Anthroposophic approach to acute and recurrent rhinosinusitis in adults and children

International experts’ recommendations

Overview

Introduction

Acute and acute recurrent rhinosinusitis are very common in both adults and children (1, 2). They are considered to be frequent complications of viral upper respiratory infection or allergic inflammation. As viral infections are the most common trigger (3, 4), antibiotics are not effective in most cases. Their use always needs to be balanced against the risk of adverse drug reactions (e.g., allergic reaction), the weakening of the organism by mainly affecting the gut microbiota of the patient (e.g. impairment of the mucosal barrier) and finally the selection of resistant bacterial pathogens. Additionally, they may contribute to an increased risk to develop chronic rhinosinusitis (5). According to current international guidelines, antibiotics should be limited to severe cases of rhinosinusitis, generally defined in children and adults as worsening symptoms during the first days of disease or persistent symptoms without improvement after more than 8–10 days (1, 4, 6, 7, 8). The criteria for when antibiotics are recommended and when they should be avoided can be found in detail in these guidelines.

Apart from antibiotics for bacterial rhinosinusitis, current international guidelines offer limited therapeutic options (1, 6, 7, 8, 9). While there seems to be some evidence for saline irrigation and for intranasal corticosteroids, without sufficient information on the long-term safety of the latter, the data are insufficient to generally recommend adjuvant therapies like oral or topical decongestants, mucolytics and antihistamines (1, 6, 7, 8, 9). Paracetamol and Ibuprofen can be considered as symptomatic treatment for pain control and fever (7). Rhinosinusitis in the context of allergic diseases needs a specialized approach, in particular for chronic conditions (3).

Looking for further therapies, complementary medicine offers additional opportunities to the conventional approach. There are often longstanding positive experiences, but evidence from high quality research is frequently missing. Especially in the context of bacterial antibiotic resistance these complementary therapies are presently gaining ever greater attention, as they can contribute to further reducing unnecessary use of antibiotics and antipyretics (10, 11). This article provides an approach from Anthroposophic Medicine for the treatment and prevention of acute and acute recurrent rhinosinusitis in children and adults based on an international, multiprofessional expert consensus process.

Symptoms of acute rhinosinusitis

Diagnosis of acute rhinosinusitis in children and adults is made clinically, based on characteristic signs and symptoms and the course of the disease (1, 7, 8).

Symptoms of sinusitis include:

  • Rhinitis, sneezing, reduced sense of smell and taste.
  • Yellow or green mucus, out of the nose and on the back of the throat.
  • Pain or feeling of pressure in the forehead, behind the nose or jaws, possibly worsening through chewing, outward pressure or bending down—less in children. The roots of the upper teeth and molars can be painful. Coughing when lying down and getting up.
  • Dullness in the head, impaired sleep and concentration.
  • Moderately pressure-sensitive swellings in the regional lymph nodes.
  • In many cases a significant decline in general condition, feeling of coldness, often cold feet.
  • Fever is more typical in young patients and severe cases of sinusitis.

Working principles of sustainable integrative therapy

Underlying factors of acute and recurrent rhinosinusitis can be addressed by attending to the following aspects:

  • Warmth: To support and balance warmth in the body: warm drinks, warming external applications, clothing and avoidance of air conditioning. Care for colder body regions!
  • Breathing: Decongesting nasal treatment, activation and regulation of the breathing. See also body exercises. 
  • Fluids: Consumption of warm fluids in sufficient quantities is essential for the function of the mucous membranes in the airways.
  • Immune supportive nutrition, therapy and microbiota care: Wholesome nutrition is more important than isolated vitamins and substances. Bitter substances enhance the immune response to acute infections and promote digestive processes.
  • Exercise, speech and body therapy: Movement therapies like eurythmy therapy and (rhythmical) massage activate breathing processes as does anthroposophic therapeutic speech. Outdoor exercise with sufficient exposure to sunlight is necessary for a healthy status of the immune system and the airways.
  • Psychosomatic aspects: Reduce stress and overload, regulate neurosensory input (screens and media), consider emotional and social conflicts.
  • Biographical and social aspects: Considering biographical and social aspects may open a window to change unhealthy behaviors and life circumstances.

Not all these principles will be explained in detail.

Behavior, general recommendations, sick leave

Patients should:

  • Stop active and passive smoking.
  • Exercise nasal breathing and care for the quality of the air.
  • Reduce screen use.

Sick leave should be individually considered and may be necessary to overcome acute or recurrent rhinosinusitis.

Therapy

Warmth and external applications

  • Drinking warm fluids is very important. An infusion of elderflower and lime blossom tea with a little lemon and honey has a strongly warming effect and is as least as effective as conventional mucus dissolvers. The quantity of fluid is also relevant (more than 1.5 l/day for adults)
  • Cooked food, ripe fruits, hot spicy soups, fermented food. Avoid processed foods, sugar and too many milk products.

The following applications help to diminish pain and congestion and balance warmth between the head region and the lower body: 

  • Foot bath or ginger foot bath: Warm water (40°C) covering the ankles, 2 tbsp. of ginger powder and 1–2 tbsp. of salt, 15 min.
    In mild cases, or for children under 4 years, apply warming oil or ointment to the feet after the footbath: e.g., Lavender 10% oil or Solum uliginosum comp. oil WALA , esp. before sleep, Copper 0.4% ointment WELEDA or Red Copper Ointment WALA (also available as Cuprum oxydulatum 0.4%, Kupfer Salbe rot), Mallow oil WALA (also available as Malvenöl).

The following local applications of warmth cause decongestion and pain relief:

  • Steaming 2–3 times a day for 10 – 15 min. above a bowl with warm water (about 60–80°C). Alternating chamomile and lime blossom infusions (chamomile alone for more than 2–3 days may cause mucosal dryness).
    Please note: Not appropriate for children under 5 years. Children only with one of their parents present.
  • Patients can also steam in the bathroom or shower by opening the warm water tap and breathing the steam carefully.
  • Heat radiation of the cheeks and forehead with an infrared lamp.
    or
  • Brief local application of horse radish on the cheeks and forehead for a few seconds until it burns, then remove and apply a soothing oil. This is helpful in managing sinusitis pain. It is very important to protect the eyes from horseradish contact. A milder alternative is the use of Cochlearia 10% ointment WELEDA (also available as Cochlearia armoracia D1 ).

Composition of the medicinal products mentioned: Solum uliginosum comp. oil: Aesculus hippocastanum e semine, Equisetum arvense ex herba, Lavandulae aetheroleum, Solum uliginosum. Copper ointment: Cuprum metallicum praeparatum. Red Copper ointment: Cuprum oxydulatum rubrum. Mallow oil (Malvenöl): Geranii aetheroleum, Malva arborea e floribus, Hypericum perforatum ex herba rec., Prunus spinosa e floribus, Sambucus nigra ex umbella, Tilia platyphyllos/cordata e floribus. Cochlearia 10% ointment: Cochlearia amoracia, radix.

Breathing: Nasal decongesting treatment

  • Local application of a nose rinse can be very helpful (level of evidence 1 A (12)); for children from age 5 years use a lukewarm 0.9% saline solution (9 g salt in 1000 ml water) 1–2 x/d (13). This treatment is an effective alternative to decongesting nose drops (Xylometazoline, which is not appropriate for children aged < 2 years and should only be used in a very restrictive way; max. 7 days).
  • In addition, saline nose sprays several times a day may augment the effect of the nose rinse.
  • With a history of allergy, a nasal spray based on quince and lemon is recommended:
    Gencydo® WELEDA (also available as Hayfever Nasal Spray, Heuschnupfenspray ), 4 x 2/d
  • Local decongesting ointment: Nasal Balm WALA (also available as Nasenbalsam) or Catarrh Cream WELEDA (also available as Schnupfencreme ).

Composition of the medicinal products mentioned:
Gencydo® (Hayfever spray):
Citrus limon, Succus; Cydonia oblonga, Fructus. Nasal balm: Balsamum peruvianum, Berberis vulgaris e fructibus, Cajeputi aetheroleum, Eucalypti aetheroleum, Prunus spinosa e fructibus, Silicea colloidalis. Catarrh cream: Aesculinum; Berberis, Fructus ø; Bryonia D3; Echinacea purpurea, Planta tota ø; Prunus spinosa, Fructus ø; Hydrargyrum sulfuratum rubrum D4; D-Camphora; Eucalypti aetheroleum; Menthae piperitae aetheroleum; Thymi aetheroleum.

Phytotherapy: Etheric oils and bitter substances

Bitter substances activate the unspecific immune system, as well as the breathing and cleaning activity of the mucous membranes of the sinuses and the digestive system (14), e.g.

  • Amara Drops WELEDA (also available as Amara Bitters): 3–5 drops pure on the tongue 3–5 x/d or
  • Gentiana comp. pillules WALA (also available as Gentiana Magen Globuli): 7–15 pill. 3 x/d or
  • Sinupret® eXtract tablets/drops BIONORICA®: 1 tab. 3 x/d, children up to 12 yrs.: 10–25 drops 3 x/d.

Etheric oils may be helpful to overcome infections in the upper airways and they have anti-inflammatory, antimicrobial, mucolytic effects.

  • e.g., GeloMyrtol® forte capsules G. POHL-BOSKAMP GmbH: acute and recurrent sinusitis: 3–4 caps./d, children up to 12 years 1–3 caps./d.

CAVE: Products with high concentrations of etheric oils like GeloMyrtol® forte can cause stomachache and nausea—and not all patients find them effective.

Composition of the medicinal products mentioned: Amara Drops: Artemisia absinthium, Herba; Centaurium erythraea, Herba; Cichorium intybus, Planta tota; Gentiana lutea, Radix; Juniperus communis, Summitates; Achillea millefolium, Herba; Peucedanum ostruthium, Rhizoma; Salvia officinalis, Folium; Taraxacum officinale, Planta tota. Gentiana comp. pill.: Artemisia absinthium ex herba ø (=D1), Gentiana lutea e radice ø (=D1), Strychnos nux vomica e semine D4, Taraxacum officinale e planta tota ø. Sinupret® eXtract tabs.: Primula veris/elatior; Gentiana lutea; Sambucus nigra; Rumex species; Verbena officinalis. Gelomyrtol® forte caps.: Rectified essential oils of eucalyptus, myrtle, lemon, sweet orange.

Regulating inflammation with Anthroposophic Medicine (15)

Sinusitis, especially sinusitis maxillaris with dull, pressing pain and severe swelling of the mucous membranes, large amounts of discharge, accompanied by exhaustion:

  • Agropyron comp. pillules/ampoules WALA (also available as Agropyron Globuli velati/Inject)
    Dosage: Children up to age 12 yrs.: 5–10 pill. 4 x/d, up to 5 pill./h in the beginning to dissolve the mucus, adult patients 10–15 pill. 4–5 x/d.
    Intensive therapy (esp. in adult patients): At the onset of treatment 1 amp. s.c. 1–2 x/d (e.g., upper arm).

Acute sinusitis, particularly painful with little secretion (ampoules s.c.), also after the acute situation to support the healing of the mucous membranes and to reduce pain:

  • Sinudoron® WELEDA (also available as Argentum/Berberis comp. ampoules WELEDA )
    Dosage: 10 drops 5 x/d, Children 5–12 yrs. 7 drops 5 x/d.
    Intensive therapy: At the onset of treatment 1 amp. s.c. 1–2 x/d in the upper arm.

Purulent inflammation, congested, viscous discharge:

  • Myristica sebifera comp. pillules/ampoules WALA
    Dosage similar to Agropyron.

Recurrent rhinosinusitis, tonsillopharyngitis:

  • Cinnabar comp. trit. or D6 tablets WELEDA (also available as Cinnabaris, Sore Throat Relief, Zinnober):
    Dosage: 1 saltsp. 4–6 x /d or 1–2 tabs. 5 x/d.

Painful sinusitis, yellow mucus, sensitive to cold weather:

  • Hepar sulfuris D4–D6 trit. WELEDA (Hepar sulphuris)
    Dosage: 1 saltsp. 6 x/d, children up to 12 years D6, adult patients D4–D6.

Chronic sinusitis, recurrent sinusitis, to complete sinusitis treatment:

  • Hepar sulfuris comp. amp. WALA (Hepar sulphuris)
    Dosage: 1 amp. s.c. 3 x/week or 1 amp. per os daily for 7–10 days.

Recurrent sinusitis, allergic rhinosinusitis, rhinosinusitis in children with adenoids and/or glue ear (16), to give structure to the mucous membrane:

  • Berberis/Quarz pillules WALA or Silicea comp. pillules/ampoules WALA (also available as Silicea comp. Globuli velati/Inject)
    Dosage: 5–10 pill. 3 x/d. Intensive therapy: At the onset of treatment 1–2 amp. s.c. Silicea comp. in the upper arm.

Composition of the medicinal products mentioned: Agropyron comp. pill./amp.: Agropyron repens e radice D3, Kalium carbonicum e cinere Fagi silvaticae D9, Taraxacum officinale e planta tota D4, Zinnober (cinnabar) D6. Sinudoron®: Argentum metallicum praeparatum D20; Berberis, Fructus D3; Quarz D12. Argentum/Berberis comp. amp.: Argentum metallicum praeparatum D20; Berberis, Fructus D3; Quarz D12. Myristica sebifera comp. pillules/amp.: Argentum nitricum D19, Kalium bichromicum D5, Myristica sebifera succus e cortice D3. Zinnober comp. trit.: Apisinum D5, Belladonna D3, Zinnober (cinnabar) D5. Zinnober D6 tabs.: Natural Mercury(II)-sulfid. Hepar sulfuris D4–D6: Calcium sulphide among other things, hepar sulfuris calcerium. Hepar sulfuris comp.: Hepar sulfuris D5, Membrana sinuum paranasalium bovis D5. Berberis/Quarz pill.: Berberis vulgaris e fructibus D2, Quarz D19. Silicea comp. pill./amp.: Argentum nitricum D20, Atropa belladonna ex herba D14, Quarz D21.

Pain management

In most cases, pain management is possible by means of the external and topical applications mentioned above, in combination with anthroposophic/phytotherapeutic medicines. Severe pain first requires careful clinical diagnostics.

Suppositories can be used for pain treatment in infants and children:

  • Fever and Teething Suppositories WELEDA (also available as Chamomilla comp. suppositories, Fieber- und Zahnungszäpfchen)
    Dosage: 1–3 x/d.

Paracetamol has analgesic effects, Ibuprofen has analgesic and antiphlogistic effects, but both have a burden of side effects. They may be useful in cases of acute heavy pain without sufficient relief. Fever is no indication to use Paracetamol and Ibuprofen (17).

Composition of the medicinal product mentioned: Belladonna D3; Chamomilla recutita, Radix D2; Echinacea Φ; Echinacea purpurea, Planta tota Φ; Papaver somniferum, Fructus immat. D3; Argentum metallicum praeparatum D19.

Anthroposophic Therapeutic Speech

Authors: Ute Poland, Franziska Schmidt-von Nell 

Anthroposophic therapeutic speech offers the following as initial exercises for aerating the nasal cavities and thus freeing nasal breathing (in cases of acute and recurrent sinusitis. In chronic cases it is recommended to consult a therapist trained in anthroposophic therapeutic speech):

  • Breathing exercise to free nasal breathing
    First the patient tries to sense: which nostril feels less blocked? Then he closes the other nostril by gently squeezing it from outside with his thumb, takes three short breaths through the unblocked nostril and breathes out again in the same manner (three short breaths). Then he repeats the process with the other nostril. The patient keeps breathing in and out in this way, alternating the nostrils, for a certain period and he will feel an improvement of the air flow over time. The patient should repeat this exercise, if possible, several times a day, most importantly before going to sleep.

  • Intonating the sounds “M”, “N” and “NG” in a humming way
    or possibly humming a melody with “hmmm, hmmm, hmmm” – guides the exhalation stream through the nose, while speaking the sentence “Moisten mason mine essence” or “Name neat Norman on nimble moody mules”.
    This causes the nose and forehead to sound, vibrate, aerate and warm through. Mucus drains off. It frees nasal breathing.

  • Exercises with the following sounds should only be learned in their therapeutic application under the expert guidance of a person trained in anthroposophic therapeutic speech
    The sounds “S”, “Sh” and “W” warm the organism and deepen breathing.
    The sounds “H”, “K”, “G”, “I” and “E” strengthen the soft palate, which only keeps the pharynx free when toned. The pressure conditions in the head change, the feeling of pressure decreases, patients experience themselves as being “more awake”.

Anthroposophic therapeutic speech exercises based on these sounds predominantly strengthen the person’s rhythmic system, their “breathing center”, particularly when the sounds are formed according to metric principles.

The exercises also strengthen the personality in its ability to defend itself against stressful influences from the outer world (e.g., “k” as in “Kung Fu”).

Experience shows that decisive biographical changes can take place during therapy with anthroposophic therapeutic speech.
All speech exercises are practiced with accompanying movements of the entire body, since using the feet and the lower body shows effects on the head area.
Anthroposophic therapeutic speech offers numerous other possibilities for sounding through the nasal forehead space, improving breathing, warming the entire organism and responding specifically to the individual situation.

Eurythmy therapy

Author: Adriana Cordón

Eurythmy therapy for acute and recurrent rhinosinusitis offers effective exercises to strengthen the “I”-organization (warmth organization), the breathing—especially exhalation—the warmth of the body and the digestion. 

Eurythmy therapy for sinusitis may prevent a relapse of sinusitis (daily exercise for months is necessary, especially in cold seasons, when using air conditioning, travelling), diminish symptoms of beginning sinusitis, support therapy of sinusitis, and complete recovery from sinusitis.

  • “Breathing” exercises:
    “L A O M”:
    Letting the breath through;
    “L-M, A-O”: Breathing in and breathing out.

  • “L M S U”— a specific exercise for Rhinosinusitis:
    “L”: The “water-sound”: unfolding life. The patient can practice the “L” horizontally forward and backward, doing it with their shoulders and with their hands in front of their face.
    Practicing this exercise contributes to opening the blocked upper airways.
    “M”: Breathing; with both arms forward and backward. Fosters exhaling.
    “S”: directing the “S” from up to down (as a leaf or feather, snowflakes or something like that). To come to rest. This exercise contributes to controlling inflammatory processes.
    “U”: Forming the “U” downward, into the warmth, grounding, narrowing space. To give a hold.

  • “L M S U” – can also be practiced with the legs and feet. Eurythmy therapy with the feet has a “mirror” effect on the head. (No jumping when there is an inflammation.)
    “S” with the feet downwards.
    “L M S” , small, gently, in front of the cheeks.

Rhinosinusitis from an anthroposophic point of view

Physiology

The breathing system develops between the metabolic system (represented by the mouth) and the neurosensory system (represented by the eyes and forehead region). The nasal sinuses develop during childhood and their development comes to completion at the age of 20–25 years. The upper and lower airways work as a unit (“united airways”) and the functioning of the nose and sinuses is important for lung function and health. Breathing, the development (pneumatization) and health of the airways are connected with the embodiment of the soul from a holistic point of view. There is a direct correlation between respiration and the soul’s experience of feeling. All sensations, feelings, emotions are reflected by changes in breathing. Breathing is part of the “rhythmic system” of the human being (including the heart and circulation) that balances the different influences and needs of the neurosensory system, the metabolic system and body movement.

Pathophysiology

In infancy and childhood, when the upper airways are in development, rhinitis and rhinosinusitis occur frequently.

Predisposing factors are:

  • Early exposure to a child community,
  • the size of the child community,
  • older sibling visiting a child community,
  • chronic cold exposure (cold floors, inadequate clothing, cold psychosocial atmosphere),
  • passive smoking,
  • allergies (dust mites, cow milk proteins),
  • swimming pools (chlorine gas, cold water, infectious agents).

Today many students and adults are affected by recurring rhinosinusitis. It is often linked to stress and it already represents a reaction to overly strong stress-induced catabolic processes in the organism, which cannot be balanced and compensated because of insufficient vitality, lack of body movement and weakness of the warmth organization. Exhaustion of vitality causes coldness in the body (e.g., legs) which increases the susceptibility to sinusitis.

To summarize, predisposing factors are:

  • Work overload, screens, media and nervous stress, lack of body movement and weakness of the warmth organization.
  • Air pollution, dry nasal mucosa, which is a central problem, especially in patients living in urban areas; active and passive smoking.
  • Allergies, malnutrition and insufficient intake of fluids, weakened digestion, microbiota (e.g., by antibiotic treatment).
  • Lack of rhythm and sleep which impairs the upbuilding life processes and the immune system.

Prevention

The integrative treatment and prevention of (recurrent) rhinitis and sinusitis aims to stabilize and balance the “breathing middle” by strengthening the patient’s warmth organization and vitality. Besides breastfeeding for infants it is recommended to care for:

  • Stable body warmth, avoiding chronic cold exposure and cooling down. 
  • Avoiding passive (and active) smoking, intense exposure to air pollution and potential allergens. 
  • Care for the dry nasal mucosa by drinking sufficiently and by topical treatment, e.g., with coconut oil or Nose Balm (mild) for children WALA (composition: Balsamum peruvianum, Berberis vulgaris e fructibus, Prunus spinosa e fructibus, Silicea colloidalis).
  • Walking in nature.
  • Eurythmy therapy and anthroposophic therapeutic speech (see previous chapters) that are effective in strengthening the warmth and breathing organization.
  • Stable rhythms in daily life, with healthy food and sufficient sleep.

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