Sinusitis

The sinuses are cavities, or air-filled pockets, that are near the nasal passage, where air enters the nose. There are four different types of sinuses, each of which is located inside the face and is part of the skull:

• ethmoid sinuses - located around the area of the bridge of the nose in the space between the eyes. This sinus is present at birth, and continues to grow.
• maxillary sinuses - located underneath the eyes and behind the area of the cheeks. This sinus is also present at birth, and continues to grow into adolescence.
• frontal sinuses - located above the eyes, in the area of the skull behind the forehead and eyebrows. This sinus does not typically develop until around seven years of age.
• sphenoid sinuses - located deep behind the nose in a space nearly behind the eye sockets. This sinus does not develop until adolescence.

Most people have 4 pairs of sinuses on the left and right sides, or 8 sinuses in total. Some patients do not develop 1 or more sinuses during the normal process of development, which is not a cause for concern in most cases.

Sinusitis is an infection of the sinuses near the nose, that then produces what we now know to be persistent areas of inflammation and blockage of the sinus passages. These infections usually occur after a viral or bacterial cold, or after an aggressive allergic inflammation, or sometimes after past surgery that led to unfavorable healing and scarring. This can also caused by nasal polyps that physically obstruct the sinuses passages, fungal infections of the nose, and even autoimmune disease. There are three types of sinusitis:

• Acute - this type of infection occurs quickly and generally gets better with the appropriate treatments.
• Subacute - this type of infection does not get better with treatment initially, and lasts less than 1-3 months.
• Chronic - this type of infection happens with repeated acute infections, from previous infections that were inadequately treated, or persistent inflammation and swelling within the outflow tracts of the sinuses. In the case of chronic sinusitis, symptoms last longer than three months.

Sometimes, a sinus infection happens after an upper respiratory infection (URI) or common cold that ‘never seems to go away.’. The URI causes inflammation of the nasal passages that can lead to profound obstruction of the opening of the paranasal sinuses, which can then lead to repeated cycles of infection and inflammation in the sinuses. Allergic disease can also lead to sinusitis because of the swelling of the nasal tissue and increased production of mucus.

There are other possible conditions that can block the normal flow of secretions out of the sinuses and can lead to sinusitis. These may include:

• structural/anatomic abnormalities in the nose and sinuses that physically narrow the sinus passages
• enlarged adenoid tissue in the back of the nose
• diving and swimming
• infections from an upper molartooth
• trauma to the nose
• foreign objects that are trapped in the nose
• nasal polyps
• obstructing, intranasal scarring after past sinus surgery
• fungal infection of the sinuses
• certain autoimmune diseases
• immunosuppression/compromised immune system
• cystic fibrosis

After the blockage of the flow of secretions from the sinuses, bacteria will sometimes begin to grow. This leads to a sinus infection, or bacterial sinusitis. The most common bacteria that cause sinusitis are:

• Staphylococcus aereus
• Streptococcus pneumonia
• Haemophilus influenzae
• Pseudomonas aeruginosa

The symptoms of sinusitis vary for each individual , and depend greatly on the age of the individual. The following are the most common symptoms of sinusitis.

Symptoms may include:

Younger children:

• Runny nose that lasts longer than seven to 10 days. The discharge is usually thick green or yellow, but can also be clear and profuse.
• Night-time cough
• Occasional daytime cough
• Swelling around the eyes
• Low grade fevers
• Children usually do not complain of headaches if less than 5 years of age

Older children (greater than 12 years old) and Adults:

• Runny nose or cold symptoms that last longer than seven to 10 days
• Complaints of drip in the throat from the nose (post nasal drip)
• Headaches
• Facial discomfort
• Nasal blockage/nasal obstruction
• Occasional, to total, loss of sense of smell
• Bad breath
• Cough
• Sore throat
• Swelling around the eye, worse in the morning
• Dental discomfort to the upper teeth
• Low grade fevers are LESS common with age

The symptoms of sinusitis may resemble other conditions or medical problems. Always consult a physician for evaluation and to try to achieve a diagnosis.

Usually, your physician can diagnosis sinusitis simply based on your constellation of symptoms and physical examination. Sometimes, additional tests or procedures are performed to confirm the diagnosis. These may include:

• Nasal endoscopy, in which a 3mm diameter telescope is gently placed into the anesthetized nose, to assess for swelling, infection, polyps etc.
• Cultures of a possible infection seen in the nose during endoscopy
• computed tomography (CT scan or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images ( slices), both horizontally and vertically, of the skull, sinus passages, and the surroundingbones, muscles, and fat. CT scans are more detailed than general x-rays. (x-rays are invisible electromagnetic energy beams that pass through internal tissues, bones, and organs to produce images onto film or now, computers).
• Blood tests

Specific treatment for sinusitis will be determined by your physician based on:

• your age, health, and medical history
• type and extent of the disease process (treatment options vary for acute sinusitis vs. fungal sinusitis vs. nasal polyp sinusitis)
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinions, past treatments, and preferences

Treatment of sinusitis may include the following:

• One of many types of antibiotics, as determined by your physician. Antibiotics are usually given for 10 to 21 days, and sometimes even longer depending on the case.
• Steroids, such as prednisone, can sometimes combat and reverse sinusinflammation
• acetaminophen for pain or discomfort
• Nasal sprays that are over the counter (OTC) such as saline (sprays, mist, irrigations), or via prescription such as steroid sprays (fluticasone, mometasone, budesonide, others) or anti-histamine sprays (azelastine, olapatadine, others) Limited use of oral and topical decongestants and oral antihistamines on a limited basis to help the symptoms of sinusitis.

Surgery may be nedded in the treatment of sinusitis in the following settings:

• Recurrent acute sinusitis. If you are experiencing multiple episodes of sinus infections within a year, but otherwise feel well between these episodes, there may be a structural/anatomic problem that is contributing to this. Surgery can often help to correct these anatomic obstructions and reduce the number and severity of sinus infections.
• Acute sinusitis rarely requires surgery since it typically resolves on its own, or with medical treatments alone. However, in select cases, if an acute infection is continuing to cause severe nasal, dental or eye symptoms, and is unresponsive to the treatment measures noted above, surgery may be required.
• Chronic rhinosinusitis. If you have constant sinus symptoms, and medications have transiently, or only minimally, helped to relieve the inflammation and infection of your nose and sinuses, then surgery can be an option to open the outflow/drainage pathways of the sinuses to clear any underlying infection, allow ventilation (increased air passage) into your sinuses, and improve the ability to deliver various topical rinse and spray medications.

Balloon sinuplasty is a relatively new procedure that is meant to widen the narrow drainage pathways of the sinuses in certain patients with sinusitis. This is done by placing, and then briefly inflating, small balloons into some of the infected/inflamed sinuses to increase the diameter of the drainage portals. However, there are only limited indications for sinuplasty, as most patients are not candidates for this procedure. It is best to ask your sinus physician about this technology, and to discuss your possible candidacy for this procedure.