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Sinuses

Doctor, what is Sinusitis?
Normal Sinuses
Aging Patients
Sinus Conditions
For Kids: Build a Sinus Mask
Learn your Sinusitis Score
Pediatric Sinusitis
Sinus Pain: Can Over-the-Counter Medications Help?
Sinus Surgery
20 Questions About Your Sinuses
Tips for Sinusitis Sufferers
Fact Sheet: Antibiotics and Sinuses
Fact Sheet: Deviated Septum
Fact Sheet: Fungal Sinusitis
Fact Sheet: Sinus Headaches

Doctor, what is Sinusitis?

Insight into sinus problems in adults and children

Sinus Facts

Have you ever had a cold or allergy attack that wouldn’t go away? If so, there’s a good chance you actually had sinusitis. Experts estimate that 37 million people are afflicted with sinusitis each year, making it one of the most common health conditions in America. That number may be significantly higher, since the symptoms of bacterial sinusitis often mimic those of colds or allergies, and many sufferers never see a doctor for proper diagnosis and treatment with an antibiotic.

What is sinusitis?

Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.

Normally, mucus collecting in the sinuses drains into the nasal passages. When you have a cold or allergy attack, your sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Diagnosis of acute sinusitis usually is based on a physical examination and a discussion of your symptoms. Your doctor also may use x-rays of your sinuses or obtain a sample of your nasal discharge to test for bacteria.

When Acute Becomes Chronic Sinusitis

When you have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.

Treating Sinusitis

Bacterial sinusitis: Therapy for bacterial sinusitis should include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart), be sure to see your doctor for diagnosis. In addition to an antibiotic, an oral or nasal spray or drop decongestant may be recommended to relieve congestion, although you should avoid prolonged use of nonprescription nasal sprays or drops. Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.

Antibiotic Resistance

Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections, such as sinusitis, challenging to treat. You can help prevent antibiotic resistance. If the doctor prescribes an antibiotic, it is important that you take all of the medication just as your doctor instructs, even if your symptoms are gone before the medicine runs out.

Chronic Sinusitis

If your doctor thinks you have chronic sinusitis, intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.

Sinus Surgery

Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease. Surgery can be performed under the upper lip, behind the eyebrow, next to the nose or scalp, or inside the nose itself.

Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope, the surgeon can look directly into the nose, while at the same time, removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor, depending on your individual circumstances.

Before surgery, be sure that you have realistic expectations for the results, recovery, and postoperative care. Good results require not only good surgical techniques, but a cooperative effort between the patient and physician throughout the healing process. It is equally important for patients to follow pre- and postoperative instructions.

Preventing Sinusitis

As always, an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack, keep your sinuses clear by:

using an oral decongestant or a short course of nasal spray decongestant
gently blowing your nose, blocking one nostril while blowing through the other
drinking plenty of fluids to keep nasal discharge thin
avoiding air travel. If you must fly, use a nasal spray decongestant before take-off to prevent blockage of the sinuses allowing mucus to drain
If you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks

Allergy testing, followed by appropriate allergy treatments, may increase your tolerance of allergy-causing substances. If you believe you may have sinusitis, see our tips for sinusitis sufferers.

When to See a Doctor

Because the symptoms of sinusitis sometimes mimic those of colds and allergies, you may not realize you need to see a doctor. If you suspect you have sinusitis, review these signs and symptoms. If you suffer from three or more, you should see your doctor.

Sign/Symptom	Sinusitis	Allergy	Cold
Facial Pressure/Pain	Yes	Sometimes	Sometimes
Duration of Illness	Over 10-14 days	Varies	Under 10 days
Nasal Discharge	Thick, yellow-green	Clear, thin, watery	Thick, whitish or thin
Fever	Sometimes	No	Sometimes
Headache	Sometimes	Sometimes	Sometimes
Pain in Upper Teeth	Sometimes	No	No
Bad Breath	Sometimes	No	No
Coughing	Sometimes	Sometimes	Yes
Nasal Congestion	Yes	Sometimes	Yes
Sneezing	No	Sometimes	Yes

A Word about Children

Your child’s sinuses are not fully developed until age 20. However, children can still suffer from sinus infection. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Sinusitis is difficult to diagnose in children because respiratory infections are more frequent, and symptoms can be subtle. Unlike a cold or allergy, bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to prevent future complications.

The following symptoms may indicate a sinus infection in your child:

a “cold” lasting more than 10 to 14 days, sometimes with low-grade fever
thick yellow-green nasal drainage
post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
headache, usually not before age 6
irritability or fatigue
swelling around the eyes

If despite appropriate medical therapy these symptoms persist, care should be taken to seek an underlying cause. The role of allergy and frequent upper respiratory infections should be considered.

Learn your sinusitis score and review 20 questions and answers about your sinuses.

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Normal Sinuses

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Sinusitis: Special Considerations for Aging Patients

People older than 65 represent the fastest-growing segment of the population. More than 20 percent of U.S. residents will be 65 or older in 2030. Of all Americans 65 and older, 14.1 percent report that they suffer from chronic sinusitis; for those 75 years and older, the rate declines to 13.5 percent. The prevalence of this condition among the elderly ranks behind arthritis, hypertension, hearing impairments, heart disease, cataracts, and orthopedic impairments. However, more Americans report having sinusitis than diabetes.

Geriatric Rhinitis Complaints are:

constant need to clear the throat
a sense of nasal obstruction
nasal crusting
vague facial pressure
decreased sense of smell and taste

For the most part, sinusitis symptoms, diagnosis, and treatment are the same for the elderly as other adult age groups. However, there are special considerations in older Americans:

Changing physiology: With aging, the physiology and function of the nose changes. The nose lengthens, and the nasal tip begins to droop due to weakening of the supporting cartilage. This in turn causes a restriction of nasal airflow, particularly at the nasal valve region (where the upper and lower lateral cartilages meet). Narrowing in this area results in the complaint of nasal obstruction, often referred to as geriatric rhinitis.

Patients with geriatric rhinitis typically complain of constant “sinus drainage,” a chronic need to clear the throat or “hawk” mucus, and a sense of nasal obstruction, most often when they lie down. Other features include nasal crusting especially in the winter and in patients taking diuretics, vague facial pressure (attributed to “sinus trouble”), and a decreased sense of smell and taste.

However, it is a mistake to blame all upper respiratory problems on the aging process. Elderly patients with symptoms such as repeated sneezing, and watery eyes, nasal obstruction with clear profuse watery runny nose, and soft, pale turbinates (top-shaped bones in the nose) may have allergic rhinitis. Patients with this diagnosis will benefit from consultation with an otolaryngic allergist.

Patients with chronic sinusitis will have a long history of thick drainage that is often foul smelling and tasting and is associated with nasal obstruction, headaches, and facial pressure. These patients usually have pus drainage and nasal redness. In contrast, the geriatric rhinitis patient usually has a dry, irritated nose. The diagnosis of chronic sinusitis can be confirmed with a screening coronal CT of the sinuses.

Recent studies by otolaryngologist-head and neck surgeons have sought to better define the association between rhinitis and sinusitis. They have concluded that sinusitis is often preceded by rhinitis and rarely occurs without concurrent rhinitis. The symptoms, nasal obstruction/discharge and loss of smell occur in both disorders. Most importantly, computed tomography (CT scan) findings have established that the mucosal linings of the nose and sinuses are simultaneously involved in the common cold (previously, thought to affect only the nasal passages). Otolaryngologists, acknowledging the inter-relationship between the nasal and sinus passages, now refer to sinusitis as rhinosinusitis.

The fluids within these cavities are dynamic and are related to dynamic pathologic changes in the bone and soft tissues of the nasal cavity and paranasal sinuses. Symptoms associated with rhinosinusitis include nasal obstruction, nasal congestion, nasal discharge, nasal purulence, postnasal drip, facial pressure and pain, alteration in the sense of smell, cough, fever, halitosis, fatigue, dental pain, pharyngitis, otologic symptoms (e.g., ear fullness and clicking), and headache.

Osteoporosis: Osteoporosis is a significant health problem in the United States affecting approximately 24 million Americans, 15 to 20 million of whom are women over 45 years of age. Because of the concerns regarding prolonged estrogen use in postmenopausal women, a nasal calcitonin spray is often prescribed to prevent bone loss in perimenopausal women who cannot tolerate estrogen. The most common side effect reported with nasal calcitonin spray is a runny nose. Other symptoms that may occur include nasal crust, dryness, redness, irritation, sinusitis, nose bleeds, and headache. Sinusitis sufferers using a nasal calcitonin spray should advise their physicians.

Medications: Treatment for this age group needs to be more individualized to meet the patient’s slower metabolism and the increasing potential for side effects. The majority (80 to 85 percent) of the nation’s elderly have chronic diseases and take multiple drugs including over-the-counter medications, and risk drug interactions more often than other patients.

Surgery: Nasal and sinus surgery is occasionally advised for older patients. Patients with structural abnormalities, such as a deviated septum or nasal valve collapse causing severe nasal problems, should be referred to an otolaryngologist for evaluation and possible surgical management. Patients with documented chronic sinusitis unresponsive to medications also should be referred to an otolaryngologist.

Sources: Administration on Aging (AoA), U.S. Department of Health and Human Services; Geriatrics.

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Allergic Rhinitis, Sinusitis, and Rhinosinusitis

What is rhinitis?

Inflammation of the nasal mucous membrane is called rhinitis. The symptoms include sneezing, runny nose, and itching, caused by irritation and congestion in the nose. There are two types: allergic rhinitis and non-allergic rhinitis.

Allergic rhinitis: This condition occurs when the body’s immune system over-responds to specific, non-infectious particles such as plant pollens, molds, dust mites, animal hair, industrial chemicals (including tobacco smoke), foods, medicines, and insect venom. Essentially, during an allergic attack, antibodies, primarily immunoglobin E (IgE), attach to mast cells in the lungs, skin, and mucous membranes. Once IgE connects with the mast cells, a number of chemicals are released. One of the chemicals, histamine, opens the blood vessels and causes skin redness and swollen membranes. When this occurs in the nose, sneezing and congestion are the result.

Seasonal allergic rhinitis or hayfever occurs in late summer or spring. Hypersensitivity to ragweed, not hay, is the primary cause of seasonal allergic rhinitis in 75 percent of all Americans who suffer from this seasonal disorder. People with sensitivity to tree pollen have symptoms in late March or early April; an allergic reaction to mold spores occurs in October and November as a consequence of falling leaves.

Perennial allergic rhinitisoccurs year-round and can result from sensitivity to pet hair, mold on wall paper, house plants, carpeting, and upholstery. Some studies suggest that air pollution such as automobile engine emissions can aggravate allergic rhinitis. Although bacteria is not the cause of allergic rhinitis, one medical study found a significant number of the bacteria Staphylococcus aureus in the nasal passages of patients with year-round allergic rhinitis, concluding that the allergic condition may lead to higher bacterial levels, thereby creating a condition that worsens the allergies.

Non-allergic rhinitis: This form of rhinitis does not depend on the presence of IgE and is not due to an allergic reaction. The symptoms can be triggered by cigarette smoke and other pollutants as well as strong odors, alcoholic beverages, and the cold. Other causes may include blockages in the nose, a deviated septum, infections (in children), and over-use of medications such as decongestants.

Rhinosinusitis –Clarifying the relationship between the sinuses and rhinitis
Recent studies by otolaryngologist-head and neck surgeons have sought to better define the association between rhinitis and sinusitis. They have concluded that sinusitis is often preceded by rhinitis and rarely occurs without concurrent rhinitis. The symptoms, nasal obstruction/discharge and loss of smell occur in both disorders. Most importantly, computed tomography (CT scan) findings have established that the mucosal linings of the nose and sinuses are simultaneously involved in the common cold (previously, thought to affect only the nasal passages). Otolaryngologists, acknowledging the inter-relationship between the nasal and sinus passages, now refer to sinusitis as rhinosinusitis.

The catalyst relating the two disorders is thought to involve nasal sinus overflow obstruction, followed by bacterial colonization and infection. The resulting nasal obstruction leads to acute, recurrent, or chronic sinusitis; conversely, chronic inflammation due to allergies can lead to obstruction and subsequent sinusitis.

Other medical research has supported the close relationship between allergic rhinitis and sinusitis. In a retrospective study on sinus abnormalities in 1,120 patients (from 2 to 87 years of age), thickening of the sinus mucosa was more commonly found in sinusitis patients during July, August, September, and December, in which pollen, mold, or viral epidemics are prominent. A review of patients (four to 83 years of age) who had surgery to treat their chronic sinus conditions revealed that those with seasonal allergy and nasal polyps are more likely to experience a recurrence of their sinusitis.

Patients who suffer from recurring bouts of allergic rhinitis should observe their symptoms on a continuous basis. If facial pain or a green-yellowish nasal discharge occur, a qualified ear, nose, and throat specialist can provide appropriate sinusitis treatment.

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For Kids: Build a Sinus Mask

To build your own sinus mask, print this page on heavy paper and cut it out. Attach a popsicle stick or drinking straw in the middle for a “mardi-gras” mask, or use a piece of string attached to each ear and tie behind the head.

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Learn your Sinusitis Score

Sinusitis is inflammation of the lining membrane of any sinus. Take the following quiz to see if you have sinusitis.
Choose “yes” if you have any of the following symptoms for ten days or longer; otherwise, choose “no.”

1. Facial pressure/pain?

Yes No 2. Headache pain?

Yes No 3. Congestion or stuffy nose?

Yes No 4. Thick, yellow-green nasal discharge?

Yes No 5. Low fever (99-100°)?

Yes No 6. Bad breath?

Yes No 7. Pain in the upper teeth?

Yes No Score:

If you’re score is three or above, you may have a sinus infection resulting from allergies, bacteria, or a response to fungi. An examination by an ear, nose, and throat specialist may be warranted.

* Editor’s Note: The text from this quiz may be freely used. Attribution to the American Academy of Otolaryngology – Head and Neck Surgery is required.

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Pediatric Sinusitis

Your child’s sinuses are not fully developed until age 20. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Unlike in adults, pediatric sinusitis is difficult to diagnose because symptoms can be subtle and the causes complex.

How do I know when my child has sinusitis?

The following symptoms may indicate a sinus infection in your child:

a “cold” lasting more than 10 to 14 days, sometimes with a low-grade fever;
thick yellow-green nasal drainage;
post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting;
headache, usually not before age 6;
irritability or fatigue;
swelling around the eyes.

Young children have immature immune systems and are more prone to infections of the nose, sinus, and ears, especially in the first several years of life. These are most frequently caused by viral infections (colds), and they may be aggravated by allergies. However, when your child remains ill beyond the usual week to ten days, a serious sinus infection is likely.

You can reduce the risk of sinus infections for your child by reducing exposure to known environmental allergies and pollutants such as tobacco smoke, reducing his/her time at day care, and treating stomach acid reflux disease.

How will the doctor treat sinusitis?

Acute sinusitis

Most children respond very well to antibiotic therapy. Nasal decongestants or topical nasal sprays may also be prescribed for short-term relief of stuffiness. Nasal saline (saltwater) drops or gentle spray can be helpful in thinning secretions and improving mucous membrane function. If your child has acute sinusitis, symptoms should improve within the first few days. Even if your child improves dramatically within the first week of treatment, it is important that you continue therapy until all the antibiotics have been taken.

Your doctor may decide to treat your child with additional medicines if he/she has allergies or other conditions that make the sinus infection worse.

Chronic sinusitis

If your child suffers from sinus symptoms that last for twelve weeks, two major symptoms or one major symptom and two minor symptoms, this is known as chronic sinusitis. If your child has chronic sinusitis or recurrent episodes of acute sinusitis numbering more than four to six per year, you should seek consultation with an ear, nose, and throat (ENT) specialist. The ENT may recommend surgical treatment of the sinuses.

Diagnosis of sinusitis

If your child sees an ENT specialist, the doctor will examine his/her ears, nose, and throat. A thorough history and examination usually leads to the correct diagnosis. Occasionally, special instruments will be used to look into the nose during the office visit. An x-ray called a CT scan may help to determine how your child’s sinuses are formed, where the blockage has occurred, and the reliability of a sinusitis diagnosis.

When is surgery necessary?

Surgery is considered for the small percentage of children with severe or persistent sinusitis symptoms despite medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your child’s sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your child’s sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections.

Also, your doctor may advise removing adenoid tissue from behind the nose as part of the treatment for sinusitis. Although the adenoid tissue does not directly block the sinuses, infection of the adenoid tissue, called adenoiditis, or obstruction of the back of the nose can cause many of the symptoms that are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal drip, bad breath, cough, and headache.

Summary

Sinusitis in children is different than sinusitis in adults. Children more often demonstrate a cough, bad breath, crankiness, low energy, and swelling around the eyes along with a thick yellow-green nasal or post-nasal drip. Once the diagnosis of sinusitis has been made, children are successfully treated with antibiotic therapy in most cases. If medical therapy fails, surgical therapy can be used as a safe and effective method of treating sinus disease in children.

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Why do we suffer from nasal and sinus discomfort?

The body’s nasal and sinus membranes have similar responses to viruses, allergic insults, and common bacterial infections. Membranes become swollen and congested. This congestion causes pain and pressure; mucus production increases during inflammation, resulting in a drippy, runny nose. These secretions may thicken over time, may slow in their drainage, and may predispose to future bacterial infection of the sinuses.

Congestion of the nasal membranes may even block the eustachian tube leading to the ear, resulting in a feeling of blockage in the ear or fluid behind the eardrum. Additionally, nasal airway congestion causes the individual to breathe through the mouth.

Each year, more than 37 million Americans suffer from sinusitis, which typically includes nasal congestion, thick yellow-green nasal discharge, facial pain and pressure. Many do not understand the nature of their illness or what produces their symptoms. Consequently, before visiting a physician, they seek relief for their nasal and sinus discomfort by taking non-prescription or over-the-counter (OTC) medications.

What is the role of OTC medication?

There are many different OTC medications available to relieve the common complaints of sinus pain and pressure, allergy problems, and nasal congestion. Most of these medications are combination products that associate either a pain reliever such as acetaminophen with a decongestant or an antihistamine. Knowledge of these products and of the probable cause of symptoms will help the consumer to decide which product is best suited to relieve the common symptoms associated with nasal or sinus inflammation.

OTC nasal medications are designed to reduce symptoms produced by theinflammation of nasal membranes and sinuses. The goals of OTC medications are to: (1) reopen nasal passages; (2) reduce nasal congestion; (3) relieve pain and pressure symptoms; and (4) reduce potential for complications. The medications come in several forms.

Nasal saline sprays: non-medicated nasal sprays

Nasal saline is an invaluable addition to the list of over-the-counter medications. It is ideal for all types of nasal problems. The added moisture produced by the saline reduces thick secretions and assists in the removal of infectious agents. There is no risk of becoming “addicted” to nasal saline. It should be applied as a mist to the nose up to six times per day. Nasal saline can also be made at home: use one cup of boiled water and Ñ˜ tsp. of non-iodized salt with or without Ñ˜ tsp. of baking soda.

Nasal decongestant sprays: medicated nasal sprays

Afrin nasal spray, Neo-Synephrine, Otrivin, Dristan nasal spray, and other brands decongest the swollen nasal membranes. They clear nasal passages almost immediately and are useful in treating the initial stages of a common cold or viral infection. Nasal decongestant sprays are safe to use, especially appropriate for preventing eustachian tube problems when flying, and to halt progression of sinus infections following colds. However, they should only be utilized for 3-5 days because prolonged use leads to rebound congestion or “getting hooked on nasal sprays.” The patient with nasal swelling caused by seasonal allergy problems should use a cromolyn sodium nasal spray. The spray must be used frequently (four times a day) during allergy season to prevent the release of histamine from the tissues, which starts the allergic reaction. It works best before symptoms become established by stabilizing the nasal membranes and has few side effects.

Decongestant medications

Pressure and congestion are common symptoms of nasal passage swelling. Decongestant medications are OTC products that relieve nasal swelling, pressure, and congestion but do not treat the cause of the inflammation. They reduce blood flow to the nasal membranes leading to improved airflow, less breathing through the mouth, decreased pressure in the sinuses and head, and subsequently less discomfort. Decongestants do not relieve drippy noses. Their side effects may include light headedness or giddiness and increased blood pressure and heart rate. (Patients with high blood pressure or heart problems should consult a physician before use.) In addition, other medications may interact with oral decongestants causing side effects. Both of these are available as single products or in combination with a pain reliever or an antihistamine. They are labeled as “non-drowsy” due to a side effect of stimulation of the nervous system.

Decongestant-combination products

Some medications are combined to reduce the number of pills. Tylenol-Sinus or Advil Cold and Sinus exemplify products that join a pain reliever (acetaminophen or ibuprofen) with a decongestant (pseudoephedrine). These products relieve both sinus and cold/flu symptoms yet retain all the attributes of the individual drug including side effects.

Antihistamine medications

Antihistamines combat allergic problems leading to nasal congestion. OTC antihistamines such as diphenhydramine (Benadryl), or clemastine (Tavist) may be used for relieving allergic symptoms of itching, sneezing, and nasal congestion. They relieve the drainage associated with the allergic inflammation but not obstruction or congestion. Antihistamines have a potential for sedation causing grogginess and dryness after use. Newer nonsedating antihistamines are available.

Antihistamine-decongestant combination products

Antihistamines and decongestant products are often combined to relieve multiple symptoms of congestion and drainage and reduce the side effects of both products. Antihistamines produce sedation; decongestants are added to make them “non-drowsy.” The combined allergy product then relieves congestion and a runny nose.

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Sinus Surgery

An otolaryngologist-head and neck surgeon will, for the most part, advocate surgery when antibiotics and other medical treatments fail to alleviate chronic sinusitis or multiple episodes of acute sinus infection. Before considering surgery, the otolaryngologist will typically prescribe four to six weeks of antibiotics plus sprays, decongestants, and possibly antihistamines and steroids.

There are circumstances when immediate sinus surgery is warranted. Malignant tumors in the sinus cavity, although rare, sometimes do not respond to radiation and chemotherapy and require surgical removal. Surgery may be the only option for some patients whose sinus condition aggravates other medical problems such as asthma. Cancer patients, having a poor immune system, will require drainage at the onset of a sinus infection (to determine the exact organism causing the infection and aid in choosing the antibiotic).

Surgery for Acute Sinusitis

Antibiotics are generally effective for most cases of acute sinusitis resulting in severe facial pain and pressure. Other treatments for lingering symptoms include sinus irrigation, which requires the placement of an instrument in the maxillary sinus to flush out that cavity with salt water.

Two types of acute sinus infection require special attention from a specialist. A severe infection of the frontal (forehead) or sphenoid sinus (behind the eyes) can be very serious. If oral or intravenous antibiotics are not effective, surgical drainage of the sinus may be undertaken. The sphenoid sinus can be accessed surgically through the nose or through an incision under the eyebrow. The latter procedure requires hospitalization.

Surgery for Chronic Sinusitis

Most surgeries on the sinuses are conducted to relieve a chronic condition. In the past, operations on the sinuses were conducted externally through incisions on the face. Incisions were made under the upper lip through the gum (the Caldwell-Luc operation) or an external ethmoidectomy, a removal of the sinuses between the eyes through an incision in the face. However, most surgical procedures for the sinuses are now carried out using endoscopic sinus surgery.

Endoscopic Sinus Surgery

Twenty years ago, otolaryngologist -head and neck surgeons would perform surgery on the individual sinuses that had become infected, leading to the use of procedures such as the Caldwell-Luc operation.

Since then, the development of endoscopic sinus surgery (ESS) ushered in a new philosophy allowing the surgeon to target the ostiomeatal complex (OMC), an area in the anterior ethmoid sinus region. Obstruction in the OMC can lead to subsequent infection of the maxillary, frontal, and sphenoid sinuses. Accordingly, endoscopic sinus surgery, a procedure through the nose, removes thickened and diseased tissue that blocks the OMC. Most of the healthy tissue in the sinuses is undisturbed allowing rapid recovery.

Endoscopic surgery can also be utilized for removal of polyps and to straighten the septum thus restoring a normal flow from the sinuses. Unlike other sinus surgical procedures, endoscopic sinus surgery has minimal and usually temporary effect on the patient’s appearance.

What to expect from endoscopic surgery

The endoscopic procedure usually lasts from one to three hours and is performed using general or local anesthesia. Generally, the patient goes home after surgery unless other medical conditions complicate recovery.

Full recovery may take several weeks. Dry blood, mucus, and crusting in the nose may occur, presenting symptoms of a severe cold or sinus infection. Nasal irrigation or salt-water sprays and antibiotic lubricants as recommended by the surgeon to facilitate normal sinus activity. Proper post-operative care is essential to prevent scar formation and allow normal healing. The surgeon performing the procedure will generally perform all required follow-up procedures.

Patients who depend on their voice for their livelihood should be warned that endoscopic sinus surgery may have an effect on their resonance. Additionally, some patients may have underlying nasal mucosal problems that remain after surgery. This is seen in highly allergic individuals or asthmatics.

The information contained in this fact sheet was drawn from The Sinus Source Book, written by Deborah Rosin, MD, an otolaryngologist-head and neck surgeon. The book is published by Lowell House; ISBN 1-56565-643-1.

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20 Questions About Your Sinuses

Q. How common is sinusitis?

A. More than 37 million Americans suffer from at least one episode of acute sinusitis each year. The prevalence of sinusitis has soared in the last decade due to increased pollution, urban sprawl, and increased resistance to antibiotics.

Q. What is sinusitis?

A. Sinusitis is an inflammation of the membrane lining of any sinus, especially one of the paranasal sinuses. Acute sinusitis is a short-term condition that responds well to antibiotics and decongestants; chronic sinusitis is characterized by at least four recurrences of acute sinusitis. Either medication or surgery is a possible treatment.

Q. What are the signs and symptoms of acute sinusitis?

A. For acute sinusitis, symptoms include facial pain/pressure, nasal obstruction, nasal discharge, diminished sense of smell, and cough not due to asthma (in children). Additionally, sufferers of this disorder could incur fever, bad breath, fatigue, dental pain, and cough (in adults).

Acute sinusitis can last four weeks or more. This condition may be present when the patient has two or more symptoms and/or the presence of thick, green or yellow nasal discharge. Acute bacterial infection might be present when symptoms worsen after five days, persist after ten days, or the severity of symptoms is out of proportion to those normally associated with a viral infection.

Q. How is acute sinusitis treated?

A. Acute sinusitis is generally treated with 10 to 14 days of antibiotic care. With treatment, the symptoms disappear and antibiotics are no longer required for that episode. Oral and topical decongestants also may be prescribed to alleviate the symptoms.

Q. What are the signs and symptoms of chronic sinusitis?

A. Victims of chronic sinusitis may have the following symptoms for 12 weeks or more: facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage, thick nasal discharge/discolored post-nasal drainage, pus in the nasal cavity, and at times, fever. They may also have headache, bad breath, and fatigue.

Q. What measures can be taken at home to relieve sinus pain?

A. Warm moist air may alleviate sinus congestion. A vaporizer or steam from a pan of boiled water (removed from the heat) are both recommended (humidifiers should have a clear filter to preclude spraying bacteria or fungal spores into the air). Warm compresses are useful in relieving pain in the nose and sinuses. Saline nose drops are safe for use at home.

Q. How effective are non-prescription nose drops or sprays?

A. Use of nonprescription drops or sprays might help control symptoms. However, non-prescription drops should not be used beyond their label recommendation.

Q. How does a physician determine the best treatment for acute or chronic sinusitis?

A. To obtain the best treatment option, the physician needs to properly assess the patient’s history and symptoms and then progress through a structured physical examination.

Q. What should one expect during the physical examination for sinusitis?

A. At a specialist’s office, the patient will receive a thorough ear, nose, and throat examination. During that physical examination, the physician will explore the facial features where swelling and erythema (redness of the skin) over the cheekbone exists. Facial swelling and redness are generally worse in the morning; as the patient remains upright, the symptoms gradually improve. The physician may feel and press the sinuses for tenderness. Additionally, the physician may tap the teeth to help identify an inflamed paranasal sinus.

Q. What other diagnostic procedures might be taken?

A. Other diagnostic tests may include a study of a mucus culture, endoscopy, x-rays, allergy testing, or CT scan of the sinuses.

Q. What is nasal endoscopy?

A. An endoscope is a special fiberoptic instrument for the examination of the interior of a canal or hollow viscus. It allows a visual examination of the nose and sinus drainage areas.

Q. Why does a physician specialist carry out nasal endoscopy?

A Nasal endoscopy offers the physician specialist a reliable, visual view of all the accessible areas of the sinus drainage pathways. First, the patient’s nasal cavity is anesthetized; a rigid or flexible endoscope is then placed in a position to view the structure of the nasal cavity. The procedure is utilized to observe signs of obstruction as well as detect nasal polyps hidden from routine nasal examination. During the endoscopic examination, the physician specialist also looks for pus as well as polyp formation and structural abnormalities that will cause the patient to suffer from recurrent sinusitis.

Q. What course of treatment will the physician recommend?

A. To reduce congestion, the physician may prescribe nasal sprays, nose drops, or oral decongestants. Antibiotics will be prescribed for any bacterial infection found in the sinuses (antibiotics are not effective against a viral infection). Antihistamines may be recommended for the treatment of allergies. Antifungal medicine will be the treatment for any fungal infection.

Q. Will any changes in lifestyle be suggested during treatment?

A. Smoking is never condoned, but if one has the habit, it is important to refrain during treatment for sinus problems. A special diet is not required, but drinking extra fluids helps to thin mucus.

Q. When is sinus surgery necessary?

A. Mucus is developed by the body to act as a lubricant. In the sinus cavities, the lubricant is moved across mucus membrane linings toward the opening of each sinus by millions of cilia (a mobile extension of a cell). Inflammation from an allergy causes membrane swelling and the sinus opening to narrow, thereby blocking mucus movement. If antibiotics are not effective, sinus surgery can correct the problem.

Q. What does the surgical procedure entail?

A. The basic endoscopic surgical procedure is performed under local or general anesthesia. The patient returns to normal activities within four days; full recovery takes about four weeks.

Q. What does sinus surgery accomplish?

A. The surgery should enlarge the natural opening to the sinuses, leaving as many cilia in place as possible. Otolaryngologist-head and neck surgeons have found endoscopic surgery to be highly effective in restoring normal functioning to the sinuses. The procedure removes areas of obstruction, resulting in the normal flow of mucus.

Q. What are the consequences of not treating infected sinuses?

A. Not seeking treatment for sinusitis will result in unnecessary pain and discomfort. In rare circumstances, meningitis or brain abscess and infection of the bone or bone marrow can occur.

Q. Where should sinus pain sufferers seek treatment?

A. If you suffer from severe sinus pain, you should seek treatment from a physician who can treat your condition with medical and/or surgical remedies.

This information (with the exception of photos) may be freely used. Attribution to the American Academy of Otolaryngology-Head and Neck Surgery is required.

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Tips for Sinusitis Sufferers

You may have sinusitis if you suffer from:

symptoms of upper respiratory infection lasting ten days or more.
facial pressure or pain.
nasal discharge that is yellow or green.
post-nasal drip.
cough.

At-home treatments for sinusitis include:

saline nasal sprays that moisturize the nasal cavity, reduce dryness, and help
clear thick or crusty mucus.
humidification (moisturizing the air) of living spaces in dry climates will aid the
movement of mucus through the sinuses.

A physician visit for your sinus pain will:

determine if you have an infection requiring an appropriate antibiotic.
discover if you require intensive medical treatment for a condition such as
nasal obstructions, necessitating sinus surgery.

Fact Sheet: Antibiotics and Sinuses

An antibiotic is a soluble substance derived from a mold or bacterium that inhibits the growth of other microorganisms.

The first antibiotic was Penicillin, discovered by Alexander Fleming in 1929, but it was not until World War II that the effectiveness of antibiotics was acknowledged, and large-scale fermentation processes were developed for their production.

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Acute sinusitis is one of many medical disorders that can be caused by a bacterial infection. However, it is important to remember that colds, allergies, and environmental irritants, which are more common than bacterial sinusitis, can also cause sinus problems. Antibiotics are effective only against sinus problems caused by a bacterial infection.

The following symptoms may indicate the presence of a bacterial infection in your sinuses:

Pain in your cheeks or upper back teeth
A lot of bright yellow or green drainage from your nose for more than 10 days
No relief from decongestants, and/or
Symptoms that get worse instead of better after your cold is gone.

Most patients with a clinical diagnosis of acute sinusitis caused by a bacterial infection improve without antibiotic treatment. The specialist will initially offer appropriate doses of analgesics (pain-relievers), antipyretics (fever reducers), and decongestants. However if symptoms persist, a treatment consisting of antibiotics may be recommended.

Antibiotic Treatment

Antibiotics are labeled as narrow-spectrum drugs when they work against only a few types of bacteria. On the other hand, broad-spectrum antibiotics are more effective by attacking a wide range of bacteria, but are more likely to promote antibiotic resistance. For that reason, your ear, nose, and throat specialist will most likely prescribe narrow-spectrum antibiotics, which often cost less. He/she may recommend broad-spectrum antibiotics for infections that do not respond to treatment with narrow-spectrum drugs.

Acute Sinusitis

In most cases, antibiotics are prescribed for patients with specific findings of persistent purulent nasal discharge and facial pain or tenderness who are not improving after seven days or those with severe symptoms of rhinosinusitis, regardless of duration. On the basis of clinical trials, amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole are preferred antibiotics.

Chronic Sinusitis

Even with a long regimen of antibiotics, chronic sinusitis symptoms can be difficult to treat. In general, however, treating chronic sinusitis, such as with antibiotics and decongestants, is similar to treating acute sinusitis. When antibiotic treatment fails, allergy testing, desensitization, and/or surgery may be recommended as the most effective means for treating chronic sinusitis. Research studies suggest that the vast majority of people who undergo surgery have fewer symptoms and better quality of life.

Pediatric Sinusitis

Antibiotics that are unlikely to be effective in children who do not improve with amoxicillin include trimethoprim-sulfamethoxazole (Bactrim) and erythromycin-sulfisoxazole (Pediazole), because many bacteria are resistant to these older antibiotics. For children who do not respond to two courses of traditional antibiotics, the dose and length of antibiotic treatment is often expanded, or treatment with intravenous cefotaxime or ceftriaxone and/or a referral to an ENT specialist is recommended.

Fact Sheet: Deviated Septum

The shape of your nasal cavity could be the cause of chronic sinusitis. The nasal septum is the wall dividing the nasal cavity into halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this natural partition is a firm but bendable structure made mostly of cartilage and is covered by skin that has a substantial supply of blood vessels. The ideal nasal septum is exactly midline, separating the left and right sides of the nose into passageways of equal size.

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Estimates are that 80 percent of all nasal septums are off-center, a condition that is generally not noticed. A “deviated septum” occurs when the septum is severely shifted away from the midline. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose. The symptoms are usually worse on one side, and sometimes actually occur on the side opposite the bend. In some cases the crooked septum can interfere with the drainage of the sinuses, resulting in repeated sinus infections.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is not generally performed on minors, because the cartilaginous septum grows until around age 18. Septal deviations commonly occur due to nasal trauma.

A deviated septum may cause one or more of the following:

Blockage of one or both nostrils
Nasal congestion, sometimes one-sided
Frequent nosebleeds
Frequent sinus infections
At times, facial pain, headaches, postnasal drip
Noisy breathing during sleep (in infants and young children)

In some cases, a person with a mildly deviated septum has symptoms only when he or she also has a “cold” (an upper respiratory tract infection). In these individuals, the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the “cold” resolves, and the nasal inflammation subsides, symptoms of a deviated septum often resolve, too.

Diagnosis: Patients with chronic sinusitis often have nasal congestion, and many have nasal septal deviations. However, for those with this debilitating condition, there may be additional reasons for the nasal airway obstruction. The problem may result from a septal deviation, reactive edema (swelling) from the infected areas, allergic problems, mucosal hypertrophy (increase in size), other anatomic abnormalities, or combinations thereof. A trained specialist in diagnosing and treating ear, nose, and throat disorders can determine the cause of your chronic sinusitis and nasal obstruction.

Your first visit: After discussing your symptoms, the primary care physician or specialist will inquire if you have ever incurred severe trauma to your nose and if you have had previous nasal surgery. Next, an examination of the general appearance of your nose will occur, including the position of your nasal septum. This will entail the use of a bright light and a nasal speculum (an instrument that gently spreads open your nostril) to inspect the inside surface of each nostril.

Surgerymay be the recommended treatment if the deviated septum is causing troublesome nosebleeds or recurrent sinus infections. Additional testing may be required in some circumstances.

Septoplasty: Septoplasty is a surgical procedure performed entirely through the nostrils, accordingly, no bruising or external signs occur. The surgery might be combined with a rhinoplasty, in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

The time required for the operation averages about one to one and a half hours, depending on the deviation. It can be done with a local or a general anesthetic, and is usually done on an outpatient basis. After the surgery, nasal packing is inserted to prevent excessive postoperative bleeding. During the surgery, badly deviated portions of the septum may be removed entirely, or they may be readjusted and reinserted into the nose.

If a deviated nasal septum is the sole cause for your chronic sinusitis, relief from this severe disorder will be achieved.

Fact Sheet: Fungal Sinusitis

What is a fungus? Fungi are plant-like organisms that lack chlorophyll. Since they do not have chlorophyll, fungi must absorb food from dead organic matter. Fungi share with bacteria the important ability to break down complex organic substances of almost every type (cellulose) and are essential to the recycling of carbon and other elements in the cycle of life. Fungi are supposed to “eat” only dead things, but sometimes they start eating when the organism is still alive. This is the cause of fungal infections; the treatment selected has to eradicate the fungus to be effective.

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In the past 30 years, there has been a significant increase in the number of recorded fungal infections. This can be attributed to increased public awareness, new immunosuppressive therapies (medications such as cyclosporine that “fool” the body’s immune system to prevent organ rejection) and overuse of antibiotics (anti-infectives).

When the body’s immune system is suppressed, fungi find an opportunity to invade the body and a number of side effects occur. Because these organisms do not require light for food production, they can live in a damp and dark environment. The sinuses, consisting of moist, dark cavities, are a natural home to the invading fungi. When this occurs, fungal sinusitis results.

There are four types of fungal sinusitis:

Mycetoma fungal sinusitis produces clumps of spores, a “fungal ball,” within a sinus cavity, most frequently the maxillary sinuses. The patient usually maintains an effective immune system, but may have experienced trauma or injury to the affected sinus(es). Generally, the fungus does not cause a significant inflammatory response, but sinus discomfort occurs. The noninvasive nature of this disorder requires a treatment consisting of simple scraping of the infected sinus. An anti-fungal therapy is generally not prescribed.

Allergic fungal sinusitis (AFS) is now believed to be an allergic reaction to environmental fungi that is finely dispersed into the air. This condition usually occurs in patients with an immunocompetent host (possessing the ability to mount a normal immune response). Patients diagnosed with AFS have a history of allergic rhinitis, and the onset of AFS development is difficult to determine. Thick fungal debris and mucin (a secretion containing carbohydrate-rich glycoproteins) are developed in the sinus cavities and must be surgically removed so that the inciting allergen is no longer present. Recurrence is not uncommon once the disease is removed. Anti-inflammatory medical therapy and immunotherapy are typically prescribed to prevent AFS recurrence.

Note: A 1999 study published in the Mayo Clinic Proceedings asserts that allergic fungal sinusitis is present in a significant majority of patients diagnosed with chronic rhinosinusitis. The study found 96 percent of the study subjects with chronic rhinosinusitis to have a fungus in cultures of their nasal secretions. In sensitive individuals, the presence of fungus results in a disease process in which the body’s immune system sends eosinophils (white blood cells distinguished by their lobulated nuclei and the presence of large granules that attract the reddish-orange eosin stain) to attack fungi, and the eosinophils irritate the membranes in the nose. As long as fungi remain, so will the irritation.

Chronic indolent sinusitis is an invasive form of fungal sinusitis in patients without an identifiable immune deficiency. This form is generally found outside the US, most commonly in the Sudan and northern India. The disease progresses from months to years and presents symptoms that include chronic headache and progressive facial swelling that can cause visual impairment. Microscopically, chronic indolent sinusitis is characterized by a granulomatous inflammatory infiltrate (nodular shaped inflammatory lesions). A decreased immune system can place patients at risk for this invasive disease.

Fulminant sinusitis is usually seen in the immunocompromised patient (an individual whose immunologic mechanism is deficient either because of an immunodeficiency disorder or because it has been rendered so by immunosuppressive agents). The disease leads to progressive destruction of the sinuses and can invade the bony cavities containing the eyeball and brain.

The recommended therapies for both chronic indolent and fulminant sinusitis are aggressive surgical removal of the fungal material and intravenous anti-fungal therapy.

Fact Sheet: Sinus Headaches

Not every headache is the consequence of sinus and nasal passage problems. For example, many patients visit an ear, nose, and throat specialist to seek treatment for a sinus headache and learn they actually have a migraine or tension headache. The confusion is common, a migraine can cause irritation of the trigeminal or fifth cranial nerve (with branches in the forehead, cheeks and jaw). This may produce pain at the lower-end branches of the nerve, in or near the sinus cavity.

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Pain in the sinus area does not automatically mean that you have a sinus disorder. On the other hand, sinus and nasal passages can become inflamed leading to a headache. Headache is one of the key symptoms of patients diagnosed with acute or chronic sinusitis. In addition to a headache, sinusitis patients often complain of:

Pain and pressure around the eyes, across the cheeks and the forehead
Achy feeling in the upper teeth
Fever and chills
Facial swelling
Nasal stuffiness
Yellow or green discharge

However, it is important to note that there are some cases of headaches related to chronic sinusitis without other upper respiratory symptoms. This suggests that an examination for sinusitis be considered when treatment for a migraine or other headache disorder is unsuccessful.

What to Do for a Sinus Headache

Sinus headaches are associated with a swelling of the membranes lining the sinuses (spaces adjacent to the nasal passages). Pain occurs in the affected region – the result of air, pus, and mucus being trapped within the obstructed sinuses. The discomfort often occurs under the eye and in the upper teeth (disguised as a headache or toothache). Sinus headaches tend to worsen as you bend forward or lie down. The key to relieving the symptoms is to reduce sinus swelling and inflammation and facilitate mucous drainage from the sinuses.

There are several at-home steps that help prevent sinus headache or alleviate its pain. They include:

Breathe moist air: Relief for a sinus headache can be achieved by humidifying the dry air environment. This can be done by using a steam vaporizer or cool-mist humidifier, steam from a basin of hot water, or steam from a hot shower.

Alternate hot and cold compresses: Place a hot compress across your sinuses for three minutes, and then a cold compress for 30 seconds. Repeat this procedure three times per treatment, two to six times a day.

Nasal irrigation: Some believe that when nasal irrigation or rinse is performed, mucus, allergy creating particles and irritants such as pollens, dust particles, pollutants and bacteria are washed away, reducing the inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better and will reduce the symptoms. Nasal irrigation helps shrink the sinus membranes and thus increases drainage. There are several over-the-counter nasal rinse products available. Consult your ear, nose, and throat specialist for directions on making a home nasal rinse or irrigation solution.

Over-the-counter medications: Some over-the-counter (OTC) drugs are highly effective in reducing sinus headache pain. The primary ingredient in most OTC pain relievers is aspirin, acetaminophen, ibuprofen, naproxen, or a combination of them. The best way to choose a pain reliever is by determining which of these ingredients works best for you.

Decongestants: Sinus pressure headaches caused by allergies are usually treated with decongestants and antihistamines. In difficult cases, nasal steroid sprays may be recommended.

Alternative medicine: Chinese herbalists use Magnolia Flower as a remedy for clogged sinus and nasal passages. In conjunction with other herbs, such as angelica, mint, and chrysanthemum, it is often recommended for upper respiratory tract infections and sinus headaches, although its effectiveness for these problems has not been scientifically confirmed.

If none of these preventative measures or treatments is effective, a visit to an ear, nose, and throat specialist may be warranted. During the examination, a CT scan of the sinuses may be ordered to determine the extent of blockage caused by chronic sinusitis. If no chronic sinusitis were found, treatment might then include allergy testing and desensitization (allergy shots). Acute sinusitis is treated with antibiotics and decongestants. If antibiotics fail to relieve the chronic sinusitis and accompanying headaches, endoscopic or image-guided surgery may be the recommended treatment.

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