What Makes Chronic Sinusitis “Chronic”?

Chronic rhinosinusitis (CRS), more commonly known as chronic sinusitis, is a challenging disease for general practitioners. This is partly because of its poorly understood pathophysiology and limited treatment options, which remain to be mostly antibiotics. It affects approximately 35 million adults and 6 million children. Chronic sinusitis is when a patient suffers from symptoms more than 12 weeks per year. It is also common for patients to return to a physician multiple times when 1st and 2nd line antibiotics do not work. [1]

When experiencing chronic sinusitis, it is difficult to understand why the infection reoccurs so often, even after multiple antibiotic treatments and/or surgery. One reason for this is the possible co-infection of a virus or the colonization of fungus in the sinuses. In 1999, The Mayo Clinic published a study where Allergic fungal sinusitis was diagnosed in 94 (93%) of 101 consecutive surgical cases with CRS. This study was based on histopathologic findings and culture results.

A later publication by many of the same researchers in 2006 focused on the role of airborne fungi in CRS. This paper described the process where fungi trigger an immune reaction in sinus tissue causing inflammation and mucous production. The immune system then reacts to the fungi by deploying eosinophils. The eosinophils are released at levels far exceeding those needed to remove the fungi. This increased inflammation results in damage to the sinus tissue lining [2]. When a disruption occurs due to the immune reaction, damage to the smooth endothelial lining, creates cavities in the sinus. It is these cavities where bacteria (staphylococcus aureus, locally found on the skin, hair, and in the nose) binds to the surface of the fungi. This creates a protective matrix around the fungi, called biofilm. This matrix attracts additional bacteria and pathogens.

Internal demonstration of sinusitis.

The Chronic Sinusitis Cycle

Chronic sinusitis often occurs when the good and bad bacteria and fungi become opportunistic when irradiated. Once a patient is diagnosed with sinusitis, they are treated first line with antibiotics. Often, physicians will not culture the sinuses and will prescribe broad spectrum antibiotics. These potent medicines will kill both the infectious (bad) bacteria and fungi neutralizing (good) bacteria. This creates a fertile environment for fungi infection to get its footing. Patients may receive some temporary relief after a few days; however, it can be followed by another full symptomatic episode of chronic sinusitis.  At this point, many physicians elect to perform surgery. Antibiotics are prescribed prophylactically post-op to prevent any bacterial infections and the cycle continues.

Biofilm and Chronic Sinusitis

A biofilm comprises any consortium of microorganisms (bacteria and fungi) in which cells stick to each other and sinus tissue cavities. These adherent cells become embedded within a slimy extracellular matrix. The sticky extracellular matrix protects the bacteria and fungi from the immune system and antibiotics. [3]

According to the National Institutes of Health (NIH) about 65% of all microbial infections, and 80% of all chronic infections are associated with the presence of biofilms. Biofilm formation is a multi-step process starting with fungal or bacterial attachment to a surface, and then to the formation of a micro-colony that leads to the formation of three-dimensional mature and ultimately diverse pathogens. During biofilm formation, many species of bacteria can communicate with one another to form a communal barrier against challenges to their well-being. Thus, bacteria in biofilm are less accessible to antibiotics and the human immune system.

Biofilms Can Become Life Threatening

Biofilms pose a bigger threat to public health as they are involved in an ever-growing variety of infectious disease resistances. Distinct pathogens such as staphylococcus aureus and aspergillus can coexist in biofilms. [4] For these reasons, treatment for CRS using antibiotics may provide temporary relief, but will not fully penetrate and dissolve the remaining biofilm. As soon as the antibiotic course is completed, the bacterial and/or fungal infection that is still present will become recalcitrant or chronic.

The fungal presence in biofilms also allows for “in -vivo” mycotoxin production, meaning that mycotoxins are being actively produced within the biofilm and within the host’s body. To support this, science has shown an increase of the mycotoxin, Gliotoxin, from Aspergillus fumigatus biofilm formation in the sinus. [5] Increased gliotoxin production makes biofilm-related sinus infections particularly difficult to treat.

Systemic mycotoxicosis occurs when mycotoxins, secondary metabolites are present in the sinus mucosa. Because fungal sinusitis poses the risk of mycotoxin production in biofilm deep in the sinuses, adjacent to the cerebral spinal fluid and the brain, cognitive dysfunction can likely continue as the biofilm matures. It then disburses particles into the sinuses and the brain. Brain fog, headaches, memory issues, motor function issues throughout the body, dizziness, etc. may not ever go away while biofilms remain in the sinuses.

Treatment and Prevention

The single most effective treatment for chronic sinusitis and allergies is the frequent rinsing of the sinuses. This becomes more effective when adding a natural antimicrobial like Agrumax to the rinse. The physical action of rinsing the sinuses with saline 2 times a day will physically remove mold spores and debris from the sinuses.  Using a nasal rinse system is much more effective than a neti pot. While a neti pot uses gravity to help rinse away mucous, nasal rinse systems, such as the SinuGator, will employ other physical properties for a “pressure wash” effect in the sinuses.

An analogous example to illustrate the concept of using nasal irrigation to prevent biofilm development in the sinus is brushing and flossing your teeth to prevent the formation of plaque. [7] The mouth hosts a variety of bacteria. Plaque is actually a formation of a biofilm on the teeth. Brushing your teeth and flossing 2 times per day are the preventative activities we perform to prevent dental disease and maintain mouth health. These activities, like nasal rinsing, stop the formation of biofilm BEFORE it occurs.

Tips to Finding an ENT That Will Listen

Many patients suggest to their ENT that mold might be their issue. This suggestion often finds an unsympathetic ear and a dogmatic opinion as it may be interpreted as trying to tell them how to practice medicine. This is frustrating. Why many physicians do not recognize mold is another discussion that centers on their lack of training. Simply Googling “ENT and fungal sinusitis” will provide local candidate suggestions that you can call in advance.

Another solution for patients is to call a local “Compounding Pharmacy”. You can ask the pharmacist which local ENT physicians prescribe special nasal sprays (Amphotericin B) in drops or nebulization. ENTs who treat chronic fungal sinusitis will often prescribe antifungal medications to kill the fungi; however, some antifungals are very toxic compounds if metabolized by the liver.

The clever approach is using these antifungal compounds “topically” inside the sinuses. This prevents large amounts of the molecule from entering the blood system. Doctors must have these prescriptions specially made in a compounding pharmacy, and there is no violation of any rules or laws for a pharmacist to provide a patient with this information, since no personal patient information is being solicited from or provided for such an inquiry. Physicians having antifungals compounded for patients are more likely to already treat fungal sinusitis given the specific use of the product. This also saves time and money.

In addition to sinus rinsing, it is always beneficial to take care of your home environment.  Change HVAC air filters often and clean your home with non-toxic products.

• Using CitriSafe Remedy Mold Spray to clean surfaces
• Washing clothes with Citrisafe Remedy Laundry Detergent
• Burning CitriSafe Air Purification Candles to remove mold spores from the immediate environment where you spend most of your time.

1. Ponikau, Jens, M.D. et. al. “The Diagnosis and Incidence of Allergic Fungal Sinusitis”.  Mayo Clinic Proceedings. October 1999.
2. Ponikau, Jens, M.D. et. al. “The Role of Ubiquitous Airborne Fungi in Chronic Rhinosinusitis (CRS).” Clinical Reviews in Allergy and Immunology, Vol. 30, 2006.
3. Jamal, Muhs “Bacterial Biofilm: Its Composition, Formation and Role in Human Infection”.  Research & Reviews: Journal of Microbiology and Biotechnology.  July 20, 1915.
4. Granillo, Adrian. et. al. “Antibiosis interaction ofStaphylococcus aureus on Aspergillus fumigatus assessed in vitro by mixed biofilm formation”. Biomed Central Microbiology. February 2015.
5. Bugli, Francesca, et.al. “Increased production of gliotoxin is related to the formation of biofilm byAspergillus fumigatus: an immunological approach” Pathogens and Disease. April 2014.
6. Fastenberg, Judd, et. al. “Biofilms in chronic rhinosinusitis: Pathophysiology and Therapeutic Strategies.” World Journal of Otorhinolaryngology and Neck Surgery. May 5, 2016.
7. Chen, Ingfei. “The Best Treatment for Sinus Complaints” New York Times. May 25, 2011.
8. Kern, Eugene, et. al. “Diagnosis and treatment of chronic rhinosinusitis: Focus on intranasal Amphotericin B.” Therapeutics and Clinical Risk Management. 2007(2) 319-325.