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Sinusitis

What is Sinusitis?

Sinusitis means your sinuses are infected or inflamed. Health experts usually divide sinusitis cases into:

Acute cases, which last for 4 weeks or less
Subacute cases, which last 4 to 12 weeks
Chronic cases, which last more than 12 weeks and can continue for months or even years
Recurrent cases, which involve several acute attacks within a year

Symptoms of Sinusitis

One of the most common symptoms of sinusitis is pain, and the location depends on which sinus is affected.

If you have a pain in your forehead over the frontal sinuses when you are touched, your frontal sinuses may be inflamed.
If your upper jaw and teeth ache, and your cheeks become tender to the touch, you may have an infection in the maxillary sinuses.
If you have swelling of the eyelids and tissues around your eyes, and pain between your eyes, you may have inflammation of the ethmoid sinuses that are near the tear ducts in the corner of your eyes. Ethmoid inflammation also can cause a stuffy nose, a loss of smell, and tenderness when you touch the sides of your nose.
If you have earaches, neck pain, and deep achiness at the top of your head, you may have infection in the sphenoid sinuses, although these sinuses are less frequently affected.

Most people with sinusitis have pain or tenderness in several locations, and their symptoms usually do not clearly indicate which sinuses are inflamed.

In addition to the pain, people with sinusitis frequently have thick nasal secretions that are yellow, green, or blood-tinged. Sometimes these secretions, referred to as post-nasal drip, drain in the back of the throat and are difficult to get rid of. Also, acute and chronic sinusitis are strongly associated with nasal symptoms such as a stuffy nose, as well as with a general feeling of fullness over the entire face.

Less common symptoms of sinusitis can include

Tiredness
Decreased sense of smell
Cough that may be more severe at night
Sore throat
Bad breath
Fever

On rare occasions, acute sinusitis can result in brain infection and other serious complications if left untreated.

Causes of Acute Sinusitis

Most cases of acute sinusitis start with a common cold, which is caused by a virus. Colds can inflame your sinuses and cause symptoms of sinusitis. Both the cold and the sinus inflammation usually go away without treatment within 2 weeks. If the inflammation produced by the cold leads to a bacterial infection, however, then this infection is what health experts call acute sinusitis.

The inflammation caused by the cold results in swelling of the mucous membranes (linings) of your sinuses, and this can lead to air and mucus becoming trapped behind the narrowed openings of the sinuses. When mucus stays inside your sinuses and is unable to drain into your nose, it can become the source of nutrients (material that gives nourishment) for bacteria.

Most healthy people harbor bacteria, such as Streptococcus pneumoniae and Haemophilus influenzae, in the nose and throat, and the bacteria cause no problems. But when you have a cold, you tend to sniff or to blow your nose, and these actions cause pressure changes that can send bacteria inside the sinuses. If your sinuses then stop draining properly, bacteria that may have been living harmlessly in your nose or throat can begin to multiply in your sinuses, causing acute sinusitis.

People who suffer from allergies that affect the nose (like pollen allergy, also called hay fever), as well as people who may have chronic nasal symptoms not caused by allergy, are also prone to develop episodes of acute sinusitis. The chronic nasal problems cause the nasal membranes to swell, and the sinus passages become blocked in a manner similar to that described above for the common cold. The normally harmless bacteria in the nose and throat again lead to acute sinusitis.

Rarely, fungal infections can cause acute sinusitis. Although fungi are abundant in the environment, they usually are harmless to healthy people because the human body has a natural resistance to fungus. However, in people whose immune system is not functioning properly, fungus, such as Aspergillus, can cause acute sinusitis. (Aspergillus is commonly found growing on dead leaves, stored grain, compost piles, or in other decaying vegetation.)

In general, people who have reduced immune function (such as those with primary immune deficiency disease or HIV infection) or abnormalities in mucus secretion or mucus movement (such as those with cystic fibrosis) are more likely to suffer from sinusitis.

Chronic Sinusitis

In chronic sinusitis, the membranes of both the paranasal sinuses and the nose are thickened because they are constantly inflamed. Most experts now use the term "chronic rhinosinusitis" to describe this condition, and they also recommend that the condition be divided into rhinosinusitis with or without nasal polyps. Nasal polyps are grape-like growths of the sinus membranes that protrude into the sinuses or into the nasal passages. Polyps make it even more difficult for the sinuses to drain and for air to pass through the nose.

The causes of chronic sinusitis are largely unknown. The condition often occurs in people with asthma, the majority of whom have allergies. It is possible that constant exposure to inhaled allergens that are present year-round, such as house dust mites, pets, mold (a kind of fungus), and cockroaches cause chronic inflammation of the nose and the sinuses.

An allergic reaction to certain fungi may be responsible for at least some cases of chronic sinusitis; this condition is called "allergic fungal sinusitis." At least half of all people with chronic rhinosinusitis do not have allergies, however.

Most health experts believe that chronic rhinosinusitis is not an infectious disease (like acute sinusitis). If you suffer frequent episodes of acute sinusitis, however, you may be prone to develop chronic rhinosinusitis. Other causes of chronic rhinosinusitis may be an immune deficiency disorder (for example, primary immune deficiency disease or HIV infection) or an abnormality in the quality of mucus produced by the respiratory system (cystic fibrosis).

Another group of people who may develop chronic sinusitis are those with significant anatomic (structure) variations inside the nose, such as a deviated septum, that lead to blockage of mucus.

Diagnosis

Because your nose can get stuffy when you have a condition like the common cold, you may confuse simple nasal congestion with sinusitis. A cold, however, usually lasts about 7 to 14 days and goes away without treatment. Acute sinusitis often lasts longer and typically causes more symptoms than a cold.

Your healthcare provider can usually diagnose acute sinusitis by noting your symptoms and doing a physical examination, which includes examining your nasal tissues. If your symptoms are vague or persist, your healthcare provider may order a computed tomography (CT) scan, a form of X-ray, to confirm that you have sinusitis.

Laboratory tests your healthcare provider may use to diagnose chronic sinusitis include

Blood tests to rule out conditions associated with sinusitis, like an immune deficiency disorder
A sweat test or a blood test to rule out cystic fibrosis
Tests on the material that is inside your sinuses to detect bacterial or fungal infection
Biopsy of the membranes (linings) of the nose or sinuses to determine the health of the cells lining these cavities

Conservative Treatment

After diagnosing sinusitis and identifying a possible cause, your healthcare provider can suggest various treatments.

Acute Sinusitis

If you have acute sinusitis, your healthcare provider may recommend

Antibiotics to control a bacterial infection, if present
Pain relievers to reduce any pain
Decongestants to reduce congestion

Even if you have acute sinusitis, your provider may choose not to use an antibiotic because many cases of acute sinusitis will end on their own. But if you do not feel better after a few days you should contact your provider again.

You should use over-the-counter or prescription decongestant nose drops and sprays only for few days. If you use these medicines for longer periods, they can lead to even more congestion and swelling of your nasal passages.

If you have an allergic disease along with sinusitis, you may also need medicine to control allergies. This may include a nasal steroid spray that reduces the swelling around the sinus passages and allows the sinuses to drain. If you already have asthma and then get sinusitis, your asthma may worsen. You should stay in close touch with your healthcare provider to modify your asthma treatment if needed.

Chronic Sinusitis

Healthcare providers often find it difficult to treat chronic sinusitis successfully. The two main forms of treatment that are used, nasal steroid sprays and long courses of oral antibiotics, alone or in combination, have not been rigorously tested in chronic sinusitis. Scientists need to do more research to determine what the best treatment is.

Many healthcare providers also recommend using saline (saltwater) washes or sprays in the nose to help remove thick secretions and allow the sinuses to drain.

If you have severe chronic sinusitis, your healthcare provider may prescribe oral steroids, such as prednisone. Because oral steroids are powerful medicines and can have significant side effects, you should take them only when other medicines have not worked.

Surgery

When medicine fails, surgery may be the only alternative for treating chronic sinusitis. The goal of surgery is to improve sinus drainage and reduce blockage of the nasal passages. During surgery, which is usually done through the nose, the surgeon

Enlarges the natural opening of the sinuses
Removes any polyps
Corrects significant anatomic deformities that contribute to the obstruction

Functional Endoscopic Sinus Surgery or FESS is minimally invasive corrective surgery for chronic sinusitis. FESS is performed through the nose using an endoscope, a long, thin, tube which has a light and a video camera on the end. Images from the endoscope are magnified and projected on a TV screen enabling your surgeon to visualize internal structures in great detail.

Computer assisted endoscopic sinus surgery, also referred to as image-guided surgery (IGS), may be used to perform your sinus surgery. Image guided surgery systems utilize CT images of the patient's anatomy to track the position of special surgical instruments during the procedure and assist the surgeon with precise targeting of internal structures. IGS enables the surgeon to perform a more thorough and precise surgery and has significantly improved the safety and effectiveness of the procedure.

Endoscopic Sinus Surgery offers many benefits over the older surgery techniques of "open surgery" where an outside incision was required. Advantages of endoscopic surgery include:

Minimal soft tissue trauma
Less pain
Faster healing time
Lower infection rate
Less scarring
Usually performed as outpatient day surgery

Surgical Treatment

Functional Endoscopic Sinus Surgery (FESS) is performed under sterile conditions in the operating room with the patient under general anesthesia or local anesthesia with sedation. This operation is usually performed as outpatient surgery enabling the patient to go home the same day.

Depending on your particular situation, your surgeon may perform additional procedures to offer you the best possible outcome for your situation. These may include the following:

Septoplasty: This is corrective surgery for a deviated nasal septum. The septum is the bony cartilage which divides the nose into two chambers. A deviated septum can interfere with breathing and predispose to sinus infections.
Ethmoidectomy: This is surgery to remove diseased tissue and bony partitions in the ethmoid sinuses.
Inferior Turbinoplasty: This surgery involves revision to the inferior choncha or turbinate bone. The turbinates are responsible for warming, humidifying, and filtering inspired air and can cause blockage of the nasal passages.
Your surgeon will perform endoscopic sinus surgery through the nasal passages with no external incision.
The nasal cavity is topically decongested and anesthetized with an injection.
An endoscope, a tiny, telescope with a light and lens on the end is advanced into the nasal passageway and the image magnified on a television screen.
In computer assisted surgery, special instruments are used that are connected to a computer system where they are tracked according to the patients' anatomy based on pre-operative CT scans.
Using tiny bone cutting instruments and debriders, your surgeon will enlarge the sinus openings and remove any abnormalities blocking the sinuses such as polyps.
If septoplasty is indicated for a deviated septum, an incision is made to the nasal septum inside the nose through one of the nostrils.
The mucous membrane is lifted away from the septum
The nasal septum is then reshaped into proper position straightening the septum. Occasionally severely deviated portions of the septum are completely removed or repaired and replaced inside the nose.
Mucous membranes are then returned to their normal position covering the nasal septum.
For an ethmoidectomy procedure, your surgeon will advance the endoscope into the ethmoid sinuses.
Special instruments are used to remove diseased tissue and bony partitions to improve airway flow and decrease inflammation.
If the inferior turbinates are large and swollen your surgeon will perform an inferior turbinoplasty.
Your surgeon will make an incision in the mucosal lining of the inferior turbinate.
The underlying turbinate bone is carefully removed as well as any diseased tissue.
Dissolvable sutures, splints and/or packing are placed inside the nose to minimize postoperative bleeding and a small gauze dressing is taped under the nose.

Post Operative Guidelines

Your surgeon will give you guidelines to follow depending on the type of surgery performed and the surgeon's preference.

Common post-operative guidelines include:

You will need someone to drive you home after surgery due to the drowsy effects of the anesthesia.
Your nostrils will be packed with sterile cotton gauze and will usually be removed before being discharged to home or at your follow up appointment the next day. The gauze dressing under the nose will need to be changed when wet and may be kept in place for a few days.
You will be given pain medications to manage your pain. Do not use aspirin or ibuprofen products as these can cause bleeding to occur.
Take all medications given to you as prescribed. These may include antibiotics, decongestants, or steroids. It is important to take your nasal sprays as prescribed to help prevent polyps from growing back.
Do not drink alcohol while taking antibiotics and pain medications.
Get plenty of rest. You should avoid strenuous activity as well as bending and lifting for 1-2 weeks after surgery as this may cause bleeding.
Sleep with your head elevated on extra pillows.
Sneeze with your mouth open so as not to dislodge the nasal packing.
Do not smoke as smoking delays healing and increases your risk of developing complications.

Risks and Complications

As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
It is important that you are informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to sinus surgery.

Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

Allergic reactions to medications
Blood loss requiring transfusion with its low risk of disease transmission
Heart attacks, strokes, kidney failure, pneumonia, bladder infections
Complications from nerve blocks such as infection or nerve damage
Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Complications are rare after sinus surgery, but unexpected events can follow any operation. Your surgeon feels that you should be aware of complications that may take place so that your decision to proceed with this operation is taken with all relevant information available to you.

Possible complications following sinus surgery can include the following:

Bleeding: Significant bleeding is uncommon. Report any abnormal bleeding to your surgeon.
Infection: Report fever of 38.5C or 101.0F or higher. Report foul smelling, greenish yellow nasal drainage as well as increasing pain or unresolved vomiting to your surgeon. Antibiotics will be prescribed to treat the infection.
Numbness: Numbness to the nose tip and upper teeth usually resolves in a few months but very rarely can persist.
Meningitis: Although extremely rare, a hole can occur between the sinuses and the brain and lead to leakage of CSF, cerebrospinal fluid. This can lead to a serious infection called Meningitis. If you have nasal drainage that looks like water it may be CSF and you should notify your surgeon immediately.
Symptoms recur: Most people have fewer symptoms and better quality of life after sinus surgery. In a substantial number of people, however, problems can recur after surgery, sometimes even after a short period of time.

Risk factors that can negatively affect adequate healing after any surgery include: