If you ever feel like you have been hit across the face with the back of a spade, there are two things to do. First of all, have a look around. Is there a possibility that you have actually been hit across the face with the back of a spade? If so, I’d run. If not, then the second thing you will have to do is consider the possibility that you are having a sinus episode.
A sinus episode encompasses both sinusitis, an inflammation of the lining of the sinuses, and the congestion that invariably follows. You have four groups of sinuses, which are air-filled cavities in the bones behind your face, with drainage ducts no bigger than the lead of a pencil. The biggest are in your cheekbones (called the maxillary sinuses) and those just above your eyebrows (the frontal sinuses). Ethmoid sinuses are found either side of your nasal cavity around the bridge of your nose and up in between your eyes. The last type, the sphenoid sinus, is behind the ethmoids. The sinuses all connect with your nose for the free exchange of air and mucus.
Light and strong facial bones
It often comes as a shock to think that the bones of your face are hollow, but it’s not something to be worried about. The reason for it is so that your head is lighter, and the hollowness doesn’t affect these bones’ strength – just think of them as being a bit like the corrugated cardboard that protects goods that come through the mail.
And did you know that the strongest bone in your body is located in your skull? It’s called the petrous temporal bone. Petrous comes from the Latin petrosus, which means ‘stone-like’ or ‘hard’, while ‘temporal’ indicates where it sits in the skull, i.e. covering your temporal lobe above your ear. Incredibly dense, rivalled only by the femur or thigh bone for strength, the petrous temporal bone carefully houses your inner ear, a beautiful spiral structure called the cochlea that converts sound waves into electrical signals your brain can understand as sound. The petrous bone is the last part of the skeleton to decompose, shows much better DNA preservation than other bones of the body, and so is a rich treasure trove for archaeologists. (It is also the only part of us that cannot be digested by sharks, as it happens; it’s just too dense for their digestive system to cope with.)
FIGURE 2 The Sinuses
The general symptoms of a sinus episode are varied. We feel it as a pressure in the face; tenderness to the touch, often escalating to facial pain radiating out from the sinuses; congestion and blockage of the nose; a bad taste in your mouth – accompanied by bad breath; an inability to smell properly, along with a productive cough that invariably keeps you awake; and of course the ubiquitous headache. We will talk about these in turn – but your biggest sign and orchestrator of all of these symptoms is simply snot. So, let’s get to the core of that issue first.
Snot matters
I was always brought up to think that snot was a very rude word. My liberal parents didn’t care, but my conservative school did and we were encouraged to use the ‘proper’ terms in language and not colloquial ones. (This was an inconsistent dictate, I discovered: the utterance of the word ‘penis’ was the quickest way to induce vertigo in a nun.) Besides, I dispute that the word snot is not proper. A Middle English word, it has been around since the late 14th century and means the perfectly descriptive ‘nasal discharge or mucus’. The original root was gesnot for nasal mucus and this in turn came from an amalgamation of the German and Dutch variants of snuttan, snotte, and snute, all from the same base of snout, which makes sense. Old High German had snuzza, and still has the related schneuzen (‘to blow one’s nose’), and the Norwegians and the Danes use snot as a noun nowadays too. One word we did lose over the time since Old English was the verb snite, ‘to wipe or pick one’s nose’. I am rather gutted that this has gone out of modern parlance but will make it my mission to bring it back. Starting now.
When you feel the need to snite, it is because you have a build-up of mucus that is clogging up your sinuses and needs to be released. Mucus is released by epithelial cells, which cover the outer surface of the body as well as all of the internal organs and blood vessels and the inner surface of cavities such as the nose and the sinuses. Epithelial cells can look and act differently depending on where you find them, but in the sinuses they are shaped like columns and have tiny hairs, or cilia, on their outermost surface. These are the same kind of epithelia – called goblet cells – that you find in the upper respiratory tract, and have the power to secrete substances and move mucus around using their cilia. Although all of these goblet cells are securely attached to the surface of the bone surrounding it, if you look at them under a microscope, they appear to be layered or stratified, when they actually only consist of a single layer. The reason for this trick of the eye is because not all of the cells are of equal height, and the nucleus (or brain) of each cell, which is the most visible part of the cell under the microscope, can appear at different levels, helping the illusion that the cells are stacked in layers. So, we now know that the lining of the sinus cavity is made up of a single layer of ciliated pseudostratified columnar epithelial cells. The mucus these cells secrete acts like a protective balm; without it the underlying cells would dry and crack, which effectively flashes a big neon sign telling bugs where to attack since they can get straight in that chink in the armour.
Mucus protects in more ways than merely providing moisture, however. It is sticky and gooey, which is beneficial since particles get caught in it and don’t go on to cause damage. Because the cilia of the goblet cells are constantly moving the respiratory mucus around (usually down the gastrointestinal tract but also out of your nose) these particulates don’t get to hang around for long.
Mucus has other ways of defending us, too. It contains lysozymes – enzymes that make something happen. In this case, they break down the cell wall of any bacteria and burst the cell like a pin in a balloon. To top it all off, the presence of immunoglobulins or antibodies that latch onto and kill various incoming bugs means that much-maligned mucus has a premier role as our first line of antimicrobial defence.
We produce more than 1 litre (1¾ pints) of mucus a day from our nose and sinuses. This seems rather prolific, but you don’t really notice it because most of it combines with saliva at the back of the mouth and is swallowed. However, when we have been exposed to a bug, or an irritant or allergen such as pollen, we produce even more mucus to defend ourselves, and the excess can trickle down the nose or run down the back of the nose to the throat – something that is called a post-nasal drip. The infection or allergy may also cause the lining of your sinuses to become inflamed, mainly due to the blood vessels to the nose and the sinus cavities swelling up. As horrendous as this sounds, this is the body’s natural reaction to damage or infection.
First on the scene: histamine
Let’s do an experiment. If you scratch your hand with a pen top right now, you will see a red line appear. This is caused by histamine, a powerful molecule that is stored in something called mast cells, which are tucked away under the skin’s epithelial layer in this case. Histamine causes blood vessels to swell, making sure more blood is brought to the area of need (the bit of skin you’ve just damaged/irritated) and making the vessel wall leaky. This allows big white blood cells, which are the next line of defence in the immune system, to get to the area of possible infection. You see all of this as a pretty instantaneous red line on your hand.
In the nose and sinuses, the release of histamine makes the goblet cells produce even more mucus, which is now mixed with white blood cells called neutrophils. This can change the viscosity and the colour of the mucus you see when you blow your nose to relieve the inevitable congestion all of this causes, giving your snot the greenish colour it sometimes gets – because neutrophils have a green pigment in them. The histamine also acts directly on the sensory receptors in the nose, causing that itch and irritation that you feel. The congestion is mainly a vascular effect and the sensation of an itchy and scratchy nose is neurological. But how does all of this cause pain too?
The pain in your face
The pain that you feel when your sinuses are inflamed can vary, depending on which of your sinuses is most under attack. It is possible for all of your sinuses to be inflamed at once of course, but sometimes the mucus barrier that stops the epithelia in one of your sinuses from drying out and getting infected just isn’t as efficient as the others, leading to a specific type of pain. For example, in addition to all of the other sinus symptoms, pain over the cheeks and just below the eyes accompanied by toothache and general headache indicates maxillary sinusitis, which makes sense because those sinuses are in the cheekbones. Frontal sinusitis, by contrast, localises your headache to your forehead. Given the position of the ethmoid sinuses, it isn’t surprising that inflammation here leads to pain behind and between your eyes, and may also cause your eyes to water. This is the headache that most people describe as ‘splitting’, with the pain radiating to the forehead. Inflammation in the sphenoid sinuses that are behind the ethmoids leads to a more diffuse headache that can be felt in the front or the back of the head. This one is the most difficult to diagnose as the symptoms are more subtle and transient than those of the other sinuses. Trouble here can cause double vision and vision loss, and nasal discharge may or may not be present. The best way to diagnose problems in the sphenoid sinuses is to do an endoscopy, which involves sending a camera up the nose to look at the lining of this sinus to see if it is inflamed. This is always much more fun for the doctor than the patient, not least because the doctor gets to ‘count your snots’, or so I once heard an ear, nose and throat (ENT) doctor say to a patient.
Sinus pain vs migraine
There is some controversy about the headache that results from sinusitis, with many people who work in the field believing that 90 per cent of these may in fact be migraines, which we investigate in Chapter 6. The difficulty is that migraine can cause the same symptoms as those described above, including the generalised rhinitis – runny nose, pain around the eyes, etc. – which means that it can be hard to tell which came first. For both migraine and sinus headache, you might feel worse when bending over, due to the increased pressure in your sinuses. The symptoms of migraine, however, are much more severe than those you would expect with sinus issues, and the systemic (whole body) sickness of migraine is much more powerful than the general ‘malaise’ that results from sinusitis, mainly caused by digesting excess mucus from your post-nasal drip all day. Not the most nutritious of diets.
As we’ve already seen, the sensation of pain in your head is caused by the trigeminal nerve getting to work, and while the nerve carries sensory information from the facial region up to the brain, signals can also be sent down via motor nerves to the face and all of its structures. This can cause the confusion between a sinus headache and a migraine.
Let me explain further. With sinus headache, the nerve endings are activated by histamine and other inflammatory substances such as prostaglandins, and these signals are carried up to the brain and interpreted as pain. Just as in brain freeze headaches, pain can originate in the nasal area but be felt up in your forehead because all of the sensory nerves are lumped together in one tract and your brain finds it difficult to distinguish them. Conversely, with migraine, changes in activity in your brain cause the activation of the trigeminal pain receptors (or ‘nociceptors’; from the Latin nocere for ‘harm’ and the English ‘reception’), also causing dilation in the blood vessels below the epithelium, leading to the release of histamine and greater mucus generation and so on. So with migraine, instead of the problem originating in your nose and causing pain in your head, it is a problem in the brain causing effects in your nose.
Bless you!
The trigeminal nerve is critical to how snotty we feel, but it also makes you sneeze. It sends signals to your sneeze centre in the brainstem (yes, you have a sneeze centre), which organises signals to your head, activating the muscles required to open the nasal and oral cavities for a forceful exhalation of air to clear any obstructions or particles.
As we have already seen with referred pain, the trigeminal nerve can become somewhat confused. When it comes to sneezing, it can be triggered in several ways:
• The trigeminal nerve runs quite close to the optic nerve – the nerve running behind your eye – and sometimes, if you are suddenly exposed to a bright light, the abrupt activity of the optic nerve activates the trigeminal nerve. The brain interprets this as the presence of an irritant in your nose and so you sneeze. Aristotle suffered from this; he thought the heat of the sun on his nose was the problem. Sir Francis Bacon rather gleefully announced 2000 years later that Aristotle was wrong as he realised that standing in the sun with your eyes closed made your nose warm but didn’t cause you to sneeze. He was almost there in his interpretation of this, but not quite. He thought that the light would make his eyes water and that this moisture would seep into his nose and irritate it. The actual answer to the ‘photic sneeze’, as we now know it, has much more to do with fuzzy electrical activity in the brain than leaking liquid. It happens in about 35 per cent of people and is actually a genetic trait, like the ability to roll your tongue.
• Plucking your eyebrows also activates the sensory fibres of your trigeminal nerve, which are again misinterpreted as irritation to your nose, and can cause a fit of inappropriate sneezing.
• Some people are known to sneeze when they have a full stomach, a reaction that is not linked to the consumption of foods that actually make them sneeze by irritating the nose, such as mints or spices. Called ‘snatiation’ (a snappy blend of ‘sneeze’ and ‘satiation’) by geneticist Judith Hall, this response is genetic too, but its mechanism is less clear. It most probably has something to do with the trigeminal nerve travelling alongside nerves from the parasympathetic ‘rest-and-digest’ system.
• Unclear, too, is research showing the link between thinking about sex (particularly in teenagers) and sneezing, although again, crosstalk from the parasympathetic system is no doubt at play here. Next time somebody sneezes on the bus next to you, think about it. They might not just want to infiltrate you with their bugs…
A snotty slide
We get the same sinus reaction whether we are exposed to a bug or an irritant, but the reaction to an irritant should be more short-lived. I experienced this myself on a visit to a waterpark. It’s not something I do very often – I may never do it again – but there is something fun about hurtling down a flume, even if somehow I managed to get stuck in one. I still don’t know how that happened so we won’t dwell on that part. It did occur to me, however, mid-hurtle, that there was an inordinate amount of water being forcefully introduced to my sinuses through my nose.
Picture the scene. I get very cold in water (a hangover from being a whitewater kayaker), and so I wear a lot.1 However, I restricted myself that day to a swimsuit topped by a rash vest and water shorts. The wearing of all of these clothes that water doesn’t naturally stick to meant that my downward motion through water on the flume effectively created an upwardly directed jet of water straight into my face. But it’s just water, right? Wrong. Water is a great place in which nasty bacteria in particular can thrive and survive. Each new human body introduces germs into the water, and one person’s natural germs are another person’s pathogens… And then of course there are the effluents that come out of humans, such as mucus or urine. In response, most pools are treated with chlorine as a disinfectant to combat the pathogens, bacteria, viruses and fungi that are found in the water.2 Chlorine combines with water to create hypochlorous acid, which attacks the bacterial cell wall, killing them by bursting them open.
So, not only are swimming pools and waterparks veritable Petri dishes, but they also contain chemicals to combat the bugs. All of this has the power to infect, in the case of bugs, or irritate, in the case of chlorine, your sinuses. The day after my waterpark experience, I therefore sounded like I had a heavy cold. My nose was blocked, there was congestion in my sinuses and I had a niggling headache in my forehead. This is hardly surprising, given the squirts of water up my nose that had flowed through the passages at the back of my mouth and then been swallowed. The same thing used to happen all the time when I was kayaking.
Here’s an interesting aside, especially if you play or work in water. To combat the ingestion of possibly infected water from rivers, lakes and seas, particularly after heavy rainfall, thousands of kayakers and open water swimmers all over the world swear by copious swigs of Coca-Cola. Despite kayakers and swimmers feeling they have inoculated themselves against impending tummy trouble through the action of ingredients like phosphoric acid (rust remover – just try the rusty 2p left in a glass of cola overnight experiment if you don’t believe me) found in the cola, there is no scientific evidence that this works in humans. The closest we have is a 2006 study by Eduardo Medina and colleagues from Sevilla, Spain who infected lettuce leaves with harmful bacteria and looked to see if Coca-Cola would kill the bugs. They also tested olive oil, vinegar, red and white wine, fruit juices, coffee and beer. The vinegar and the olive oil had the best anti-bacterial performance followed by red and white wine, which killed most strains after five minutes. All the remaining drinks had zero effect. The moral of this story is that kayakers and swimmers should chug olive oil or vinegar after a race or training session. Failing that, wine is a good option, a suggestion that made me very popular among my paddling friends.
In actual fact, though, our stomachs should in any case do a good job of neutralising swallowed respiratory bugs because our stomach acid is too harsh for them to survive in. The point is, there is no harm in swallowing mucus, or phlegm as it is also called. It’s a good job, too, since we heard earlier in the chapter that we usually swallow about a litre of the stuff a day, and this is increased when your sinuses are producing more mucus. Each litre of mucus contains just over 200 calories, but I certainly wouldn’t use it as a replacement for breakfast.
Right up my nose
What happens if we irritate our sinuses? If they are just irritated by the chlorine, for example, the inflammation in the sinuses should settle down after exposure because the immune system doesn’t get involved. It’s a good example of non-allergic sinusitis. However, the congestion caused by irritation can lead to an unwanted effect: everyday pathogens that would normally be trapped by the mucus and moved away before they have a chance to infect the epithelial cells get stuck because there is more mucus and it is moving less freely and not draining so well through the tiny (remember – lead-in-a-pencil-sized) ducts. Stuck bugs have more time to act and will cause infection, whether they came in with the irritant or were cold viruses that were sniffed up later. I was lucky: my congestion led to a mild headache and stuffiness for a day or two and then it resolved. No stuck bugs for me. And no, I haven’t been back to the waterpark.
But why is it that something that is a minor irritant for one person causes an allergy in another? To answer this, we need to understand what an allergic reaction is: a heightened immune response to a substance. In the case of the sinuses, the most common allergen is pollen. You become allergic by changing your sensitivity to the allergen. Your body sees a seemingly innocuous substance like pollen to be an enormous threat and so raises antibodies in response to it. These immune markers then short-circuit your immune system, immediately indicating threat. That means that the next time you are exposed to the substance your body is ready and can swing into gear to fight this foe quickly and with everything you’ve got.
What makes your body decide that pollen is a bad thing in the first place, I hear you ask. Well, it seems to be mainly outside of your control, with genetics at play again. In 2012, Syed Hasan Arshad and his colleagues from the University of Southampton discovered that mothers seem to pass on their susceptibility to allergy to their daughters and fathers to their sons, meaning that allergies are carried on the sex chromosomes. There is still the chance that environment has a role to play here though, both while the baby is gestating in the uterus and in early life. Factors such as parental smoking, for example, or even experiencing a respiratory infection in their first six months can affect a child’s risk of developing an allergy.
In addition to raising antibodies there is one other reaction mechanism your body can throw at pollen. Remember that epithelium layer in our sinuses and nasal passages? Well, beneath this layer is something called the sub-mucosa, where the histamine-containing mast cells live. In the case of people with sensitivities or allergies to triggers like pollen, these mast cells have migrated to sit on top of the epithelial layer and this is what makes people who suffer from hay fever extremely sensitive. The second that pollen is detected by the mast cells (and there is no barrier of the epithelium layer, remember) BOOM, they dump out all of their histamine, causing the inflammation and the dilation of blood vessels and the leaking of white blood cells out into the mucus membrane.
It’s a bug’s life
The pathogens that cause sinusitis are generally viruses and bacteria. Bacteria will respond to antibiotics, but most viruses, including the cold virus, are very resistant to them and, unfortunately, most cases of sinus infection are caused by viruses.
The crafty cold virus
There are more than 200 viruses that can cause cold symptoms and sinusitis, the most common of which is rhinovirus, which only affects humans, chimps and gibbons (but not rhinos!). Rhino is a root Greek word for ‘nose’. Rhinovirus is incredibly adept at infecting humans and has three main species types: A, B and C. Depending on the surface proteins these have, however, you can mix and match them into more than 160 different varieties. This makes it very hard to defend against them because your body raising antibodies to one type will not defend you against the other 159 types; you have to start all over again each time you encounter a new one. Ordinarily, if you are exposed to a bug you have already encountered and have antibodies for, your immune system swings effectively into gear, killing and carting off the bugs without you realising it is even happening.
The bugs can attack us directly causing a primary infection. We can make it easy for the bugs because viruses can easily get stuck – your body’s gunky inflammatory response to something (like mine to swimming, for example). This then causes further congestion due to the immune response to the virus. But then other bugs can sneak in by stealth, like bacteria getting caught up in the congestion that is produced when the body is already busy fighting the primary infection. This is called a secondary infection.
Bacterial sinusitis is much more rare than viral infection of the sinuses, and is most common after a bout of viral infection. A typical culprit is Streptococcus pneumonia, more commonly named pneumococcus,3 which can now helpfully be detected by a simple urine test. (It used to be that a nasal swab would be taken and the bugs on the swab would be cultured and grown in a Petri dish in a lab, which takes valuable time away from treatment.)
Haemophilus influenzae is an example of a Gram-negative bacteria (see box, p. 37) that attacks the sinuses. As you can tell from the name, it was (incorrectly) blamed for causing influenza; it was first described by German bacteriologist Richard Pfeiffer during an outbreak in 1892. However, by 1933 it was clear that the cause of ’flu is the Influenza virus, meaning that the original name of Pfeiffer’s bacillus (bacillus: Latin for ‘rod’) seems more appropriate than Haemophilus Influenzae. Under the microscope, though, this bacterium looks like a hybrid of a spheres and rods, making it a ‘coccobacillary’, if we want to be really accurate.
Illuminating bacteria
When bacteria are isolated, you can look at them under a microscope. However, in order for them to show up, they need to be stained with various chemicals that cling to different parts of the cell, making them visible to us. In 1882, a Danish microbiologist called Hans Cristian Gram developed a way of doing just this, using a dye called crystal violet to cling to a component of the bacterial cell wall. Gram realised, though, that not all bacteria had enough of this component to survive the process of being got ready to be put on a slide for a microscope. These other bacteria did, however, react to a different stain called safranin, which turns them pink. In consequence, Gram realised there are two different types of bacteria, differentiated by their cell walls, and detectable by his stain. Cells that turn purple are Gram-positive and cells that turn pink are Gram-negative. When he published his work in 1884, he was quite downbeat about it, hoping that in another’s hands it ‘may turn out to be useful’. In fact, this turned out to be one of the understatements of that century; Gram staining is an absolute cornerstone of medical microbiology.
Both S. pneumoniae and H. influenzae live in the respiratory tract as part of our naturally borne bacteria or flora. (Yes, indeed, your tubes are a veritable botanical garden, with tiny living organisms dwelling in them.) These two, however, have a bitter rivalry over who gets to dominate in your airways. We know this because Christopher Pericone and his colleagues from the University of Pennsylvania introduced these bacteria to each other in a Petri dish in a really elegant set of experiments published in 2000. It turns out that S. pneumoniae destroys H. influenzae and a couple of other bacteria by releasing hydrogen peroxide, a fact that led the authors to reasonably conclude that this is how the presence of S. pneumoniae inhibits a number of other bugs also competing for resources in our upper airways. Then, in 2005, Elena Lysenko from the same Pennsylvanian team, led by Jeffrey Weiser, went a step further and introduced the bacteria to the real nose of a mouse. It turned out that strains of either S. pneumoniae or H. influenzae could colonise the nose quite efficiently if they were tested individually. However, when they were applied together, only H. influenzae survived after two weeks. It seems that S. pneumoniae started to attack H. influenza – just as Christopher Pericone and his team had seen on their Petri dish – but that this then triggered an immune response that specifically killed S. pneumoniae. It is therefore only the combination of the two species that sets off the immune system in this way. This is really important, because some of our treatments and certainly our vaccines are concerned with getting rid of one particular species of bug, when in fact we also have to be mindful of the secondary effects this can have, as a result of inadvertently changing the competition between existing bugs. There may be another, lurking, waiting to dominate when the competition is removed.
Although both of these types of bacteria cause a variety of symptoms, as the common cold virus does (but with more serious effects), H. influenzae is particularly likely to cause you a headache through sinus congestion. What’s worse, Gram-negative bacteria like H. influenzae are harder to kill because it’s really difficult to get anything through their cell wall, and also because various Gram-negative strains have acquired resistance to some antibiotics that used to work.
However, there is some light at the end of the tunnel. At the turn of the 21st century, researcher Terhi Tapiainen and her team from Oulu in Finland found that something as simple as xylitol, the sweetening component in your sugar-free gum that is also present in a small amount in your body, can stop both Gram-positive S. pneumoniae and Gram-negative H. influenzae from sticking to your mucus membranes. This built on work showing that the addition of xylitol in a Petri dish can inhibit the growth of both of these bugs. The dosage required to treat an infection would be quite high but could be administered in a syrup or chewing gum. Sometimes we use a sledgehammer to kill a gnat when all we need is a feather that was lying about anyway.
’snot fair
There are a number of other irritants that can affect our sinuses in a minor, albeit distasteful, way in comparison with allergic or infectious responses. We have all experienced changes in our mucus viscosity in extreme changes of temperature or when we enter a smoky environment, for instance, and perfume and paint fumes can cause similar responses. Other substances include alcohol or spicy foods.
Let’s take the last example. I worked at Manchester University in the 1990s, and every week, my Greek friend Dimitri and my German friend Johannes and I would go a couple of miles south of the city to an area called Rusholme and in particular a street called the Wimslow Road. Here lies the Curry Mile, which boasts more than 70 restaurants dedicated to the cuisine of the Middle East and Southeast Asia. We went for the Indian curry. I was quite young and had never in my life experienced such tastes – the spicier the better for me. I loved it, but one thing was for sure – I needed to pack some tissues! This is because pickles, pepper and chillies all contain capsaicin and allyl isothiocyanate (which is also found in radishes and mustard) that protect the plant from being eaten by animals. Birds can eat as much as they like as they are not sensitive to it, so if your bird feeders are being raided by squirrels, just add chilli flakes. The birds won’t mind, but the squirrels will go elsewhere. Both of these substances activate temperature sensors on your tongue, making you interpret them as hot, leading eventually to a numb tongue through overactivation of the sensory receptors. I enjoy radishes very much, but I learned the hard way not to eat a whole bag just before giving a lecture. My inability to control my tongue movements that day led to many a slip-up.
The most common effect of capsaicin is that it irritates the pain receptors of the nose, causing the rapid production of mucus. This is because such pain is interpreted as threat. It is no good having a beer with your curry to slake the heat, as you might think, because there isn’t enough ethanol in it to grab the capsaicin molecules and they don’t dissolve in water. Your best bet is milk; the casein found in milk loves fats and will hug the capsaicin molecules and rinse them out of your mouth. The traditional Indian yoghurt-based drink lassi is therefore ideal.
Drinks aside, all of these responses to spicy foods rarely lead to an episode of headache associated with sinusitis since the effects here are rhinorrhea, or runny nose, as opposed to congestion. Having said that, rhinorrhea can be used, however temporarily, to relieve stuffed-up sinuses, so it’s worth cracking out the chillies if you have a blocked nose.
And then there’s alcohol. Ever felt bunged up after a heavy night out? While some of you will swear that your sinuses clog up following a night on the beer, wine or champagne, there is little evidence in research literature to explain why this may be so. However, we can extrapolate from what we know is in alcohol and what we know triggers sinusitis and conclude that the typical culprit is histamine, the release of which is triggered by the ethanol in booze.
Why is this? Well, ethanol directly causes vasodilation in the blood vessels of the face, which tricks our brains into thinking we are under attack and causes the release of histamine, leading to the sensation of congestion both through the enlarged blood vessels taking up more space and the increased mucus release. But alcohol itself also contains histamine (as well as ethanol), which although metabolised by the stomach, may raise histamine levels in the blood over time. These histamines are also found in aged cheese, pickles, olives, avocados, sour cream and even bananas. Many of these foods have been implicated in dietary causes of migraine, too, further blurring the confidence that ‘sinus headache’ is unrelated to migraine if the headache presents on its own. In addition, the more alcohol you drink, the more dehydrated you get, making your mucus less runny and therefore harder for the cilia in your epithelial layer to move – leading to congestion as it all gets stuck up there rather than moving down into the post-nasal drip.
Sensitivities and sinus
Two other purported dietary demons for sinusitis are lactose, which is found in all dairy products, and gluten, found in wheat, barley and rye (bread and beer). However, there is a dearth of scientific medical evidence on this subject. What we do know is that some people have an allergic reaction to gluten – specifically one of its components, called gliadin – and this immune reaction causes inflammation in the small intestine, eventually leading to sufferers not being able to absorb nutrients from their food and resulting in the symptoms of Coeliac disease. But what about non-Coeliac consequences from gluten? Is it possible that the antibodies raised to gliadin or some other component of gluten can cause an inflammatory response in the sinuses?
One of the nasty consequences of raising antibodies to gluten is that they attack the intestinal lining, making a previously bumpy landscape, which is perfect for absorption, flat as a pancake. This is why Coeliac disease is called an autoimmune disease: it attacks your own tissues. The main class of antibodies that are raised are called Immunoglobulin A, or IgA for short. The thing is, IgA is also found in the mucous membranes of the respiratory passages and saliva and tears. The second immunoglobulin that is elevated in Coeliac disease is Immunoglobulin G (IgG), which is the antibody that is responsible for our immune reaction to pollen and pet dander (it is these tiny and microscopic flecks of skin that come off our furry and feathered friends that cause allergy, not the pet hair itself) and is found in copious amounts in all body fluids since it is our first line of defence against bacteria and viruses. So, is it possible that the elevated levels of IgA and IgG related to gluten (but which are not enough to cause Coeliac disease) can cause sinusitis? Thousands of people who have kept food diaries and tried restriction diets where they have systematically cut out gluten think so.
There is more peer-reviewed evidence in the case of lactose effects on sinusitis, with one paper related to this published in 2005; OK, not much more evidence than this one paper, but evidence nonetheless. Stephanie Matthews and colleagues from Cardiff University reported the case of a 53-year-old woman with lots of disorders and a 10-year history of asthma, eczema, sinus problems, muscle and joint pain and lack of concentration. She had been prescribed a number of pills, sprays and unctions and was on the waiting list for a knee replacement operation. Stephanie’s team tested her for lactose intolerance, which involves ingesting 50g (2oz) lactose and analysing how much hydrogen gas is exhaled over the next three hours. If the value is more than 20 parts per million within three hours, it means you don’t digest lactose well at all. Stephanie’s patient’s hydrogen level never reached this value and it was therefore declared that she was not lactose intolerant. The only problem with this was that the patient nevertheless suffered with a variety of symptoms after the ingestion of lactose, and these lasted for three days. So, the medical team decided to advise a lactose-free diet, just for a month, just to see.
One month later their patient was a new woman; the diarrhoea had cleared up, her skin was ‘wonderful’, her asthma and sinus problems disappeared and she was mentally less foggy and not worried she was getting dementia any more. Again, this resonates with many people around the world and brings into question what it is that we purport to be normal. While everything that we can measure medically has a ‘normal’ range, does that mean that you, as an individual, are represented within it? Our 53-year-old lactose-intolerant lady certainly wasn’t and the proof was in the dairy-free pudding. The human body is as fascinating as much as it is a complex enigma. It’s time we started treating people as individuals and not data points.
Your face’s fault?
In contrast to these external causes of sinusitis, there are a variety of internal causes. The most common of these is nasal polyps. Originating most often in the ethmoid sinuses, they hang like teardrops from the mucosal lining. They are made of bits of debris, immune cells and connective tissue and are covered in the same ciliated pseudostratified epithelium that lines the cavity they live in. These soft and non-cancerous growths don’t go away by themselves and can keep growing to block the sinus completely, in addition to having the capability to secrete mucus through their own goblet cells. They are caused by persistent sinus infections and allergic rhinitis, asthma and aspirin allergy4 and are also prevalent in those who have cystic fibrosis.
The growth of our facial features up to and beyond adolescence can change the shape and indeed the existence of the sinuses. The ethmoid and maxillary sinuses (the ones around the bridge of the nose and the cheekbones) are there from birth but the sphenoid sinus behind your face only starts to grow at age seven and ends its spurt at the age of 15. The frontal sinuses only get filled with air from the age of four up to the age of 12, but they don’t reach their final size and shape until we are 25; imagine the life you were leading in your early 20s when you thought you knew it all – and now you know that part of your face hadn’t even finished developing yet! In addition to these structural changes, though, non-allergic sinusitis often happens during periods of hormonal imbalance, and particularly for females during puberty, menstruation and pregnancy, all the way from the second month of pregnancy until birth. Non-allergic sinusitis is also a symptom of an underactive thyroid gland, which leads to a slower metabolism. The mechanism by which hormone imbalance causes sinusitis is not really understood yet, beyond the idea that in response to such fluctuations the blood vessels of the nasal pathways enlarge, leading to an inflammatory response and a feeling of congestion. As if that person didn’t have enough to deal with already.
The way it makes you feel
Those of you who have suffered from any of what we’ve covered in this chapter already know how pervasive a bout of sinusitis is; it might not be the most blinding headache you’ve ever had, but it is dull and it is always there, and in addition to the congestion, it means that extra energy is required just to go about your daily life. People who don’t suffer from sinusitis sometimes have a lack of understanding about how it affects their friends, colleagues or families. However, now we have a questionnaire by which to measure the phenomenon (or ‘phlegmomenon’, as I like to call it). Questionnaires are tricky, because they ask you how you feel about certain things on a scale of usually 1 to 5. The answers are subjective of course, but filling one out does give a sense of how an individual is feeling over the period of time that the questionnaire is asking about; how their condition affects them. The same condition may affect another person less, or differently. This is the hard part: it doesn’t reveal anything objective about how bad the sinusitis is; only other tests like sending a camera up the nose could tell us that. It is therefore possible for somebody to score really highly on a questionnaire with the same physical presentation as someone who scores lower, showing that the former person doesn’t cope as well as the latter. There may be many reasons for that. What the questionnaire does tell us is how the episode of sinusitis is affecting someone at a particular moment. Administered to enough people over time, a questionnaire’s questions are tested for how reliable their answers are throughout a sample, and whether the answers are valid representations of their collective experience.
Jay Piccirillo, a head and neck surgeon and ENT doctor from Washington University School of Medicine in St Louis, Missouri, USA, and his team have since 1998 been developing the SNOT-22 as a questionnaire to test the physical and emotional impact of sinusitis. Don’t you just love it when an acronym works out to describe what it is actually representing? In this case, it stands for Sino-Nasal Outcomes Test, and it features 22 questions relating to issues such as how bad your sneezing or runny nose is, through ear fullness and thick nasal discharge all the way to how fatigued you are and how it has affected your concentration, your productivity, your mood. These latter questions relate to quality of life; it is now clear that chronic sinus problems can severely affect you in ways that go beyond a ballooning of your weekly tissue budget.
The SNOT-22 in action
I gave the SNOT-22 questionnaire to a 52-year-old woman called Susan, who was teaching first aid to a bunch of us in my lab. She had been clearing her throat the whole time and sounded snotty and uncomfortable. During a break I asked if she had the dreaded lurgy (the cold that was doing the rounds). She said she’d had that about five weeks ago but this was just residual sinusitis – it always happened this way for her. What was very interesting to me was how it affected her daily life. Explaining that it was a bit of a drudge because she clearly wasn’t ‘sick enough’ to take time off work, such a sub-threshold illness just had to be coped with, but it was both annoying and exhausting. She completed the SNOT-22 after the day’s session and answered the questions relating to her experience over the last two weeks using a scale of 0 to 5, where 0 is no effect at all and 5 is as bad as could be. There is a maximal score of 110, given that there are 22 questions. Anything below 8 is non-existent, 8–20 denotes a mild problem, 21–50 is a moderate problem and anything above 50 is severe. Susan scored 61 – it’s a severe problem – and got high (i.e. problematic) scores on all of the quality-of-life questions (except embarrassment; it has been bad for the last 15 years and so she is ‘beyond that’). Interestingly, the worst quality-of-life issues that were flagged up related to sleep and fatigue. Poor sleep and not feeling rested can have huge effects on our ability to deal with life in general, never mind a chronic health issue. It can subjectively make everything worse and is a well-known contributor to depression, for example. The cause here for Susan was clearly the congestion, the post-nasal drip, the cough, the headache; the effect was a lack of good, restful sleep, and then that made the cause seem worse the longer this cycle went on.
I specifically asked Susan how she felt about the sinus headache. Her answer was that it was there all the time, usually a dullness or a heaviness. She had trained herself to ignore it but if ever she realised it wasn’t there, she felt lighter and almost elated and found everything much easier to cope with. This is not unusual. Our brains can choose to ignore pain but our individual abilities to do this vary considerably. It is called pain gating. The simplest example of this is when we bang our leg on something and the first thing we do is rub it better. This works because the brain can’t do two things at once – it can either receive the pain signal, or the feeling from your skin that something is touching it, and it is this latter ‘somatosensation’ that wins. This is a less obvious cure in the case of sinus headache as the source of pain is somewhat unreachable – you can’t directly rub your sinuses. However, temporary relief can be gained by massaging between the eyes at the bridge of the nose and up into the eye socket where your ethmoid sinuses are, or even rubbing your forehead where your frontal sinuses are.
A higher-level example is the role of attention in pain. If you get to watch the television while you are sitting in the dentist’s chair, I can predict two things. The first is that you are not with my dentist, and the second is that you will need less numbing agent because your brain doesn’t feel pain as much because your attention is diverted. Susan is doing something similar, using her thinking brain, her sheer force of will, to ignore the headache caused by her severe sinusitis. Knowing that she is an ex-hockey player, I feel she has had practice building her pain tolerance…
I ask many of those I meet who suffer from sinusitis: are you sure your headache is a ‘sinus’ headache? Some ENT surgeons, like Nick Jones from Nottingham University Hospital, feel that ‘sinus headache’ in fact only happens in very specific cases, such as an infection in the sphenoid sinus, which is relatively rare. Is there the possibility that they are mixing it up with tension headache, as Nick thinks? Susan weighed up this question carefully. The tiredness and fatigue that sinusitis causes could make her more tense, leading to a tension headache, she thought, but her symptoms don’t follow those of the classic tension headache, of which more in the next chapter. I hear this a lot. Some people are willing to say that their sinus issues cause head discomfort as opposed to pain; one young man said trying to make such a distinction was like splitting hairs and was entirely unhelpful. ‘You know it was pain because when it is no longer there, it is bliss,’ he told me.
Investigating sinusitis
What can be done for Susan and the countless others who suffer with sinusitis and all of its effects in both acute and chronic episodes? Given all of these causes of sinusitis, it is pretty clear that there is no one fix for this effect, so treatment must in part be related to its cause. As with all conditions, and particularly headaches in general, this is the key to their treatment. If it is not obvious to you then keep a diary and the cause should become apparent, allowing you to avoid your triggers. If not, it is time for an appointment with your ENT specialist, who can investigate for polyps or structural malformations for example, and whether or not surgery might be helpful.
In my conversations with Kate Blackmore, a specialised paediatric ENT surgeon, I learned about the diagnostic pathway in sinus problems. If a patient has a headache that is accompanied by other symptoms relating to the sinuses then it is easy enough to attribute the headache to the sinus problems. By the time a patient gets to her, they will probably have already been through a course of antibiotics, which will have made the patient feel better, indicating that it was indeed a sinus infection. Sometimes, a GP will have had a Computerized Tomography (CT) scan done too, ‘to be helpful’. The problem is, these scans will only give you a snapshot in time, and one-third of all people at any one time will show some kind of massing of fluids. This doesn’t necessarily signify anything; the rate at which our cilia move the mucus along means that in most cases this doesn’t indicate any kind of underlying problem. Worse, these CT scans are basically three-dimensional X-rays, so repeated scans to check to see if the build-up is resolving are out of the question, unless you particularly want to glow from irradiation after a while.
Rather, Kate has become a detective, particularly in paediatrics with her younger patients, when they can’t articulate what their discomfort or pain feels like. When I speak to people who work with children it always seems remarkable to me how much we have to experience pain in order to be able to talk about our experience of it. She told me this is why she loves ENT as a speciality; she gets to be a surgeon but there is also a fair amount of medicine involved, so she has to be interested in her patients as people. They hold the clues to their conditions. She needs to winkle out those nuggets and put them all together to make a diagnosis and then decide what the best route of treatment is for that individual. She asks lots of questions about the symptoms, onset and what the kid gets up to, for example. She will invariably stick a camera up her patient’s nose to look out for anatomical issues or things that should not be there, such as inflammation, pus or polyps both in the nasal cavity and around the sinus ostia. It is the ostia (Latin for ‘opening’) in the bone that allows the air into the sinus cavities. She might also take some swabs to see if anything unusual grows in the lab.
Treating sinusitis
Sinusitis that is the result of allergy is easier to treat if it is caused by pet dander as opposed to pollen; ultimately, pets are easier to avoid. Kate says that she has seen a huge rise in allergy to dust mites (tiny relatives of spiders that feed on dust, which is made up mostly of flakes of dead skin we have shed) over her years of practice. The rise is still there even when you take into account better recognition of dust mites as an allergen in itself. There is still the prevailing view at the population level that this rise has happened because we are ‘too clean’, decreasing our exposure to dust mites so that our body sees them as the exception rather than the norm, mounting large immune responses when we are exposed to them. Some people I know, whom I won’t name, see this as a great excuse not to dust. ‘We don’t want to disturb the dust mites, do we?’ This makes as much sense as the five-second rule when you drop food on the floor. What? Is there a group of bugs with a stopwatch standing there saying, ‘No, lads no, not yet… hang on … 3, 2, 1 … go for it!’ I don’t think so. But the point is that there is such a thing as being too clean.
Once you know what irritants trigger you then you should avoid them, if you can. However, for sinusitis following a cold and those things that you just can’t see coming, there are a number of options. For example, if it’s likely that you have a sinus infection (sinusitis that just doesn’t shift for four weeks after the initial insult, such as a cold, for example), then antibiotics may be called for. Many diagnoses in general medicine happen by treatment. For example, if antibiotics clear up the symptoms in the patient and the pain and discomfort goes away, then it must have been a sinus infection. If not, there must be another cause.
Antibiotics and how they work
The most common antibiotic is penicillin, which was identified by Alexander Fleming in 1928. Penicillin and its relatives have something called a beta-lactam ring (oxygen molecules bound by carbon to hydrogen and nitrogen molecules) and these mimic a core component of the bacterial cell wall, helping them to bind to them and destroy their walls. Unfortunately, bacteria over the years have dealt with this threat by producing enzymes that can break down the beta-lactam ring before it can catch hold of the bacteria. In addition, penicillin has a much better action against Gram-positive bacteria than it does against Gram-negative bacteria as it finds it hard to attack the tougher cell wall of the latter.
People who are allergic to penicillin or for whom penicillin did not work may be prescribed a different kind of antibiotic, such as erythromycin, which has a slightly broader range than penicillin. It works by stopping proteins from being made inside the bacterial cell, preventing it from replicating. But again, these have limited success against tough-walled Gram-negative bacteria.
One antibiotic class that can attack Gram-negative and -positive bacteria is the tetracyclines, such as doxycycline, that were discovered in the 1940s, and act in a similar way to macrolides. However, these too have become less efficient due to bacterial adaptation.
Given the antibiotic resistance that many bacteria exhibit, a more targeted approach might be required. If the bacteria can be collected through a nasal swab and cultured and identified in the lab, the correct antibiotic treatment can be selected at the get-go. The problem is, this takes time – and often this is something that is in short supply, for a variety of reasons.
Doctors commonly say that people turn up at their surgeries in great discomfort and as a result they feel compelled to help them by prescribing something straight away. It’s a human thing, they say. There is also the danger that due to the sinuses’ proximity to the brain, bacteria trapped there can spread and infect the meninges or outer membrane of the brain (causing meningitis) or the tissues around the eyes. Therefore, if sinus problems cause you to experience severe headache, become confused or less alert and affect your vision, which could be dangerous, treatment is needed urgently. If you experience any of these symptoms, your nearest health professional should be your first call.
Surgical ‘solutions’
Most of the interventions that ENTs will do for sinus problems involve prescribing medicines, as described, but if these don’t work, then surgery is the next option. Historically, however, sinus surgery has been pretty brutal, focusing on widening the drainage ducts of the sinuses by drilling away the surrounding bone. This can be dangerous because there may be some collateral damage to other structures, such as the turbinates in the nose – bony structures that moisten the air as it comes up the nose. What’s more, it’s not usually appropriate for children because their faces aren’t completely developed, and anyway they mostly respond to medical care. It is much more likely that ENT surgeons will operate on the children’s adenoids (from the Greek adēn for ‘gland’) – little masses of tissue between the back of the nose and the throat that trap bacteria and viruses. Because of where they are, enlarged adenoids have the power to affect breathing and cause congestion, leading to a Darth Vader-type of respiration. Although enlarged adenoids might respond to a nasal steroidal spray, they ultimately may need to be taken out under anaesthetic.
What can you do?
We always like to think that the doctor is the last resort, so let’s dwell instead on the things we can do for ourselves when avoiding the cause of sinusitis just hasn’t worked.
Flush the bugs
The first thing to try is flushing out the sinuses at home with a sinus lavage, or nasal wash. It’s very important that the solution you use is as clean as possible. You can buy sterile saline to use or make it at home according to your doctor’s recipe, using boiled water, salt and bicarbonate of soda, with the resulting solution kept in the fridge. You can snuffle it up or you can use a teapot arrangement to squirt it up one nostril and out of the other, or you can buy a kit. This looks like an Olympic skill to me – I’ve broken my nose too many times to have this work personally – but it does have value; if you clear away stuck debris (which is useful by itself to feel less bunged up) before you take any inhaled medicine, there is more chance it will get to where it needs to be. You must be sure that your saline is as clean as possible though because you don’t want to introduce more bugs where they are not wanted.
Menthol bungbusters
When I am feeling clogged up and have that ‘hit across the face with a spade’ feeling, I use a menthol stick, which merely requires you to insert the tube into your nostril and breathe deeply. These sticks are not to be confused with lip balm sticks (which treat sore, dry or chapped lips); even though they look the same shape, shoving a lip balm up your nose has less pleasant effects and if anybody catches you doing it, you will be teased unmercifully and, on balance, that is probably fair enough. But a menthol stick brings great and instant relief. How does it work? It stands to reason that the menthol is acting to dissolve the mucus plugs that are sitting at the bridge of my nose, doesn’t it? Well, not exactly. This is one of those cases where reason does not predict reality.
Humans have been using this mint plant extract for hundreds of years in Asia, where it originated as a medicine for the treatment of respiratory diseases. In the Western world, however, it has only been used since the 19th century. These days it comes in many forms: vapo-rubs, sticks and sprays, lozenges, cough syrups … the list goes on. What menthol actually does is act on the sensory receptors that detect coolness, which is why this is what we experience when we inhale it. So, despite menthol having absolutely no effect on airflow through your nose, you subjectively feel clearer. You don’t feel bunged up any more.
What’s happening here is that the menthol is influencing your perception of relief without affecting the congestion at all. It’s selling you a dummy. Yet the perception that you can actually breathe decreases the inflammatory response from your brain, part of which was generated by you feeling that you couldn’t breathe. Not being able to breathe through your nose is quite an emotional issue. It’s stressful. Any stress will cause a stress response, the biggest effect of which is, yes, a rush of blood to the area. For this reason, feeling worried about not being able to breathe will make matters worse because it causes blood vessels in your head and sinuses to dilate, making the sinus ducts get even smaller. Menthol merely interferes with your perception of how bunged up you are, and in turn decreases this stress-related inflammatory response. The beauty of this is that even though you now know its secret, menthol still works. Our autonomic brain (the parts that keep us ticking in the background) functions without much interference from our conscious brain, and the cool receptors are all autonomic.
Menthol is only a relatively quick fix, and in the long term you will probably die of complications from Type 2 diabetes from all the sweetened menthol lozenges you are eating to control it long before you fix the sinus congestion. It is important to get on top of the congestion, though, because headache pain and dyspnoea (difficulty breathing) leads to fatigue and difficulty sleeping, leading to more fatigue. The body finds this stressful, making the inflammation worse, and distracting your immune system from fighting off other common bugs.
Make some space
What else can we turn to in our arsenal? Over-the-counter decongestants include pseudoephedrine (such as Sudafed) as an oral tablet (common in most cold and flu remedies), or oxymetazoline as a nasal spray. Both of these cause constriction in the blood vessel wall, creating more space to take in the air (unlike menthol, which just makes you feel like it has) by decreasing the space the blood vessel is taking up. Another happy consequence is that by decreasing the blood flow to the area, the inflammatory agents aren’t transported in at such a rapid rate, dampening the progressive bunged-upedness (this is my technical term).
Antihistamines
Also at our disposal are antihistamines. We saw earlier that histamine is a first line of defence in our immune system, a molecule that helps release white blood cells to fight infection out of the blood vessels by making them leakier and diverting more blood to the region that needs them by dilating the blood vessels. So, if you take an antihistamine, you cut off this inflammatory response at the knees.
There are two types of antihistamine. The one that was first developed will make you drowsy, as it crosses the blood–brain barrier and acts to decrease the histamine in your brain, whose role is to keep you alert. The other only acts to block the histamine receptors in the rest of the body and so decreases the inflammatory response there, but has no effect on your brain chemistry. The drowsy version is very handy when you want a good night’s sleep to help you battle the effects of the bodily effort it takes to withstand the infection or allergy. The non-drowsy ones help with the symptoms during the day. Unfortunately, if you take antihistamine during pollen season, for example, you have to remember that you are decreasing your first line of defence to all threat. The most noticeable effect of this is that you will heal from skin scrapes and cuts more slowly than you normally would.
Rescue steroids
Man-made steroids act in the same way as our natural cortico-steroids, which are released by your adrenal glands, which sit atop your kidneys. Made from cholesterol (yes, contrary to popular belief, it has its uses), cortisol is released in times of stress and has an important role in releasing energy into the body, reducing inflammation and constricting blood vessels as well as suppressing your immune system to focus on the stress at hand. Directing a dose of cortico-steroid straight to the area in which you have inflammation and a heightened immune response constricts the dilated blood vessels blocking your sinuses. What’s more, over time the spray actually makes you less sensitive to what it is you are allergic to, be it pollen or pet dander. Most people just need short courses, however.
Kill the pain
Non-steroidal anti-inflammatories such as paracetamol or ibuprofen have more systemic effects, as they are taken orally. Ibuprofen, however, can cause breathing difficulties, particularly in those with asthma, as it causes airways to narrow in a condition known as bronchospasm, so for relief of a sinus headache, I would plump for paracetamol as the painkiller of choice.
Eating the problem away
If we think about inflammation as being central to the sinusitis experience, and working on the principle that a drug mimicking our body’s own natural anti-inflammatory can be used to good effect, are there natural ways for us to increase the anti-inflammatory power of our own bodies? Remember, inflammation is a really important response to threat to the body, but sometimes, as in sinusitis – and indeed other conditions, such as arthritis – this becomes counterproductive.
Foods rich in anti-inflammatory properties should boost your ability to cope with inflammation. Omega 3 fatty acids, for example, have anti-inflammatory effects, and fish is a good source of this. Turmeric can also be used; there is evidence of such an application that can be traced to 4000 years ago in India, although there is more recent (250 BCE) evidence that it was used as a medicine in South Asia, mainly to treat poisoning. Today, there is a widespread use of turmeric, which contains curcumin as an anti-inflammatory, in alternative medicine. This use has been validated over the last 20 years; there have been a number of scientific papers that have defined the mechanism of the actions of this natural remedy both in a lab (in vitro) and in a living person (in vivo).
Earlier, I mentioned the role of capsaicin in making your nose run, hence relieving congestion. In contrast to menthol, we perceive this spice as heat. For a while, it looked like the application of capsaicin in the nose could be used in the same way as menthol, to trick the brain into thinking the air was moving more freely than it was. In 2015, Artur Gevorgyan and his team from Amsterdam reviewed the evidence and found that there was some value in trying it as a topical treatment, but the studies that have been done don’t report objective measures such as air flow in the nose or levels of inflammation so can’t be taken as gospel.
Bringing it all to a head
While it is pretty well accepted that allergic and non-allergic sinusitis could involve overly sensitive sensory pathways, we need more evidence to show how and how well these treatments actually work. This way, we can choose the right remedy for each person every time.
Despite a feeling in clinical and scientific fields that the sinus headache is a misnomer and possibly misdiagnosed when it is really a migraine or tension headache, the experience of the sinus sufferer indicates that it is a real and specific phenomenon for them. This is supported by the prevalence of other snitey symptoms in addition to the headache and the fact we know that what is going on in the sinuses of the face area is detected as pain in the head. If cross-diagnosis with a different headache is happening, it is much more likely that tension headache, rather than migraine, is the go-to alternative. We’ll see why in the following chapters.