Sinus Fatigue

A little less than 10 years ago a research project that I had been working on for many years was published in the Archives of Internal Medicine. The observation that propelled me into the relationship described in the article related to my first experiences as a clinician.

I was aware that sinusitis caused fatigue years before I became a doctor because of personal experience and conversations with others who also suffered from sinus problems. I was surprised that my own doctor seemed unaware of the association and I was surprised that fatigue was not listed as a symptom in the general medical texts that I searched in college.

Nothing changed in medical school. Although the lists of illnesses that caused fatigue was quite long, and the lectures on the subject quite thorough, no one that I can recall mentioned sinusitis as a cause of fatigue.

When I first started practice my experience confirmed my own observations that patients with sinusitis were fatigued but, again, a thorough search of the medical literature produced nothing. I then started noticing that patients with a primary complaint of fatigue often, on more detailed questioning, acknowledged sinus symptoms but considered the sinus issue quite minor compared to the more pressing complaint of fatigue.

After trying to redirect the focus towards the sinus issue and initiating treatment, patients would usually notice a great improvement in fatigue. Patients found this puzzling. In fact, often a patient would return months later with the primary complaint of serious fatigue completely having forgotten the link with sinusitis. Once again I would treat the sinusitis and the fatigue would remit.

In the late 1980s I began to see some notice in the medical literature. A consensus conference of ear, nose and throat physicians in 1987 described fatigue as one of the diagnostic criteria for making the diagnosis of chronic sinusitis. I reported several cases of patients diagnosed as having chronic fatigue syndrome who experienced a complete or nearly complete resolution of fatigue following sinus surgery.

Nothing on the subject was mentioned in the internal medicine literature, an unfortunate omission since internists are the doctors who treat fatigue.

I was curious about how common sinus problems are found in patients with a primary complaint of unexplained chronic fatigue. This is how the project unfolded.

I examined 297 consecutive patients who were younger than 41 years, administered a detailed questionnaire and performed a battery of screening laboratory tests. Young patients were chosen in an effort to exclude the illnesses of older age groups that might confound the results.

Of the 297 patients, 65 (22%) noted unexplained fatigue that has persisted for more than one month, fatigue unexplained by the lack of rest, illness, or undo physical or mental exertion. Fifteen (23%) of these patients met the diagnostic criteria for chronic fatigue syndrome, an illness characterized by prolonged and severe fatigue.

When the 65 patients with unexplained chronic fatigue were compared to the remaining group of 232 patients most sinus symptoms were much more common in the group with unexplained chronic fatigue: facial pressure (80% vs 13%), heavy-headedness (80% vs 8%), nasal obstruction (87% vs 42%), frontal headache (53% vs 6%), sore throat (33% vs 8%) and cervical node tenderness (60% vs 6%.)

Of note, symptoms usually associated with unexplained illnesses such as gastrointestinal problems, sleep disturbance, and psychiatric illness were similar in the group with unexplained chronic fatigue when compared to the group with fatigue explained by a physical or mental illness.  However, sinus symptoms were much more common in the former when compared to the latter.

The results confirmed my suspicion that there is a peculiar and predominant relationship between chronic sinusitis and unexplained fatigue.


Chronic Sinusitis

Chronic sinusitis is the most common chronic illness in the United States.  Both the diagnosis and treatment are, unfortunately, controversial.  Some feel that signs of obstruction and inflammation are required to accept chronic sinusitis as an appropriate diagnosis.  Others feel confident that it is defined by its symptoms regardless of X-ray or other findings.  Similarly, one physician may feel that evidence of infection is necessary before prescribing antibiotics.  Another may consider worsening of symptoms alone as justification for their use.

Some Cautions

Natural treatments for sinusitis are quite appropriate after considering several caveats.  See your doctor if you develop a fever, severe facial pain, or symptoms not typical of your experience with chronic sinusitis in the past.  Remember that a fever may indicate an acute sinus infection or a worsening of chronic sinusitis.  Antibiotics are usually needed in the presence of fever and may be required for persisting colored nasal discharge, poor response to other treatments, unrelenting fatigue, continuing facial pain, or simply failure to improve.

Medication Side Effects

Certain medications can cause or exacerbate sinusitis.  In vulnerable individuals, these include particular medicines for high blood pressure, depression, and heart conditions.  Oral contraceptives also occasionally cause problems.


Remember the basics:  What are you putting into your body each day?

Foods That May Cause Problems

One the most common dietary causes of nasal congestion is milk.  Eliminating milk and milk products from your diet will tell the tale; no need for a medical allergy evaluation.  Give it two weeks.  Often the results can be dramatic.  Eliminating milk and milk products cures sinusitis and fatigue in approximately 10% of our patients.

Although less often than milk, wheat can cause sinus symptoms.  A wheat elimination diet is difficult, but can be fruitful.

Likewise, other foods and food additives, such as artificial sweeteners, can cause problems.  Try eliminating different groups of foods either by yourself or with the help of a dietitian.  As you might guess, the foods we often like best are sometimes to blame.

Foods That May Help

On the other hand, some foods clear the sinuses.  Garlic, horseradish root, and cayenne (red pepper) may produce a desirable effect.  Drinking substantial amounts of water or other fluids frequently help to loosen nasal mucous.

Few people with sinus trouble are able to drink wine or beer without causing problems.  Spirits are generally better tolerated.


Outdoor Climate

A crisp cool day with a slight breeze and no dust, molds, pollens, or pollutants is just what you need.  But where?  If you could find the place, you probably couldn’t make a living there!

Heavy, humid, still days with atmospheric inversions are terrible, particularly if you add in smog and pollutants.  Dry, dusty days are also a problem.

Barometric shifts often swell the nose, blocking sinus drainage ducts, since spongy areas inside the nose expand to equalize pressure with the outside lower pressure.

Indoor Climate

Evaluate your house for allergens, irritants, humidity and dust.  Clean scrupulously while watching for dust collectors such as books, carpets and bedding.  Bedding can be a difficult problem.  Try covering your mattress and box spring with a special fabric encasing (a product is available through National Allergy Supply, Inc. (, and equipping the heating, ventilation and air conditioning duct system (HVAC) with good filters.  For single rooms, a high-efficiency particulate air filter (HEPA) is best.  A good one is available through Bionaire, Inc. at  One caveat:  Air supplied  continuously to a room (home or office) from a central fan through a duct system washes out the filtered room air.  Consider a HEPA filter for the entire central air system.  Alternatively, you may also apply disposable filters monthly over the incoming air ducts to the room.  These are also available from National Allergy Supply, Inc.

Sick Building Syndrome

Many “sealed buildings” built in the last 30 years, particularly office buildings with no functioning windows, do not permit the introduction of adequate fresh air, causing sinus symptoms (sick building syndrome).  Smoke, substances in cleaners, copiers, rug adhesives, etc. can also be irritating to vulnerable individuals.  Try talking to the building engineer.  Are the fresh air intake valves open far enough or, for reasons of economy, is the same air being continuously recycled?   Where is the fresh air intake duct located: on the top of the building to minimize pollution, or is it near street level where exhaust fumes are highest?  Similar problems exist in airplanes.  The “virus” many people feel they caught while flying is actually a sinus infection caused by dry, stale, polluted airplane air.  Air pressure changes as the plan changes altitude also exacerbate sinus problems.

Personal Habits

Smoking irritates the sinuses and should be avoided.  Some people become exquisitely sensitive to perfumes, soaps, newsprint, etc.  Individuals should avoid these and other substances that prove problematic.

Adequate sleep is good, but excessive amounts of sleep can be trouble.  Lying down reduces the size of the sinus ducts by 20%.  Raising the head with a few pillows can help restore flow.  Curiously, sleeping on one side of the body improves airflow in the opposite nostril.  Stick with the amount of sleep that you usually require when healthy when your sinuses act up.

Exercise can be a highly effective and healthy way to deal with sinus trouble.  It can open the nose and improve sinus drainage.  Sinus clearing is the benefit that many people feel after exercise.

Vitamins & Supplements

Many people feel that vitamins and dietary supplements are helpful.  This is difficult to prove.  Vitamins, herbs and food supplements can produce beneficial changes in the nose and, occasionally, a marked improvement.  Large doses of certain vitamins, supplements and herbs can cause medical problems.  Additional concerns include the lack of standardization and government testing of herbal products.  Those with medical problems or those who take regular medications should consult with their doctor before taking such preparations.  Of course, when pregnant or nursing, no product should be taken without careful consultation.

Some individuals may benefit from a multivitamin, vitamin C in large doses, zinc (25mg), evening primrose oil (linoleic acid and gamma linolenic acid in a gel cap – twice daily), Echinacea pallida herbs and ginseng.

Local Treatments

Nasal Saline Spray

Nasal saline spray often soothes dry, inflamed nasal membranes and reduces mucous viscosity.  In some individuals, it has a separate decongestant effect.  All commercial preparations are not the same.  Some contain a preservative that may be irritating.  AyrTM is a well-tolerated product (available from B.F. Ascher & Co.:

Saline Nasal Rinses

Warm, hypertonic saline nasals rinses (see below) may be quite helpful, but occasionally are counterproductive and cause irritation.  A saline rinse is prepared easily:  Mix two to three heaping teaspoons of pickling or canning salt (not table salt) and one teaspoon of baking soda with one quart of clean tap water.  Instill into the nostrils by using a bulb syringe or a pulsating jet (Water Pic with nasal adapter, Teledyne Water PicTM at  Store at room temperature and discard after one week.  If the solution seems too strong, decrease the salt content to one or one-and-a-half teaspoons.  A similar spray in prepackaged form is available at ENTsol (available from Kenwood Therapeutics at

Wetting Agents

Wetting Agents (propylene and polyethylene glycol) may be beneficial between or instead of nasal rinses (PretzTM, available at Parnell Pharmaceuticals, Inc. at

Because the nose tends to dry and crust, paving the way for sinus infection, nasal emollients are often helpful.  Spraying with sesame oil is quite effective. Alternatively, an antibacterial ointment moisturizes and kills germs in the nose that lead to infection.   BactrobanTM (available in pharmacies) is particularly effective against nasal staph bacteria.  Nasal barriers also protect against continual irritation during vulnerable times.  Ayr gelTM ( protects delicate membranes.  Viscous lidocaine, a topical anesthetic, may be applied inside the nose with the tip of the small finger.

Nasal Steam Inhalation

Nasal steam inhalation, with or without astringents (eucalyptus, pine oil, menthol), decongests and soothes the nose.  Warm, dry air alone is also often productive.  Likewise, infrared heat directed at the face may help.  Nasal steamers offer convenience (available at the Steam Inhaler, Bernhard Industries, Inc., at, and as VirothermTM from Sunbeam-Oster Household Products, Inc.,  You may also simply inhale from a cup of hot water.  Try a damp face cloth heated by the microwave for approximately 20 seconds.  A warmed or chilled mask filled with jell and placed on the face is another alternative.

In the colder months, or in drier climates, indoor humidification helps prevent drying, irritation, swelling and secondary infection. Steam humidification is superior to cold mist or ultrasonic.  Warm mist may be added to filtered air in a single unit (available as the BionaireTM series of warm humidifiers,  The BionaireTM CM-I is small and particularly convenient for simple humidification.  Larger, evaporator type humidifiers for the house include the BionaireTM W-65 (, and the Emerson HD850 (

Nostril Expanders

Occasionally, abnormalities of the nasal openings may predispose to chronic sinusitis symptoms.  These small passageways control the flow of air across the nasal membranes.  Minor changes because of accidents or inflammation can cause increased nasal obstruction.   Even in the absence of abnormalities, spreading this area using a small stainless steel dilator spring occasionally offers dramatic help with nasal symptoms (available as the Mechanical Therapeutic Nasal Dilator from Breathe With Eze, Inc., Brooklyn, N.Y. 11207, 718.498.1686)

An adhesive spreader externally applied to the lower nose can give similar benefit with greater comfort although it is visible on the nose, unlike the dilator spring which is placed  inside the nose (available as Breathe RightTM external nasal dilator, manufactured by CNS Inc., Chanhassen, MN. 55317; 612.474.7600).

Local Nasal Treatments

Nasal Decongestant Sprays

Nasal decongestant sprays may be of help when used sparingly three times daily for three days or less.  Xylometazoline (OtrivinTM) or oxymetazole (AfrinTM) is effective but not particularly harsh.  Chronic use (more than three consecutive days) may induce “rhinitis medicamentosa,” a problematic condition of rebound swelling often requiring oral corticosteroids as therapy.  The risk of rebound is less with more dilute nasal sprays.  Adding water to the spray bottle to accomplish I:2 to I:8 dilution is helpful.

Local Corticosteroids

Local Corticosteroids (BeconaseTM, NasacortTM, RhinocortTM, VancenaseTM, FlonaseTM, NasalideTM, and NasonexTM are the sprays least associated with absorption into the body and the potential problems that could cause.

Cromolyn (Nasal CromTM) blocks the nasal response to allergic challenge but is usually less effective than steroids sprays.  Both local corticosteroids and cromolyn can cause nasal irritation and drying.  Often it is prudent to discontinue these mediations during a worsening of sinus symptoms.

AtroventTM is a nasal spray used primarily to stop watery nasal discharge.  AstelinTM antihistamine nasal spray blocks allergens as they come in contact with the nose.

Oral Medications

Oral Decongestants

Oral decongestants often help the symptoms of chronic sinusitis.  Pseudoephedrine reduces nasal blood flow and, thereby, nasal engorgement.  It is occasionally associated with blood pressure elevation.  Some people find the drying agents used in “cold preparations” to be helpful and other do not.  Ipratropium (AtroventTM) is recommended by some physicians as a nasal inhaler under certain conditions, but it may cause excessive drying and increased nasal mucous viscosity.


Antihistamines are sometimes helpful with the symptoms of chronic sinusitis.  Allergic inflammation, often seasonal, predisposes some individuals to chronic sinusitis.  A selective HI-antihistamine (ClaritinTM, AllegraTM, ZyrtecTM) may be a desirable option.  Iodinate glycerol is a mucolytic agent that stimulates ciliary action and offers some help.  Guaifenesin (HumibidTM, or with an oral decongestant, EntexTM) reduces mucous adhesiveness.

Oral Corticosteroids

Oral corticosteroids may provide relief for sinus disorders not responsive to local steroid sprays.  Their effect can be dramatic, although they must be used with caution.  Aspirin and nonsteroidal anti-inflammatories (AdvilTM, MotrinTM, etc.) can trigger asthma, nasal problems, and sinusitis in susceptible individuals. Occasionally these medications are helpful as anti-inflammatories, decreasing the symptoms of chronic sinusitis.

Oral Medications continued

Antibiotic Therapy

Antibiotic therapy usually offers the most help for those with sinusitis.  When the sinus cavity contains pus, antibiotics may be required for a number of weeks.  If this is not the case, antibiotics may still help.  Often the nasal membranes are covered with infected mucus and the individual experiences sinus pain, aching and fatigue.  Antibiotics can resolve the problem in days, although the medicine should be taken for an entire week or more.  In the absence of infected nasal discharge or evidence of superimposed acute sinusitis, the use of antibiotics for chronic sinusitis has been questioned.   Some feel that most cases do not represent an infectious process and do not require antibiotics.  Most authorities, however, consider evidence for the importance of antibiotics to be strong.  A one-week course is often beneficial.

Other Options


Surgery is an excellent option if medical treatment isn’t working.  The newest method (endoscopic surgery) is much less traumatic than earlier techniques.  Most people, armed with determination and the help of a physician, can beat this illness or substantially reduce symptoms.