of mucus in the sinuses causes increased pressure. Also, bacteria can become trapped and infect the mucous membrane, a condition termed sinusitis.

Many people notice nasal blockage at night when lying in bed. One side of the nose is “plugged”, causing them to have to alternate sides they sleep on to breath comfortably. This is called the nasal cycle, a well-recognized normal physiological phenomenon where each side of the nose alternates through phases of congestion and decongestion. The cycle varies from person to person, taking one to four hours, and has been suggested to synchronize with the sleep cycle [1].

There are two types of sinus congestion:

• Acute sinus congestion is most often caused by the common cold.
• Chronic sinus congestion often results from environmental irritation.

Causes

One of the principle causal factors of chronic sinus congestion is subtle food allergies. Allergic food reactions can result in the expansion of blood vessels in the mucous membrane and typically occur one hour after consumption of the food allergen. Although people can be allergic to any food, the following accounts for the majority of all food allergic reactions:

• Pasteurized dairy
• Cooked eggs
• Peanuts
• Tree nuts
• Wheat
• Soy
• Shellfish

Another common cause of sinus congestion is inhalation of allergens such as pollen, mold, dust mites or animal dander. Exposure to various household cleaning chemicals may also contribute to sinus congestion; the Household Products Database of the National Library of Medicine is an excellent resource to research products based on chemical ingredients. Twenty two years ago in 1985, an EPA report concluded that “toxic chemicals in household cleaners are three times more likely to cause cancer than outdoor air pollution” and the Consumer Product Safety Commission reported that “150 common household chemicals have been linked to allergies, birth defects, cancer, and psychological abnormalities” [2]. Further, the National Institute of Occupational Safety and Health analyzed 2,983 chemicals used in personal care products and found 884 to be toxic [3]. Indoor and outdoor air pollution may also be a factor in susceptible people. Smoking and secondhand exposure to tobacco smoke have been implicated in chronic sinus congestion [4]. Clearly, each of us are exposed to a great number of allergens and toxic chemicals on a daily basis, any of which could cause sinus congestion.

Medications

Decongestants are frequently used to reduce sinus inflammation and relieve congestion. Decongestants come in both nasal and oral form. Nasal decongestants such as oxymetazoline (Afrin) and phenylephrine (NeoSynephrine) may provide relief from sinus congestion, but they should only be used for short periods of time. When used for a long time and then discontinued, symptoms often worsen (a rebound effect) because the mucous membrane tissue becomes dependent on the medication. Decongestants constrict blood vessels and reduce blood flow to the mucous membranes, thus reducing swelling. However, oral decongestants affect blood vessels in other parts of the body and can cause side effects such as nervousness and high blood pressure. Oral decongestants should not be used if you have heart disease, high blood pressure, migraines, Raynaud’s disease, difficultly urinating (for example, from an enlarged prostate), emphysema or take certain medications such as antidepressants.

Steroid nasal sprays decrease inflammation and are especially effective at relieving the symptoms of allergic rhinitis (meaning hay fever). Steroid nasal sprays such as fluticasone propionate (Flonase), triamcinolone (Nasacort AQ) and mometasone furoate (Nasonex) deliver a precise dosage of medication directly to the area of your body that needs it and are far safer than oral steroids. However, the risks of adverse effects are increased by excessive dosing or simultaneous inhaled or topical corticosteroid therapy [5]. Typical side effects of nasal steroid sprays are minor and include burning, dryness or irritation inside the nose, or increased sneezing. However, the longer you use steroid nasal sprays, the more side effects you risk. If your doctor prescribes nasal steroids for more than a few weeks, make sure you get regular checkups.

Your doctor may prescribe antibiotics if a bacterial infection is suspected or present.

Nasal Irrigation

In contrast to steam inhalation, which has been shown to have no beneficial effect on symptoms of the common cold [6], irrigation of the nasal passages with heated water or saline decreased nasal secretion [7].

Nasal irrigation with warm water or (preferably) saline can help to reduce sinus congestion. A recent study showed that daily nasal irrigation with hypertonic saline improves chronic sinusitis symptoms [8]. During the study, a number of patients actually decreased or eliminated medication altogether. A comfortable saline solution can be made by mixing 1/4 teaspoon of non-iodized salt into one cup of warm water. Mucous membranes are sensitive and the ideal solution for nasal irrigation should be similar to your body’s blood temperature, salinity and pH.

The following technique may provide relief to some people suffering from nasal and sinus congestion:

1. Prepare a comfortable saline solution (see above). Nasal irrigation is commonly done using a small vessel called a neti pot, however other types of irrigators are available, including ear wash bulbs, hand squeezed nasal irrigators, electrical pump nasal irrigators and nasal attachments for water picks.
2. Stand over the bathroom sink, tilt your head slightly to one side and let the saline solution flow into the upper nostril. Do not to open your mouth or swallow during the procedure as it could cause infectious material to move from the nasal passage into the sinuses or the ear.
3. Allow the solution to drain from your nose out the lower nostril. As the solution runs out of your nostril, you can blow gently to help remove any mucous and waste materials that are in your nasal passageway.
4. Repeat 2 — 3 times for each side of your nose.

Vitamins and Herbs

Histamine is associated with increased nasal and sinus congestion. In one study, vitamin C supplementation (1,000 mg three times per day) reduced histamine levels in people with either high histamine levels or low blood levels of vitamin C [9]. Another study found that 2,000 mg of vitamin C helped protect people exposed to a histamine challenge test [10]. Although preliminary evidence supports the use of vitamin C when injected into the sinuses of people suffering with acute sinusitis, the effect of oral vitamin C specifically on symptoms of sinusitis as well as generally on sinus congestion has yet to be formally studied [11].

Mint plants such as spearmint and peppermint have a long history of medicinal use, dating to ancient Egypt, Greece, and Rome. Peppermint is hybrid mint, a cross between spearmint and water mint. Menthol, a constituent of peppermint oil, is sometimes included in inhaled preparations for nasal congestion; eucalyptus oil can also be used. Eucalyptus oil is said to function in a fashion similar to menthol by acting on receptors in the nasal mucous membranes, leading to a reduction in the symptoms of nasal stuffiness [12].

References

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2. Dadd, DL. Home Safe Home. Tarcher, 1997.
3. Berns, J, The Cosmetic Cover-up. Human Ecologist Fall 1989;43.
4. Benninger, MS. The impact of cigarette smoking and environmental tobacco smoke on nasal and sinus disease: a review of the literature. Am J Rhinol 1999;13:435-8.
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5. Allen DB. Systemic effects of intranasal steroids: an endocrinologist’s perspective. J Allergy Clin Immunol. 2000 Oct;106(4 Suppl):S179-90.
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6. Macknin et al. Effect of inhaling heated vapor on symptoms of the common cold. JAMA 1990 Aug 22-29;264(8):989-91.
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7. Georgitis JW. Nasal hyperthermia and simple irrigation for perennial rhinitis. Changes in inflammatory mediators. Chest 1994 Nov;106(5):1487-92.
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8. Heatley et al. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg. 2001 Jul;125(1):44-8.
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9. Clemetson, CA. Histamine and ascorbic acid in human blood. J Nutr 1980 Apr;110:662-8.
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10. Bucca et al. Effect of vitamin C on histamine bronchial responsiveness of patients with allergic rhinitis. Ann Allergy 1990 Oct;65(4):311-4.
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11. Nikolaev et al. Clinical and biochemical aspects in the treatment of acute maxillary sinusitis with antioxidants. Vestn Otorinolaringol 1994 Jan-Feb;(1):22-6.
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12. Schulz V, Hansel R, Tyler VE. Rational Phytotherapy, 3rd ed. Berlin: Springer Verlag, 1998, 146-7.