Sinusitis and ear infections

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By Dr Manik G Hiranandani

(Revised January 28th, 2014)

Introduction
Hari (name changed for confidentiality) is a talkative young man who works as a marketing executive in Bombay. His job requires him to meet clients in different areas of the city. He works irregular hours, meeting clients and goes in and out of air-conditioned offices and cars.

Hari came to my clinic with complaints of always being tired, he had frequent headaches which, starting above his eyes spread to the back of his head. He also had a constant dry cough, which often disturbed his sleep. He was always clearing his throat, he sometimes brought up thick yellow mucous and he frequently had an upset stomach. He had blurred vision on some days, which did not improve by wearing spectacles. He often had pain in his upper teeth, which had not resolved with numerous visits to the dentist, root canal treatments and antibiotic courses. Hari had been diagnosed with sinusitis and migraine. He had been through many courses of treatment with antibiotics, and even had surgery to drain his sinuses. All these treatments had failed to give him any permanent relief from these problems.

He was desperate for an answer when he came to consult me. I examined him fully, made a diagnosis and advised him that the only cure for his problem was to take a holistic view of his problems which involved changes in his life style and diet along with treatment.

He was advised to take steam inhalations with holy basil (tulsi) leaves 5 to 6 times a day, and advised to use an ionizer in his house, in his office and in his car to reduce the effects of air pollution. He was treated with acupuncture which relieved his pain and congestion by helping to drain his sinuses. He was advised to avoid rapid changes in temperature by switching off his car air-conditioning a few minutes before reaching his destination; to set his office air-conditioning at a temperature of 25 degrees C, so the change in temperature would not be too sudden when he went in and out of his office.

I advised Hari to avoid alcohol and foods which increase mucous formation (described later on in this article). After a couple of weeks of treatment he was comfortable and pain free.

When he came back for a review after six months he was a happy man. His sinuses were no longer tender, his cough had reduced. His stomach was comfortable, he was sleeping well, he was not tired, and he was feeling stronger and well. I advised him to come back and see me again after another year. When he returned to see me he was feeling good, his cough had resolved, he had no headaches for eight months and there was no tenderness over any of the sinuses. His teeth were no longer painful and giving him trouble.

A large percentage of people (30-50%) who live in the urban world have chronic sinusitis and ear infections due to pollution, dust, mould, air-conditioning and rapid changes in temperature. Sinus infections are difficult to treat and can take up to 2 years to resolve with the correct treatment. Staying in a polluted environment causes continual irritation of the sinuses and retards healing.

Sinusitis is a disease strongly influenced by diet, lifestyle and environment. To recover from sinusitis requires modification of your lifestyle, diet and environment so your body has a chance to heal. Sinusitis is a common problem in polluted urban areas all over the world. It is also common in areas where people live in artificially heated or cooled environments.

What are the sinuses? The sinuses are spaces which lie above, below, behind the eye and on the side of the nose. The sinus which lies above the eyes is called the frontal sinus because it lies inside the frontal bone. The sinus which lies under the eyes and above the teeth of the upper jaw in the maxillary bone is called the maxillary sinus. The sinus which lies on the side of the nose in the ethmoid bone is called the ethmoid sinus. The sinus which lies behind the eyes in the sphenoid bone is called the Sphenoid sinus.

The sinuses drain into the nose through a small tube which is about the thickness of a ball-point pen refill. It is easy for this small tube to get blocked. When this is blocked, sinus fluid accumulates in the sinus. When this gets infected it causes sinusitis.

The ears have a chamber called the middle ear which carries out the function of hearing. This chamber communicates with the throat, through a tube called the Eustachian tube which can get blocked, leading to a loss or alteration of hearing. The fluid in the middle ear can get infected leading to otitis media and eventually to infection in the bone behind the ear called mastoiditis. Mastoiditis leads to a loss of bass in what you hear. Infections in the middle ear can lead to loss of balance, nausea, dizziness (vertigo), and tinnitus. This may sometimes be misdiagnosed as Meniere's Syndrome.

Infections from the sinus often spread to the ears, teeth, throat and lungs as well as vice versa. If you have a sinus infection, all these other areas should also be checked and treated if necessary.

 

Position of sinuses

Function of the sinuses
The function of the sinuses is to clean, purify, humidify and adjust the temperature of the air we breathe in to the temperature of the body.

The air we breathe comes into close contact with the blood in the lungs, so any bacteria, virus or suspended particle can be directly absorbed into the blood stream. If the air is too dry it can damage the delicate membranes which line the alveoli of the lungs. Air has a humidity which varies from a 0% to 100% depending on the place and climate. The sinuses increase the humidity of the air we breathe in, to bring it near 100 percent. They also regulate the temperature of the air bringing it close to 37 degrees C, the temperature of the body.

The Sinuses act as a filter to remove dirt, particles of air pollution, pollen, smoke, and any other suspended particles. Each sinus has a number of folds of thin mucous membrane rather like the filter of a car, and has many hairlike projections which help clean, purify and humidify the air. The total surface area, available in each sinus to perform this function is more than a hundred square metres.

The internal surface of the nose and sinuses is negatively charged to attract the positively charged particles which are present in the air we breathe. This charge allows it to attract and remove these particles from the incoming air, so clean air can go into our lungs. The positively charged particles in the air include the particles of air pollution, pollen, smoke, lead, acid, carbon, dust, mould, bacteria, viruses and any other suspended particles. These particles irritate and attack the lining of the nose and sinuses causing colds, sinusitis and nasal allergies.

In certain environments like the sea side, forests and mountains there are an excess of electrons (negative ions) in the air. These electrons reduce the particulate matter in the air, which settles down, cleaning up the air. When the air is clean, the sinuses and lungs are no longer under continuous attack and they have a chance to heal. This fact was made use of in the pre antibiotic era, when people went to sanatoriums at the sea side, the countryside, to mountains or forests to help themselves heal.

Air pollution is an important cause of sinusitis. The World Health Organization (W.H.O.) recommends that air with particle counts of less than 20 micro grams/cubic meter of air of particles between 2.5-10 microns in size and less than 10 micro grams/cubic meter of air for particles less than 2.5 microns in size is safe for human health. http://www.who.int/phe/health_topics/outdoorair_aqg/en/ .

In contrast most Indian cities have particle counts of between 100-350 micro grams/cubic meter of air making their air quality positively harmful for human health. Air pollution is a significant cause of sinusitis, tonsillitis, sore throats, allergic rhinitis, bronchitis, asthma, skin discoloration, eczema, arteriosclerosis, lung cancer and lead poisoning.

Charged particles repel each other when they come close to each other, thus staying in motion because of a phenomenon called Brownian motion. Charged particles are called ions. Electrons are examples of negatively charged particles. Dust, smoke, bacteria viruses, mold, pollen etc are examples of positively charged ions. An excess of ions in the air allows them to stay in motion. When a positively charged particle comes into contact with a negatively charged particle the charge on both particles is neutralized and the particle sinks to the ground.

Ionizers improve the quality of the air bringing it to safe levels by generating large numbers of negative ions which combine with the positively charged particles of dust, smoke, bacteria, viruses and fungal spores, causing them to settle down. This improvement of the air quality helps the sinuses to heal.

The sinuses do their cleaning work of the air we breathe in sequence. All the sinuses do not function at the same time. We have all noticed that we some times breathe more through one side of the nose at different times. This is because the nasal septum moves from side to side to open and close the sinuses and allow them to act as a filter. At any one time, only one or two of the sinuses are open while the others are cleaning themselves, to prepare to filter the air when their turn comes up in sequence.

When a patient has surgery to repair a deviated nasal septum the flexibility of the nasal septum is lost, and this predisposes to chronic sinusitis. Adhesions in the nose often follow this surgery leading to diminution of the airway and return of the sinusitis within a year. An effective way to correct a deviated nasal septum and retain its function is with cranial osteopathy. The sinuses also add depth and timbre to your voice as the spaces can allow resonance of the sound to take place. This is lost in sinusitis giving your voice a nasal twang.

Surgery to treat sinusitis by scraping out the sinuses, leads to loss of the filtering & humidification process & predisposing to chest infections.

Symptoms of sinusitis
The characteristic symptom of sinusitis is post nasal drip causing a dry cough. A person with sinusitis repeatedly clears the throat, to remove the irritation at the back of the throat. Take a torch and look at the back wall of the throat; in sinusitis, it is often seen to be inflamed and red, showing a clear, white or yellow pus-like fluid draining down the back wall of the throat.

Headaches are the next common symptom of acute sinusitis. Low grade headaches occur with chronic sinusitis which can escalate into severe headaches with the aggravating factors described below. Headaches from the frontal sinus start above the eyebrows and radiate to the top or back of the head. Maxillary sinusitis causes pain in the cheeks or teeth. Ethmoid sinusitis causes eye pain. Sphenoidal sinusitis causes pain behind the eyes in the centre of the skull and can be agonizing. Sphenoidal sinusitis can affect the pituitary gland leading to hormonal abnormalities. Sinus headaches are often misdiagnosed as migraines.

Chronic sinusitis causes a feeling of being unwell and can cause tiredness, fatigue or weakness. It is also a leading cause of bad breath, sleep apnoea, nasal polyps, as well as a reduced sense of smell and taste.

Complications and side effects of sinusitis
The infected fluid flowing down the throat into the stomach often causes gas, indigestion, abdominal discomfort, dysbiosis (unhealthy bacteria in the intestines) and poorly formed stools.

Lung infections. People with chronic sinusitis are more prone to infections of the throat and lung infections like bronchitis and pneumonia. This is because the sinus which is meant to protect the lungs, when infected cannot do its job and instead becomes a source of infection. Any effective treatment of these conditions has to start with the treatment of the sinuses.

Meningitis. Infections from the sinus may also spread into the brain, and cause a brain infection called meningitis.

Nasal Polyps. Chronic sinusitis causes irritation of the adjoining nasal lining which can cause the development of nasal polyps. Nasal polyps obstruct the breathing causing the voice to have a nasal tone. They also lead to a loss of smell and taste.

Toothache. Infections from the sinus can spread into the roots of the upper teeth causing infections in the tooth and pain.

Tonsillitis and Adenoids. Infection from the sinuses can spread into the adenoids and tonsils.

Ear Infections. Infection from the sinus can easily spread into the ear and mastoid bones causing ear and mastoid infections.

Eye Problems
1. Sinusitis often causes pain, swelling, puffiness, redness in the eye and dark circles around the eyes.
2. The optic nerve lies under the Sphenoidal sinus, and infection in this sinus can compress the optic nerve causing reduction or loss of vision.
3. Chronic sinus infections on all sides of the eye, can lead to infections and problems in the eye.  Chronic sinusitis is  associated with glaucoma, irido-cyclitis, Spots and floaters in the field of vision, and other problems in the eye.

Snoring often accompanies sinusitis and can lead to sleep apnoea. This can also disturb your partners sleep, causing serious health and marital issues. Treatment of these conditions is possible with cranial osteopathy and has to be accompanied by treatment of the sinusitis.

Halitosis. Sinus infections are a common cause of bad breath. Sinusitis also causes a coating on the tongue.

Ear infections cause pain in the ears, loss of hearing, tinnitus and loss of balance. They may cause headaches and difficulty in opening the mouth.

How does sinusitis occur ?

Irritation and swelling of the lining of the nose is the starting point of sinusitis. This swelling leads to blockages of the channels through which the sinuses drain leading to accumulation of the secretions of the sinus. This stagnant fluid forms a medium in which viruses, bacteria and fungus can grow. This fluid attracts white blood cells as the bacteria grow leading to formation of pus. If this pus is unable to drain out into into the nose it starts to cause the symptoms of sinusitis like headaches. When it drains out it causes irritation to the back of the throat causing a post nasal drip and a dry cough.

Sinusitis can occur from allergies or irritation from pollen, perfumes, dust, dust mites, fungus, mould, smoke, cigarette smoke, or chemicals. Air pollution is an important cause for sinusitis and 50% of people living in heavily polluted cities suffer from sinusitis leading to many avoidable health problems. Sinusitis is also common in people working in dusty environments like quarries, construction sites, factories, libraries, law offices, accountant offices etc. Air conditioning and central heating both deplete negative ions from the air and predispose to chronic sinusitis. By recycling the air they also recycle the dust, stale air and mould which further irritate the sinus. Carpets tend to retain dust and mould. Hence carpeted offices and hotel rooms are major causes for sinusitis. This is why office workers working in these environments have a high incidence of sinusitis. Bars and environments full of cigarette smoke can cause or aggravate sinusitis.

With a cold, the lining of the nose swells up and blocks the opening of the sinus. The fluid secreted by the sinuses to humidify the air accumulates in the sinus instead of draining into the throat as normally happens. The bacteria, fungi or viruses (which have been filtered by the sinus) infect this accumulated fluid. The infection leads to redness and congestion in the sinuses due to release of the substances formed by the body fighting the infection. The accumulation of this infected fluid causes pressure on the sinus and can cause a headache, a toothache, and can affect the vision. This is called acute sinusitis and usually cures itself or responds to treatment with antihistamines or steam inhalation.

If the acute sinusitis does not resolve over 2-3 weeks it is then called chronic sinusitis which can persist for years. Over time, fibrosis occurs in the sinuses as the body attempts to wall off the infection. Bacteria, viruses, fungi and their spores get entangled in the scars. Healing then becomes very difficult as the body's white blood cells are unable to penetrate this fibrous tissue to kill the infection.

Sinusitis may also be caused by injuries to the head, nose and face which block the drainage of the sinus. A Sinusitis often follows a broken nose as the injury distorts the structure of the nose affecting drainage from the sinuses. Thus boxers are very prone to sinusitis. Sinusitis often follows facial injuries from accidents and causes much of the residual suffering from these accidents. A deviated nasal septum is a pointer of an injury in the past and if it is present the physician should always check for sinusitis.

Any injury on the head should ideally be corrected by cranial osteopathy. Sinusitis is very common in children delivered with the help of forceps. Proper treatment requires them to be treated with cranial osteopathy.

If cranial osteopathy treatment is not available surgery may be considered. The results with surgery are poor over the long term due to scarring which often follows the surgery. This scarring distorts the fine tubes through which the sinus drains, often causing blockage and a recurrence of the sinusitis.

Dust mites

Tiny flakes of our skin fall off the skin at all times. Dust mites eat these flakes, and live in mattresses, pillows, blankets, quilts, carpets, curtains etc. Their faeces (wastes) are highly irritating and cause allergic reactions which lead to rashes and blocking of the nose. If you wake up with a blocked nose it is likely that your mattresses, pillows, blankets, quilts etc. are full of these contaminants. These waste products of the dust mite irritate the lining of the nose and throat causing rhinitis, blocked nose sinusitis and asthma.

To deal with this problem, vacuum the mattress, blanket, quilt and pillows once a month outside the house and keep them in the sun for a few hours. Vacuuming these items outside the house helps discharge the dust containing the dust mite waste outside the house. Doing the vacuuming inside the house can recirculate the waste. Using a vacuum cleaner with a water filter can trap the dust mite feces in the water. Sunlight helps kill dust mites. Wash or vacuum clean carpets and curtains regularly at least once every two months. This will help remove and reduce dust mites and help your sinuses and allergies. It is also a good idea to change the mattress every 2-3 years.

Diagnosis of Sinusitis

Clinical Examination is the best and easiest way to make a diagnosis. Tenderness over the sinuses, dark circles or puffiness under the eyes and a post nasal drip all indicate the presence of sinusitis.

X-rays, CT scan & MRI scan may show fluid levels in the sinuses if they are properly exposed. Over exposure of the film prevents the physician from seeing the fluid levels. Laboratory findings are a raised Erythrocyte Sedimentation Rate (E.S.R) and an increase in the number of lymphocytes in the blood.

Diagnosis of Ear Infections.

Clinical Examination is the best and easiest way to make a diagnosis. If you have an ear infection there may be tenderness both in front and behind the ear and a post nasal drip. Examination with an otoscope may reveal congestion of the ear drum and a clear, opaque or pus-filled fluid behind the eardrum.

In case of doubt about the diagnosis, investigations which may help confirm the problem are X-rays, CT scan or MRI scan, which may show fluid levels or a darkening of the bones around the ear. An audiogram may show reduced air conduction indicating fluid in the ear. A tympanogram may also help make the diagnoses in some patients.

Laboratory findings are a raised Erythrocyte Sedimentation Rate (E.S.R) and increase in the number of lymphocytes in the blood.

Prevention of sinusitis
Avoid rapid changes in temperature. When sleeping in an air-conditioned room, switch off the air conditioner a few minutes before you leave the room and let the temperature in the room equalize with the temperature outside the room. When traveling in an air-conditioned car switch on the air-conditioner, after getting in the car and switch it off a few minutes before reaching the destination so the change in temperature to the outside is gradual.

In cold climates, before going outside into the cold from a centrally heated room, first go into another room which is not heated. This gradual change in temperature allows the body to gradually adjust to the change in temperature. Rapid changes in temperature can cause vasomotor changes causing the nasal lining to swell very rapidly. This can block the opening of the sinuses causing an attack of sinusitis.

Dry your hair throughly after a shower with a towel or a hair dryer. Avoid sitting under a fan or air-conditioning when your hair is wet.

Avoid mucous forming foods like dairy products, bananas, guavas and oily food.
Avoid cooling foods like cold drinks, cucumber, coconut water and ice-creams.
Avoid rapid changes in temperature and air conditioning.

Ionizers

Use an ionizer wherever you have pollution, air conditioning or central heating. Always install an ionizer in your car as heavy traffic has high levels of pollution. If you live in a polluted city use an ionizer in every room in which you spend time. A good ionizer should generate at least a trillion ions a second. Ionizers available in the market generate between 1500 ions per second to 45 trillion ions per second. Ionizers with a light and Himalayan salt usually generate 1500 ions per second and are inadequate in highly polluted areas. An ionizer which generates a trillion ions a second can reduce the particle count in a room with a cubic capacity of 3000 cubic feet (300 square feet with a height of 10 feet) (84 Cubic Metres) by 99.98 percent in 1 hour. Keep your ionizers on all the time so air quality in the room is good whenever you enter it. Ionizers use between 3 to 15 watts per hour, so running costs are negligible. Ion concentrations reduce with the square of the distance from the ionizer. So if your area is larger than 3000 cubic feet, 2 ionizers will be more effective than 1 large ionizer. The price of a good ionizer begins around Rs 3000 ($50).

Place the ionizer a distance of about 3 feet from where you sleep. Ionizers cause the suspended particles to settle down so the area around an ionizer turns black. To prevent this dirt from spoiling your walls or furniture place the ionizer on the floor or on an easily cleanable surface like a glass or stone table. Placing electrostatic paper behind the ionizer also helps to trap the dust. This paper can then be changed every few months. Some ionizers contain a filter to trap the dust. These filters are HEPA filters which have to be replaced periodically. Often the replacement cost of the filter can exceed the cost of the ionizer over a period of a year! This makes ionizers with a filter unviable in heavily polluted areas. Spend 5 minutes to clean and maintain your ionizer every week as advised in the instruction manual of your ionizer to ensure that it keeps giving you the full benefit.

Treatment of Sinusitis and Ear infections.

The best way to treat sinus and ear infections is to help the sinuses and ears to drain. This happens by helping the lining of the nose, sinus canals and Eustachian tube to shrink, and then to liquefy the accumulated secretions in the sinus or ears so this can drain into the throat.

Steam inhalation taken five to six times a day with holy Basil (Tulsi), cardamom or tea tree oil for 5 min at a time, through the nose can help to treat sinusitis. In case of an acute sinus problem the steam may be required for between seven to ten days. In chronic and long-standing sinus problems the steam may need to be continued for up to 2 years.
For ear infections breathe the steam in through the mouth to help open the Eustachian tube.

Salt water inhalations either by going to the seaside, using a salt inhalation chamber, spraying saline solution in the nose or through Jal Neti (putting salt water in one nostril and bringing it out from the other nostril) are all useful in shrinking the lining of the nose and unblocking the sinuses.

Doing Pranayam (yogic breathing) in the form of Kapal Bharathi (forceful exhalation) can help drain the sinuses. This should not be done without supervision and never by people with high blood pressure.

Treatment with acupuncture is an effective treatment to help the sinuses to drain and to heal. Acupuncture may be done with needles, laser or ultrasound acupuncture.

Regular treatment with acupuncture can speed up the time taken for the sinusitis to heal.

Eating condiments like strong mustard and wasabi (Japanese horseradish) with your food, can help the lining of the nose to shrink and can help to open up the sinuses.

Keep an ionizer on wherever you spend time, in your office, in every room in your home in which you spend time, and in your car.

Antibiotics especially ampicillin in a dose of 30-40mgm/kg of body weight may be useful in treating acute sinusitis. Most other antibiotics do not penetrate the sinuses in adequate quantity to be effective.

Antibiotics are of little use in chronic sinusitis, as this requires long term treatment for many months. Most patients are unable to tolerate prolonged antibiotic treatment for the 6-9 months it may take to clear the sinusitis. Chronic sinusitis usually has mixed bacterial and fungal infections and if antibiotics are used, anti-fungal drugs are required as well for the treatment to be effective.

Homeopathy and Ayurveda also have effective treatments for sinusitis and ear infections.

The link below shows the audiogram of a gentleman who had severe loss of hearing and had been advised a hearing aid. This image shows the improvement in his hearing before & after treatment with steam inhalations.

Factors which aggravate sinusitis and ear infections

Air pollution: Air pollution and smoke are major causes of irritation of the sinuses. People who work in industry, on construction sites, thermal power plants, major roads with heavy traffic, and industrial areas are exposed to air pollution from dust, solvents, paints, and chemicals. They often suffer from chronic sinusitis.

Air conditioning also irritates the sinuses because the aluminium fins in the air conditioning condenser, strip electrons from the air. This leaves an excess of positively charged particles in the air which attach themselves to the lining of the nose. This irritates the nose and sinuses and can lead to sinusitis.

Rapid Changes in Temperature: The lining of the nose and sinuses are very sensitive to changes in temperature. Going in and out of air-conditioned or heated rooms frequently is a cause for sinusitis.

Dust Mites: Dust mites and their faeces accumulate in pillows, mattresses, quilts, blankets, sofas, curtains and carpets causing allergies.

Dust and Mould also aggravate sinusitis. Going into damp rooms and cellars where mould flourishes can aggravate sinusitis.

Smoking and cigarette smoke irritate the sinuses and nose.

Cold and cooling Foods like ice cream, cold drinks, bananas, guavas, coconut water and oily food aggravate sinusitis.

Alcohol aggravates sinusitis and all infections in the body. If you have sinusitis or any other infection you should not drink alcohol. If you do drink you will notice an increase in the problem a few hours after you have taken alcohol. Drinking alcohol with an infection is like pouring the alcohol on a fire!

Colds cause swelling of the lining of the nose and aggravate sinusitis by blocking their drainage.

Hay fever, caused by allergy to pollen and other particles in the air can cause or aggravate sinusitis.

Synthetic carpets and furnishings deplete negative ions from the air and predispose to sinusitis. Use silk or wool carpets if you need carpets.

Food allergies especially to milk, gluten and nuts increase mucous secretion and aggravate sinusitis.

Bright sunlight aggravates sinusitis causing headaches and photo-phobia.

Facilities available at “The Clinic” for Treating Sinusitis and Ear infections.

At the clinic we have the expertise and specially designed facilities to enable quick and effective non surgical treatments of sinusitis and ear infections. We use a multi-disciplinary approach tackling the problem with a range of treatments to speed up your recovery. 

“The Clinic” has the first salt and steam inhalation chamber in India.   This unique facility of salt and steam treatment has been built specially to treat patients suffering from chronic sinusitis and ear infections. Using this facility speeds up your recovery from sinusitis and ear infections.

Salt air and salt water (also called halotherapy) help shrink the lining of the nose, allowing the sinuses to drain. The salt inhalation chamber uses this principle to help the sinuses to drain. This followed by taking 15 minutes of steam which liquefies the accumulated secretions in the sinuses and allows it to flow out. The steam also helps to detoxify the skin and bring out the toxins from the lymphatic system.

The chamber has been designed with wheelchair and handicapped access for the convenience of patients.

Procedure. First take deep breaths to inhale the salt air for 30 minutes followed by steam inhalation for 15 minutes. Talk softly if necessary.
Please keep the door of the chamber closed, so the salt air and steam, do not escape from the chamber.
The temperature in the steam room gradually rises to a maximum of 43 degrees.

You should not stay in the steam room for more than 15 minutes as your blood pressure may drop.
Please ensure that a staff member is in attendance when you use the chamber.
After using the steam room, massage your skin upwards towards the heart with a loofah and take a cool or luke warm shower.
Preferred Dress : Shorts and a T-shirt.
Please remove your shoes and costume jewelry outside the chamber.
Please switch off and leave your mobile phone in your room.
The salt air & steam can corrode & seriously damage your, watch, jewelry and phone. Please remove them before entering the steam room.