OK, a terrible play on words—but sinuses are probably the most common complaint we hear from patients, and singers are no exception. In this column, I would like to discuss what sinuses are, what they do (and don’t do), and some common misconceptions, especially about how sinuses relate to singing.
Sinuses are air pockets that surround the nose. They arise as outpouchings of the nasal cavity, and are in some ways similar to the nose: they have bony walls and are lined with mucous membrane. Sinuses are much less complex than the nose, however: They are not involved in breathing, in smell, or in the heating or humidification of the air. In fact, we really don’t know the function of sinuses. Some of the many theories include suggestions that they lighten the head, absorb the shock of chewing, or that they act as surge tanks during nasal breathing, damping the force of nasal inspiration and expiration. All opinions, not facts.
One thing we are pretty sure about: Sinuses do NOT play a significant role in singing. Yes, they resonate (along with the rest of the skull), but their audible contribution to vocal resonance is negligible. Let me qualify that: Sinuses do not significantly modify the sound coming from the mouth (what the audience hears). The bone-conducted sound a singer hears, however, the vibration he or she feels through the skull, may be affected.
Adults typically have four sets of sinuses. The largest, the maxillary sinuses, are in the cheeks. Two smaller clusters of air pockets, the ethmoid sinuses, are crowded between the inner corners of the eyes and the nose. Frontal sinuses reside in the forehead, right above the nose and the eyes, and the deepest sinuses, the sphenoid sinuses, are hidden at the back of the top of the nose, below the base of the skull.
Sinuses form at different times during childhood, the frontals being the last to develop (usually around age 18). Some people never form frontal sinuses at all, and are no worse off for it, either physically or vocally.
Thanks mostly to TV commercials, many patients confuse nasal inflammation (rhinitis) with sinus inflammation (sinusitis). Although the two frequently occur together, they are distinct entities. Rhinitis causes nasal blockage, nasal discharge, snoring, and postnasal drip. Sinusitis causes pain and pressure over the cheeks, around and behind the eyes, and over the forehead. Pain or pressure over the hard palate and the teeth may also be a feature.
The superficial sinuses predictably cause pain directly where they are located (forehead or cheek), but deeper sinuses are less well localized. Sphenoid sinusitis can cause pain at the top, and even the back, of the head.
Rhinitis and sinusitis do share one common symptom: nasal drainage. Since every sinus opens into the nasal cavity, sinuses drain into the nose, and may be infected by bacteria traveling up from the nose. Chronic nasal drainage, especially if it is discolored, is strongly suggestive of sinus disease.
Sinus inflammation may be painful, but many patients with greatly swollen sinuses have no symptoms at all. A sinus completely filled with fluid, thickened mucous membrane, or even polyps, and not draining into the nose, may not cause any discomfort. On the other hand, a sinus lining that is minimally thickened and only partially occluding its drainage to the nose may cause a great deal of pain.
This is especially an issue for singers who are frequent air travelers. The sinus is unable to adjust to pressure changes during flight, and the pressure differential between the inside of the sinus and the outside (nasal cavity) can cause severe pain, the so-called “vacuum headache.” But there is no linear correlation between the amount of “pathology” within a sinus and the symptoms it produces.
Causes of sinusitis include chronic infection and allergies. Nasal blockage due to septal deviation or other forms of abnormal nasal anatomy may predispose people to sinus blockage. Since the roots of the molars are directly under the floor of the maxillary sinuses, dental infections may also cause sinusitis. An examination and a CT scan can tell you a great deal about the state of your nose and sinuses.
What about treatment? Most nasal and sinus disease is benign. Unless there is a suspicion of a tumor or other serious medical condition, most sinus treatment is elective.
Medications, as well as surgery, can have side effects. Antihistamines may be excessively drying; surgery may have complications. Especially when considering surgery, you should consider seeking a second, independent opinion.
My recommendation is to place any treatment within the context of your symptoms, your discomfort, and your impairment level. Both medical and surgical treatment can be highly effective for sinus disease, though some patients require long-term management, including allergy shots, antihistamines, nasal steroid spray, even repeated endoscopic surgical treatment.
Disclaimer: The suggestions Dr. Jahn provides in these columns are for general information only, and are not to be construed as specific medical advice or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.
