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surviving sinusitis
(and other catarrhal catastrophes)

One of the first conditions I started formulating for when I began to be interested in herbs was sinusitis; that was almost 20 years ago, and I recently discovered an old batch of sinus tincture, which I’ve kept around both for nostalgia’s sake and to remind me how much more nuanced I’ve become since making that gazillion herb shotgun formula.   As I learned to differentiate between various manifestations of sinusital woe, I wrote up an article on the topic, which has been on my site for close to 15 years, and become quite popular.  This, of course, led to lots of emails and clients and experiences with the fronts of many faces, and I’d like to share some of the insights I’ve gleaned from these folk, and finally revamp that old, dated write up.

I should say that very little of my experience is personal.  I don’t often get hit with anything more than transient upper respiratory discomfort during the occasional cold or flu, and have only really had bad sinusitis a few times.  It was really pretty damn awful, and offered me a deep well of compassion for those who deal with this on an ongoing basis.  One such person was an old girlfriend (and current wife), who had me concocting some of my first formulas and getting my first successes (I’ll just assume that’s not the only reason she married me).  She was the first of now many people I’ve worked with who had chronic sinusitis, and no longer do.

First, before jumping right into "take this or take thats", let's acknowledge that sinus problems come in various guises, and so to should herbal treatment.  Matthew Wood has created a simple and concise energetic model with six basic “tissue states”; descriptions of the variations tissues can experience.  These include hot (increased activity), cold (decreased activity), damp (congestion), dry, relaxation (I prefer the term “laxity”) and constricted (which includes both tension and spasm).  Of course, different modalities (Ayurveda, TCM, Greek, Sindarin) will use different terms or models, but these simple states create a very effective and easily applied structure on which to assess a person’s problem and create a sensible protocol.  

That all said, without explanation, these terms might not be easily interpreted by those suffering, because we’re not used to thinking about sinuses outside of the “you have an infection” model and because critical thinking can be difficult when your sinuses ache.  I like to rely on the terms that people know and use without thinking about it, as these point towards tissue states anyway.  Most often, I've come across three variations of sinus troubles:  leaky (lax), stuffy (damp) and dry (dry).  Tension is less often encountered (though sneezing can count as spasm... try a drop or two of lobelia for uncontrollable sneezing fits), and hot and cold... well, I'll get to that later. 

Different types of herbs are used in to address each state (or combination of states), and this is quite important to know.  Too many people play name association games with herbs, the kind where they simply associate the name of a problem with the name of the herb that was written next to it somewhere.  But you don't want to go giving drying herbs like Goldenseal to someone with dry sinuses, even though it's supposed to be "good for sinus problems".  It is good for sinus problems, but not that kind.

It’s also useful to recognize whether sinus troubles are chronic (all the time), episodic (they come and go and come and go and...) or acute (you got an inhalation full of some irritating substance and the irritation is the direct result of that).  Chronic problems require a dedicated, consistent, long term commitment to a herbal regimen, as well as making whatever lifestyle changes are called for.  Obviously, the issues that might require attention are myriad, and it’s not really feasible for me to try to list all the possibilities.  But it is safe to say pay attention to your diet, how much rest and relaxation you're getting and minimizing stress levels.  It probably wouldn't hurt to get your ductwork cleaned.  You may know or be told that dairy and wheat are especially bad for sinus sufferers, because they promote mucous production (or are inherently bad).  This is true in some (perhaps many) cases, but I do know people who've successfully recovered from chronic sinus problems without totally eliminating wheat and diary, though they have been smart and steadfast enough to drastically reduce or eliminate it when their sinus troubles have flared up.  The "comes and goes" variety also indicates the need for focused attention, as it suggests the problem is coming and going as your body's vitality or resistance is ebbing and flowing.  Acute conditions, more often than not, can be treated acutely as well.  Take your herbs till it gets better, and then go on your merry way.

dry...
Because dry sinus issues get the least attention, I’ll start here.  In this state, the tissues are usually hot and the mucus is dried out like rubber cement on the sinus tissues.  Symptoms manifest as dry, tight mucous membranes, nose picking (because of the rubber cement nature of the mucous), bleeding nose, and perhaps the sensation of stuck obstructions.  There will often, though not always, be dry eyes, and perhaps you’ll see this reflected on the tongue and in the mouth as well.  In almost all cases I’ve seen, the mucous membranes throughout the body tend towards dryness, though I’ve seen “damp people” with dry membranes caused by inhaling some dry, absorbent irritant, such as clay.

When thinking about how to address this, one of the first questions to ask is, “Are they hydrated?”  Increasing the intake of water and fluids can be the most important suggestion to offer, especially if the mucosa tend to be a bit dry all the time, and flare up when they get a head cold. 

Dry tissues keen for demulcents; adding mucilaginous teas (ideally prepared via cold infusion) is a good idea.   Marshmallow is archetypal.  A strong preparation with be thick, slimy and very effective, but you can water it down by adding a half to one cup to a quart of water and using that as a drinking beverage; feel free to dilute more if desired, or to add a bit of honey or maple syrup to sweeten.  There are also many milder demulcents that don’t require dilution that make for excellent drinking if treatment will be long term, such as violet leaf, sassafras leaf (not root), and/or common mallow.  I’ll frequently blend these with a bit of plantain.  Though tinctures don’t extract mucilage well they can work – sometimes quite effectively – but I feel teas are more suitable; after all, if dryness is the main quality presenting, a cup of infusion makes much more sense than drops of tincture.

Still focusing on internal consumption, we should remember that tissues are hydrated by both water and oil, and if one is lacking you can’t replace it with the other.  Quality dietary lipids/fats/oils (which do include saturated fats from healthy animals and the occasional plant) are important.  If someone has dry tissues and doesn’t consume fats and oils, it’s a no brainer to add them.

Topical application is always important for upper respiratory issues.  For dryness, there are a few strategies I employ.  One is for more transient dryness and focuses on the nostrils.  Make a cold infusion of marshmallow, slippery elm, or something else that’s demulcent enough to be slimy to the touch.  Strain, wet a cotton ball or cloth, and insert into the nostril.  Please… if you don’t want to be the ER attendant’s “weirdo of the day” story, make sure you leave enough of the material outside your nose that you can get it back out.  Let it sit and hydrate the dry tissues for 10-20 minutes.  This is usually immediately soothing, but sometimes fails to produce lasting results.  You can supplement this technique with a topical oil application.  Stick your finger in some oil (make sure it’s one you like the smell of) and then stick your finger in your nose.  Wipe around well to cover as much tissue as you’re able.  I generally see more lasting results with oil applications, and this technique rocks for dry noses in the winter, when the furnace or woodstove is kicking and all your respiratory tissues are being desiccated as a result.      

For dryness affecting deeper tissues, the approach is similar, but applied differently.  In Ayurveda, “nasya” refers to nasal administration, and oil nasya is an important practice that’s virtually non-existent in western herbalism.  Do it like this: have a dropper bottle with some oil handy.  Lay down, with your head slightly reclined.  Put the dropper by one nostril, and at the same time you squeeze a bit (just a few drops), inhale sharply; you’re trying to “snort” the oil up into the sinuses, so give it your all.  Sit up, let the oil run down, and spit out anything you’re able.  Repeat with the other nostril.  This technique is amazing, and the results are often spectacular.  You can use infused oils if desired.

Water based rinses, either using a neti pot or nasal spray bottle, are also excellent.  Again, make a demulcent tea, but not super strong; you want the rinse to flow.  I like mixes of plantain, with violets and/or mallow leaves a lot.  You can add a teeny bit of marshmallow or slippery elm, but remember not to make it too strong.  Because you’re going to be pouring or spraying this up your nose, do a good job straining plant material out of the tea.  To each 8 fluid ounce cup, add teaspoon salt, perhaps slightly rounded.  Use this in a neti pot twice daily, or fill a nasal spray bottle and use as needed (really, as much as you want).  Blow you nose afterwards to expel mucous that has loosened up, or spit out anything that comes down your naso-pharynx.

leaky drippy...
If you ask someone, perhaps all red eyed and swollen with allergies, if their sinus tissues are “relaxed”, they’ll probably look at you like you’re crazy.  Because of a culturally sparse vocabulary (getting worse every year), many people won’t even readily connect with the term “laxity”.  But ask them if they’d say their head feels “leaky drippy”, and they’ll be able to answer you with surety (not that they’ll need to, since it’s usually readily apparent to anyone within a few feet of them).  The key symptom is leaking fluids; they’ll have a runny nose and eyes, and often drainage from the sinuses down the back of the throat.  This commonly causes a sore throat, or a cough (coughing can be a way to “scratch the itch” of the irritation).  Sniffling is keynote; there can be sneezing, too.  Were you there, in front of them, for that sneeze?  Are you all wet?  The wetter, the leakier.

Hay fever is a prime example of this state, though similar conditions can arise from myriad causes.  Hay fever and seasonal allergies do, though, offer a good example to explore.  Ragweed pollen is miniscule, copious and windborn.  The pollen itself looks like a mace - not the pretty red stuff surrounding nutmeg but those heavy metal balls with the spikes on them that you might associate with orcs, ogres, or perhaps politicians (speaking of copious irritants). 

Photo by David McLain, National Geographic

When ragweed is blooming, pollination occurs not through pretty insects like butterflies and bumblebees, or even bothersome ones like flies, but by blowing from one plant to another.  Inhaling this airborne Ragweed pollen is akin to inhaling powdered fiberglass… what, of course, does the body do when this happens?  It does what makes sense: tries to get the stuff out of the system.  And how?  By causing the eyes to water, the nose to run, sneezing... all methods to flush out and expel irritating particles from the respiratory passages.  So we see that the symptoms of "hay fever" are a sensible response by the body to the problem at hand.

Sometimes, though, the body over-reacts; it goes into the full blown allergic response when it might not be called for at all.  Here's a good example of this: Think back to an occasion when you might have had too much, let's say... Southern Comfort at a party.  The next day (or maybe that night) you get very, very, very sick.  Some time after recovering, you find yourself at another party, and someone has some Southern Comfort, but while you don't drink any, just the smell of it - just knowing it’s there next to you - makes your stomach churn.  Your body is overreacting in a way that it hopes will let you know: "Not that stuff again!"

Same thing can happen with allergies.  You're exposed to a house with 138 cats, and tufts of cat hair floating around like pixies in a meadow, and all the sudden you can't be in a room with just one cat, which doesn't make sense cause you grew up with two who you liked very much and whose presence certainly never bothered you.  What's happening is that you've become sensitized to the ________________ (fill in appropriate allergen here).  Post traumatic stress disorder of the sinuses.            

Of course, this problem might also be due to a perfectly legitimate reaction to an ever-present irritant.  There’s dust, mold and other irritants blowing out of the ductwork and throughout households every time the furnace or air kicks on.  I know a carpenter whose sinus problems are undoubtedly the result of his intimate & ongoing relationship with sawdust.  Perhaps the offending irritant has injured the tissues, and so they no longer possess the strength to "close back up and reel in the secretions."

Regardless of the cause, when we see tissues that are swollen, enflamed, and leaking, astringents are indicated, as they help restore tone to tissues, lessen secretion and swelling, and act as local anti-inflammatories.  The plant kingdom is rife with tannin rich astringents, but some seem to have a special affinity for the upper respiratory mucosa, and these can be used as teas, tinctures, and topically for nasal rinses.  Favorites I rely on often include goldenrod, yarrow flowers and leaves, ox eye daisies and ragweed (yup, that ragweed, which is fine even if you react to the pollen… just strain your tincture or tea through a coffee filter).  These herbs are also aromatic, which helps to decongest the sinuses… I’ll elaborate on that below.  With regard to form, I don’t have a strong preference towards teas or tinctures, if anything, I like using them both together (we have to get out of that “either or” mindset whenever we can).  In a pinch, you can simply grab some leaves, give them a few cursory chews, and put them in your cheek to suck on; that can work quite well.  Plantain, too, adds its salubrious influence here, when blended with more specific remedies; try adding some to your tincture, tea, or chew.

Topically, I've seen incredible results obtained by making a saline tea (again, add 1/4 teaspoon salt per 8 fluid ounces of well strained tea) of these plants, and using this in a nasal spray bottle or neti pot to irrigate the sinuses.  I’ve also used willow bark; which combines the anti-inflammatory action of astringents with the anti-inflammatory action of the salicylates it contains, and alleviates pain.  Tea works very well, but you can also add tinctures to your water salt solution.  If using a nasal spray bottle, please be sure to rinse and refill it every day or so... such a tea isn’t preserved and you don't want to go spraying spoiled tea up your nose if you're sick.  If the affliction is acute and you don’t normally have sinus issues, you can use it till you feel better and discontinue.  If you do have regular or chronic upper respiratory issues, then you’ll really need to make this a part of your routine; probably not for the rest of your life, but think in months, not weeks.  Because astringents (any astringent, if used topically) act locally and on contact, binding proteins together to constrict tissues and reduce secretion, results can be pretty impressive fairly quickly.  "Wow!" one person said.  But keep up with it regularly to really heal the tissues, lest it become merely a simple way to suppress inconvenient symptoms and never manifest its full potential.

plugged up stuffy...
This manifestation of upper respiratory woe is characterized by swelling, inflammation, and lots of congestion & mucous; but it's not really leaking or dripping: it's stuck.  The mucous seems to have more than filled up the sinuses, all the tissues are swollen (which increases the sensation of pressure), the eyes are usually sore, the head hurts, mental acuity is, well, pretty much gone, and there’s often a hypersensitivity to being around movement, noise and really any kind of activity, which inclines the person to (or at least want to) lie down in a quiet dark room away from stimulation and (hopefully) fall asleep and wake up feeling better.  You could blow your nose, get out loads of thick mucus, blow it again, get out more, blow it again, get out even more... it gets to the point where you wonder if your sinuses are like the Tardis, because it seems like you got more out than the amount of space there must be in there, and you're still congested.  Lots of chronic sinusitis is of this sort, and while this condition may manifest after an initial infection, it rarely is associated with the onset of an acute conditions (where optimally we have secretion of healthy, clear slightly viscous mucus).

Whenever congestion is a key symptom, the use of aromatics is pretty close to imperative.  There is an endless array to choose from, and most will have a dispersive effect on upper respiratory congestion.  Aromatic herbs contain volatile oils responsible for their decongestant virtues, and these oils also have a tendency to lend an anti-inflammatory and antimicrobial action to the herbs that contain them.  Among my favorites are wild bee balm, sage, thyme, garlic (some people just love garlic and cayenne), hyssop, yerba mansa, calamus, ginger and elecampane.  Aromatics are very effective as teas, tinctures, chews, foods, nasal rinses and steam inhalations, though the flavor of some may dictate use (most people would prefer to use a tincture of elecampane than drink 8 ounces of the tea...). 

For topical application, both steam inhalations and nasal rinses are exceptional for stuffy congestion.  It's often best to start using steam inhalations to break up congestion, because while a nasal rinse is very therapeutic, they're not good if you're so plugged up that the rinse won't run through.  This can create physical discomfort, but can also potentially worsen the condition if your saline tea just becomes one more thing stuck in your sinuses.   While most aromatic herbs are effective for steam inhalations, I tend to use sage as a standby.  I do also love wild bee balm, which seems especially antimicrobial and deep reaching.  Thyme, mint, eucalyptus... there are a lot of choices, and in a pinch just straight inhaled steam will help.  Steam inhalations are usually best done a few times a day (I generally say at least twice, hoping for more, but praying for at least every day).  Continue till the sinuses are open enough that a nasal rinse is feasible.

Make the nasal wash using the same ratios for tea and salt given above; as with the astringents, you could also add tinctures to a simple water and salt saline solution.  Any markedly antimicrobial aromatics seem also to work topically, so this direct application helps immensely.  An old formula I found in
Ellingwood's Therapeutist for a excellent yerba mansa nasal spray is prepared as follows, and uses glycerin rather than salt: combine 5-30 drops yerba mansa tincture (I've always used 5-10 drops, which seems to work fine) with 1 dram (about 60 drops) glycerin and add enough distilled water to make 2 fluid ounces of the mixture.  The author writes "As a rule, an acute attack yields quickly to the treatment, but a chronic case naturally requires more time to effect a cure."

I've made nasal washes with a slew of aromatic herbs (often mixed with plantain, because plantain is just awesome at healing mucous membranes).  Wild bee balm rocks, but is irritating (because it's hot/spicy) if used straight or too strong.  Adding plantain makes it easier to tolerate, or it can be diluted with more water (remember to add salt to make it saline).   I've also added elecampane tincture to a neti pot solution with great and immediate results.


mucous membrane trophorestoratives...
Sometimes the mucus membranes lining the sinuses need more focused attention.  “Trophorestorative” is a term used in some schools of western herbalism to refer to an herb that restores both the structure and function of an organ, system or tissue to a healthy state.  Beyond that, the benefit gained from its use is a lasting one; something that remains even after the herb is discontinued (provided, of course, that it was used long enough to manifest this potential).  Two herbs that strike me as specifically trophorestorative to the mucous membranes are goldenseal and yerba mansa.

Goldenseal is, of course, well known and lauded as a potent herb useful in combating sinus infections, but its virtues are frequently deemed the result of its action as a "natural antibiotic".  A problem with this hypothesis is that the antibacterial action of goldenseal manifests primarily when it comes into direct contact with tissues, and because it's not especially well absorbed through intestinal tissue, using this action to explain the effects of internal use on sinus infections can be found less than convincing.  If, however, we see goldenseal as a trophorestorative that restores the upper respiratory mucosa to a healthy state from a skewed one, the results obtained can be deemed the product of a natural and healthy mucus response.  Organic, wild cultivated goldenseal is an ideal consideration for acute sinus infections: your head cold started to get worse rather than better at 4ish days, your mucus is getting thicker and is obtaining a yellow/green color, and you feel freakin' lousy.  Take goldenseal, in 5-10 drop doses 3-5 times daily (Paul Bergner has written eloquently about the historical basis for using
smaller doses of goldenseal).  As goldenseal is a drying herb (useful for both leaky drippy and plugged up stuffy sinusitis but not appropriate for dry), larger doses can aggravate conditions by over-drying the tissues.  I don't advise more than 15 drop at a dose.  Also, don't use goldenseal right when you start to get sick, especially in large doses of tincture or capsules - that's not what it's for.  Its drying quality can inhibit healthy mucous secretion, which is an important initial immune response.

Although when people speak of "goldenseal substitutes" they frequently limit their exploration to other yellow berberine rich herbs, yerba mansa seems to me far more similar in its actions to goldenseal than any of the other berberine containing plants.  It, too, is a mucous membrane trophorestorative, restoring healthy function to the mucous membranes.  Both herbs seem to instigate an initial release of mucus, as if to push the unhealthy mucus secretions out, and then improve the quality of the mucus that follows, along with the tone of the tissues.  The significant different between the two is that while goldenseal is considered a cooling herb (good for hot/flared up/acute sinus issues), yerba mansa is warming, and indicated when sinus congestion has become chronic and low grade.  That day fourish worsening of your head cold?  It got better (after it got a lot worse), but it never got all the way better; you're still congested, but the mucus is opaque or white and thick, and not yellow anymore.  You feel like you're better...  but compared to when you felt like crap, not when you actually felt fine.

This brings us back to the tissue states we started with.  Mucus color tells us whether a condition is "hot" (yellow/green mucus) or "cold" (opaque/white mucus).  Hot and cold doesn't refer to the presence of an infection, or even inflammation: you can have both in either state, but simply to how the condition is expressed.  Think about a bonfire: a flaming pile of pine boughs is hot; all bright yellow and crackling and popping and you can't get anywhere near it.  The next morning, there's no fire and the ashes are grey... the fire looks out, but if you hold your hand over it you can feel that embers are still smoldering, and will flare up given the right conditions.

Back to yerba mansa: small doses of the tincture - say from 3 to 15 drops - should be taken as needed, consistently. 

what about just killing stuff causing the problems?
As the focus I've offered has primarily been on the state of the mucous (which tells us the state of the mucosa), some may be wondering about infections.  It's my opinion that while fighting infection is of course important, it's not necessarily proper to make that the first consideration when formulating a treatment protocol (if it was, people would be real happy with the approach offered by conventional medicine).  Also, it's usually the case that by treating to the state of the sinuses, you are treating the infection.  Because astringents act as antimicrobials.  Because aromatics act as antimicrobials.  Because hot steam is antimicrobial.  Because mucus itself is antimicrobial, and if you can restore proper function to the mucosa, the same mucus that was causing problems will help resolve them.  And of course, some sinus issues aren't microbial.  Think of those with seasonal allergies.  Or those who work surrounded by airborne irritants (carpenters frequently have sinus issues, as do many natural builders).  Think of forced air furnaces and woodstoves drying out mucosa.   Think of those with food allergies.

Once you've assessed the state of the sinuses, and chosen herbs with that in mind, then you can say (if you feel an infection is at play), "let's add something more potently antimicrobial."

If you're going to do that, it makes sense to think about what types of microbes cause sinus issues.  We know bacteria do, and the use of antibiotics is the hallmark of conventional therapy; they'll try stronger and stronger options, and if that doesn't work, they'll surgically trim out the excess swollen tissue to open of the airways.  What gives?  Are these antibiotic resistant bacteria?  Well, I'm sure that's a pending crisis but the main reason that antibiotics work so poorly, especially for chronic sinusitis is that there is often a concurrent bacterial and fungal infection at play.  This was discovered when a surgeon who performed the said surgical procedure sent out tissue samples to be biopsied; over 96% tested for both bacterial and fungal infection, explaining why antibiotics offered short term but rarely lasting relief for chronic sufferers.

Most herbs are best termed antimicrobials, and not antibiotic (which means strictly antibacterial), and many address both bacterial and fungal infections.  Garlic, wild bee balm, goldenseal, elecampane, black walnut and yerba mansa stand out, especially for topical use in nasal rinses.

treating chronic sinusitis...
Actually, the treatment I use for chronic sinusitis isn't so different than what I'd do for any other issue; I just tweak the formula to be sure that antifungals are involved, always use mucous membrane trophorestoratives,  plan for a longer haul (months not weeks) and make plain how important it is to do both internal and topical remedies constantly.  As anyone who has ever had foot or nail fungus can attest, fungal infections are tenacious.  You think you get the best of them, lighten up on what was working, and they come back fighting (after all, they have a vital force, too).  A long haul internal and topical approach, continued for at least a month after the person feels better provides the best chance of success. 

I will say that while I strive to treat each case individually, my experience has taught me that the most specific herb for chronic sinusitis is yerba mansa, and that's often a core of my treatment (and occasionally it's just "the treatment").  Yerba Mansa acts both as an astringent and stimulates circulation into the sinuses; when I've seen people use this herb daily, on a long term basis, the severity and duration of sinus headaches, congestion and infections lessen and can altogether cease.  As the symptoms ease, the person can taper down the dosage and frequency of use, and may eventually be able to use the herb only when/if they need to.  By using it topically in nasal rinses as well, a direct contact antimicrobial action against both the bacterial and fungal infections potentiates its internal use.

I use yerba mansa in the chronic, low grade stage of chronic sinusitis.  If the infection flares up, I switch to goldenseal internally, and a saline tea of plantain with goldenseal topically to reel things in.  In addition, I recommend steam inhalations regularly, especially if stuffiness pervades.

putting it all together…
It’s not the case that demulcents are only indicated by dry tissues, astringents by leaky ones, and aromatics by congestion.  These tissue states call attention to a certain property, they don’t exclude others.  So, if your leaky drippy allergies have been draining down the back of your throat and are causing inflammation and discomfort, add a demulcent to the astringents to coat and soothe those irritated tissues.  If your running mucus is thin and watery and just leaking leaking leaking, use more astringents, but if the running mucus of thicker and more viscous and you feel stuff and drippy at the same time, add more aromatics or use more aromatic astringents.  If your congestion is more stuffy and stuck, but everything feels swollen, include astringents with your aromatics.  Just adjust the proportions to the needs of the specific situation at hand, relying on a comprehensive understanding of herbal actions to guide your treatment.   

So...
that's as much as I have to share here (for now, at least), but if I can offer one parting thought (well... certainly I can... it's my write up, who's gonna stop me?) it's this:

If you've had sinus problems for a while, they're not going to disappear overnight, or in a week or two.  Please keep at it a while after you’re feeling better to ensure you stay better.  Remember to reassess your protocol as you go; what you needed when you started may change as you progress. Be consistent, follow through, start again if you fall off the bandwagon and give thanks to all the plants that help you on your way. 

jim mcdonald

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