Dr. Suresh Raja explores the underlying causes of sinus issues, what symptoms can be present, and how to treat them.
Prakash Chandran (Host): If you suffer from allergies, you're not alone; 50 million Americans have allergies, but sometimes what might present like allergies, might actually be an underlying issue with the sinuses. Here to tell us more, is Dr. Suresh Raja, a Sinus Surgeon and Otolaryngologist for Aspire Allergy and Sinus. This is Ah-Choo, the podcast for people with allergies and sinus issues from Aspire Allergy and Sinus. I'm your host Prakash Chandran. And so Dr. Raja really great to have you here today. So, I wanted to start by asking, when people experience what they think might be allergies, what are some key indicators that actually can tell them that it might actually be a sinus issue?
Suresh Raja, MD (Guest): Well, thanks for having me Prakash. The first thing is you shouldn't really have a nose problem that doesn't go away and you really shouldn't have a nose problem that recurs itself in episodic fashion. And a lot of times people will also have a lot of pain behind their eyes and cheeks. And of course the anterior front of the face, sinus pressure, headaches.
Things like not being able to breathe through your nose sometimes it's one side, sometimes it's both. Sometimes it switches, of course, the thick colored discharge that people will blow out of their nose, or may be expectorate from their mouth associated with bad breath and even dental pain can be associated with sinus infections.
Host: Yeah. So when you say dental issues, this is definitely something that I've heard before. So if someone, for example, has bad breath or a localized tooth pain, what you're saying is this could be an indication of an underlying sinus issue, is that correct?
Dr. Raja: That's right. The nerves that follow along the upper teeth represent the roof of the mouth, but also the floor of the sinus. So if you have a pre-molar or molar nerve, that's running a little high riding, sometimes the dentists talk about that. You would get a dental source of pain, but actually it's stemming from the sinus lining itself because it's a shared nerve.
Host: Okay. Understood. And I guess I just wanted to ask a more basic question. What exactly causes sinus infections in the first place?
Dr. Raja: So the way that we usually see, I'm here in south Florida. So allergies are fairly rampant and in general, people are a little bit more inflamed in today's modern society, but in general, we have what I term the sinus valve. And it's a structural area where all the air and mucus kind of exchange, exchanges itself in a particular portion of your nose.
And that can just be narrow just the way that you are built. But if you happen to have some allergies on top of having a narrow sinus valve, I would say that's probably very much the typical presentation for someone who has a sinus issue.
Host: Okay. And I've heard of the term sinusitis before. Does that just mean a sinus infection?
Dr. Raja: Right. So it generally means an inflammation and the thing is being a sinus doctor for 26 years now, if your nose is bad, your nose is bad either, you have allergies or you trap infection, or it's a combination of both and sometimes your nose is infected. Sometimes it's just not working well, but it's not infected.
So it is really more inflammation. And so it would be for a sinus person, a mixture of either infection or allergies or somewhere in between. Where are you on the scale? We don't necessarily want to look too much into it. It's more like, is your nose bad enough or not for us to consider some of the other procedures that we have to help convert your closed system into an open system?
Host: Okay, before we get into potentially some of those procedures, I wanted to just ask, I guess, at a high level, when exactly is it time to see a specialist about this? You know, you touched on this a little bit in the beginning. People shouldn't have this recurring pain, but when is it time to really see that specialist about the conditions that you may be experiencing?
Dr. Raja: Right. So if you were to get a cold from a virus, let's say, you would maybe get better in two or three days and your nose would work just fine after that. So one of the instances would be if it happens over and over again. A lot of times I might put my patients on what I call probation. They might come in with a sinus infection and we give them some medication, antibiotics or decongestants, something of that nature, maybe some saline irrigations, and they stay away for six months, eight months, nine months.
So that's not necessarily failing probation. You're entitled to get sick once or twice a year. But let's say you can't even last two months. So, that's the probationary period. Yeah, I got some medicine, within a couple weeks, that same thing happened all over again. Or this is actually very common, people take a lot of medicine for their nose, just on a constant basis, over the counter, maybe Afrin, Sudafed, allergy medicines, and just assume that's normal.
So that's actually someone who probably should see a sinus doctor, cause you shouldn't need that all the time. Right. And actually taking over the counter medication scan have deleterious effects. It can keep you awake. It can raise your heartrate, your blood pressure. And in certain instances, if you just take your allergy pill every night it can also be situation where you might be subject to drugged driving or even a risk factor for dementia. So those are the kinds of things we want to talk about.
Host: Okay. Understood. So when people go to see a specialist like yourself, what can they expect out of their initial appointment to diagnose what's going on?
Dr. Raja: Well, we of course give them a very thorough head and neck, ear, nose and throat exam, and if it's in particular for a nasal issue, it usually would include a nasal endoscopic exam where we're able to look at your anatomy more detailed with a fiber optics. We also like to do a good imaging study, like a CAT scan of your sinuses so that we can see the interior and see if it's filled with mucus.
And actually we do a questionnaire called the SNOT 20, the Sino Nasal Outcome Test. And that really gives us a good snapshot of exactly how well your nose is functioning. If your score's over 20, that means your noses isn't really working that great. And a lot of times when we talk about maybe some type of intervention, their scores are in the mid thirties.
Host: And is there ever a time where there's like a more comprehensive examination, like a CT scan to see what's going on?
Dr. Raja: Sure. So that would be part of the initial treatment plan would be a nasal endoscopy, a CAT scan, and actually even allergy testing, if we think that is something worth pursuing, especially if the symptoms are coupled with things like a chronic cough, asthma, facial swelling, or skin rashes.
Host: Okay. So let's move into the different treatment options that are available. Maybe start with first-line defense treatment options and then move up from there.
Dr. Raja: Right. So we always want to go from a non-invasive to minimally invasive nowadays to tell you the truth. And the first thing would be to treat you with medications that would allow your sinus valve to remain open and stay open. And that might include things like decongestants or perhaps steroids or some topical steroid sprays and certainly antibiotics if we think it's a closed space infection and we see some colored discharge and those regimens tend to run from 10 days to even up to three weeks in length to see if we get relief from our treatment regimen or not. And so that would be medical treatment. And, you know, we always like topical. So things like irrigating your nose with saline irrigation is always great and things done in small amounts of time, not chronically is what we're talking about, including topical steroids sprays like a Flonase and Nasacort and things of that nature. So, we usually treat people for something like that and place them on probation. And if they can't pass probation, meaning they can't last two months, and the same thing happens all over again; that usually makes a situation where they're trapping infection over and over again, because their architecture of how their sinuses clear the air and mucus tends to be more on the closed side than the open side. And if that's the case, then the most common procedure that were commend is something called the balloon sinuplasty.
And the balloon sinuplasty is a procedure where we used a very specific device that has a fiber optic wire that's very navigable. You can't even break an egg yolk with it. It's so noninvasive and we find the natural openings of the six largest sinuses that you have in your head. And once we find that we see a very particular light pattern over the sinus where that portion of the face is located.
So for instance, if it's in your forehead, we see a bright red light in your forehead. So we know that we passed through your natural opening and now we're inside the sinus. Then we pass a balloon over that, which is small. It's about an inch and a half long it's elliptical. It actually inflates to a maximum diameter of seven millimeters, and that actually would enable your sinus openings to permanently be 70%, 7- 0% larger than what it normally is anatomically.
And if we do that for all of the six sinuses, now we've just converted your closed system to an open system. Of course, the balloon doesn't stay in. It's just meant as a permanent stretching device because the tissue that we compress against tends to be very eggshell thin, or sort of like a honeycomb. So once we kind of compress it, it stays compressed.
Host: Yeah, that sounds fascinating. And I have heard of minimally invasive before, but not being able to break an egg yolk. I mean, that feels pretty gentle.
Dr. Raja: That's right. The fiber optic wire people, oh, you're putting a wire, it's really, you know, not like putting a rubber hose up your nose or something like that is extremely delicate and it requires a certain amount of expertise to use. And now it's all done as office-based procedures, even under oral sedation or even straight local or in certain instances, even under general anesthesia and the treatment time is really about 10 or 15minutes. Not that we're rushing, but the instrumentation is so good and the tech is so good, it takes what it takes.
Host: Yeah, that's pretty amazing. And so for the people undergoing a procedure like the balloon sinuplasty, is this something where they start to feel better immediately? Talk a little bit about what their experience is like afterwards.
Dr. Raja: Right. So, it's not magic. So, there is a certain amount of healing that you need to do. And the main thing is that you can be congested for four or five days, somewhat, even significantly after we do the procedures. There's no packing in your nose. You know, you have a little bit of pain, a little bit of bleeding for a day and a half.
Very manageable, nothing like when I was trained 25 or 26 years ago. So, you can expect congestion for less than a week. And after that people really tend to breathe a lot better. My favorite thing is taking away headaches. People have really bad headaches because you're converting your system to an open system. And they're very grateful and very happy. And it makes for a very satisfying profession when you choose your patients carefully.
Host: Absolutely. And so, you know, just before we close here, I'm sure that you have seen so many people that have come to you with sinus problems and maybe they wish they may have come sooner. For people that might be experiencing some of these longer-term symptoms, you know, outside of the probation period that we're talking about, what would be one piece of advice that you have for them?
Dr. Raja: Well, if your nose is deemed a bad nose, and if you have a lot of trouble with headaches and difficulty even sleeping at night, because you can't breathe through your nose, you're not alone. There is technology out there that insurance covers and done by someone who has expertise in it. You don't have to suffer for years and years. Go see your local ENT person who has a specialty in doing balloon sinuplasty and get a consultation.
If it happens to be coupled with things like asthma, chronic cough, facial swelling, skin rashes, then maybe you should also get allergy tested as well. So that's the advice and, you know, we're of course Aspire Allergy and Sinus. So we do a lot of innovative things, even on the allergy side.
Host: Yeah. It definitely sounds like it. So, Dr. Raja, I really appreciate your time today. Thank you so much. Is there anything else you'd like to leave our audience with?
Dr. Raja: I think that breathing through your nose has become much more important and the ancient people knew it. There's even gasses one in particular called nitric oxide, that's produced in the sinus lining in the cheek sinuses and we're finding it helps with vasodilation. It helps with blood pressure.
And guess what, if you're a chronic mouth breather, you're not actually getting that gas to go down into your lungs so it can distribute in your body. So, we're finding that making a good nose that can breathe really well happens to be much more important even for sleep. And even for your activities of daily living, than you just might realize.
Host: Yeah, it's amazing. I've definitely read some things about this. And my wife even now makes me tape my mouth when I go to sleep just so I can train myself to breathe through my nose. And I always find, even though it feels very strange, that I have a more rested sleep. I can't really explain it. People definitely make fun of me when I hear that, but, I've been hearing more and more about nose breathing and the benefits that it has. Do you have patients that do that as well?
Dr. Raja: Oh, for sure. And now we're living in the era of biometric wearables and there's a particularly good book by James Nester called Breath. And he talks all about his experiences with that and really nothing new. It's just that it's being rediscovered. And it's critically important for us to breathe through our nose actually.
Host: Well, Dr. Raja, thank you so much for your advice. And I really appreciate your time today.
Dr. Raja: Thank you. Thanks for having me Prakash.
Host: That was Dr. Suresh Raja, Sinus Surgeon and Otolaryngologist for Aspire Allergy and Sinus. Find more information and episodes ataspireallergy.com/podcast. This has been Ah-Choo, the podcast for people with allergies and sinus issues from Aspire Allergy and Sinus. I'm your host Prakash Chandran. Stay well.
Dr. Raja has spent many years of his career specializing in minimally invasive, patient tailored Balloon Sinuplasty Procedure which offers patients an alternative to invasive full endoscopic surgery. He is also a consultant for several Silicon Valley-based biotech companies specializing in producing the tools that are advancing this next golden age of rhinology, including Acclarent (Division of Johnson and Johnson), Intersect (nasal implant technology) and Spirox (nasal exoskeleton implant technology).