Is It a Cold, Flu, Allergies or Something Else?

Murray Grossan, MD.  About the author: Dr. Grossan is an otolaryngologist and head and neck surgeon with the Tower Ear, Nose and Throat Clinic at Cedars-Sinai Medical Center in Los  Angeles and the founder of the Web based Grossan Sinus & Health Institute (http://www.grossaninstitute.com). He is author of Free Yourself from Sinus and Allergy  Problems Permanently.

How to tell what it is and the best way to treat it:

Sniffling, sneezing and wiping your eyes? You might assume you have a cold…but not so fast! These symptoms also can come from the flu, allergies, something similar to an allergy, or even from something else entirely—sinusitis! Telling these five conditions apart can be tricky, even for doctors, but knowing the difference is the key to getting the most effective treatment.

COLDS

Colds can be caused by more than 100 different viruses. Your symptoms will depend on the specific virus you are infected with.

TELLTALE  SIGNS: In addition to common cold symptoms such as sneezing, a sore throat, congestion and/or a cough, you may also have a low-grade fever, mild body aches and aching, swollen sinuses. Symptoms usually last a week or two.

My favorite cold remedies: Get into bed and rest! Chicken soup, hot soups and decaffeinated green tea with lemon and honey may help, as chicken soup and green tea have anti-inflammatory properties that help fight infection. If you can, watch a funny movie. Some research shows that laughing promotes healing. If you need help sleeping, try 3 mg to 10 mg of Melatonin, an over the counter sleeping aid.

For an immune-boosting herbal cough syrup: Mix one-half teaspoon each of cayenne pepper and freshly grated gingerroot, two tablespoons each of honey and apple cider vinegar and four tablespoons of water. Take one teaspoon every few waking hours.

THE FLU

The flu will make you feel awful.

TELLTALE SIGNS: Symptoms can be the same as a cold, but you will have significant body aches and probably a fever. The flu also comes on more suddenly than a cold.

My advice: Get a flu shot once you have recovered, or in advance. If you still come down with the flu, stay home for at least 24 hours after any fever is gone so you will not spread the virus. Adults over age 65 and those with any chronic health problem should take an anti viral drug such as oseltamivir (Tamiflu) to avoid flu complications including pneumonia. Anti-virals work best if taken within 48 hours of starting to feel sick.

ALLERGIES

Allergic rhinitis (nasal allergy) is caused by a hypersensitive immune system that identifies an otherwise innocuous substance as harmful and attacks it, causing uncomfortable symptoms.

TELLTALE  SIGNS: Nasal allergies can cause symptoms nearly indistinguishable from a cold—congestion, sneezing, red and runny eyes, scratchy throat, etc.—but allergies do not cause the mild fever or achiness of a cold. With seasonal allergies, you get symptoms from exposure to pollen (trees in spring, grass in summer and weeds in fall). Allergies to pet dander, dust, etc., tend to occur year-round.

Helpful: Use a diary to track your symptoms and the times they occur. It will help you distinguish allergies from other conditions.

My advice: Steroid sprays such as fluticasone propionate (Flonase) and azelastine (Astelin) work for most people with less risk for side effects than antihistamine pills. Avoid strong odors and spicy foods, which can worsen nasal allergies.

NONALLERGIC RHINITIS (Vasomotor Rhinitis)

This condition causes virtually the same symptoms as allergies, but is not a true allergy that involves the immune system. Non-allergic rhinitis is triggered by specific irritants such as certain odors, smoke and exhaust— or even changes in the weather.

TELLTALE SIGNS: With nonallergic rhinitis, standard allergy medications fail to relieve symptoms, and allergy tests are negative. Postnasal drip (an irritating flow of mucus down the back of the throat) tends to be worse with nonallergic rhinitis than with seasonal allergies.

My advice: Avoid irritants that you are sensitive to and consider using the prescription drug Ipratropium Bromide (Atrovent), an inhaled nasal spray that helps relax and open air passages. This drug can cause side effects including dizziness, so use it only when needed and at the lowest dose possible.

SINUSITIS

Sinusitis is tough to diagnose because it often occurs in conjunction with colds and allergies because of excess mucus from congestion providing an optimal breeding ground for bacteria and viruses.

TELLTALE SIGNS: Congestion accompanied by tenderness and a feeling of pressure around the eyes, cheeks or forehead. In addition, when you blow your nose, the mucus will usually have a yellow or greenish color. Fever may be present as well. Symptoms can last for several weeks (acute) or even longer (chronic).

My advice: Prescription nasal sprays such as TK  help open the airways. Acetaminophen (Tylenol) or naproxen (Aleve) work for sinus pain. Bromelain (from pineapple) and papain (from papaya) also help reduce pain. Antibiotics are not always needed for acute sinusitis.

Natural Remedies for All Sinus Problems!

Nasal cilia (tiny hairlike strands) help clear mucus from the nasal cavity. Slow-moving cilia can lead to nasal and sinus irritation and congestion.

To stimulate cilia:

 Hum. It may sound far-fetched, but the vibrations from humming break up and thin accumulated mucus. Patients of mine who hum for a few minutes several times a day tend to get fewer sinus infections.

Keep the nose moist by using a preservative-free saline nasal spray such as NeilMed NasaMist Hypertonic Saline Spray, available at Walgreens and online. Do daily irrigation with a NeilMed NetiPot or NeilMed Sinus Rinse.

Stay warm. Cold temperatures can slow the movement of nasal cilia, so wear a jacket, a hat and scarf to keep warm. Additionally, avoid cold beverages and drink hot green or black tea, which contain L- theanine, an amino acid that increases ciliary activity. The excess fluid will also help thin and clear mucus speeding recovery.

For more information, visit:
www.grossaninstitute.com
www.ent-consult.com

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Why Do My Sinuses Still Get Infected After Sinus Surgery

Martin Desrosiers, MD, FRCSC. Clinical Professor. Program director, ORL-HNS Université de Montréal

Patients who have undergone endoscopic sinus surgery (ESS) for management of chronic sinusitis (CRS) with or without nasal polyposis may nevertheless continue to have symptoms of chronic sinusitis and/or episodes of infection despite initially apparently successful sinus surgery. Several studies have shown that even well-performed sinus surgery can have recurrence of nasal polyps after surgery. In a study from Sweden, 50% of patients showed signs of recurrence of nasal polyps as early as five months after surgery.
Despite patient concerns, only rarely this a consequence of technical with performance of surgery. Chronic sinusitis, with or without nasal polyposis, is a chronic disease which reflects changes at the level of the sinus mucosa. While we don’t yet know everything about nasal polyposis, we do know that chronic sinusitis represents an ongoing form of inflammation, and that medication should be used to prevent recurrence of the inflammation. The reasons for this are multiple, and reflect the chronic nature of CRS and the factors underlying its development.

1. Medical treatment needs to be continued medication after surgery. Medication is usually required after sinus surgery to avoid recurrence of disease. If patients are not taking medication In the same study referred to earlier, patients who continued using an intranasal topical corticosteroid spray after ESS delayed return of the nasal polyps by an additional period of several months. Frequently, physicians will attempt to increase the effectiveness of this therapy by using sinus irrigations composed of salt water and corticosteroids mixed together. This underlines the importance of continuing therapy after ESS. and ensuring that you’re following physician recommendations faithfully.

2. The type of underlying inflammation may require treatment with an alternate type of anti-inflammatory therapy. It’s possible that the type of inflammation that drives your chronic sinusitis may be of a type that does not respond well to corticosteroids. Some patients have a form of inflammation which is neutrophilic, as opposed to eosinophilic in origin. Unfortunately this type of inflammation frequently does not respond as well to corticosteroids. While there is no magic bullet currently available for treatment of this condition, physicians will often try and use a alternate anti-inflammatory treatment, such as the macrolide antibiotic azithromycin taken at low doses for a several month period to help regain control.

3. Persistent low level bacterial infection. Another reason that may be at play is a persistent bacterial infection. The bacteria present in chronic sinusitis have a tendency to form a thick, tenacious film called a biofilm, which protects them by ‘hiding’ them from natural defence mechanisms and destruction by white blood cells and making them resistant to antibiotics. This may make these infections more difficult to clear and lead to persistent symptoms and recurrent infections. Occasionally, physicians will use a type of surfactant, or “soap” to try and get rid of these. One homemade recipe for this that is often used is a small quantity of baby shampoo in the sinus irrigation solution. However, this therapy is not for everyone and may carry some minor risks so it should only be used on the position of vice of course.

4. Recurrent viral infections triggering bouts of sinusitis. Exacerbations of your sinus condition may occur following exposure to viruses producing viral upper respiratory tract infections. Patients frequently exposed to viruses, such as daycare workers, elementary school teachers, and certain healthcare workers, as well as parents with children in day care, may have frequent “colds” which may unbalance the delicate balance of their sinus situation, leading to development of acute infection.

5. An underlying immune deficiency. Lastly, if you find your getting sick too often after surgery, there is a possibility that you may have a problem with your immune system which defends itself well against infection. While these conditions are rare, you should discuss this with your physician as specialised consultation and/or specific testing may be required to explore this possibility.

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Cough, your Baby and You—What’s a Parent to Do?

Gustavo Ferrer, MD. About the author: Dr. Ferrer is one of the top pulmonologists in the country, an expert who is often able to cure coughs in patients who have seen a dozen other pulmonologists. He is the founder of Cleveland Clinic’s Cough Clinic in Florida and the author of the Amazon bestseller Cough Cures: The Complete Guide to the Best Natural Remedies and Over-the-Counter Drugs for Acute and Chronic Coughs.

The FDA requires cough medications to be labeled “not for children two and under” because of the potential of overdosing and side effects. In fact – as I explain in my book Cough Cures – most cough medications are ineffective at best and unsafe at worst, even for adults.
In doing the research for my book, I found that people tend to assume that medications in a drugstore have been thoroughly checked by the FDA and that their effectiveness have been documented by research studies. Nothing could be further from the truth. The FDA cannot possibly check the tens of thousands of over-the-counter medications. What’s worse, companies can make all kinds of advertising claims on the front part of the label without having to submit a single research study. Some of the most common cough medicines like guaifenesin have no research supporting their use.
You must be especially wary of combination medications, ones that combine several different ingredients for different purposes. Perhaps one is meant to suppress the cough, another to thin the mucus, and a third to help you sleep. Many combination medicines contain acetaminophen (Tylenol), and it’s very easy to unintentionally take too much in 24-hour period. You have to read the back part of the label and add up how much Tylenol you’re getting in all your different medications combined. The FDA considers 3000 mg a day as a safe level, but I recommend only 1500 mg, because too much Tylenol can cause liver failure and its attributed to hundreds of deaths per year. I still see many patients at the Intensive Care Unit where I work with liver failure from Tylenol, even after the FDA lowered the safe dosage to 3000 mg a day.
Robitussin and other cough syrups contain codeine. It’s a small amount and not enough to cause dependency for short term use. It could be a problem with long-term use however, and the real problem is that teenagers can easily buy enough of it over the counter to get a dependency-forming amount of codeine. If you have teenagers in your house, please go to www.StopMedicineAbuse.org for a long list of all the cough syrups that can be abused by teens.
What about prescription medications? As you probably know by now, the antibiotics prescribed by doctors for coughs, colds and flu are ineffective because these are viral illnesses, and antibiotics only work against bacteria. It’s a common myth that the antibiotics will protect against a secondary bacterial infection. But there is no research evidence that they do, and in fact the World Health Organization has said that antibiotics should not be used to prevent a cough from turning into bronchitis or pneumonia.
So what can we do instead? For adults, who prefer drugstore medicines, the only type I recommend is antihistamines, because they dry up the post nasal drip that causes many coughs. Even then, I teach readers to distinguish between the “first generation” or older antihistamines like Benadryl, which have stronger side effects, and the “second generation” or newer ones like Claritin, Zyrtec and Allegra. If you research the side effects online they are about the same for both types of antihistamines, but they occur less often and are milder with the second generation. The trade-off is that the second generation antihistamines are not as effective, but I recommend starting with them. Only go to a stronger one like Benadryl if the newer ones fails to help. Be wary of “PM” cough medications in which include Benadryl to make you drowsy: sleep doctors advise NOT to use Benadryl as a sleeping aid, because it can increase sleep apnea.
The reason antihistamines work for coughs is their ability to dry up postnasal drip, but there is a better and safer way for everyone in the family. Before you turn to a drugstore medication or natural remedy, the safest way to stop coughs caused by postnasal drip is to use a saline rinse, specifically one administered with a prefilled NeilMed plastic squeeze bottle. As I explain in Cough Cures, the NeilMed system solves two common problems with saline rinses: it has a bulb tip that regulates the flow, preventing the water from coming into the nose under too much pressure; and it slightly alkalinizes the saline solution, so that it does not irritate the sensitive nasal tissues. Fortunately for the harried parent of a coughing infant, NeilMed provides Nasabulb, a special version just for babies.

For more information, visit:
www.GustavoFerrerMD.com
www.CoughCuresBook.com
Amazon: Cough Cures

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The spectre of super-bacteria resistant to antibiotic therapy is once again in the news. Media coverage, (notably in The Economist, a widely read newsweekly) has highlighted that bacteria are increasingly gaining the capacity to be resistant to commonly used antibiotics, and that this will have a serious impact upon human health.
What impact does this have on sinusitis sufferers? Possibly quite a bit.
Acute bacterial sinusitis is frequently caused by the bacteria Streptococcus pneumonia. This used to be easily treated with . However, in 1988 Don Low, a Canadian infectious disease specialist working at the University of Toronto reported the emergence of a penicillin-resistant Streptococcus pneumonia in samples form respiratory tract infections. National monitoring strategies were put in place over the following decade and showed an increase not only in penicillin resistance, but also showed the emergence of resistance to the macrolide class (claritrhromycin (Biaxin™) and azithromycin (Zithromax™)). Further work from Dr. Low and others demonstrated how inappropriate use of antibiotics to treat respiratory infections was responsible for the development of bacterial resistance in Streptococci. As sinusitis is responsible for 25% of all oral antibiotic use in humans, this led to the development of guidelines, both in Canada and internationally, for appropriate antibiotic use in order to minimize risk of development of resistance.
While these had been reasonably effective in Canada, in many other countries, antibiotic resistance to these two agents has reached epidemic levels . Thus, in many places, effective treatment of acute bacterial sinusitis now requires either newer, stronger medications or drug combinations.
Patients with chronic rhinosinusitis (CRS) also have cause for concern. Staphylococcus aureus is frequently implicated in CRS, and antibiotic resistance in S Aureus has been increasing rapidly. While resistance to penicillin by S Aureus was noted only 3 years after the introduction of penicillin, methicllin resistant staphylococcus Aureus (MRSA) are now seen in patients with CRS, particularly those with long standing disease and multiple sinus surgeries. In an additional novel twist, Gram-negative agents such as Acinetobacter and Klebsiella are increasingly resistant to ampicillin, a synthetic penicillin recommended as first line therapy by many guidelines. Thus, clinicians are increasingly required to perform a culture of sinus secretions in order to precisely identify bacterial resistance in patients not responding to initial therapy.
What does the future hold? It’s not hopeless but will certainly require new strategies as new antibiotics may not be an option. While drug companies were previously able to invent new molecules to treat these antibiotic resistant bacteria, this strategy appears to be growing thin and we may be running out of the effective medication to treat these bugs which are easily capable of modifying their genetic makeup to develop resistance strategies.
Novel strategies may instead involve use of bacteriophages, small viruses which attack and destroy bacteria. Or they may instead opt to introduce ‘healthy’ bacteria into the sinuses, in order to drive out replace ‘bad’ bacteria or prevent them from taking hold. In all instances, continued efforts to educate patients and physicians on the responsible use of antibiotics will vital in preventing the further development of resistance.
This column is dedicated to the memory of Don Low, who passed away in 2013 at the age of 68. We miss you Don but your wisdom carries on.

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Green mucus anxiety and managing childhood respiratory events. Part 1: Expectations

Professor Richard Harvey MD PhD. Rhinologist, surgeon and educator. About the author: Professor Harvey leads innovative research into the causes of chronic sinus disease and novel therapies to manage the condition. As program head, Rhinology and Skull Base Surgery, at UNSW and Macquarie University, he is asked to speak nationally and internationally on changing the traditional paradigms in upper airway and sinus care. His research has provided fundamental shifts in the way sinus disease is managed.

As nose and sinus specialist, I’m often asked for advice, by parents, on managing recurrent respiratory symptoms during childhood. The symptoms of nasal discharge, congestion and cough, are common during childhood and may even appear persistent as the break between events is short. While there are some significant medical problems that can produce true ‘persistent’ nasal symptoms, with no return to normal function in between, most respiratory events during childhood are ‘episodic’ and represent part of the normal exposure and immune development that occurs during these years.
Unfortunately, the medical marvel of antibiotic development, which changed the mortality associated with severe bacterial infections such as pneumonia, sepsis and meningitis, is now over applied in our community. There is a growing concern that modern health therapies applied inappropriately and unnecessarily to our population, and especially children, is not only wasteful but harmful to health. A great example of this is the overuse of antibiotics to manage recurrent respiratory exacerbation in childhood. These events are viral and don’t represent bacterial infections. I intentionally avoid the use of the term ‘majority of events’ as this is misleading and an unnecessary ‘disclaimer’ as the number of viral respiratory events that become bacterial and need treatment is much less than 1%. Unfortunately, 50% of children still leave an consultation from a local family doctor with a course of antibiotics1 and while this is an improvement from the 1990’s, when sadly, up to 75% of all antibiotic prescriptions were used on children2, it still remains unacceptably too high.
Mucus production observed by parents drives much of this anxiety3. And, in particular, green or discoloured mucus. As a parent myself, its normal behaviour to want to help our children when they are ill, however, understanding the nature, duration and frequency for these mucus producing events is critical to ensuring that care or interventions we offer our children are both safe, effective and appropriate.
The green color of mucus is produced from myeloperoxidase or MPO. This enzyme arises from white blood cells (neutrophils) and presents 5% of the dry weight neutrophils4. The green pigment iron-containing heme groups within MPO. Neutrophils and MPO are normally expressed (100 fold) during viral respiratory events. Green mucus is not a sign of ‘bacterial’ infection but simply an immune response from our children.
Viral events are common in childhood. Communal day-care, centralised schooling and urban living all provide much closer human contact at an earlier stage in life compared to our ancestors. One of the resulting effects is frequent viral respiratory events, as multiple serotypes are quickly transmitted. The frequency of these events is 4 episodes a year5(Table) and duration of viral events commonly 10 days6. Thus the average ‘healthy’ child should expect to have 40 days or more with respiratory symptoms (and green mucus) as part of their normal immune growth and development.
Over a series of postings we will discuss the expectations, symptom management and prevention strategies for childhood respiratory events.

1. Jansen AG, Sanders EA, Schilder AG, et al. Primary care management of respiratory tract infections in Dutch preschool children. Scand J Prim Health Care 2006;24:231-236.
2. Acute respiratory infections: the forgotten pandemic. Communique from the International Conference on Acute Respiratory Infections, held in Canberra, Australia, 7-10 July 1997. Int J Tuberc Lung Dis 1998;2:2-4.
3. Taylor JA, Kwan-Gett TS, McMahon EM, Jr. Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial. Pediatric Infectious Disease Journal 2005;24:489-493.
4. Schultz J, Kaminker K. Myeloperoxidase of the leucocyte of normal human blood. I. Content and localization. Archives of Biochemistry & Biophysics 1962;96:465-467.
5. Leder K, Sinclair MI, Mitakakis TZ, et al. A community-based study of respiratory episodes in Melbourne, Australia. Aust N Z J Public Health 2003;27:399-404.
6. Lambert SB, O’Grady KF, Gabriel SH, et al. Respiratory illness during winter: a cohort study of urban children from temperate Australia. J Paediatr Child Health 2005;41:125-129.

Follow Dr. Harvey on social media
YouTube: https://www.youtube.com/channel/UCT5IlPYouT2x-zpsK-bt8Bg
Facebook: https://www.facebook.com/ProfRJHarvey
Website: http://www.richardharvey.com.au/

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