Your Sinuses: Their Care and Feeding

Your sinuses rank high on the list of body parts which serve no apparent purpose (which includes the appendix and the hair that grows on the ears of old men). There have been many suggestions, such as humidifiers, excavations that lighten the skull, and others- none really explain why these cavities really develop.

But, useful or not, your sinuses are right there, as plain as your face- in your cheeks and your forehead, between your eyes, and in the back of your nose. And, while they are mostly silent, when sinusitis does develop, they can cause a great deal of discomfort.

This column will deal with how to keep those sinuses quiet, how to avoid sinusitis, and what to do should sinusitis develop.

There is one single feature that every healthy sinus needs- an open an unfettered connection to the nasal cavities. Sinuses develop as outpouchings from the nose, and this connection must be kept open and clear to avoid sinusitis. Like the nose, both the sinuses and these connecting passages are lined by mucous membrane which may become covered by secretions, swollen or infected. So the first rule of healthy sinus maintenance is: keep these connections clear!

Nasal irrigation has over the last 10 years become almost routine for most singers. The Neti Pot used for hundreds of years by yoga practitioners ("neti" apparently means "nose" in Hindi) and its various avatars, such as the NeilMed device, and the WaterPik type irrigators all work in a similar fashion- they mechanically wash the mucous membrane surface of the nasal cavities, removing mucus, dust, pollen and other debris. While the saline water doesn't normally enter the sinuses, the stream does pass by the sinus openings, and helps to keep access to the sinuses unimpeded. Contrary to what some might think, simple saline sprays (such as Ocean Mist, Ayr, or Simply Saline) do not work nearly as well- while they do help to moisturize the mucous membranes, they lack the mechanical force to wash away particulate matter and debris.

It is usually recommended that the saline solution used be isotonic - that the salt concentration in the solution is the same as that found in normal tissue fluids. This means that during the irrigation there is no osmotic pressure on the tissues, i.e. there is no net transfer of fluids into or out of the mucous membrane. Isotonic saline (also called "normal" saline) has a 0.9% sodium chloride concentration. Anything less than that (hypotonic) will create a sensation of burning during the wash. Higher concentrations (hypertonic) of saline can be used to draw fluid out of nasal tissues and reduce swelling- but this also comes at the price of a burning sensation. To obtain the right concentration of salt, you can either buy them in packets with the NeilMed device, or just add about 1/2 to 2/3 teaspoons of kosher or sea salt to a Neti Pot filled with lukewarm water. Since recent newspaper reports of "brain eating amoebas" in Louisiana, it is recommended that you boil the water before irrigating, but in fact this is not a real issue in most cities with a clean water supply.

If the preparation is too daunting or time consuming, consider buying large bottles of "normal saline". which is also used for IV infusion or bladder irrigation- these have the double advantage of having the correct concentration of salt, and sterile preparation. Check with your pharmacy to see whether this is available or can be ordered.

Nasal irrigation should not be reserved for allergy season only- it is a four season activity! In the warm months, it removes pollen and other seasonal allergens from your nose, reducing the incidence of allergic rhinitis and sinusitis. In the cooler seasons, it washes away perennial allergens (such as dust, dust mites and animal dander), and moisturizes the lining of the nose dried out by heating in your home. For the nasal cilia to work effectively, the mucous membrane surface should be moist and free of debris, all year round. And if you also use medicated nasal sprays (either steroid or antihistamine type), washing your nose before spraying has the added advantage of cleaning the mucous membranes, which makes the spray more effective.

When prescribing such sprays (usually for nasal allergy), I usually tell my patients to irrigate the nose first, then blow hard- only then should they apply the prescribed nasal spray.

What if your saline irrigation doesn't work? If you find that the saline passes through one nostril easily but doesn't easily come out the other side, you may have a deviated septum. Another clue is when a routine cold routinely lingers or progresses to sinusitis. This sort of structural obstruction, whether from a deformed septum, enlarged turbinates, or nasal polyps, may need to be identified by your doctor. Not all such obstructions require surgery, but if the blockage causes symptoms, including recurrent sinusitis, it may need to be corrected.

While saline irrigation has a beneficial effect on the nose and its connections to the sinuses, inhalation of humidified air reaches even more of the mucous membrane surface. The only manoeuvre however that directly moisturizes the lining of the sinuses is adequate oral hydration- yup, the good old 8 glasses a day of water! This is because the connections between the nose and sinuses are quite narrow, and neither irrigation or steam inhalation will pass freely through them.

Of historical interest- in the old days, otolaryngologists did wash the sinuses directly. This could be done either by filling the nose with saline and then tipping the patient's head backwards or sideways to let the air in the sinuses come out and be replaced by saline (Proetz displacement method), or, when clinically necessary, inserting a cannula or needle through the nose directly into the sinus and flushing saline into the cavity using a syringe. This technique was useful, if uncomfortable, and was mostly done for the maxillary (cheek) sinuses only.

Do sinuses play a role in singing? The short answer is no, but, as always, the complete answer is more nuanced. While sinuses don't affect the sound you produce, they do play some role in the "mask" sensation you experience during singing. It is the nasal cavity, rather than the sinuses, that is more important in both these respects, as any singer will tell you after correction of a badly deviated septum.

There is one final point to be made, and it is an important one. While sinus CT scans may help to identify infections or other important medical problems, a great number of abnormalities seen on sinus CT scans have no clinical significance. These include isolated cysts or small polyps, thickened sinus lining, or even at times a completely cloudy sinus. So, if your sinus CT is abnormal, ask your doctor to correlate the radiologic findings with your symptoms. Unless there is a concern about serious disease (such as fungal infections or tumors), sinuses should only be operated on if they cause clinically significant symptoms that don't respond to good medical therapy.

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