Still, it is questionable whether this justifies the use of ephedrine or any of the vaso-constrictors in an acute infection of the nose. If the process of repair or inflammation in an infected area be considered, it will be remembered that the first change is an increase in blood supply to the part to bring up anti-toxins and white blood cells to neutralize the poisons produced by the bacteria and to devour the bacteria and destroyed cells. Now, if the vaso-constrictors are used to prevent the increased amount of blood, natures greatest protective mechanisms has been interfered with.
In the case in which there is complete retention of secretions within the nose, or lack of drainage when a single daily shrinking might be permissible. And, it is definitely known that the excessive use of vaso- constrictors will cause a paralysis of the vessel walls, thus increasing the swelling and interfering with the movement of the blood streams. In spite of all the propaganda, there can be no other logical conclusion that vaso-constrictors have a small place in the treatment of acute colds.
The only excuse for using vaso-constrictors in the nose, is that it will increase the breathing space and there are certain people that become panicky when there is the slightest obstruction to the breathing. But when these drugs are used, let it be remembered that a symptom is being treated at the expense of the disease.
Then the question of a sinus disease. There is no place in medicine where more confusion and misconception has arisen than in sinus disease. To the rhinologist, sinus disease implies an infective focus within the sinuses. While allergy of the nose and vaso-motor disturbances, while they involve the sinuses, are not considered sinus disease.
It is to be regretted that the term sinus disease ever was created. While such a condition does exist, many symptoms that are due to entirely different causes have been laid to sinus disease. This is due, in fact, to a lack of thorough understanding of the physiology and pathology of the nose. More real enlightening work has been accomplished along this line in the past decade, than during all previous time.
In a sense, it is so new that the rhinologists are not all enlightened, and medical men as a whole, have no idea what it is all about. Then, to add to the confusion, it is the popular disease in society, and all kinds of nasal symptoms have been treated by all sorts of physicians and pseudo-physicians, by all imaginary methods. It is impossible to explain in detail etiology of all the symptoms attributed to sinus, but some clarification is in order.
The symptoms most frequently attributed to sinus disease are nasal discharge, nasal occlusion, headache and neuralgic pain, cough, recurrent and continuous colds, and all the conditions secondary in to focal infection. While all these may be present in infected sinuses, none of them are consistently symptoms of that infection.
Patients are constantly coming and being sent to the office, saying they have; :sinus disease,” because they have an intermittent or continuous discharge, either posterior or anterior from their noses. There are many causes for nasal discharge. First of all, the nasal cavity is a moist cavity. It is lined by a mucous membrane that secretes mucus, having a continuous layer over the entire surface, to temper the inspired air and to filter out foreign materials. Some people just have more mucus in their noses than others.
Some are exposed to extreme degrees of temperatures, humidity, and dust, and it is a normal function to have an increased amount of secretion for protection against these conditions. Consequently, all excesses of secretion are not the result of pathology at all, but are simply an over functioning of a protective mechanism. Persons with a disturbed endocrine balance with resulting vaso-motor changes, tend to have an increase of secretion. Allergic disease in the varied degrees of intensity, is a very frequent cause of increased discharge.
In acute allergic attacks, there is a profuse watery discharge; in the more chronic cases, the discharge is more tenacious and drains posteriorly and is apt to be in chunks of egg white consistency. If it has laid in the nose some time, it may be somewhat opaque. This seems to be the most frequent cause of excessive non-purulent post nasal secretion. An excessive amount of tears drained into the nasal cavity will increase the secretion. There may occur meningeal fluid in the nose. And, of course, purulent secretion from the nose indicates a pyogenic process somewhere in the lining of the nasal cavity or its accessory sinuses.
Nasal occlusion may be the result of deformation of the bony framework or from increase in thickness of the soft tissues. The soft tissues may be swollen due to endocrine vaso-motor disturbances, allergic reactions or inflammatory reaction. In chronic rhinitis, inflammatory swelling is not the rule unless accompanied by allergy. In fact, maxillary and frontal infections are more usually found in the open side of the nose.
HEADACHE AND NEURALGIA PAIN.
There are some three hundred conditions that may cause headaches, but still nearly all headaches are at some time blamed upon sinus disease. It will be much easier to discuss the pains resulting from nasal conditions than all those that are not. Any pressure within the nose, be it caused by framework contacts or soft tissue pressure, may cause headaches. Thus, a septum infringing a turbinate may cause pain. Still, except in acute extensive inflammation of the maxillary sinus, in most inflammation of the frontal which has the characteristic midday pain, and involvement of the sphenoid in which the pain is of the atypical fifth nerve neuralgic or Sluder syndrome type pain, pain is not especially the rule in nasal affections.
COUGH.
Whenever there is an excess of secretion draining post nasally and accumulating in the pharynx or bronchial tree, there will be a cough. The secretion may be purulent or of the allergic type. In fact, if the nasal affection is allergic, the cough may be of the asthmatic type, rather than direct irritation of the secretions.
RECURRENT AND CONTINUOUS COLDS.
Many people present themselves and say that they have a sinus headache or a sinus attack with a history of having no cold or nasal discharge. This is utterly impossible. But, on the other hand, others complain of very frequent or continuous colds with constant occlusion and discharge. Frequent acute nasal infections may not all be the result of chronic sinus disease, but may be suggestive, particularly if the cold never entirely recovers. But care should be taken to determine whether the condition is characterized by a purulent or watery discharge. The condition may be a chronic allergic attack with acute exacerbations.
FOCAL INFECTIONS.
Considerable controversy exists over the degree of toxic absorption from pyogenic sinuses. If practical observation is of any value, there are cases of focal infection in the sinuses, producing lesion in the other parts of the body. Still, patients with a very marked infection of the maxillaries have been observed for years without the resultant diseases accredited to focal infection. Probably sinus infections are much less dangerous than infected teeth and tonsils.
Chronic purulent noses with polyps and perhaps asthma, just plain chronic purulent noses, and polyposis of the nose without purulent discharge, perhaps with asthma, presents a real nasal problem in both diagnosis and treatment. A colleague, who is a chest specialist, frequently sends me this type of a patient. The patient has a frank asthma with a nose filled with polyps with or without purulent discharge.
His x-ray of the sinus shows them to have thickened lining. He asks that I clear up the sinuses to relieve the asthma. What is the pathology chronologically? Did this patient first have a purulent infection of the nose, then develop a bacterial allergy that produces the asthma or was the patient allergic to some extrinsic proteins which produce the asthma and the polyps. The sinus x-ray will show a thickened lining of the sinuses regardless of whether there is an infection of the nose, or an allergic reaction. Either condition may exist.
If the infection is primary and the allergy secondary, probably the infection should be attacked radically and supporting desensitization used. But if the allergy is primary, surgery, except to remove the polyps for the sake of breathing, is absolutely useless. And in the former condition, it is no easy task to clear up an infection in the presence of an allergic reaction. Too, another situation sometimes arises as exemplified by a patient under my observations. The patient had a severe maxillary infection which was very slow in recovering fully. It finally became chronic and frequent lavages over a period of three years, did not improve the condition.
The patient eventually stopped smoking cigarettes and immediately the sinus became normal. The explanation is this. The patient acquired a mild bacterial allergy from the infection, which delayed the recovery, but as happens frequently, the bacterial allergy subsided and a sensitiveness to the cigarette smoke developed. It was this sensitiveness that was keeping the sensitized tissue irritated. When the cigarette smoke was removed, the whole process was quiet. Cigarette smoke is only one allergen. Any other inspirator or ingested protein may do the same thing.
