Sinusitis: Antibiotics or Herbs?
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Sinusitis: Antibiotics or Herbs?





The Infectious Disease Society of America advises against the routine use of antibiotics for acute sinusitis, because most cases are viral [i]. 






Symptom relief for viral sinusitis include hydration, Tylenol or NSAIDS, warm or cool compresses & steam inhalation; topical decongestants, steroids, and anticholinergics. There is inconsistent evidence that zinc, or vitamins C and E help. And there is poor evidence for the benefits of saline spray & irrigation, and antihistamines.  Decongestant use can precipitate sinusitis with 25% of allergic rhinitis sufferers at risk. Oral antihistamines should be avoided (restricted to allergic rhinitis). While very effective for allergic rhinitis, steroids may in fact increase the viral load associated with viral sinusitis.

How does one determine if sinusitis should be treated with symptom relief for a viral infection, antibiotics for a bacterial infection, or Chinese herbs for either one? These are important questions because untreated, partially treated or inadequately treated sinusitis may lead to worse problems. For example, approximately 75% of orbital and peri-orbital infections are due to sinusitis [iv]. 

Viral sinusitis usually lasts less than 4 weeks [ii] and usually follows a common upper respiratory infection. It may turn into a bacterial sinusitis in 2% of all cases. The probability of bacterial sinusitis increases with the number of the following symptoms that are present [iii]:

  • * fever at 102 F  (39 C) or higher with dehydration
  • * tooth pain
  • * pain upon position changes
  • * yellow-green mucous  (viral mucous may be clear-yellow)
  • symptoms unimproved over 10 to 14 days without treatment
  • symptoms worsening, with or without treatment
  • one-sided sinus tenderness/pain
  • lymph node swelling
Other symptoms can include:
  • anosmia (decreased sense of smell)
  • headaches
  • bad breathe
  • fatigue
  • ear pain/pressure
  • loss of appetite
Serious symptoms to follow-up on:
  • chills
  • palpitations
  • dizziness/ vertigo
  • weakness, numbness & tingling
  • eyeball redness
  • swelling around or drainage from the eyes
  • alteration in vision such as sensitivity to light

COMPLICATIONS OF SINUSITIS
Complications require prompt medical attention. They prolong suffering & medical expense at their least; and are potential emergencies at their worst. However, the  risk for these complications is rare to low:

  • Chronic Sinusitis. Low risk. Inflammation of the paranasal sinuses lasting more than 12 weeks. Treatment may include endoscopic sinus surgery for patients unresponsive to medical treatment [v]. Acute vs. chronic sinusitis are generally caused by different bacteria. So the antibiotics used for acute sinusitis (e.g streptococcal)  may not be effective for chronic sinusitis (e.g. staphylococcal) [vi]. Chronic sinusitis persists 2 weeks after an acute episode and lasts > 12 weeks. Chronic sinusitis is generally bacterial, and can be asymptomatic or mildly symptomatic. 

  • Cellulitis. Low risk. An infective process affecting the muscles and fat in the posterior orbit, to the orbital septum. The eyeball itself is not affected. It is usually due to underlying bacterial sinusitis [v].

  • Cavernous Thrombi. Low risk. The cavernous sinuses are not nasal sinuses but rather adjacent cavities that house blood vessels and nerves that govern eyeball, pupillary, and eyelid movement, as well as facial sensation, and movement. The most common cause is acute sinusitis. One eye is typically affected first, followed by the second eye within 48 hours. Antibiotics should be started immediately because they have the greatest effect on prognosis. And it must be differentiated from meningitis [v]. 

  • Bone Abscess. Low risk. Incidence is unknown, but common enough to require familiarity with it. Patients with an abscess >2 cm and age >9 years are more likely to require surgery [v].

  • Meningitis. Low risk, rare but serious. Most commonly affects those <5 years and >60 years old because of immature or waning immunity respectively [v].

  • Brain Abscess. Low risk, males <30 are at highest risk for this urgent condition that requires early recognition and intervention. The prognosis is closely related to neurologic status at presentation [v]. Nearly half of patients with intracranial complications of sinusitis present with orbital cellulitis or abscess [vi].

ANTIBIOTICS OR CHINESE HERBS?
Antibiotics are NOT going to be effective for viral sinusitis, but may be prescribed to prevent secondary bacterial infection. The type of antibiotic used depends on the bacteria most likely implicated [the epidemiological risk factors]. Whether the problem is acute, subacute, chronic, or recurrent. As well if antibiotic resistance, or immunodeficiency exists. There is also fungal sinusitis, which requires medical attention.

Chinese herbs can be used for,  (1) a viral or bacterial infection, (2) reluctance to use antibiotics, (3) symptom relief, and (4) to prevent progression of viral to bacterial sinusitis. You may use antibiotics in conjunction with herbs, but they may help or hinder the antibiotics.

Chinese medicine doesn't differentiate sinusitis as viral vs. bacterial, but rather by the pattern of symptoms a person presents with. A pattern includes Western medical symptomology (e.g. cough, fever, color of discharge)  plus tongue & pulse diagnosis. These reveal for example Wind-Heat, Cold, Damp, or Blood & Qi stagnation. Further, certain channels, and organ systems are involved (Lung, Gallbladder or Spleen). Jim McDonald (Western herbalist) differentiates sinusitis in a similar way- by “tissue states” that include hot (increased activity), cold (decreased activity), damp (congestion), dry, relaxation (laxity) and constricted (tension & spasm). 

Many Chinese herbs are anti-microbial against either bacteria, virus, or both. For example, jin yin hua & lian qioa are antiviral, ban lan gen & da qing ye are anti-bacterial [Chen, n.d.]. Ban Lan gen is also the herbal basis for sulfa antibiotics [Chen, n.d]. Some herbs are valued for their potency against specific organisms. For example, star anise is the basis for Tamifu, a drug used for Avian flu [Chen, n.d]. Some herbs synergistically moderate harmful inflammatory responses, or mediate beneficial immune responses (a few antibiotics can do this too). These herbs create a terrain in which the problem, or another problem is less likely to occur. Inharmony, they clean-up metabolic debris created by a disharmony and/or from correcting a disharmony. Ultimately, herbs clear the way for the body to heal itself.

CHINESE HERBAL FORMULAS FOR SINUSITIS
PREVENTION IS THE BEST MEDICINE. Warm and moist secretions from upper airway mucosa is the first barrier against upper airway infections such as sinusitis. Many of the formulas specifically for sinusitis are not very MOISTENING. Sinus and respiratory problems that are precipitated by "warm or cool dryness" may become worse with some of the more drying formulas. This is particularly the case in high altitude, windy and/or arid regions like New Mexico where the use of moistening, yin nourishing, and jinye [fluid] generating substances are beneficial to prevent sinusitis: 

  • Mai Men Dong Tang is beneficial for asthmatics, who are at 50% increased risk of getting some form of sinusitis. This formulas treats Stomach and Lung yin deficiency with heat. Which in part, means dry mucous membranes of the upper and lower airways and upper GI. This formula is mucoactive, meaning it increases mucocilliary clearance, and is a potent anti tussive. It has a beta-agrenergic affect against airway hyperactivity. It is particularly effective for coughs due to severe allergic inflammation and has a marked anti-tussive effect in asthmatics and non asthmatics.  Large doses [60 to 70g] of the lead herb mai men dong is needed.
 
Warm & Cool Dryness Injuring the Lung
  • Crystal sugar is cool-natured for wind heat symptoms in spring & fall. Spring allergy symptoms can be stirring of unresolved/ un descended Ministerial Fire from the previous winter. Ministerial Fire is supposed to descend into the earth after summer solstice. If it does not descend, the upper Jiao [HEENT area] is heated, leading to red eyes dry mouth, headache etc. The fall is a dry season when steamed Crystal Sugar & Asian Pear can be used to moisten the lung -even more superior when Bei Mur Er  is dded [Kai]. 

  • Warm-dryness: 
Sāng Xìng Tāng/ Mulberry Leaf & Apricot Kernel Decoction 
Qing Zao Jiu Fei Tang 

  • Cool-dryness:
Xing Su San/ Apricot Kernel & Perilla Leaf Powder 
Jia Jian Xiang Su Cong Chi Tang / Modified Cyprus, Perilla, Leaf, Scallion, & Prepared Soybean Decoction.
     
    Exterior Immunity
    • Jade Wind Screen Formula is best used to avoid getting sick.
    • Sielax & Amla / Gooseberry boost immunoglobulin A [IgA]- the main defense of mucous membranes in the respiratory and GI tract, against external pathogens.

    Here are base formulas used for the patterns of disharmony associated with sinusitis. Some of them are sold in health food stores as patents (pills). Companies may produce different versions of each. Pill/patent formulas are prescribed based on individual presentation and can be modified in the form of loose herb, or powdered teas. 

    • Cang Er Zi San is generally the Chinese herbal decongestant. It is the prototype formula for Wind-Heat attacking the head with thick white or yellow nasal discharge and frontal headache. It is also used for Wind-Cold with interior Heat in the muscles. 

    • Xin Yi San is generally the Chinese herbal antihistamine. It is the prototype formula for nasal congestion, profuse watery discharge or continuous postnasal drip due to Wind-Cold. Useful for the common cold with stuffy nose & headache, loss of smell, difficulty breathing. It is effective in the treatment of perennial allergic rhinitis [vii], which is usually due to dust, mites, and mold (vs. pollen). In this case, nasal mucous membranes will appear pale & boggy. All versions contain Xin yi hua/ Magnolia bud, which is the primary herb for sinus problems due to damp-cold. Different versions may focus on either headache, swelling or pain; and may contain mu tong for red eyes and irritability. Xin yi hua/ Magnolia essential oil can be inhaled for quick relief of damp-cold sinus congestion. 

    • Pe Min Gan Wan. Nasal congestion, profuse rhinorrhea, headache pain, and inflammation. Generally for acute allergic rhinitis. A company may produce a version for Wind-Heat or Wind-Cold.

    • Bi TONG Pian / Wan. Nasal congestion, profuse rhinorrhea, sneezing & pain. due to Wind with Phlegm-damp. Generally for acute & chronic allergic rhinitis and sinusitis. It combines aspects of Pe Min Gan (above) with Bi Yan Pian [below]. However, it is distinguished by E Bu Shi Cao [Herba Centipeda NOT the insect] for phlegm-damp as the lead herb always in the "Bi Tong" family of formulas. The Bi Tongs are also antiseptic and decreases sinuses infection & inflammation with Huang Qin. This herb clears all types of heat (especially Wind-Heat and Phlegm above the diaphragm), nourishes yin, invigorate the Qi of the chest, and diminishes Spleen Dampness. Huang Qin is comprehensive for Liver and Gallbladder channels [which traverse the sinuses], and for hypersensitivity or allergic reactions. This formula reduces painful headaches, swelling, and disperses clumping of Heat Toxin or phlegm nodules [adenopathy], if it contains Wu gong (Scolopendra subspinipes).

    • Bi YAN Pian. Nasal congestion with profuse rhinorrhea, sneezing & eye inflammation due to Wind-Heat. Generally for sinusitis, but specifically for eye symptoms, and allergic conjunctivitis. It is an anti-inflammatory yet slightly moistening if it contains wu wei zi and zhi mu. 

    • Bi YUAN Wan. Nasal congestion, thick rhinorrhea, foul-turbid & yellow fetid  rhinorrhea, and possibly fever due to Wind-Heat. Acute/ chronic rhinitis and sinusitis. This formula focuses on polyps (nasal angioma/ polyps) due to chronic blood stasis if it contains qian cao gen (Radix Rubiae).

    • Bai Zhu Fu Zi Tang. Wind-Cold-Damp attacking the channels & collaterals of the head with dizziness, feeling of general head and maxillary sinus heaviness. It is for chronic maxillary sinusitis due to Spleen deficiency. Also, facial myositis, neuralgia, or paralysis [e.g. bell's palsy].

    • Qing Wei San is an example of a formula that might be used for sinusitis secondary to an infection in the HEENT [Head/ Ear/ Eye/ Nose/ Throat] area, Infections specifically due to stomach heat.

    • Example Custom Formula. A colleague recently published a case study in the Journal of Chinese Medicine  in which a patient lost his sense of smell due to chronic sinusitis. His sense of smell was restored with acupuncture plus 2 custom formulas: Xin Yi San (for Wind-Cold) plus Chuan Bei Mu & Gua Lou Shi to soften and moisten dried phlegm. Yi Guan Jian &  Xuan Shen (Scrofularia) to soften swelling and drain heat; and Bo He (peppermint) to soothe the Liver and Gallbladder (whose channels traverse the sinuses).

    FUNCTIONAL MEDICINE
    In Functional Medicine, there are many methods and tests to get to the root of chronic upper respiratory problems, due to immune dysregulation. The best time to nip an upper respiratory problem in the bud is in the early stages. This is a problem because in most cases the symptoms are vague and can go unnoticed (e.g a feeling of chilliness, headache, malaise). This is when to start regulating, not necessarily boosting the immune response [see Influenza & Cytokine Storm).

    TH!:TH2 Immune Responses
    The TH1 immune response attacks virus and intracellular bacteria (e.g. mycoplasma & chlamydia). Substances that boost TH1: Astragalus, Medicinal Mushrooms, licorice, Melissa (Lemon balm), Echinacea, Panax Ginseng, Chlorella, and Grape Seed Extract. If one feels better when taking these herbals it is more likely a viral problem. 

    The TH2 immune response attacks bacteria, and allergens. Substances that boost TH2 [anti-bacterial pathway]: caffeine, green tea extract, pine bark extract, white Willow Bark, Lycopene (in tomatoes and red fruits excluding strawberries and cherries), Resveratrol (found in grape skin, sprouted peanuts, and cocoa), Pycnogenol (found in the extract of the French maritime pine bark and apples), Curcumin (found in turmeric], Genistin (found in soybeans) Quercitin (a flavanoid in onions/ scallions, berries and kale). If one feels better taking these, it is likely a bacterial problem. 

    It is optimal [and safest] to help the body swing back and forth between TH1 and TH2 immune responses as needed. Substances that balance TH1:TH2 [anti-viral & anti-bacterial pathways]Probiotics, Colostrum, Vitamin A, Vitamin E, EPA & DHA. The vitamin D receptor assists with regulating TH1 and TH2. So the point is to support the receptor, not necessarily to supplement with vitamin D.

    Cong Bai Dou Chi San is a Chinese formula that boosts TH2 and balances TH1:TH2- preventive of secondary bacterial infections. This combination of green scallion [quercitin] & fermented soybean [probiotic] is a traditional home remedy for very early stages of an upper respiratory tract infection when one can't yet tell if it is cold or heat in nature- very roughly equivalent to viral or bacterial.


    Integrative Medicine Tip:
    CRP is a protein- an acute phase reactant- that tends to be elevated in bacterial infections AND NOT VIRAL infections, thus an underused lab marker to rule out viral infections and/or rule-in the need for herbal or pharmaceutical antibiotics [Ludell, 2013]. Any elevation of CRP is abnormal, the degree of elevation is important. Persistent low level elevation of 0.5- 7 means chronic/ systemic inflammation linked to cardiovascular disease risk [e.g atherosclerosis]. Whereas levels  >7 is suspect for bacterial infections. The higher the elevation, the more acute the inflammation or trauma. 

    CRP is produced by the liver, and is a non specific marker of cytokines [IL6] production. It is elevated in most but not all cases of inflammation . It is also elevated in specific response to antigen-immune complexes indicating an auto-immune process [Rheumatoid arthritis, lupus, collagen vascular diseases]; methylation pathway defects; cancers. 


    Sources
    Chen, J. [n.d.] An intro to pros and cons of drugs & Chinese medicine. In Lotus Institute of Integrative Medicine.

    Lundell, B. (2013). Holistic Blood chemistry and urinary analysis reference manual.



    1 Comment to Sinusitis: Antibiotics or Herbs?:

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    acupuncture on Monday, February 13, 2017 9:52 PM
    It’s really NICE………… I really like this page so much, so better to keep on posting! Thanks… Acupuncture Sports Medicine
    Reply to comment

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