8 Little Sinuses Are One Major Headache

Look around you. You can see it and feel it happening.

The weather warms a bit, hinting that the end of winter is near. Buds form on the tree limbs where newly returned birds are perched. Grass and flowers begin poking up through the soil, announcing that soon the emerald Orange County spring will be upon us, spreading pain and misery in its wake.

Granted, this is the biased viewpoint of the sinus sufferer, but there seem to be so many of them. “You can go to any office in Orange County, toss a paper clip and probably hit someone who complains of sinus problems,” said Dr. Victor Strelzow, director of the UC Irvine medical school’s airway disorders section and a nose and sinus specialist.

But according to Strelzow, who has treated thousands of such sufferers with medicines and with surgery, the main cause of sinus complaints in Orange County is not spring’s pollen or humidity or smog or head colds or line-drives to the cheek. It’s television.

“People blame a lot of nasal complaints--postnasal drip, runny nose, stuffiness, headaches--on sinus problems because of television advertising,” he said. In reality, a small minority of those complaining actually have anything wrong with their sinuses, he said.

It’s probably about one in 10, according to Dr. Victor Passy, a UCI professor of head and neck surgery or otolaryngology. (If “otolaryngology” seems a mouthful, it used to be “otorhinolaryngology.”)

“Anyone who thinks his headache is a sinus headache is probably wrong,” said Dr. Harold S. Novey, a UCI immunologist specializing in allergies. “Tension headaches are much more common, in my opinion.” He estimated that 7% of the population suffers from allergic sinus problems.

To those who do suffer, however, the symptoms of sinusitis can be a general feeling of malaise or a nagging, recurring ache or a sudden onset of severe pain. An amazing number of people simply live with the pain, unaware of what is actually causing it and what can be done to allay and prevent it, Strelzow said. The sinuses are merely air-filled cavities in the skull, eight altogether: one in each cheek, two between the eyes, two behind those, and two in the forehead above the nose.

Each is lined with the same kind of membrane that lines the nose, and each is connected to the nasal passage by a small hole in the skull called an ostium. The hole is a bit smaller than the opening in the smallest drinking straw.

Do these sinuses serve any good purpose? There are differing opinions among physicians. Novey said the best opinions are only educated guesses ranging from warming inhaled air or insulating the base of the skull to improving voice resonance or merely making the skull lighter. Strelzow, however, believes the sinuses’ purpose is to provide room for additional nasal membrane. These membranes are needed to produce the fluids that prevent the nasal and throat passages from drying out.

“When you get a cold and have to breathe through your mouth, your mouth and throat can get very dry and sore,” Strelzow said. “So when you breathe through your nose, why doesn’t your nose get dry and sore?”

The reason, he said, is that clear mucous is produced in the nasal membranes and is carried back through the nasal passage by the motion of microscopic hairs called silia. Strelzow said an adult produces between 1 and 1 1/2 liters of this mucous each day, much of it in the sinuses, to counteract the drying effect of inhaling air. The mucous also protects by trapping inhaled bacteria and microscopic particles.

Generally speaking, only one thing goes wrong: The sinus openings swell shut for some reason or become obstructed, and that prevents the mucous from draining. The mucous is still produced, however, creating a pocket of warm fluid that is heaven for bacteria. That can lead to inflammation and infection, and for most sinus sufferers, that means pain.

Allergic reactions can cause the blockage by turning a person’s own antibodies against him or her, according to Novey.

Antibodies are proteins produced in the body that attack and neutralize threatening intruders such as bacteria and viruses. Allergic people, however, are genetically disposed to produce antibodies against harmless substances such as plant pollen. These well-meaning but overzealous antibodies can be produced within the nasal membranes, where they wait to sound the false alarm.

The pollen becomes lodged in the nose and sinuses, drawn in with the 10,000 quarts of air inhaled by a person in one day. The pollen breaks down, its component parts soak through the nasal membrane, and there they meet the antibodies. There can be 60,000 antibodies waiting on one membrane cell. If two or more adjacent antibodies react simultaneously, they set off a reaction in that cell, and in Rambo fashion, the cell shoots first and asks questions later. Ordered to attack, it releases microscopic beads of chemicals intended to wipe out the invading enemy.

This is good if the intruder is a tuberculosis bacterium, but it is bad if the threat is non-existent and therefore can’t be killed. The cell keeps on firing, and the victim winds up being the nasal membrane itself. It becomes inflamed, swells, closes off the ostium and prepares the way for a real infection.

Sinus blockage also can be caused by a person’s extreme sensitivity to toxic substances, such as smog, or even to normally benign influences, such as rapid changes in temperature or humidity, Strelzow said. “Some very sensitive people even sneeze in reaction to the day’s first contact with sunlight,” he said.

The sinus openings also can be blocked by polyps that develop after repeated sinus problems, by stones that develop in the sinuses, by inherited malformations of the skull, by head injuries, even by foreign objects such as buttons, marbles, crayons and food that some children like to store in their noses.

What can be done?

If the problem stems from allergy, Novey said, the symptoms can be treated with antihistamines, which counteract some of the irritating chemicals being released by the nasal membrane, and with antibiotics, which fight bacterial infection. Once the symptoms have subsided, tests can determine just what is provoking the allergic reaction and the sufferer either can avoid the substance or receive inoculations to reduce his sensitivity to it. “There is some benefit in 85% of cases and nearly complete cure for many years in 50% of the cases,” Novey said.

If the problem is blockage of the sinuses, and if medicines or application of heat does not solve the problem, surgery can correct it, Passy said. “It’s not really tough. It’s relatively simple,” he said. People with small sinus openings that are blocked, or easily become so, so can have the openings enlarged or new ones created. “The whole thing is drainage. If you get them to drain, they cure themselves,” Passy said.

The introduction of the sinus endoscope has made such surgery more precise and less traumatic, Strelzow said. The sinus endoscope is a thin metal tube with a tiny lens and light at one end and an eyepiece at the other. It can be inserted far back into the nasal passage, allowing a surgeon to see and operate on areas that previously were accessible only by incision.

The result, Strelzow said, is that sinus surgery can be conducted in an office or an outpatient facility with only local anesthetic and sedation. The pain of recovery is greatly reduced, and the patient usually is back to work after “a couple of days,” he said.

But before a person comes in for sinus surgery, he should ask a few questions, Strelzow said.

Is the pain really sinus pain? Typical sinus pain is a dull ache over the cheek and forehead, perhaps seeming to come from the teeth and eyes. It feels like pressure, and it gets worse when you lie down. Sinus infections often prompt fever and chills and frequently follow what otherwise is a simple “head cold.”

Oftentimes, the suffer can cure himself in 10 days to two weeks with over-the-counter antihistamines and decongestants. But if there is no improvement within five to seven days, it may mean that a bacterial infection has taken hold and the sufferer will need antibiotics prescribed by a physician.

The physician will examine the nasal passage, and if he suspects serious sinus problems, X-rays will be taken to confirm it. “X-rays are essential for an accurate diagnosis,” Passy said.

“If there’s a problem, there is a lot we can do about it,” he said.