Introduction

If you have sinusitis, you are not alone. Sinusitis is one of the most commonly diagnosed diseases in the United States, affecting more than 30 million adults. Americans make nearly 800,000 emergency department visits annually for sinusitis. Over $2 billion is spent each year in the U.S. for over the counter medications for nasal and sinus disorders, and about $200 million on prescription medications. Furthermore, people with sinus problems undergo more than 460,000 sinus surgeries each year in the U.S., making it one of the most commonly performed surgical procedures (1,2).

These numbers are up from a decade ago, and health experts expect further increases in the future. Possibly due to pollution and other factors, the prevalence of all breathing-related ailments – not just sinusitis, but also allergies and asthma – is rising and shows no signs of leveling off.  And not only is sinusitis common, it strikes people during their most productive years. It’s far more likely to occur between the ages of 20 and 65 than during childhood or teen years, or late in life.

 

What is sinusitis?



Sinusitis is an inflammation or infection of the sinuses. The sinuses are air-containing spaces within the bones of the skull and face. We have four pairs of sinuses – the frontal, maxillary, ethmoid, and sphenoid sinuses (see figures). These sinuses are lined with tiny glands that secrete a thin layer of mucus which sweeps bacteria and other foreign particles out of the sinuses and into the nose through pinpoint openings called ostia. If these ostia become blocked, the sinuses fill up with mucus. When bacteria overgrow in this mucus, the sinuses become infected and sinusitis occurs.

 

     

Causes of sinusitis

The sinuses can become blocked by anything that leads to swelling inside the nose. A common cold is the most frequent cause, but environmental allergies, such as hay fever, which cause the membranes lining the nasal cavity to swell can also result in a sinus infection. Other causes include dry indoor heat during the winter months or a deviated nasal septum. (The septum is the partition that separates the right and left sides of the nasal cavity. If it is very crooked, it can obstruct the sinus outflow passages and lead to sinusitis.)

 

 

 

 

 

 

Symptoms of sinusitis

The three most common symptoms of sinusitis are:

Facial pressure/headache: The dull, throbbing pain, ache, or pressure that is a hallmark of sinusitis results from inflamed tissue putting pressure on nerve endings in the lining of your sinuses. This pain's location is often specific to the infected sinus:

·        Frontal sinusitis causes forehead pain or headache.

·        Maxillary sinusitis causes cheek pain, which may radiate to the teeth in the upper jaw.

·        Ethmoid sinusitis causes pain between the eyes or across the bridge of the nose. 

         Sphenoid sinusitis causes pain behind the eyes, on the top of the scalp, or along the back of the head.

If all four pairs of sinuses are infected (what's known as pansinusitis), your pain and pressure is usually more spread out and may encompass the entire face or head.

                Difficulty breathing through the nose/congestion: The combination of swollen nasal membranes and excess mucus makes it difficult to breathe through your nose.

For some sinus sufferers, the term congestion refers not to blocked nasal breathing, but to a sense of fullness or blockage of the face, particularly in the cheeks. This sensation is caused by blockage of the sinuses themselves. When ostia swell shut, the mucous membranes in the sinuses absorb oxygen, creating negative pressure (or a vacuum), which can produce this sense of facial congestion, or even pain.

                Nasal drainage/post-nasal drip: Mucus from the sinuses normally drains in minute quantities into the nose and down the back of the throat before being swallowed. During an infection, increased secretion by the nose and sinuses results in a larger volume of mucus, which is often thick and yellow or green. This mucus, which may contain large quantities of bacteria and white blood cells, flows down the back of the nose and throat. Some people blow a large amount of mucus out the front of the nose as well.

 

Other symptoms of sinusitis include:

Loss of smell: The roof of the nasal cavity is lined with smell receptors. Swelling of the membranes in the nose can block the odor molecules from reaching these receptors, leaving you with a reduced sense of smell.

Loss of taste: A normal sense of taste, particularly the ability to perceive different flavors, depends on an intact sense of smell. Consequently, many people who lose smell from sinusitis also describe a corresponding decrease in their sense of taste.

Bad breath: The discolored mucus that drains from infected sinuses contains bacteria and debris that emit foul-smelling odors. As a result, thick mucus that runs down the back of your throat may produce bad breath (halitosis) when these odors are exhaled.

Cough: When mucus runs down the back of the throat, it may touch the vocal cords and trigger an involuntary cough response. Coughing is often worst when lying down at night or upon awakening in the morning.

Sore throat: The thick mucus that drains during a sinus infection is more acidic than normal watery mucus, so it can irritate the membranes that line your throat.

Fatigue: Your body uses extra energy to mount an immune response. This shifting of calorie reserves from normal daily activity to infection-fighting can leave you feeling tired. In addition, poor nasal breathing and frequent coughing during the night can cause poor quality sleep, resulting in less energy during the day.

Ear fullness: Inflammation and drainage from sinusitis may block the eustachian tubes, passageways that connect your ears to the back of your nose. If these tubes become blocked, you can develop an uncomfortable feeling of fullness or pressure in the ears.

                Fever: Occasionally, the body may mount a fever in response to the marked inflammation and the presence of a large quantity of bacteria during a sinus infection. Fever is more common in acute, rather than chronic sinusitis.  Acute sinusitis refers to a sinus infection which lasts less than 4 weeks. 

 

How do I know if I have sinusitis, a cold, or an allergy?

Unless you have prior experience with sinusitis, you may have trouble distinguishing it from other ailments such as colds and allergies. People often mistakenly confuse the three because so many of their symptoms are similar. But they are, in fact, three different entities, with three different causes.

            Colds: Whereas sinusitis is often caused by bacteria, colds are caused by viruses. These much smaller microorganisms invade the body's cells, where they reproduce and are eventually released into the bloodstream to invade other cells. The body's immune system is usually quite effective at controlling viral infections, so most colds go away within a week. Colds can occur at any time but are most common during winter ("cold season"). What can be confusing is that it's not uncommon for a cold to precede a sinus infection.

Allergies: Allergies are usually caused by environmental irritants such as pollen, dust mites, or pet dander, not bacteria or viruses. These irritants, known as allergens, activate an immune response that is different from the immune response to an infection. During allergic reactions, a powerful molecule called histamine causes the membranes of the upper respiratory tract, including the nose and sinuses, to swell and weep mucus. Histamine release can also trigger repeated sneezing and make your nose and eyes itch.

Allergies can be either perennial, meaning they occur year-round, or seasonal. Allergies to dust and pet dander are often perennial. Seasonal allergies tend to be worst during the spring, when flowers and trees bloom, and the fall, when ragweed is in the air. As with colds, allergies may precede and trigger sinusitis.

 

Table One: Telling Symptoms. The decision on how to treat sinusitis, cold, and allergy symptoms depends on what’s causing them. Here’s how to tell them apart.


Symptom	Sinusitis	Cold	Allergy
Facial pressure/pain	Yes	Sometimes	Sometimes
Duration of illness	More than 10 days	Less than 10 days	Varies
Nasal discharge	Thick, yellow-green	Thick and whitish or thin and watery	Clear, thin, watery
Itchy eyes	No	No	Yes
Headache	Yes	Sometimes	Sometimes
Bad breath	Sometimes	No	No
Cough	Sometimes	Yes	Sometimes
Nasal congestion	Yes	Yes	Sometimes
Sneezing	No	Yes	Yes
Fatigue/weakness	Sometimes	Yes	Sometimes
Sore throat	Sometimes	Yes	Sometimes

 

 

Diagnosing sinusitis: when is it time to see your doctor?

Table One lists many of the differences between sinusitis and colds and allergies. Understanding these differences is helpful, but it won't make your symptoms go away. If severe nasal symptoms linger for more than a week or two, it's advisable to see your doctor. A visit to your Primary Care Physician (PCP) is often a good first step.

 

History: A good patient history is the single most important tool your doctor has to confirm the diagnosis of sinusitis. This same history is also critical for determining whether something other than sinusitis could be causing your problems. For example, if you only have facial pain without congestion or drainage, your problem could be neurological in nature, with migraine headaches and neuralgia as possibilities, and you may be referred to a neurologist. If you have sneezing, itchy eyes, and thin, watery post-nasal drip, it's likely you have allergies, and you may be referred to an allergist.

Exam: Once the history is completed, your PCP may look inside your nose with a small flashlight. She won't be able to see into your sinuses, but she can see the front portion of the nasal cavity and assess how much swelling there is and whether any drainage is present.

If your symptoms persist, your PCP may refer you to a specialist known as an Ear, Nose, and Throat doctor (ENT) or Otolaryngologist. The ENT doctor will likely examine you with a thin telescope known as a nasal endoscope. This endoscope can be passed into the nose with a minimal amount of discomfort to visualize the areas through which the sinuses drain (Figure).

 

 

CT Scan: Your doctor may order a computed tomography (CT) scan to confirm the diagnosis. A CT scan is a radiological technique that has largely replaced plain sinus X-rays for evaluating sinus disease. A CT scan enables your doctor to see the individual sinus ostia through which the sinuses drain and determine whether or not they're blocked. On a CT scan, air shows up black and bone appears white (Figure). Gray areas in the sinuses often signify abnormalities such as pus, mucus, polyps, or cysts.



 

 

 

Nasal irrigations: the key to healthier sinuses

Nasal irrigation (also known as nasal lavage or nasal rinsing) is easy and inexpensive and has no negative side effects. I strongly advise people who suffer from nasal congestion and drainage to incorporate it into their daily hygiene routine. A popular option is to "Brush and Flush”; in other words, irrigate twice a day, right after brushing your teeth.

Nasal irrigation washes out excess mucus that might otherwise lead to bothersome drainage or blocked breathing. Along with the mucus, you're also flushing out unwanted debris, including bacteria, mold, dust, and other irritants that can cause nasal tissues to swell. So nasal irrigation really achieves two goals: it opens more room to breathe and clears obstructions that might predispose you to sinusitis.




Squeeze Bottle: The most convenient way to rinse your nose and sinuses is with an irrigation kit that can be purchased at most local drug stores. This kit comes with a plastic squeeze bottle and small packages of a salt mixture (Figure).  You simply place the contents of one package (or a teaspoon of salt) into the bottle and fill it with warm water. Leaning over a sink, you gently squeeze the bottle, so that salt water squirts out the hole in the top of the bottle and into your nostril. The solution will run into your nose and then drain back out the nostril into the sink. Sometimes the water may run to the back of the nose and drain out the opposite nostril – that’s not a problem. It’s also okay if some of the water drains into the back of your mouth; just spit it out. Repeat the same steps to irrigate the other nostril the same way. Typically, you would use half the bottle for each side of the nose. Nasal irrigation may feel unusual the first time you try it, kind of like getting water in your nose when you jumped into a pool as a kid. But once you get the hang of it, it's very soothing.

 

Bulb Syringe: An alternative to the squeeze bottle for nasal irrigations is the bulb syringe, a common device used to clean newborn infants' noses (Figure). It can be purchased at most drugstores and medical supply stores for less than five dollars. A small ear syringe, used to flush wax from the ear canal, also works, but I prefer the nasal version because its larger size allows for more efficient irrigation and the tapered tip fits comfortably in the nostril.



Instead of the prepackaged salt that comes with squeeze bottles, you place a tablespoon of salt into an eight-ounce glass of lukewarm tap water.  You fill the bulb with the saltwater solution and irrigate each nostril while leaning over a sink in a similar manner to using the squeeze bottles. It's a good idea to wash the bulb weekly with soap and water to clean off any debris and excess salt that accumulates. You can also boil the bulb for a few minutes once a month, to clean the inside. With regular use and cleaning, eventually the bulb will start to crack. When this happens, it’s time to buy a new one.

 

Neti Pots: Neti pots are small cups that look like a genie's lamp, with a handle on one end and a spout on the other (Figure). The name comes from "jala neti," a centuries-old yoga practice in which these pots are used for nasal irrigation.

You fill the neti pot with saltwater and tilt your head sideways. While breathing gently through your mouth, you pour the water into the top nostril. The water flows through the nasal cavity and drains out the bottom nostril. Then you tilt your head the other way and repeat the procedure, pouring the saltwater through the other nostril.

Neti pots can be purchased in most local drugstores and are available in a variety of materials, including ceramic, stainless steel, or plastic. An advantage of the Neti pot is that it's more durable than a squeeze bottle or bulb syringe; as long as you boil it occasionally, you can use the same one for years. It is very effective for daily nasal hygiene and the clearing of thin mucus. The disadvantage of a neti pot is that it lacks the force of an irrigation bottle or bulb syringe, so it is not so efficient at clearing the thick, copious mucus that is often associated with a sinus infection. 

 
 
For a video demonstration of nasal irrigation techniques, visit www.sinusvideos.com
 

   

Medications for sinusitis; a stepwise approach

             Cold and Allergy Medications; There are five major categories of over-the-counter drugs relevant to nasal symptoms: decongestants, mucus-thinning agents, antihistamines, pain relievers, and cough suppressants.  Most of these medications are approved to treat symptoms of colds and allergies, not sinusitis, but because sinusitis sufferers often have similar symptoms – such as congestion and a runny nose – they can be helpful if you have sinusitis.


            Steroids: Steroids can be delivered to the nose in two ways: by spray or pill. Both forms are potent anti-inflammatory agents. Simply put, they reduce swelling. Steroids act by passing through a cell's membranes into its nucleus, stopping the process that causes inflammation at its source.

Nasal steroid sprays are a logical and common next step for many sinusitis patients whose symptoms do not respond to over-the-counter treatments. Spraying steroids directly into your nose delivers the steroid in relatively high concentration to the nasal membranes, where it can block inflammation from allergies and other causes. Steroid sprays may be taken for many months or years with minimal side effects in most people.

Although oral steroids (e.g., prednisone or methylprednisolone) are very effective at reducing nasal swelling and symptoms of sinusitis, they can have serious side effects, especially when taken for extended periods of time. Also, the effects of oral steroid are often only temporary, with nasal swelling returning once the steroids are stopped. For these reasons, oral steroids are usually prescribed sparingly for sinusitis.


            Antibiotics: Physicians prescribe hundreds of millions of dollars worth of antibiotics each year for people with sinusitis. These bacteria-slaying medications generally are effective. In most cases, antibiotics eliminate the infection-causing bacteria, allowing inflamed nasal mucous membranes to shrink and your sinuses to drain.

            Unfortunately, it's not always so straightforward. Antibiotics sometimes fail to do away with the offending bacteria or provide only temporary improvement, with a return of symptoms as soon as you stop taking the medication. Also, antibiotics can be expensive and they have side effects.

There are four major classes of antibiotics used to treat chronic sinusitis: penicillins, cephalosporins, macrolides, and quinolones, as well as a few other minor categories.  Most antibiotics are prescribed for a 10-day course, although patients typically note an improvement in their sinusitis symptoms within 48 hours after starting the medication.  If an infection fails to show signs of improvement after 10 days or if an infection goes away but comes back within a few weeks, your doctor has two options: having you take the first antibiotic again for a longer period of time (typically 21 days) or trying a different antibiotic that kills a larger variety of bacteria (what's known as a "broad-spectrum" antibiotic).

 

When all else fails: surgery for sinusitis

When to operate: As a rule of thumb, it's time to consider surgery if you have four or more sinus infections each year. If this is the case, you're spending a large percentage of your time suffering and recovering from infections, so surgery's benefits are likely to be tangible.

Another consideration is the duration of your infections. Over time, some people find that infections that formerly lasted a few days are now lasting several weeks because antibiotics are less effective. Surgery may still be advisable for someone who has only two or three infections a year if they last several weeks or months.

Realistic expectations. It's important to have realistic expectations of what the procedure is likely to accomplish. Bear in mind that for most patients, sinus surgery does not provide a complete cure. Some sinus infections will still occur, but the frequency and severity of infections will be reduced. If you've had five or six sinus infections each year, surgery often can reduce the number to two or three. Every cold won't turn into another case of sinusitis. And if the procedure is successful, infections that do occur will be of shorter duration; a briefer course of antibiotics will control your symptoms.

Benefits of surgery: Although it's important to have realistic expectations, I don't mean to downplay surgery's genuine benefits; it really does help. My colleagues at Harvard Medical School and I published a study in which we followed more than 100 patients who underwent surgery for sinusitis (3). They rated their symptoms, such as headache, congestion, and drainage, before surgery and afterwards at regular intervals for one year. They also reported on use of sinus medications and completed questionnaires about how sinusitis affected their quality of life. Overall, 82% of patients were found to have significant improvement following sinus surgery.

Another study we published focused exclusively on the economics of sinus surgery. We found that the cost of sinus medications – including prescription and over-the-counter remedies – averaged $1,220 per patient per year before surgery and $629 after surgery, a 48% reduction (4).

Because surgical techniques have continued to improve in the past decade and more sinus medications are now available, I suspect that both the 82% symptom improvement rate and 48% reduction in medication costs would be even greater if we conducted similar studies today.

The operation: Nowadays, most sinus surgery is performed under general anesthesia, so the patient will not remember anything or feel any discomfort during the procedure. The procedure is often referred to as Endoscopic Sinus Surgery, or ESS for short, because the surgeon passes a thin telescope called an endoscope into the nose. A miniature video camera is attached to the endoscope, so the surgeon can visualize the area of blockage within the nose and sinuses. A variety of specialized instruments are passed alongside the endoscope, such as tiny scalpels, curettes, forceps, and a suction device to remove blood and mucus. During ESS, the surgeon's goal is to remove any diseased tissue obstructing the sinuses and causing infections (5). Ideally, elimination of this obstructing tissue will allow the formerly blocked sinus passages to remain open permanently.

Specialized instruments. Today's surgeons have access to a variety of additional tools in the operating room. Whether or not a surgeon uses these devices is a matter of personal preference; it's possible to do effective sinus surgery with or without them.

·         

 

 

 

 

        Microdebriders: A microdebrider (also known as a microdissector or shaver) is a thin hollow tube with a rotating blade at one end and suction device at the other. The surgeon activates the blade with a foot pedal and shaves away tissue, which automatically gets suctioned down the tube. 

·        Image-guidance system: The same global positioning technology that directs drivers to their destinations and missiles to their targets is used to help surgeons guide their instruments through the sinus cavities with millimeter accuracy (5). These systems use either an infrared beam or an electromagnetic signal to track the position of the tip of the surgical instrument, which is depicted, on a 3-D video display of the patient’s sinus CT scan in the operating room (Figures).

For a video demonstration of live sinus surgery, visit www.sinusvideos.com

·       Balloon dilators. Within the past few years balloon catheters have been developed that can be used during surgery to widen obstructed sinus drainage passages, similar to the way balloons are used to dilate blocked coronary arteries in the heart. Because these devices are relatively new, there effectiveness over the long-term is not known.

Complications: Although technological advances have reduced the incidence of surgical complications, the element of risk can never be completely eliminated. Bleeding and infection are the most common complications from sinus surgery, occurring in about 5% of patients. Less common complications include impaired nasal breathing from excess scar tissue formation, loss of smell from injury to the nerves for olfaction, excessive tearing from injury to the tear duct which drains into the nose. Very rare but serious complications from sinus surgery include spinal fluid leak from a breach in the layer of bone separating the sinuses from the brain, decreased vision from injury to the eye or optic nerve, and stroke from injury to the brain or carotid artery which carries blood to the brain. Although these last complications sound frightening, it's important to realize that they are extremely rare. Your doctor will review all potential complications that apply to your surgery and answer any questions you may have.

 

Finding out more about sinusitis

There are several websites and professional organizations that provide free information about sinus disease, including the following:

This site has large collection of videos for healthcare providers and their patients who suffer from sinusitis. Many of the narrated videos show live sinus surgeries. There is a collection of videos specifically for patients which includes techniques for nasal irrigation. 

http://www.entnet.org/healthinfo/

Produced by the American Academy of Otolaryngology, this site provides useful information about a host of ENT disorders, including sinusitis.


http://www.american-rhinologic.org/patientinfo.phtml

Hosted by the American Rhinologic Society, a group of physicians who specialize in the treatment of sinusitis, this site provides detailed information about a variety of sinus-related topics.


http://www.nlm.nih.gov/medlineplus/sinusitis.html

A government-sponsored website which contains a number of links to other sinusitis-related sites and information.


Additional information on this subject from the author, including lifestyle, diet, and alterative therapies for sinusitis, can be found in The Harvard Medical School Guide to Healing Your Sinuses by Dr. Ralph Metson.

 

References


1. Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngology-Head and Neck Surgery 2007;137:365-377.
2. Lethbridge-Cejku M, Rose D, Vickerie J. Summary health statistics for U.S. adults: National Health Interview Survey, 2004. National Center for Health Statistics, Vital Health Stat 2006;10:19-22.
3. Metson R, Gliklich RE. Clinical outcomes in patents with chronic sinusitis. Laryngoscope 2000;110 (Suppl. 94):24-28.
4. Gliklich, RE, Metson R. Economic implications of chronic sinusitis. Otolaryngol Head Neck Surg 1998; 118:344-9.
5. Kingdom TT, Orlandi RR. Image-guided surgery of the sinuses: current technology and applications. Otolaryngol Clin N Am 2004; 37:381-400.