Complementary and alternative medicine offers treatments for a variety of ailments, and otolaryngological conditions are not exempt. Sinusitis is a common complaint with many causes including allergy, acute infection, chronic illness, trauma, lifestyle factors and more. The open-forum nature of the internet has opened up a whole library of natural remedy resources. Are there any treatments that are effective, aside from anecdotal evidence? This article is going to explore some of those popular social media remedies and blogger favourite natural cures for one of the most common ailments, sinusitis.
Tim Minchin has often been quoted when the debate about the efficacy of complementary and alternative medicines surfaces.
He rhymes (an extract from Storm):
“… Pharmaceutical companies are the enemy
They promote drug dependency
At the cost of the natural remedies
That are all our bodies need
They are immoral and driven by greed.
Why take drugs
When herbs can solve it?
Why use chemicals
When homeopathic solvents
Can resolve it?
I think it’s time we all return to live
With natural medical alternatives.”
And try as I like,
A small crack appears
In my diplomacy dike.
“By definition”, I begin
“Alternative Medicine”, I continue
“Has either not been proved to work,
Or been proved not to work.
Do you know what they call “alternative medicine”
That’s been proved to work?
“So you don’t believe
In ANY natural remedies?”
“On the contrary, Storm, actually:
Before we came to tea,
I took a natural remedy
Derived from the bark of a willow tree
A painkiller virtually side-effect free
It’s got a weird name,
Darling, what was it again?
Oh, yeah, Aspirin!
Which I paid about a buck for
Down at the local drugstore…”
This also brings an interesting question to the topic – what complementary medicine practices have been absorbed into biomedical healthcare? When looking for the best available treatment it is worthwhile to consider all of the options. Think of it as picking for a sports team: if you picked only your friends, you might not pick the best team. Do the right treatments options exist outside the box?
The Story of Grapefruit Seed Extract
Grapefruit Seed Extract pops up as an antimicrobial agent useful in the treatment of bacterial sinusitis (not to be confused with grape seed extract). Grapefruit seed extract is said to effectively treat a broad-spectrum of gram-negative and gram-positive bacteria. There is plenty of anecdotal evidence that claim GSE is a suitable antibiotic for sinusitis, but is there any evidence?
There is a study from 2002 that looks most promising. Now I am no expert on microbiological studies, but I have spotted a major flaw (which to be honest is not a problem with the study design, only it’s interpretation) in generalising this study: it is an in-vitro (Petri dish) study that examined the mechanism of action and toxicity. This does not automatically translate to equal efficacy in the human population. What is good to see is the study appears to live up to its title: it demonstrated the GSE’s mechanism of action and it’s toxicity. Firstly, it was observed that the GSE breaks down the cell walls of microbes. In the lab it has shown good efficacy as a broad-spectrum antibiotic at a dilution of 1:512, capable of eliminating gram-positive and gram-negative bacteria. Secondly this dilution was shown to be non-toxic to the skin fibroblasts used during the in-vitro testing.
Looking beyond the publically available abstract, this study tested a commercial preparation of GSE. Drug companies (including natural medicine ones) will fund studies to prove that their product a) works and b) is safe. Natural medicine companies often the sole publishers or financiers of complementary and alternative medicine research projects. The product should be tested, yet there an obvious conflict of interest here. To solve this bias, independent, randomised double-blind control studies are performed to demonstrate sound efficacy. These types of studies need lots of money, participants and time. What is easier than all of that? In-vitro testing.
We know that broad spectrum antibiotics are often prescribed for acute and chronic infective sinusitis- could this treatment actually work? Even though it was a commercial preparation this preliminary evidence appears promising, but we need to look further into GSE. What was the study actually testing? Further independent research has revealed that commercial preparations of GSE contain preservatives. Preservatives that without their presence are likely to eliminate the antimicrobial effect of GSE preparations, moreover the research proves this hypothesis again and again. Grapefruit seed extract has a number of chemicals; unfortunately none of them are effective antimicrobials.
In spite of the evidence, natural medicine companies continue to push data about the antimicrobial efficacy of commercially prepared GSE. On the back of the GSE bandwagon, social media sources continue to push homespun GSE preparations are sinus spray for sinus complaints. Now, the internet is rife with websites and social media sources continuing to cite research that has been disproven. Ultimately, grapefruit seed extract’s evidence is low level at best and consumers should be sceptical of claims made by natural medicine companies, vendors, social media and anecdotal evidence.
Nasal Saline Rinses
Nasal saline rinses, also known as saline nasal irrigation, are one of the go to treatments for sinus complaints and it isn’t just on alternative medicine recommendations. Nasal saline rinses are prescribed by GP’s and Ear, Nose and Throat [ENT] specialists for the management of sinusitis and post-operative recovery. Where did this neat little idea come from? If Tim Minchin’s musing are to be believed, their proven efficacy has shifted their label from alternative medicine to medicine... and that is not too far from the truth!
The first commercial product Netipot’s name is derived from the Sanskirt jala neti. The jala neti is described in the Hatha yoga texts and is said to improve mind, body and spirit, and the prana (life force). Ayervedic medicine – the traditional medicine of India— used saline nasal irrigations as part of the treatment for a range of ailments, including sinusitis. There is evidence that other traditional medicine systems used a similar technique for sinus health. Good sinus health for optimal breathing continues to be taught and nasal irrigations are still used in yoga today.
When did Western doctors start to keep nasal saline irrigations in their (metaphorical, not metaphysical) medicine bag? The story is not particularly clear but there seems some evidence to say that doctors have known about nasal irrigations for a hundred years or so, after the meeting of the East and the West. After all, nasal saline irrigations were as common place as teeth brushing is to us today. Doctors regularly began recommending saline rinses for sinus complaints in the 1930’s and since then, ENT specialists have repeated the prescription.
A history lesson is always fun, but is there any evidence to say it is even a good thing to do? I tell patients all the time how great it is to do this crazy thing where you wash salty water around your sinuses. Stepping up the level of evidence from the GSE studies, saline nasal irrigation have a great deal of good evidence behind them. In 2007, a systematic Cochrane review of 8 high level studies indicated that saline nasal irrigations are beneficial to patients. The physical flushing of nasal mucous can improve comfort, decrease risk of infection and improve breathing. It can even be the best conservative treatment for allergic rhino-sinusitis for some patients. Tim Minchin was correct in his observation of effective alternative treatments; saline nasal irrigations work and we routinely include them in a standard practice called medicine.
Naturopathy is a form of complementary and alternative medicine [CAM] that utilises herbal remedies, dietary guidance, lifestyle changes, and vitamin and mineral supplements to heal the body. Some Naturopaths also train in homeopathy, massage, iridology and aromatherapy. Compared to mainstream medicine, naturopathy has far less supporting evidence; however some remedies and some interventions have very sound research accepted by the medical and CAM community.
Herbs and supplements that are recommended by Naturopaths include verbena (Verbena officinalis), elderberry (Sambucus nigra), cowslip (Primula veris) and vitamin C. Some of these ingredients can be found in commercial preparations from a pharmacy or put together at a naturopath. It is interesting to note again that commercial preparations have been found successful in the treatment of sinusitis. The testing has been sponsored by the manufacturer but independent testing has shown varying levels of efficacy too.
During episodes of sinusitis, clients often report a poor sense of smell, foul odour and decreased ability to breathe through the nose. Though the effect of aromatherapy is hard to test in RCT and there is little evidence to support its use, it may offer comfort to patients who are suffering sinusitis. Some oils also increase the sensation of airflow through the nose (peppermint) and some have well documented antimicrobial properties (tea tree). At the simplest level, smelling pleasant essential oils can provide great subjective comfort to patients, and the use of humidifiers combined with aromatherapy diffusers can combine the pleasant experience with good nasal health practice.
There have been no conclusive studies to show that homeopathic treatments are useful in the treatment of sinusitis beyond a very good placebo, but homeopathy continues to remain a popular alternative treatment. The placebo however is an important clinical effect (and the placebo effect still happens when people know they are receiving a placebo) and recent research has linked it with the feeling of being cared for. Though there is a role for client education, healthcare providers should also be mindful of the healthcare choices of autonomous patients. There is little worry of drug interactions between homeopathic and mainstream medicine treatments, but patients are encouraged to discuss all medicines they take with their healthcare practitioner.
There are many available treatments out there with varying levels of evidence from sketchy to solid, and the quality might not always be obvious to the general public. Open communication about treatment choices, safety profiles, efficacy and patient preferences is always going to be important, but the internet (unfortunately) has an ever increasing persuasion with miracle pseudo-science and anecdotal evidence. As tempting as it might be to throw all CAMs away, one day some treatments may well be called medicine. The coming times might be turbulent; health practitioners will need to help patients navigate complementary and alternative medicine using good research to guide them through the storm.
Bibliography and Further Reading
- Nasal/Sinus Irrigation – American Rhinologic Society
- History of Nasal Washing – Nasopure
- National Center for Biotechnology Information
- Homeopathy-Topic Overview – WebMD
- Sinupret Forte: for the relief of sinusitis and sinus pain – Flordis
- Grapefruit seed extract fraud- yet another body blow to the industry! – Dr Nibber
- What is Naturopathy? – ntpagesTV – YouTube