Question: I believe I have some form of chronic rhinosinusitis. This is been by far the worst medical condition I have ever had, its persistence has had a devastating effect on what I have been able to accomplish over the years, especially with regards to more scholarly type of work, as well as having a profound effect on my overall quality of life. I have been ready to tackle my sinus issue one last time with everything possible in order to really do something with my life and be happy before it is too late.
I spend at least half of the year in Latin XXXXXXX In May I came back to Canada and have been in Calgary since, staying at my mother’s place. It has gotten much worse, to the point where it is devastating. I desperately need help.
So I saw my GP regarding this condition about two months ago, who referred me to a ENT specialist. Unfortunately the specialist would not see me if my CT scan were clear and – unsurprisingly (see history below) it turned out clear (again). My GP will prescribe what I ask but has been of no significant help.
In the fall I return to Panama. My condition is never as bad there as it is here in the dry air of Canada, but it does bother me a fair amount, especially indoors. (Though it is possible to go for a couple of weeks where it isn’t so bad)
All the details are below.
I very much hope you can help me.
-Sincerely XXXXXXX Hunter

Symptoms
1.     Facial Pain and pressure behind the nose. Very severe when in the midst of a prolonged episode.
2.     Often feeling of completely clogged behind nose and I can hear and feel the congestion internally, like it is rattling around inside my head behind my nose as I tilt my head back and forth. Also a general foggy feeling especially 15 or 20 minutes after getting up.
3.     Fatigue upon waking up.
4.     Headaches can arise very easily, especially days spent inside.
5.     Tender under both cheek bones, a symptom that has lasted many years.
6.     Dark circles under my eyes even though I regularly exercise very vigorously and my diet at the current time is quite good.
7.     Pain, especially about 10 minutes after getting up, on both sides of forehead. I use IcyHot cream every morning and throughout day to manage the side of the forehead pain and have been for years (along with stretchy tape on my nose like a “breathright” when im inside to slightly reduce pressure.
8.     During severe times, clear throat several times throughout day
9.     Heavy thick muscus – though usually clear or white – often inside the sinuses but not always in the nasal passages. In the morning is the only time (except after exercise) that there is a great deal of mucus that reaches the nose. Can hear and feel congestion in my ears when it is bad or after I sneeze or blow my nose.
10.     Feeling that breathing is restricted generally BEHIND my nose, not in the nasal passages unless I am having a sudden moment of excessive mucous discharge.
11.     Much worse in morning. Some mornings awake at 5 due to a headache originating in the sinuses behind the nose.
12.      When it is bad, indoor air is much worse. Usually use transparent tape that stretches across the bridge of my nose to slightly relieve pressure and make the pressure bearable.
13.     Dry air of Canada is MUCH worse generally for me than humid air of Latin XXXXXXX



History
-     Began after a diagnosed (with a regular x-ray) sinus infection in 1996
-     1 year extremely bad
-     Saw various doctors and tried an assortment of treatments to no avail, including Flonase, anti histimines, and anti biotics. CT scans were clear. Doctors told me that there was nothing they could see or do. It was beyond frustrating. I gave up.
-     There have been periods when it was minimal but It always comes back.
-     Mostly made somewhat liveable over the years by living near salt water bodies in Latin Americav and being outside and moving around a lot (and also, self-medicating), though it can also get quite severe especially during times when I spend a day or two mostly inside. But as I say, coming to the dry air of Calgary usually is brutal.
-     I would term the last three months – the entire time in Calgary and its dry climate as absolutely brutal, 24/7 the condition exists and several times throughout the day it is terrible.
Additional notes
-I have known allergies of dust, dust mites, mold and cat hair, though there seems to be far more correlation simply being indoors and in dry environments and the sinus pain rather than being in dusty or moldly places. But I certainly do have allergies.
-SNOT-20 questionnaire score of 50 out of 61, moderate to severe, see specialist was the recommendation.
-a year ago my thyroid stopped working and I had a ths level of 150. I have been on t4 replacement since and my levels have finally basically returned to normal.
- I do get regular heartburn, though it doesn’t seem to have any correlation with my sinus pain.
-chewing gum seems to help a fair bit, though not when it is really bad.


Current treatment
After so many years of being unable to truly pursue my life’s goals and time spent studying extensively almost always results in headaches and pain and pressure behind my nose I am extremely committed to treating this until it has basically gone away.
Two weeks ago I started steroid irrigation with 0.25 mg of budesonide after a week of an oral steroid.. After a few days there seemed to be some progress, some loosening of the congestion. I administered it at night and in the morning there seemed to be slight improvement. However after about a week the improvement basically stopped, though it does seem that right after the irrigation it feels quite a bit better; better than just a saline rinse (although that could be due to the extreme care I use when irrigating with the medication).
Also I regularly use steam for some small temporary relief along with the saline irrigations a few times a day
I have also modified my diet significantly, focusing on healthy food along with foods that have anti-inflammatory properties.
I believe I am going to start with a mucus thinner, as that seems like when I do have the excessive discharge in the morning it is quick thick and sticky (though as I say, clear)
Questions
1 Is that the proper dose of budesonide? How many times a day should I use it given my history? Is there a better drug to try.
2. What is the likelihood of this being related to fungal issue? Is this always seen on a CT scan?
3. Relation of endoscopy and clear ct scan…can an endoscopy help, for example to examine tissue samples within the sinuses, or to see something that the CT scan didn’t pick up? Bottom line: is an endoscopy of the sinuses recommended despite the clear CTscan?
4. What other treatment options are there? What should I do?

thank you very much for your reply.

2 quick follow ups and a note:

1. are you saying the steroid spray is better than the steroid irrigation? from what i have read it is difficult for the spray to reach the troubled area of the sinuses.
2. any particular anti histimine or dosage?

also: tomorrow i am going to see my GP to get a prescription for the anti-leukotriene and retrieve my ct scan. Then i will upload it and send it.

thank you again.