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Health Query
I have a chronic sinusitis, I wash my sinuses with saline water, take symbicor, prednisone I was down to 5mg/day and
when I have episodes I go to 40 for 3 days and down to 30,15 and 5 cannot get rid of the sinusitis which I feel has an
action on my asthma, what would you suggest ?

I am a male, 36 years. No medical history of other chronic diseases.

- David (Name Changed for confidentiality)

Specialist Opinion by Dr. Bhatti, Certified Otorhinolaryngologist

Hi David,

Thanks for the query. I had gone through the details.

I would recommend the following:

 Get a plain CT PNS (Para nasal Sinuses) on a multi-slice CT scan machine with 1 mm coronal, axial and
sagittal cuts done. It is not possible to look into the sinuses even with nasal endoscopy. The CT will show
signs of chronic sinusitis, nasal obstructions like DNS, polyps and enlarged turbinates due to hypertrophy or
concha formation.

 List all your symptoms in chronological order along with your patient profile such as age, history, previous
investigations, treatment, any co-existing disease besides asthma, any known allergies, drug sensitivity.

 Undergo a nasal endoscopy. It can help differentiate between infection, allergy or vasomotor (intrinsic)
rhinitis besides ruling out obstruction, polyps and turbinate hypertrophy.

 If you are preparing the saline solution at home

I. I will recommend that you use Normal Saline 0.9% which is used for I V infusions.
II. Household salt may contain anti-caking agents and too strong or too weak a solution will damage your
delicate nasal mucosa.
III. If you still want to prepare the solution at home prepare a mixture of Sodium bicarbonate (loosens
crusts) 50 gm, Sodium biborate (antiseptic) 50 gm, Sodium Chloride (for isotonicity) 100 gm and then
add 1 teaspoon to 300 ml luke warm water.
IV. Another option is to add a pinch of baking soda to a pinch of common salt, + luke warm water,
V. Attach a piece of rubber catheter to a 20 cc disposable syringe. Keep your head bent forwards and
downwards, mouth kept open while performing this alkaline nasal douche.

 Undergo a blood test to rule out eosinophilia. Do you have a history of acid reflux ? GERD (Gastro-
Esophageal Reflux Disease) makes the airway more sensitive.

 Avoid exposure to tobacco, smoking or second hand smoke, as the case may be. Avoid aspirin (Samter's
Triad).

 You are correct in linking the chronic sinusitis to exacerbations to your attacks of asthma. The concept of
'one airway one disease' is widely accepted and the control of chronic sinusitis will help reduce the severity
of asthma.

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 You are already on Symbicort which is a combination of inhaled budesonide (steroid) and formoterol (a long
acting beta agonist). Formoterol can also worsen sinusitis. Inhaled steroids can induce overgrowth of fungi,
hence your chronic sinusitis may have a fungal component and hence is not cured by conventional therapy.

 You are on oral steroids (Prednisolone) and large doses approaching 1mg/kg/day will cause immuno
supression, which can worsen your sinusitis.

 You should consult your physician for:

I. A trial of anti-histamine (Cetrizine, Loratidine) and anti-leucotriene agents (Montelukast, Zafirlukast)

which may benefit you in both conditions.
II. A nasal spray trial which have micro doses of steroids like Fluticasone, Ciclesonide and anti allergic
agents may help without significantly altering your treatment profile.
III. Regular Steam inhalation.

 Your chronic sinusitis may be related to Biofilm formation.

In short my recommendations are:

 Know how to prepare proper saline solution at home and do the lavage as per instructions above.
 Get the Nasal Endoscopy, CT scan PNS (Paranasal sinuses), AEC (Absolute Eosinophil count) and follow
up with your treating ENT Doctor.
 Avoid Aspirin, high dose steroids, tobacco and second hand smoke.

Hope it helps.

Dr. Sumit Bhatti

Certified Otorhinolaryngologist

This advice is based upon history as provided by the patient. The patient has not been examined per se. The
advice is not valid for medico-legal purposes.

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