Rhinosinusitis is becoming more common and it causes significant symptoms which affect quality of life. The sinuses can be affected by a variety of conditions including allergies, sensitivity to chemicals, infections, structural problems, tumors, hormones, and injury. Many of these conditions have symptoms which overlap and some people have more than one condition present which makes it difficult to determine the specific cause of their problem. Typical sinus symptoms include reduced ability to breathe through the nose, increased mucus production, post-nasal drip (mucus that goes into the throat), facial pressure, sneezing, itching, upper teeth pain, low-grade fever, thick colored mucus, and bad breath. Contrary to common belief, most people who have severe pain in there face do not have sinusitis; usually this is a migraine headache or another facial pain condition.
Sinuses are paired air spaces located in the face and skull and they are named according to the skull bone they are within. Some sinuses are present at birth and others form latter as they skull grows. The maxillary sinuses are the largest and they are in the cheek region. The frontal sinuses are in the forehead. Ethmoid sinuses are between the eyes and an average person has eight to twelve ethmoid sinuses. The sphenoid sinus is deep in the skull. The eye socket is nearly surrounded by sinuses and the upper teeth may have roots that enter or lie close to the sinus cavity. The nasal passages have a special mucus membrane with tiny hair cells called cilia. Cilia move mucus and trapped material like viruses, dust, and pollen into the throat where it is swallowed. The mucus membranes and cilia are defense mechanisms to keep our noses clean.
Sinusitis is often used as a general term to include all conditions that affect the nose although this is not a precise use of the word. It is simpler to categorize people according to certain symptoms and by the duration of symptoms as it helps in diagnosis. Problems which have been present for less than four weeks are acute conditions. Those with symptoms between 4 to 12 weeks are sub-acute and those more than 12 weeks are chronic.
Acute sinusitis may be confused with acute rhinitis, the common cold, which is caused by a viral infection. Most colds have a rapid onset of symptoms and last ten days or less but some viruses may cause symptoms for weeks. Symptoms are usually symmetric involving both sides of the nose. Viral infections may affect anyone but those with decreased immunity are at greatest risk. Examples are those who lack proper sleep, have poor diets, or are exposed to others who are sick. If a cold has persisted longer than ten days it is more likely that a bacterial sinus infection is present. A high percentage of sinus infections follow colds but only 2% of colds become sinus infections.
Acute sinus infections occur because the lining inside a sinus cavity and the nasal passages become swollen and the swelling obstructs the natural opening used to drain the sinuses. Most infections affect all the sinus cavities but it is common for only one or several sinuses to be affected, especially if underlying sinus problems are present. During viral infections, the cilia are impaired so the natural mechanism to clear particles, irritants, and infectious debris is impaired. The sinus cavities are typical sterile, while the nasal cavities are heavily colonized by germs. Mucus production is increased when sinus tissue is inflamed and it becomes trapped inside the sinus cavity. Mucus provides a nutrient source for bacteria that find their way inside the sinuses. As the process progresses, symptoms such as pain, pressure, increased mucus, and nasal airway obstruction result.
Chronic sinusitis is a complicated spectrum of diseases that share inflammation as an underlying problem. These groups of people are often difficult to treat and tend to fail standard treatments. Some of the more common factors to consider are unresolved infections with infection of the bone, biofilms, allergies, non-allergic rhinitis, structural conditions, and hormonal conditions.
Factors Involved with Chronic Sinusitis
Allergic rhinitis also known as hay fever: This is a common condition and it is often seasonal and relates to histamine release and sensitivity. Symptoms include a rapid change in condition from a normal state to significant symptoms after exposure to certain materials like dust, pollen, animals, food, or medications. Sometimes symptoms are not distinctly seasonal and symptoms such as chronic nasal obstruction and post-nasal drip are present all year.
Non-allergic rhinitis: This condition includes a few different conditions and symptoms may be acute with a rapid change in condition or they may be chronic with low grade yet constant symptoms. This condition is often confused with allergies but it is not a histamine based disorder; it is caused by sensitivity to certain chemicals, perfume, smoke, pollution, and other less identifiable materials. A fundamental abnormality of our response to airborne materials may the cause of this condition. In others, it is due to temperature variations, medications, and hormones such as occur during pregnancy. It is likely that many people who have non-allergic rhinitis have the same condition which causes asthma. Asthma as a co-condition is common in people with allergic and non-allergic rhinitis. Patients may have significant symptoms yet have negative allergy tests.
Structural abnormalities: This category includes bony abnormalities where the facial bones and sinuses do not form properly or because an injury damaged the nose. Examples include deviation of the septum, large turbinates, polyps, growths, or foreign bodies within the nose.
The key to treatment is to identify the conditions which are responsible for a patients symptoms. A history and physical exam are necessary for diagnosis and in some cases more advanced techniques are needed including endoscopy, a procedure used to examine the nose with a special telescope, or a CT scan used to obtain detailed pictures of the sinus anatomy.
Acute rhinosinusitis: Typical symptoms include sore throat, clear nasal discharge, nasal obstruction, headache, and facial pressure. Because the incidence of bacterial infections is low, symptomatic treatment is the first line of treatment with decongestants like pseudoephedrine, saline irrigation, Mucinex, and Acetaminophen or Ibuprofen. If symptoms do not improve or are much worse after ten days, treatment for a sinus infection may be indicated
Acute bacterial sinusitis: Symptoms include purulent discharge, nasal obstruction, facial pressure, reduced sense of smell, and possible fever. Current best practice guidelines for treating acute sinusitis include not using antibiotics for viral infections. When treated, an antibiotic is taken usually for ten days. Many options are available for common infections. Other modalities include saline irrigation, decongestants, mucolytic agents, increased hydration, and rest.
Allergic rhinitis: This is a chronic condition but symptoms can vary from mild to severe. For mild symptoms, avoidance of the stimulant is best. If avoidance is not possible, irrigation of the nasal passages with saline, or oral antihistamines pills are effective treatments. For people with more severe symptoms or who do not respond well to the oral medication, nasal steroid sprays are useful such as topical steroids and antihistamines. Allergy testing may be ordered to determine the cause of the allergies and this may be done with skin pricks or by a blood test called RAST testing. Allergy symptoms may be improved with desensitization (immunotherapy) therapy. Traditionally this required weekly shots, but now it is possible to use liquid oral drops or special pills.
Non-allergic Rhinitis: Typical symptoms include nasal discharge and post-nasal drip, nasal obstruction, and facial pressure. This condition is often confused with allergies or chronic rhinosinusitis and it is not-uncommon for people to have both conditions. Treatment may include antihistamines, steroid sprays, saline irrigation, and other topical products like Atrovent. This is not a curable condition and our best efforts aim to control symptoms.
Structural abnormalities: When structures are abnormal they may negatively affect the function of the nose and sinuses. Sometimes the abnormality may be mild or well tolerated. For others, the abnormality is significant and if the defect is fixed sinus and nasal function is improved such as a better ability to breathe through the nose, fewer sinus infections, or resolution of a persistent infection. Clinical judgment is needed to determine who is a good candidate for surgery and it is important that goals and expectations are clearly defined.
Chronic sinusitis: This is the most complex category and treatment varies depending on the degree of symptoms and nature of the condition. Symptoms include nasal discharge, nasal obstruction, facial pressure, reduced sense of smell, headache, ear pressure, bad breath, cough, and fatigue A fraction of patients with chronic sinusitis have nasal polyps. Polyps are tissue growths that grow inside the nose and obstruct sinuses and the airway. The specific cause is not known, but inflammation is a major factor. Polyps form when the amount of swelling from inflammation is greater than the amount of shrinkage. An individual approach is always needed but may include oral antibiotics, IV antibiotics, saline irrigation, irrigation of the nose and sinuses with antibiotics, nebulized medications, oral or topical steroids, sinus surgery, and immunotherapy. This is a condition where providers may have differing opinions; some doctors are more conservative and prefer medical treatment first, while other doctors wish to offer surgery. National organizations are trying to establish guidelines to improve quality and consistency of care. It is important to understand, that unless anatomic abnormalities exist, surgery is unlikely to cure this condition.
The use of surgery for sinusitis is directed at restoring normal anatomy. A CT scan of the sinuses is almost always required before considering any form of sinus surgery. The goal is to identify factors that impair normal sinus function. The septum may be crooked (deviated) and this may affects airflow through the nose. The lower turbinates may be enlarged and affect breathing. The middle turbinates may be abnormal and affect sinus cavity drainage. Sinus cavities may be obstructed by swelling, polyps, or because they did not develop normally. The specific type of surgery depends upon the patient's findings. Sometimes only one sinus is a problem, other times there are multiple problems. Sinus surgery has evolved over the years. At first large windows were made to permit the sinuses to drain. This technique was abandoned when it was determined that the sinuses do not drain by gravity. Mucus travels through the natural openings. With the use of fiberoptic scopes, the natural openings were able to be improved with low risk and it was common practice to create wide large openings into the sinuses. This technique helped many patients, but in some cases their noses became too dry because the anatomy was altered from an obstructed sinus to an abnormal wide-opened sinus that also disturbs normal sinus function. Modern technique is focused upon creating natural sized sinus openings to restore function rather than aggressive surgery. Treatment success has improved. The risks of surgery, complication rates, and post-operative recovery have also improved. Newer techniques exist to open the sinuses with balloon catheters is possible. This technique may be done in the hospital under anesthesia or in the office while awake. It offers a very fast recovery, minimal risk, and provides high success rates in the properly selected patient. It is important to identify a surgeon who is thoughtful about your surgery so the least invasive and most effective procedure is used. It is also important to understand that surgery may not eliminate all symptoms, usually it does not "cure" sinusitis, but it may provide a substantial improvement in quality of life.