Sinusitis

Sinusitis is inflammation of the mucous membrane lining the sinuses.

It is also known as rhinosinusitis (“rhino” means nose)  because inflammation in the sinuses is usually accompanied by nasal inflammation. When the mucous membrane around the sinus openings (ostia) become obstructed, the sinuses fill with fluid creating a moist environment in which bacteria can grow.

The bacteria then cause further inflammation of the mucous membrane, creating a self-perpetuating cycle.

Symptoms

Sinusitis is accompanied by many possible symptoms. The four most common symptoms are:

• Nasal obstruction, congestion or fullness, which can cause difficulty breathing
• Facial pain/pressure/fullness (including sinus “headache”)
• Discolored nasal or postnasal discharge of varying colors and thickness
• Decreased sense of smell

Other symptoms include fever, fatigue, bad breath (halitosis), cough, ear pressure and tooth pain.

Acute vs. chronic sinusitis

• Acute sinusitis. This refers to a sudden onset infection, with fewer than four weeks of symptoms. The typical history of an acute sinus infection is a common cold that continues to worsen over several days, or initially improves followed by sudden worsening. Antibiotics are typically effective for treating acute sinus infections.
• Chronic sinusitis. This refers to symptoms of sinusitis lasting longer than 12 weeks. These symptoms may not necessarily have started with an acute sinus infection, but patients with chronic sinusitis may also experience periods of infections characterized by worsened symptoms.
• Recurrent acute sinusitis. This is diagnosed when patients experience four or more bacterial sinus infections each year. Patients who truly have this diagnosis without underlying chronic sinusitis are asymptomatic in between episodes, and typically have normal exams or negative CT unless done in the middle of an infection.

Causes

An estimated 50 million people in the United States suffer from sinusitis. It is thought to be on the rise because of pollution, urban sprawl and antibiotic resistance.

There are multiple causes of sinusitis which include:

• Anatomy. Anatomic factors that cause sinusitis include variations in sinus cell development and deviated nasal septum, resulting in narrowing of the sinus drainage pathways.
• Genetics. Genetic causes include cystic fibrosis and ciliary dyskinesia, leading to abnormal mucus production and clearance. Specific genes involving immune system elements may be involved and research is ongoing to further characterize these genes.
• Environmental. Environmental factors are pollutants such as tobacco smoke and chemicals, and allergens such as pollen, molds, dust mites and pet dander.
• Other medical conditions. Various medical conditions also contribute to or are associated with sinusitis. Greater than 1/3 of patients with asthma also have sinusitis. Immunocompromised states such as poorly controlled diabetes, human immunodeficiency virus (HIV) infection, or recent chemotherapy may also contribute. Sinusitis may also be caused by tissue growths blocking the sinus drainage pathways, including polyps and tumors.

Often, a combination of these contributes to development of disease, although in many cases, every possible cause may not be identified.

Treatment

Studies have demonstrated that chronic sinusitis leads to a significant reduction in quality of life, comparable to diseases such as chronic lung disease, chronic back pain, angina (chest pain), and congestive heart failure.

Fortunately, appropriate treatment of disease has been shown to result in meaningful improvements in quality of life in the majority of patients. Therefore, patients should try to commit to a treatment regimen to help maintain maximum control of symptoms.

Medications are first-line treatment for chronic sinusitis. Both over the counter and prescription medications are available and effective in many cases.

Over-the-counter:

• Decongestant tablets or sprays*
• Saline sprays or rinses
• Mucus thinning agents (guaifenesin)

*Important note about decongestant nasal sprays: Use for more than two to three days is not recommended due to the risk of bothersome rebound congestion.

Prescription:

• Nasal steroid sprays
• Oral steroids (prednisone, medrol dosepak, etc)
• Antibiotics

If medications fail to result in enough improvement, sinus surgery may be indicated.

Medication is important to continue even if surgery has also been recommended. Chronic sinusitis can be compared to diseases like diabetes and hypertension, in which ongoing treatment is required to keep the blood sugar or blood pressure under control, but stopping the medications results in recurrence.

Treatment of chronic sinusitis is individualized to each specific patient depending on the symptoms and findings of evaluation.

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