"When all you have is a hammer every problem seems like a nail." Anon

Doctors usually treat nasal and sinus disorders with the three most powerful tools in their armamentarium - steroids, antibiotics and surgery. Consequently the nasal world is frequently perceived in terms of allergy, infection and altered nasal structure. The "quick fix" surgical and medical approach often works, but how does one help people with nasal and sinus complaints, who do not fit into these classifications or have failed these interventions? I often see patients who have had repeated prescriptions for oral steroids and antibiotics, as well as multiple operations, yet they are no better, and unfortunately sometimes worse.

From a simplistic surgical perspective, I theorized that if the nasal structures appeared adequate, then perhaps part of the problem might lie with function. How were the patients using their noses? I began to observe how patients used their lungs to pump air in and out of the nose. I started to examine my patients below the collarbones, a territory not normally considered the domain of an ear, nose and throat surgeon. I had to explain to some of my female patients, that all I was observing was their breathing patterns! Initially I observed that those patients complaining of nasal obstruction with structurally adequate noses appeared to breathe abnormally; they breathed both rapidly and predominantly in their upper chests. In retrospect, such a finding was not unexpected. The lungs connect to the nose. It has long been recognized that the nose influences lung function. Any good design engineer would put in place feedback mechanisms that allowed the lungs to also regulate and influence nasal function. Lung malfunction could then easily lead to nose malfunction. I started to observe my patients' breathing patterns more closely.

As I contemplated my patients' breathing patterns, I started to realize that many of my patients had numerous, other medical non-nasal complaints (Table 1). Patients give an interpretation of what they feel is relevant to their problem, and what they think the doctor should know. They may often have other symptoms that they feel, and most doctors feel, are probably unrelated to their current problems. The patient with "sinusitis" may have seen a neurologist for headache, a cardiologist for palpitations, a psychiatrist for depression, a gastroenterologist about their indigestion and the orthopedic surgeon for low back pain. It was not unusual for these patients to have consulted numerous specialists, had numerous investigations and no one had been able to find anything wrong! I started to realize that dysfunctional breathing patterns were involved in many of my patients' problems. Attention to breathing patterns allowed them to attack their problems on a number of fronts: it helped them relax, improved brain biochemistry, restored normal carbon dioxide physiology, reduced muscle irritability and reestablished normal posture.

To a number of people, this is no revelation and represents only a small part of the total picture. Our breathing patterns have for centuries been considered a link between the body and the mind. In the Christian religion, the Jesuits stress the importance of breathing during prayer and contemplation. Inspiration literally means to breathe in the spirit. Buddhism, Taoism and yoga all emphasize the importance of good nasal diaphragmatic breathing to health. These philosophies confirm what the physiology books teach us: at rest we were designed not only to breathe slowly using our diaphragms, but also for maximum benefit, we were designed to do so through our noses. Over the years these ideas have been neglected, and in Western cultures they are frequently overlooked, if not ignored. However, when some of my patients started to tell me that they had been given "a new lease of life" or, they had "never felt better", not through their operations, but solely through changing their breathing patterns I thought it might be time to investigate things a little more closely.

Surgeons, such as myself, view the world simplistically. Initially, I felt the situation could be corrected solely by addressing the underlying breathing pattern. I discovered that the situation was not that simple. Firstly, I had not realized the complexity of the factors driving breathing patterns. One has to identify and unravel some of these forces. At times this may be easy; all that might be required is better medical control of the patient's asthma. On the other hand, some patients who have suffered stressful major life events need to have these issues addressed. For these people, sometimes there may be no one simple answer; however breathing re-education has been a small but valuable part of an overall management plan. It is certainly better than spending tens of thousands of dollars in the fruitless search for a surgical panacea.

Secondly, the breathing pattern may not be the total problem; real disease may aggravate pre-existing symptoms. Hyperventilation is a well-known cause of dizziness. While hyperventilation, by itself, can cause dizziness, some patients may have adopted a stressful breathing pattern, because they are fearful of a severe dizzy attack from another cause. This disordered breathing pattern can in turn cause dizziness, faintness or unsteadiness. The chicken and egg conundrum needs to be resolved.

Thirdly, abnormal breathing patterns may cause postural and musculoskeletal imbalances in the neck, shoulder, chest and low back muscles that can also contribute to headache and low back pain. If we breathe rapidly at twice or three times the normal breathing rate, as some people with a breathing pattern disorder do, accessory breathing muscles that were designed to be kept largely in reserve for "emergency" breathing, or to provide postural support to the head and low back are being grossly misused. Typical symptoms include pain over the frontal sinuses and maxillary sinuses, referred from shortened and fatigued neck and shoulder muscles. Until the forces driving the breathing pattern are identified, and the breathing pattern is corrected, these accessory respiratory muscles will continue to be sore and generate referred symptoms to the face, ears and neck.

In our daily lives, we survive and adapt to our environments by adopting simplistic "cause and effect" models. We assume that our bodies behave the same way. Often they do; at other times they do not. Chest pain may occur in people with a poor blood oxygen supply to the heart. However the causes of the poor blood oxygen supply are often multi-factorial. Elevated blood fat levels, diabetes, cigarette smoking, obesity and diet all are part of the tapestry. The factors relating to health and disease are like the strands of a rope; they intertwine and interact. If a constant force is applied to the rope, there is a predictable lengthening of the rope; beyond that it breaks unpredictably. The breaking point cannot be predicted by the initial lengthening of the rope. With disease there may be very gradual imperceptible changes occurring in the body, but beyond a certain point symptoms start to appear. The rope starts to fray and finally breaks. In my work, when I see patients where the rope is gradually lengthening and about to break, I have come to realize that identifying, isolating and strengthening the individual strands in the rope is also important. However the strands of the rope interlock and interact with each other in complex ways.

This book has been written for a number of reasons. Often I cannot provide my patients with the "quick fix" that they desire. My patients are not just cases of disordered structure or metabolism. This book gives me the opportunity to convey the information, skills and encouragement that my patients need to know to be able to help themselves. The time required to communicate all the information to help my complex patients is simply not available in a normal consultation. Although some very good books are out there I have become frustrated that none cover the information that my patients need. Some of my patients are unable to find the books that I have recommended. Diverse fields ranging from muscle pain, posture, diet and immunology, to respiratory physiology need to be covered. Some patients have recognized that "stress" is a factor in their problems. This book is able to explain why and offer management ideas and techniques. Some patients cannot understand why symptoms such as palpitations, tingling in their fingers and abdominal bloating (Table 1) might be associated with "their nasal and sinus problems". They find it even harder to comprehend that they might not have nasal or sinus disease at all. Hopefully this may go some way to explaining why.

Secondly, this book also offers me the opportunity to answer some critics. One general practitioner told me that breathing was irrelevant to an ear, nose and throat surgeon's practice! I asked him what the nose was designed to do. Another told me that good surgeons should focus solely on surgery. I partially agree; surgery is an important part of my work but being a good physician also helps my patients. Firstly, it is important to have the correct diagnosis to ensure that one does the correct operation. The best operation in the world is useless if it was not necessary. Secondly, better surgical results are achieved if both preoperative and postoperative medical management is optimized.

This book is not the last word on the subject, and history will show that not all the ideas are correct. "Knowledge" rapidly becomes obsolete. However some of these ideas may direct us on the correct paths. This book starts by addressing the critical, fascinating, but forgotten, role of "smell" and the "nose brain" in our everyday lives. The physiology and anatomy of the respiratory tract are then discussed. The focus is then on the way that muscles interact to allow you to breathe and how these muscles may become dysfunctional. It then looks at some of the central influences of the brain on respiration. Nutrition is then discussed. These chapters all have a brief summary at the end. This allows people to jumpstart to the chapters on self-help techniques and methods. Very few people are sufficiently strongly motivated that they will practise every day. On the other hand, many of the described techniques do not make excessive time demands, and with practice can often be used anywhere, anytime. At the conclusion of the book various conditions are explained and related physiologically to a disordered breathing pattern. These are conditions where treatment has focused on drugs and surgery, but where breathing well, though neglected, has been shown to make a relevant and important contribution.

Key Point:
Breathing well helps us relax, normalizes body biochemistry, reduces muscle pain and allows the re-establishment of normal posture and movement.