With Dr. Bob Knox
A moderated chat event was held on Monday, May 20 featuring Dr. Bob Knox. The questions and answers from that chat are listed below. We all wish to thank Dr. Knox for generously contributing his time to inform sleep disorder patients regarding sinus problems. Each question is linked to the answer for your easy reference.
About Dr. Bob Knox
Robert D. Knox, M.D. is an assistant clinical professor at University of Louisville, Louisville, Kentucky. Dr. Knox, an ear, nose and throat specialist, also serves as President of SuccessIsAChoice, a motivational speaking company. A graduate of the University of Louisville School of Medicine and Wittenberg University, Dr. Knox is a fellow of both the American Academy of Otolaryngology – Head and Neck Surgery and the American Rhinologic Society.
Dr. Knox has published 10 articles in general medical and ENT publications including the Archives of Otolaryngology Head Neck Surgery, Laryngoscope and Urology. He also has been a keynote and motivational speaker at over 90 presentations. Some recent presentations include, “Sinusitis: What’s Old and What’s New” and “Sinusitis 2002: Facts and Figments?”
1. I normally do not have nasal congestion except when I use CPAP. Why is that and how can I relieve this problem?
2. I am a chronic mouth breather, I think because I cannot breathe well through my nose. ENT evaluation did not show a deviated septum or allergy condition, can one train themselves to stop mouth breathing to benefit from CPAP without using a full face mask?
3. Do nasal sprays like Flonase harm the nasal lining? Are they addictive?
4. I have heard people talk of nasal lavage in the chat rooms here, what is this and how is it helpful?
5. I seem to suffer from frequent colds that include a stuffy nose that make CPAP use impossible. Is there a safe over the counter solution to unplug my nose on nights when I cannot breathe through my nose? I hate not being able to use CPAP for even one night!
6. I am on a high CPAP pressure of 16. I use a heated humidifier, but still, my nose dries out and it is painful. Is there a medication or answer for dry nose with CPAP use?
I was recently diagnosed with UARS (upper airway resistance syndrome) How does this differ with sleep apnea? Is it treated the same way? My doctor is deciding on whether or not to prescribe me with a CPAP.
7. I suspect I have a sinus allergy condition. How can I find out what I am allergic to?
8. What is the best use for nasal congestion, a nasal spray or a medication tablet?
9. I frequently have watery eyes in addition to my nasal congestion. What does this indicate? It seems to be seasonal, when pollen count is high, but makes CPAP use next to impossible.
10. What is Rhinisitis (did I spell that right)? How is it best treated?
11. What is Somnoplasty? My doctor mentioned the possibility for me, but I am not keen on any surgery.
12. Are there any over the counter nasal sprays that can be harmful with frequent use? I use Afrin and now I have nosebleeds.
13. Is there an easy way for me to tell if I have a deviated septum, or does it require a doctor’s evaluation?
14. What does it mean to have a nasal obstruction?
15. Are sinus infections and sinus allergies treated the same way? How can you tell which one you have?
16. My doctor gave me a free sample of Flonase. I use it when I am congested, 2 squirts in each nostril just before bedtime. I need it about once a week. It does not work well for me. Someone told me you have to use it every night or it won’t work, is this true?
17. Can CPAP use alone cause nasal problems? I never had problems breathing through my nose until I started on CPAP several years ago. I worry that long-term CPAP use is damaging my nasal lining. Your thoughts? Any research on this?
18. Is it safe to put Vicks ointment inside the nostrils when I have a cold and want to use my CPAP? It seems to help “keep me open” so I can breathe better.
19. What does it mean to have enlarged turbinates?
20. What are nasal polyps? What causes them? Must they be surgically removed? My primary care physician who wants me to see an ENT told me I have them. I do not want to have any kind of surgery!
21. My doctor wants me to have a test where they put some kind of scope down your nose to look for something. What are they looking for? Does it hurt? What is this procedure called?
22. Why is breathing through the nose supposed to be better than mouth breathing. I simply cannot seem to nasal breathe.
23. I use a full-face mask successfully, but is this hurting me somehow long term?
24. Some nights I am in a panic because I cannot breathe thru my nose to use CPAP, is there an over the counter remedy that will guarantee relief from nasal congestion for at least 6 hours or so to allow good sleep?
25. What is a deviated septum?
26 . Can a deviated septum be straightened?
27. When I lie down, my nose clogs up. This prevents me from using my CPAP mask. What else can I do?
28. Any specific health care question for a certain person’s condition, that is asking specific medical advice online.
29. Why does my nose clog up when the weather changes?
30 . Is snoring a normal part of sleep?
31. What is a LAUP?
32. What is Somoplasty?
33. What is injection snoroplasty?
34. What causes snoring?
35. What is Upper Airway Resistance Syndrome (UARS)?
36. Is surgery a guarantee to cure sleep apnea?
37. What is the difference between a common head cold and a sinus infection?
38. What is the best treatment for a sinus infection?
39. Is snoring associated with a stuffy nose? What can I do about loud snoring?
40 . Are fungal infections responsible for sinus disease?
41. What is the most accurate way to distinguish between a sinus infection and allergies?
42.Does sinus surgery cure sinus disease?
43. What are the functions of the nose and sinus passages?
44. Can sinus problems cause asthma or chronic cough?
45. Are allergies more common today, and why does everyone seem to have allergies?
46.Is excessive weight associated with sinus disease?
47. How do I know if my headaches are related to sinus disease?
Dr. Knox Answers: The CPAP does not actually cause the nasal congestion. Likely, something else happens when you are using the CPAP. The most likely situation is, when you lie down your nose becomes passively congested (the veins in your nasal tissues fill up), and this gets worse as the night goes on if your apnea is not controlled by the CPAP. Try sleeping with you head elevated ~ 15 degrees (three pillows), or if you don’t have high blood pressure, take an oral decongestant tablet, say, 45 minutes before bedtime. The longer acting decongestants are less associated with a rise in blood pressure. The turbulent airflow of CPAP may create enough irritant to cause some of the congestions. Changes in air temperature and pressure can cause alterations in nasal blood flow. Just the way nature works.
David asks: I am a chronic mouth breather, I think because I cannot breathe well through my nose. ENT evaluation did not show a deviated septum or allergy condition, can one train themselves to stop mouth breathing to benefit from CPAP without using a full face mask?
Dr. Knox Answers: Well then, “why are you a chronic mouth breather?” Ask your ENT why your nose is so clogged if you don’t have allergies or a deviated septum. You need another explanation. Perhaps, you have non-allergic rhinitis or enlarged turbinates, or may actually have narrowed nasal passages – a condition called pyriform stenosis. This is a congenital narrowing of the opening in front of, or behind the nasal passages. Unfortunately, it is very difficult to make this diagnosis. It is hard to “train” yourself to something that is not “conscious” in origin, but you might try just be actively trying to keep you mouth closed as your breathe – while awake. If this is not possible, get another ENT opinion. Sleep disordered breathing can actually cause or make the stuffy nose worse – a vicious cycle.
Dr. Knox Answers: It depends on how you think. As you know, all drugs have intended effects and unintended side effects. If you want to know what works best, then medicines like Flonase, as a class (that is, nasal inhaled corticosteroids) is the most effective class of medicines to treat chronic rhinitis. No other medicines work as well as this class. Flonase is the best-selling medicine in this class. Generally, side effects are limited to itching, stinging, burning, or a short-lived smell alteration. Continued use, especially if the nozzle is aimed toward the midline, has been associated with nose bleeding in about 5 – 10% of regular users. I would suggest you “prime” the nose with a salt-water spray before using the Flonase, and then point the nozzle “toward the corner of the same eye” as you gently sniff. And, “no”, they are not addictive. If you want a lawyer’s opinion, he or she will give you a different answer. Remember, benefit = risks. Only use medicines when non-medicine alternatives are not helping enough. No medicine is without risks, but we have lost sight of risks vs. benefits in America. Next time you see your doctor, ask him or her to give you a copy of the PDR pages on Flonase.
Dr. Knox Answers: A nasal lavage simply means a nasal rinse – this could be any substance. The most commonly used substance is 0.9% sodium chloride (salt water). This is available without prescription, or can be made by mixing 1 /4 teaspoon salt / 16 ounces of water. Use a bulb syringe (like that used to flush a child’s nose), hand the head over the sink, and flush away. This works great, but it is only effective if used frequently. If removes particulate matter, dried crusts, and actually dilutes inflammatory chemicals found in the nose. You can’t flush too much!
Frequent colds asks: I seem to suffer from frequent colds that include a stuffy nose that make CPAP use impossible. Is there a safe over the counter solution to unplug my nose on nights when I cannot breathe through my nose? I hate not being able to use CPAP for even one night!
Dr. Knox Answers: Unless you work around children, or in a health care environment, and you feel “sick” these “colds” are actually flare-ups of rhinitis – an inflamed, swollen nose. See you doctor and ask about medical treatments for chronic or recurrent rhinitis. Oral decongestant tablets may help relieve some of the swelling, however, swelling is part of sleep disorders, and may require more aggressive measures if you are failing CPAP.
Dr. Knox Answers: Take a steamed shower before you go to bed. Flush or rinse the nose with salt-water sprays (over the counter, or make yourself) before you start the CPAP. Consider an ultrasonic humidifier for your bedroom. Drink plenty of fluids. Anything you do to keep you nose moist helps. The humidified loop is just not enough. Are you on any medicines that may be drying your mucus? Most antihistamines, and many hypertension medicines may dry the nose.
New to all this asks: I was recently diagnosed with UARS (upper airway resistance syndrome) How does this differ with sleep apnea? Is it treated the same way? My doctor is deciding on whether or not to prescribe me with a CPAP.
Dr. Knox Answers: To you, UARS is the same disease as sleep apnea. To the sleep doctor, they are different. To have “bone fide” sleep apnea, you must have more than 5 episodes of greater than 15 seconds of apnea / hour. Many UARS sufferers have hypopneas ( slow, incomplete, but not absence of breath ), which may cause the same effect to the brain – lack of sleep. UARS should be treated the same as SA if you are symptomatic, that easy, excessive daytime sleepiness, fatigue, or any other symptom of SA. They are the same disease to you, just not to your doctor. If you have an “arousal index” – how many times you wake up / hour greater than 5, the effects are the same. Your doctor is thinking “inside the box”. He or she is doing what the guidelines recommend, but UARS is a new diagnosis, and is still regarded as a disease “unique” from SA. Think outside the box, and get treatment. All the same options exists in UARS as SA.
Dr. Knox Answers: Go see your doctor, and ask for medical treatment of chronic rhinitis. This may consist of medicines, avoidance of suspected allergens, or formal allergy testing. If your doctor does not perform allergy testing, and you fail a trial of medical therapy, see an allergist or ENT (who performs allergy testing) in your area. The only way to know what you are allergic to is through formal allergy skin testing or a blood test, called RAST (radioallergosorbent test).
Dr. Knox Answers: Of the medicines designed to treat nasal congestion, tablets that contain pseudoephedrine are, by far, the most commonly taken medicines for stuffy nose. Prescription nose sprays that contain a corticosteroid are the most effective type of medicine, but Americans are funny about using nose sprays. Most doctors will start with the tablet decongestant and / or an antihistamine. If response is incomplete, then add the inhaled prescription spray, such as Nasacort® or Flonase®, and many others. Many decongestants are also available over the counter. Another option is an inhaled antihistamine, called Astelin® (azelastine), which is an inhaled antihistamine – and may have the effects of an inhaled steroid, plus mild effects like a decongestant – all in one.
Dr. Knox Answers: Runny, itchy eyes are part of allergic rhinitis. Allergic rhinoconjunctivitis is a better term for what you are describing. The conjunctivae, or linings of your eyes are also sensitive to allegens – in your case. An antihistamine will often help, such as Claritin, Allegra, or Zyrtec. An over the counter option, is Allergy Eyes®, available OTC. If symptoms persist, many prescription allergy eye drops are available. Your primary care doctor can probably suggest, or one trip to the allergist or eye doctor will help exclude other conditions, such as blocked tear ducts – also to be considered, but unlikely if symptoms occur with allergy flare ups.
Dr. Knox Answers: Rhinitis is any “inflammation of the nose and nasal passages”. Sinusitis is the same disease, but usually the end-stage of an inflamed nose. Anything that irritates the nose can cause rhinitis. Also, changes in weather, such as temperature, humidity, and sudden barometric pressure changes often affect an already inflamed nose. Many systemic (affect the whole body) disease can also be part of rhinitis. The most common is allergies, but diabetes, high blood pressure, blood vessel disorders, and many medicines can be part of rhinitis. Treatment first involves getting a diagnosis. See your doctor.
Treatments vary from avoidance of offending substances, symptomatic over the counter medicines, that contain an antihistamine and / or decongestant, to prescriptions with similar ingredients, to prescription anti-inflammation (“itis”) inhaled steroids, or inhaled antihistamines. Start with over the counters first. If they fail, or you experience side effects, such as undue sedation, then see your doctor.
Dr. Knox Answers:: Generally, surgery is the most effective treatment, and the only option that may cure the disease. Are you a pessimist, realist, or optimist? Do you do the most possible, the least possible, or “I’ll just live with it”. You need to answer these questions first. Now, the reality, surgery is not the best option for most people. The best treatment option for most of us is – weight loss. Guess how most people do with this option?
Somnoplasty is just one of the options. Generally, it is most effective in non-obese UARS / SA suffers who do not suffer from nasal congestion. If involves a special “heat probe” that literally “cooks” the tissues under the mucous membranes. It can be used to treat swollen nasal membranes, an enlarged soft palate or uvula, big tonsils, and even an enlarged tongue base. It is performed with a local (spray or injection) anesthetic, in the surgeon’s office. No sedation is necessary. It generally is best suited for “social snoring”, that is, non-sleep disorder snoring, in non-overweight patients. It is still used in other situations, due to patient preference for the “least invasive” procedure, and is effective about 75 – 90 % of patients depending on number of treatment sessions (usually 2 -3), severity of sleep disorder, associated nasal congestion, and weight of patients.
Dr. Knox Answers: All the over the counter decongestant nose sprays are addicting and can cause severe drying of the membranes, thus, nosebleeds. The best approach is to quit “cold turkey”. If you have tried and failed, start using salt-water nasal sprays (available any drug store without prescription). Count how many sprays / day / nostril. Try to eliminate one spray / day. Or another approach, dilute the Afrin, and discontinue over a week or two. If none of this works, see an ENT specialist.
Dr. Knox Answers: Unless you can take your nose off, and look around in there, unfortunately, you are going to have to let someone else “look up there”. Unless you are married to, or date an amateur nose specialist, go see an ENT doctor or allergist, and get a thorough exam. Remember, it is your nose. Find out what is wrong, and then with your doctor’s advice, determine what is best for your nose.
Another approach if you have unlimited funds, many freestanding CT scan facilities offer an X-ray without doctor’s consultation. Check the yellow pages, and see if you have such a facility in your city. CT scans very accurately pick up a deviated septum and also would tell you about the condition of your sinuses. However, this is very expensive, and may not actually alter how you are treated. Not my advice, but I have known wealthy folks to do stranger things.
Dr. Knox Answers: A stopped up or congested nose. Says nothing about cause, just effect. Your nose is blocked up. Usually with swollen, inflamed membranes. The usual diagnosis is rhinitis, or an inflammation of the nasal and sinus passages.
Dr. Knox Answers: Two different manifestations of the same disease. Allergies are just one cause of rhino (nose) sinusitis (an inflammation or blockage of the sinuses). Infections are treated with time, decongestants, and antibiotics – if not improving. Allergies are best treated by accurate diagnosis, avoidance of allergens, and medicines that prevent or treat inflammation. Antibiotics don’t help allergies. Allergies may, however, cause enough sinus blockage that infections (bacteria, fungus, or viruses) develop inside blocked sinuses. Allergies are most short-term in nature, and follow the exposure. Infections often follow a head cold or allergy flare up. Symptoms are more severe, and last longer, generally peaking 10 -14 days after the head cold or allergy flare up.
Sleepless in VA asks: My doctor gave me a free sample of Flonase. I use it when I am congested, 2 squirts in each nostril just before bedtime. I need it about once a week. It does not work well for me. Someone told me you have to use it every night or it won’t work, is this true?
Dr. Knox Answers: Flonase®, and other anti-inflammatory nasal medicines, generally work best when used regularly, with onset of symptom relief within a few days, but improvement occurring up to 4 – 6 after repeated, daily doses. Use the medicine every day for 4 weeks to determine how effective it will be is a general rule. Generally, it is best to use for a couple months at a time, and then take a break. If symptoms return, and use greater than six months per year is required, consider an allergy evaluation, or see an ENT specialist.
Justin asks: Can CPAP use alone cause nasal problems? I never had problems breathing through my nose until I started on CPAP several years ago. I worry that long-term CPAP use is damaging my nasal lining. Your thoughts? Any research on this?
Dr. Knox Answers: CPAP may contribute to nasal drying, crusting, and discomfort due to the attachment “hardware”, but not other long-term effects are known. Research in this area is vast, extensive, and conclusive. The nasal congestion is more likely part of your sleep disorder than due to the CPAP. Most people with sleep-disordered breathing experience stuffy nose at some time. Try a time away form CPAP. How do you feel now? If symptoms recur, see you sleep doctor, and ask about other treatment options. Remember, CPAP, or variations are the most effective treatment of airway obstruction sleep disorders, but only work when used. It doesn’t cure the disease, but is controls the symptoms in most patients.
Dr. Knox Answers: Vicks® ointment is safe, moisturizing, and effective in most users. Many other medicines may also be helpful if symptoms are chronic. “Dab away”!
Dr. Knox Answers: Humans have three, paired bones that project into the nasal passages from the outer wall of the nose: upper, middle and lower turbinates (or concha). They increase surface area, and thus, filtering, warming, and “smelling” ability. The membranes are rich in blood supply. They may become enlarged with chronic irritation, or any other condition that affects blood vessels. Their enlargement is the most common cause of stuffy nose.
OhBoy asks: What are nasal polyps? What causes them? Must they be surgically removed? My primary care physician who wants me to see an ENT told me I have them. I do not want to have any kind of surgery!
Dr. Knox Answers: The answer here is easy, then live with the stuffy nose. Most polyps are benign, so you won’t die due to them, but do you want to breathe well through you nose? If not, live with them. If not, ask your doctor about a short (2 -3 month) course of medical therapy before seeing the surgeon. Oral decongestants, topical steroids, and even oral steroids will often shrink polyps to restore breathing – for a while.
Polyps are generally fluid-filled mucous membranes. Any chronic irritant, infection, or allergen can cause them. A biopsy will exclude malignancy, or other more serious conditions, but “no”, not everyone chooses surgery to remove the polyps. Surgery is the most effective therapy, but medical therapy is necessary even after removal to prevent recurrence. Even then, about 25 – 40 % of surgery patients may have recurrence.
Most doctors will recommend a simple biopsy if patients elect not to have polyps removed — to exclude the rare, but possible malignant “polyps”.
Dr. Knox Answers: The procedure is called a nasal endoscopy, and involves inserting a small rigid or flexible lighted “magnifying lens” to examine the nasal and sinus passages. Usually, a local anesthetic spray is applied first. Does it hurt? Yes, a bit, but most people describe it about like having “someone pick his or her nose”. The real question is, “how bad does your nose bother you? What are you and your doctor concerned about?” If a growth is suspected, endoscopy with a biopsy, is almost always recommended. If no growth is suspected, it is the most accurate diagnostic procedure. Combined with a biopsy or CT scan, in some individuals, an accurate diagnosis is usually obtained.
Smitty asks: Why is breathing through the nose supposed to be better than mouth breathing. I simply cannot seem to nasal breathe. I use a full-face mask successfully, but is this hurting me somehow long term?
Dr. Knox Answers: Nasal breathing is not “better”, but it is what nature intended. The nose warms, humidified, and filters inspired air prior to reaching the lungs. The sense of smell (and most taste) comes from a functioning nose. However, if you just want dry oxygen for your lungs, the mouth works just fine. In fact, humans have a much bigger mouth than nasal passages; therefore, it is much easier and effective to mouth breathe. But the main functions of warming and humidification are lost. Dry, cold air “angers” the lungs.
Collin asks: Some nights I am in a panic because I cannot breathe thru my nose to use CPAP, is there an over the counter remedy that will guarantee relief from nasal congestion for at least 6 hours or so to allow good sleep?
Dr. Knox Answers:: No, no over the counter is likely to give you that much relief. Try an oral decongestant containing pseudoephedrine ( if you don’t have untreated high blood pressure). If you are not getting good relief, try adding salt-water nasal flushes before bed. Still not helpful – see your doctor. Many prescription medicines are helpful. A humidified CPAP loop is often (actually, nearly always) helpful.
Dr. Knox Answers: The wall that divides the left from the right nasal passage is made of bone and cartilage, and lined by a delicate mucous membrane. In many individuals, this partition is crooked, or deviated, and may cause blockage of nasal breathing. Most often, the deviation is a “gift” of nature, but individuals who have broken their nose may also experience nasal blockage due to a deviated septum.
Dr. Knox Answers: If a nasal physical exam shows a deviated septum, and blockage is severe enough to warrant regular use of medications, or if medications do not provide relief of nasal blockage, surgery may be warranted. However, straightening a crooked septum as a sole operative procedure seldom provides adequate improvement in breathing. Swollen membranes, as seen in rhinitis (an inflamed nose), may also contribute to nasal congestion. If blockage to breathing is severe, see your doctor. Try medicines first. If symptoms don’t improve, see an ENT specialist.
Dr. Knox Answers: Unfortunately, the veins in the face become congested, or full, when many of us lie down. If the nose clogs up, then any attempt to blow air through the nose may be very difficult. Many individuals with sleep apnea or sleep-disordered breathing experience chronic nasal congestion. The sleep disturbance is made worse by the stuffy nose, and the stuffy nose is made worse by the sleep disorder. This vicious cycle is very difficult to break, but usually responds best to weight loss. Medications may help treat the symptoms.
Answer: Accurate treatment of any condition requires a complete history and thorough physical exam. Only you and your health care provider can determine specific medical treatment for your health care. “Online healthcare” is not a substitute for an established doctor – patient relationship. Our information is offered only for general medical conditions, and does not apply to any one person with the given disease. Specific medical care requires a visit to your doctor — who is familiar with your health and your medications. Do not use information from this website as an alternative to seeing your doctor. Do not use online information as a substitute for the sound opinion of your doctor. We provide information only – not health care advice.
Dr. Knox Answers: The human nose is affected by many factors, most importantly, sudden changes in temperature, humidity, and barometric pressure. The main functions of the nose involve warming, filtering, and humidifying inspired air. The lungs depend on warm, wet air to absorb oxygen. Air must be warmed to body temperature and become bathed in water to be utilized by the lungs. Most commonly, when a cold weather front passes through, the barometric pressure drops suddenly. This causes our nasal membranes to swell, and leads to blockage of sinus passages. Air and mucus may become trapped in the sinuses, and this may lead to facial pain or pressure, and allow bacteria to grow in stagnant mucus. This is how we get a sinus infection.
Dr. Knox Answers: No, snoring means the airway is partially blocked during breathing. In most individuals, this is only of “social” significance to a sleeping partner. However, in some this blockage is so severe as to cause disruption of normal sleep patterns, strain the heart, affect ability to absorb oxygen, decrease release of carbon dioxide, and create many other strains on the body. Generally, as snoring becomes more severe, the breathing pattern becomes more labored and erratic. The most sensitive symptoms of severe snoring, or the development of sleep-disordered breathing are excessive daytime sleepiness, excessive fatigue, difficulty concentrating, and many other. If you suspect a sleep disorder, or witness pauses in your sleep partner, ask your doctor about ordering a sleep study. This involves measuring many variables during normal sleep. It is the only test that diagnosis airway obstruction during sleep, and may lead to a diagnosis that allows restful sleep.
Dr. Knox Answers: A laser-assisted uvulopalatoplasty. This procedure, performed in the US for about ten years, involves using an invisible gas (usually carbon dioxide) laser to cut tissues. This is usually performed with a local numbing anesthetic applied to or into the tissues being treated. Multiple treatments (3 -5) are usually required, spaced 4 -6 weeks apart. The laser light is very hot, and actually cuts through human tissues. Most commonly, this is used to shrink the soft palate, tonsils, or base of tongue. In non-obese patients, this operation improves snoring 80 -85 % of the time. It is rarely curative, but most treated will experience lessening of snoring volume. Most commonly, this procedure is used only for loud social snoring or mild sleep-disordered breathing. Its effectiveness is negatively affected as weight increase.
Dr. Knox Answers: A sound (ultrasonic) heat probe is used to shrink tissues, most commonly of the nose (turbinate reduction), soft palate or uvula (the fleshy part of the upper palate), the tonsils, or the base of the tongue. No incisions are made, and often little anesthetic is needed. Multiple treatments (2 – 4) are usually required, spaced over 3 – 6 weeks apart. Success occurs in reducing snoring volume in about 80 % of patients. Severe sleep disorders are generally not treated with somnoplasty. However, this is the simplest surgical treatment available, and many will choose this as a first choice.
Dr. Knox Answers: This simple, office-based treatment involves injecting a stiffening agent into the soft tissues of the throat, usually the soft palate or uvula. By making the tissues “stiffer”, they are less likely to collapse and block the airway. Initial reports of success or now being replaced by more cautious reports of failures, especially with any diseases more than mild in severity, or associated with other sites of obstruction. Generally, I do not recommend snoroplasty, as better options exist.
Dr. Knox Answers: Reversible, blockage of the upper airway during sleep. The three main sites of blockage are: nasal passages, soft palate / back wall of throat, and base of tongue / back wall of throat. Nasal blockage is the most common site in most individuals, and is often associated with allergies, sensitivity to weather changes or smoke, or conditions that affect blood vessel swelling. Soft palate and tongue base obstruction tend to worsen with increasing weight, and are usually treated after nasal obstruction is managed. Surgical procedures to address each site of airway blockage are available, and usually are performed from the “nose down”, as anatomy dictates.
Dr. Knox Answers: Airway obstruction during sleep that affects quality of sleep (just like sleep apnea), but is not complete in severity (apnea means absence of breathing). This partial blockage of airflow is called hypopnea (decreased breathing, or shallow breathing), and has only recently been appreciated as a unique medical disorder. Technically, this disorder is diagnosed when the respiratory disturbance index (# of breathing episodes / hour) is greater than 5, but apnea episodes are less than 5 / hour. Hypopneas predominate, but do not technically meet criteria established for sleep apnea (greater than 5 episodes of absent breathing / hour, duration longer than 15 seconds / episode). Episodes must be longer than 15 seconds with no breathing to constitute an “apnea”. Hypopneas, or decreased breathing, do not meet original definitions for sleep apnea.
The problem with the older definition of “apnea only” is that the effects on quality of sleep, and stain on the body may be the same for upper airway resistance syndrome as frank sleep apnea. Treatment is the same as for sleep apnea, but most doctors have not put the two diseases on the same platform with regard to seriousness. Many sleep centers do not diagnose UARS. Always look at the number of arousals ( times of light sleep) to determine effects of airway obstruction on sleep quality.
Dr. Knox Answers: Only one operation “cures” sleep apnea or upper airway resistance syndrome – tracheostomy. This involves creating a permanent opening into the windpipe or trachea. An incision is made to create an opening (usually closed during waking hours with a plug) that prevents airway blockage in sleep. Very effective, but most patients will reject this aggressive approach. Almost never necessary, except with severe, life-threatening apneas – usually seen only with serve obesity.
Dr. Knox Answers: The common head / nasal cold is the most common viral infection that affects humans. The common rhino (nose) virus is acquired through airborne spread from another person. The virus grows in the nose and sinus passages, causing intense swelling and additional production of mucus. The body’s immune system clear this infection in 3 – 7 days, but the swelling that persists may lead to a secondary bacterial infection due to plugging of nasal and sinus passages. A sinus infection may follow a head cold, but typically is best described as a “cold” that won’t go away. Sinus infections start 7 – 14 days after a head cold, but also may follow any other condition that causes prolonged blockage of nasal and sinus passages. A cold is due to a virus – a sinus infection is usually caused by a bacterium (most commonly Streptococcus pneumoniae or Hemophilus influenzae – two common upper respiratory bacteria).
Sinus infections usually cause continued production of colored mucus, dull facial pain, perhaps tenderness in upper teeth, but may rarely extend into the soft tissues around the sinuses, such as the facial or eye tissues. Any head cold that does not clear after 7 – 14 days, should be considered a sinus infection.
Dr. Knox Answers: Any treatment that helps loosen mucus and allows drainage of nasal and sinus passages — that is, symptomatic treatment — and a few days. Most head colds will clear as soon as swelling decreases. Flushing nasal mucus with salt water and using oral decongestants, such pseudoephedrine, usually hasten recovery. If symptoms progress despite time, flushes, and decongestants, then an antibiotic may be necessary. A critical point: antibiotics only treat one component of the infection – they decrease the number of bacteria in mucus. The mucus must be kept flowing to allow clearance of the infection.
Most sinus infections will resolve without therapy — in 7 – 21 days. Medications decrease symptoms. Antibiotics may prevent spread of bacterial infections into adjacent tissues. Antibiotics are absolutely necessary in complicated infections, or those associated with facial swelling, eye or brain involvement (rare). The best antibiotic is one that kills bacteria. Individuals with immune compromise, occurring with diabetes or acquired immune deficiency states may require much more aggressive therapy to prevent complications. Most current guidelines for treatment of rhinosinusitis recommend a penicillin class antibiotic or sulfa class antibiotic. Discuss specific needs with your health care provider.
Dr. Knox Answers: Snoring is never a normal part of rest, but usually it is more annoying than dangerous. If snoring is associated with frequent pauses in breathing, headaches, fatigue, high blood pressure, weight gain, or other problems, then a thorough evaluation is warranted. In individuals with stuffy nose during sleep, breathing disorders may be worsened. In fact, a stuffy may start the snoring cycle, and the breathing disorder may make the nose stuffier. Often, this is seen with increasing weight and fatigue.
Dr. Knox Answers: Yes, but rarely is a fungus the major component of the infection. Two recent publications have demonstrated fungus is present frequently in sinus mucus. The first of these is the most quoted study from the Mayo Clinic. The second from the University of Graz, Austria repeated the first study. Each study concentrated nasal and sinus mucus in a high-speed centrifuge to create a dense paste of cellular material. An antibacterial was added to a fungal culture medium, and voila — fungus grew in greater than 95% of cultures. Is this new “news”? No. Only a new technique to recover fungus was demonstrated.
The common sense answer is this: antibiotic use inhibits the growth of bacteria. Frequent use of antibiotics in chronic sinusitis will “select” fungus by inhibiting the growth of bacteria. Chronic sinusitis (greater than 3 months of symptoms) will likely have fungus living in the mucus if appropriate culture techniques are used.
Antifungal medications probably add little to the treatment of acute sinusitis (except in severe diabetics or immunocompromised patients), but may play a role in individuals with chronic disease not responding to traditional medications. Computerized tomogram (CT) scans of individuals with chronic sinusitis may demonstrate highly dense mucus (seen as calcium deposits) on close inspection of scans. This implies long-standing obstruction, which may lead to the growth of fungus.
Dr. Knox Answers: A detailed history of duration and type of symptoms, coupled with CT scans of the sinuses which demonstrate sinus blockage. Skin prick tests using common airborne allergens, such as dust, cat dander, grass or tree pollen, may demonstrate a heightened immune reactivity as seen in allergic individuals. Skin tests do not prove that allergies cause the problem, but show a relationship.
Dr. Knox Answers: No, but it is the most effective therapy in chronic sufferers. Surgery should be considered only in individuals who are not responding to medical therapy, or who have chronic, severe symptoms of sinus blockage. The spectrum of rhinosinusitis may be interrupted with appropriate ventilation and drainage of the sinus passages. Ask you health care provider about treatment options, or schedule an appointment to see a sinus specialist.
Dr. Knox Answers: The nose is the first entrance into the body for inspired air and airborne particles. Air is warmed to core body temperature, humidified, filtered of contaminants, and then presented to the lower airways to allow absorption of oxygen and elimination of carbon dioxide. The lungs function better when the nose is doing its job more effectively. In addition, the sinuses provide for vibration of facial structures, and give our voices tonal qualities. Lastly, the facial bones are constructed to allow distribution of forces during impact, and provide protection to the brain from forces compressing the facial structures.
The nose “prefers” warm (98.6-degree farenheidt) and humid (85 – 90 % relative) air. Our bodies are composed of salt water, and we are warm-blooded animals. Oxygen is only absorbed in the lungs when the inspired air is mixed with water. Warm, wet air keeps the nose and sinuses functioning more efficiently.
Dr. Knox Answers: I look at sinus disease as the same process as bronchitis – only involving a different target tissue. “Asthma is to the lungs as sinusitis is to the nose”. It is all the same disease, but “the nose can’t cough, and the lungs can’t sneeze”. When the nose is congested, air is not warmed, filtered, and humidified optimally. The lungs may dry or be exposed to unfiltered, cool air. The lower airways (windpipe and lungs) respond to a poorly functioning nose by creating additional mucus, and may even spasm to protect the delicate lung tissue from the effects of drying. This spastic, wet lung is the disease called chronic, asthmatic bronchitis; however, all bronchitis is not asthma. Ask your health care provider about treatment options.
Many individuals with chronic sinusitis also have chronic, asthmatic bronchitis. Treatment of one condition often requires treatment of the other condition for symptom control. The treatment of each process is very similar to the other process. Anti-inflammation medications, decongestants, and mucus loosening medications are often helpful.
Also, acid from the stomach can come up the esophagus when lying flat in bed. This acid may enter the back of the nose and cause swelling of nasal membranes, and may also trickle into the lungs and cause chronic irritation, resulting in cough and mucus production. Always consider acid reflux in the disease processes of rhinosinusitis and bronchitis. Your health care provider can help you distinguish the problems, and come up with a solution.
Curious1 asked: Are allergies more common today, and why does everyone seem to have allergies?
Dr. Knox Answers: Allergies, per se, are not more common today than in years past, but our awareness of these diseases, treatment options, and ability to detect common allergies is much more common today. Some physicians theorize that the over-use of antibiotics may have “protected” our immune systems from common infections, and thus created heightened immune reactivity to common allergies. This theory is surely plausible with our “love affair” with antibiotics. Nature gave us viruses and bacteria for a purpose, but their exact roles are open to speculation.
Any chronic condition, such as chronic sinusitis or bronchitis, should trigger our suspicion of allergies. Also, chronic irritants, such as perfumes and chemicals, can create many of the same symptoms as allergies. A thorough environmental exposure history, family history of allergies, and skin testing for common allergies may help identify suspected allergens or irritants.
Changes in weather, such as sudden changes in temperature, humidity, and barometric pressure may also “simulate” allergies. Of these, barometric pressure changes are most important. Whenever the pressure drops, our tissues swell. This swelling may cause narrowing of nasal and sinus passages, and result in blockage of drainage – the perfect environment for the growth of bacteria and viruses. Cool, dry air of winter months creates the “cold season”.
Answer. Absolutely — in some people. I believe excessive weight is the number one cause of “sinusitis” in America. With increasing weight, the airway narrows, especially during sleep. This airway obstruction during sleep is manifested as snoring. Snoring may progress to complete blockage of the airway. This is called sleep apnea (a = absence, apnea = breath). Sleep apnea may be associated with morning headaches, excessive daytime sleepiness, high blood pressure, and poor mental ability. Sleep apnea is often associated with chronic nasal stuffiness. Nasal stuffiness is associated with loud snoring – and the cycle repeats. An individual with sleep apnea should consider the severity of nasal stuffiness in treatment of the disease. Often nasal and sinus surgery is performed on individuals with sleep apnea and stuffy nose. Not all patients with excessive weight experience stuffy nose. Modern medicine has difficulty identifying the association of weight with nasal congestion as the association is based on history only. Few tests prove the relationship, and most physicians feel there is no relationship. In my practice, I believe obesity is the most common association with incomplete relief of symptoms after sinus surgery. However, I don’t know how to associate the two with absolute certainty. Weight loss often helps relieve nasal obstruction, but how do we prove this?
Dr. Knox Answers: Pain does not show up on a blood test, biopsy or x-ray. All headache management requires a thorough history, elimination of serious diseases, then a trial of avoidance or medications. The history of pain type, location, duration, and associated symptoms will allow a diagnosis more often than any CT or MR scan. Physicians are trained to exclude disease better than to prevent disease. Why else would we order so many x-rays when evaluating headache patients? I have never seen a patient’s pain on a CT scan, or results of blood tests.
In general, infection doesn’t hurt. Inflammation and swelling may cause nerve compression or stretching. Sinusitis causes headaches in less than 10 % of individuals with chronic headaches. Swollen blood vessels and compressed nasal passages may hurt, but how do we put the two together when pain does not show up on an x-ray? By taking a thorough history, trying to eliminate blood vessel active substances such as caffeine and nicotine, and a trial of symptomatic therapy.
If a strong association between nasal congestion, runny nose, and headaches is noted, the pain may be due to sinus disease. However, most of the time, pain is due to swelling – not infection. Antibiotics give little relief of pain in most circumstances. “Whatever helps the swelling, helps the pain.”. Always shrink the blood vessels first when treating pain.
A sinus infection is best viewed as a head cold that won’t get better. A headache is not sinus until proven otherwise. Two rules to live by.
Saying all of this, however, I have seen many patients cured of “migraine” headaches by decompression sinus surgery. Deciding which patients benefit – before surgery, is the real challenge. Seventeen year’s of “practice” have not given me the wisdom to predict. Headaches that don’t respond to therapy warrant radiographic evaluation, and a doctor-patient relationship centered on trust and new theories.
Poor sleep is probably the most common reason for pain in America. How do we make the association? History and judicious theorization.