An in-depth report on the causes, diagnosis, treatment, and prevention of sinusitis.
Nasal congestion; Rhinosinusitis
Sinusitis is an inflammation or infection of the sinuses, the air-filled chambers in the skull that are located around the nose. Symptoms of sinusitis include thick nasal discharge, facial pain or pressure, fever, and reduced sense of smell. Depending on how long these symptoms last, sinusitis is classified as acute, subacute, chronic, or recurrent. Viruses are the most common cause of acute sinusitis, but bacteria are responsible for most of the serious cases.
Non-Drug Treatment of Sinusitis
Home remedies such as saline (salt) washes or sprays are helpful for removing mucus and relieving congestion. Steam inhalation is also beneficial. Patients with sinusitis should drink plenty of fluids to avoid dehydration. Water, which helps lubricate the mucous membranes, is the best fluid to drink.
Drug Treatment of Sinusitis
Medication depends on the type of sinusitis and its cause. Non-prescription pain relievers such as acetaminophen and ibuprofen can help mild-to-moderate pain symptoms. Decongestants may help relieve congestion, but they do not cure sinusitis. Antihistamines can dry the mucus and sometimes worsen the condition. Cough or cold medication is not recommended for children younger than age 4 years.
Because many cases of acute sinusitis resolve within two weeks with non-prescription treatments and home remedies, doctors generally wait at least 7 - 14 days before prescribing an antibiotic.
For chronic sinusitis, antibiotics and nasal corticosteroids are the main treatments, but this condition is difficult to treat and does not always respond to these drugs. Other drugs may also be prescribed. If drugs are ineffective, some patients with chronic sinusitis may need surgery.
New Guidelines for Managing Acute Bacterial Sinusitis
In 2012, the Infectious Diseases Society of America (IDSA) released updated guidelines for recognizing and treating acute bacterial sinusitis. Bacterial sinusitis can be difficult to distinguish from sinusitis caused by a viral infection. It is important to know the difference because viral infections do not respond to antibiotic treatment. The IDSA emphasizes that bacteria cause only 2 – 10% of acute sinusitis cases. Viruses, such as those from the common cold, are the main cause of acute sinusitis. Most cases of acute sinusitis resolve on their own within a few weeks.
The IDSA’s guidelines recommend diagnosing a bacterial rather than viral cause based on how symptoms start, how they progress, and how long they last. When an antibiotic is prescribed, the IDSA recommends amoxicillin-clavulanate as a first choice. Many types of antibiotics formerly used for acute bacterial sinusitis are no longer effective or recommended.
Sinusitis (also called rhinosinusitis) is inflammation of the mucous lining of the nasal passages and sinuses. The sinuses are air-filled chambers in the skull (behind the forehead, nasal bones, cheeks, and eyes) that are lined with mucus membranes.
Four pairs of sinuses, known as the paranasal air sinuses. connect to the nasal passages (the two airways running through the nose):
- Frontal sinuses (behind the forehead)
- Maxillary sinuses (behind the cheekbones)
- Ethmoid sinuses (behind the nose)
- Sphenoid sinuses (behind the eyes)
Sinusitis occurs if obstruction or congestion cause the paranasal sinus openings to become blocked. When the sinus openings become blocked or too much mucus builds up in the chambers, bacteria and other germs can grow more easily, leading to infection and inflammation.
Sinusitis is classified as acute, subacute, or chronic, or recurrent. The classification is based on how long symptoms last:
Acute: Less than 4 weeks
Subacute: 4 - 12 weeks
Chronic: 12 weeks or longer
Recurrent: 3 or more acute episodes in 1 year
Acute sinusitis can be caused by viral, bacterial, or fungal infections. Allergans and environmental irritants are other possible causes. In most cases, acute sinusitis is caused by an upper respiratory tract viral infection, such as the common cold, and usually resolves on its own.
Chronic sinusitis refers to long-term swelling and inflammation of the sinuses. Chronic sinusitis can result from recurring episodes of acute sinusitis or it can be caused by other health conditions like asthma and allergic rhinitis, immune disorders, or structural abnormalities in the nose like deviated septum or nasal polyps.
Viral, Bacterial, and Fungal Infections
Viruses. Viruses cause 90 – 98% of acute sinusitis cases. The typical process leading to acute sinusitis starts with the common cold virus. Most people with colds have inflamed sinuses. These inflammations are typically brief and mild and very few people with colds develop true sinusitis. Instead, colds and flu set the stage by causing inflammation and congestion in the nasal passages (called rhinitis), leading to obstruction in the sinuses. Rhinitis always accompanies sinusitis, which is why sinusitis is also called rhinosinusitis.
Bacteria. A small percentage of cases of acute sinusitis, and possibly chronic sinusitis, are caused by bacteria. Bacteria are normally present in the nasal passages and throat and are normally harmless. However, when a cold or other viral upper respiratory infection blocks the nasal passage and prevents the sinuses from draining, bacteria can multiply within the mucus lining of the sinuses, causing sinusitis. Streptococcus pneumonia. Haemophilius influenzae. and Moraxella catarrhalis (a common cause of childhood illnesses) are the bacteria most often linked to acute sinusitis. These bacteria plus other strains, such as Staphylococcus aureus, are also associated with chronic sinusitis. (The role of bacteria in chronic sinusitis is still being debated.) Bacterial sinusitis usually causes more severe symptoms and lasts longer than viral sinusitis.
Fungi. An allergic reaction to fungi is a cause of some cases of chronic rhinosinusitis. Aspergillus is the most common fungus associated with sinusitis. Fungal infections tend to occur in people with sinusitis who also have diabetes, leukemia, AIDS, or other conditions that impair the immune system. Fungal infections can also occur in patients with healthy immune systems, but they are far less common.
Allergies, Asthma, and Immune Response
Allergies, asthma, and sinusitis often overlap. Seasonal allergic rhinitis and other allergies that cause mucus blockage may predispose people to develop sinusitis. Many of the immune factors observed in people with chronic sinusitis resemble those that appear in allergic rhinitis, suggesting that in some people sinusitis is due to an allergic response. Asthma is also strongly associated with sinusitis and many people have both conditions. Some studies suggest that sinusitis may worsen asthma symptoms.
Chronic sinusitis and recurrent acute sinusitis are also assocated with disorders that weaken the immune system or produce inflammation in the airways or persistent thickened stagnant mucus. These conditions include diabetes, AIDS, cystic fibrosis, Kartagener's syndrome, and Wegener's granulomatosis.
Structural Abnormalities of the Nasal Passage
Structural abnormalities in the nose can cause blockage and thereby increase the risk for chronic sinusitis. Some abnormalities include:
Polyps (small benign growths) in the nasal passage block mucous drainage and restrict airflow. Polyps themselves may result from previous sinus infections that caused overgrowth of the nasal membrane.
Enlarged adenoids can lead to sinusitis.
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Adenoids are masses of tissue located high on the posterior wall of the pharynx. They are made up of lymphatic tissue, which trap and destroy pathogens in the air that enter the nasopharynx.
- Cleft palate
- Deviated septum (a common structural abnormality in which the septum, the center section of the nose, is shifted to one side, usually the left)
Sinusitis is one of the most common diseases in the United States, affecting about 30 million Americans each year.
Young Children and Sinusitis
Before the immune system matures, all infants are susceptible to
respiratory infections. Babies catch a cold about every 1 - 2 months. Young children are prone to colds and may have 8 - 12 bouts every year. Smaller nasal and sinus passages make children more vulnerable to upper respiratory tract infections than older children and adults. Ear infections such as otitis media are also associated with sinusitis. Nevertheless, true sinusitis is very rare in children under 9 years of age.
The Elderly and Sinusitis
The elderly are at specific risk for sinusitis. Their nasal passages tend to dry out with age. In addition, the cartilage supporting the nasal passages weakens, causing airflow changes. They also have diminished cough and gag reflexes and weakened immune systems and are at greater risk for serious respiratory infections than are young and middle-aged adults.
People with Asthma or Allergies
People with asthma or allergies are at higher risk for non-infectious inflammation in the sinuses. The risk for sinusitis is higher in patients with severe asthma. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter's, or ASA, triad) are at very high risk for chronic or recurrent acute sinusitis.
Some hospitalized patients are at higher risk for sinusitis, particularly those with:
- Head injuries
- Conditions requiring insertion of tubes through the nose
- Breathing aided by mechanical ventilators
- Weakened immune system (immunocompromised)
Other Medical Conditions Affecting the Sinuses
A number of medical conditions put people at risk for chronic sinusitis. They include:
- Gastroesophageal reflux disease
- Nasal polyps or septal deviation
- AIDS and other disorders of the immune system
- Oral or intravenous steroid treatment
- Hypothyroidism (underactive thyroid gland) causes congestion that clears up when the condition is treated
- Cystic fibrosis is a genetic disorder in which the mucus is very thick and builds up
- Kartagener's syndrome, a genetic disorder that impairs function of cilia, the hair-like structures that normally move mucus through the respiratory tract
Miscellaneous Risk Factors
Dental Problems. Bacteria associated with infections from dental problems or procedures can trigger cases of maxillary sinusitis.
Changes in Atmospheric Pressure. People who experience changes in atmospheric pressure, such as while flying, climbing to high altitudes, or swimming, risk sinus blockage and therefore an increased risk of developing sinusitis. (Swimming increases the risk for sinusitis for other reasons, as well.)
Cigarette Smoke and Other Air Pollutants. Air pollution from industrial chemicals, cigarette smoke, or other pollutants can damage the cilia responsible for moving mucus through the sinuses. Whether air pollution is an important cause of sinusitis and, if so, which pollutants are critical factors, is still not clear. Cigarette smoke, for example, poses a small but increased risk for sinusitis in adults. Second-hand smoke does not appear to have any significant effect on adult sinuses, although it may pose a risk for sinusitis in children.
Bacterial sinusitis is nearly always harmless (although uncomfortable and sometimes even very painful). If an episode becomes severe, antibiotics generally eliminate further problems. In rare cases, however, sinusitis can be very serious.
Osteomyelitis. Adolescent males with acute frontal sinusitis are at particular risk for severe problems. One important complication is infection of the bones (osteomyelitis) of the forehead and other facial bones. In such cases, the patient usually experiences headache, fever, and a soft swelling over the bone known as Pott's puffy tumor.
Infection of the Eye Socket. Infection of the eye socket, or orbital infection, which causes swelling and subsequent drooping of the eyelid, is a rare but serious complication of ethmoid sinusitis. In these cases, the patient loses movement in the eye, and pressure on the optic nerve can lead to vision loss, which is sometimes permanent. Fever and severe illness are usually present.
Blood Clot. Blood clots are another danger, although rare, from ethmoid or frontal sinusitis. If a blood clot forms in the sinus area around the front and top of the face, symptoms are similar to orbital infection. In addition, the pupil may be fixed and dilated. Although symptoms usually begin on one side of the head, the process usually spreads to both sides.
Brain Infection. The most dangerous complication of sinusitis, particularly frontal and sphenoid sinusitis, is the spread of infection by anaerobic bacteria to the brain, either through the bones or blood vessels. Abscesses, meningitis, and other life-threatening conditions may result. In such cases, the patient may experience mild personality changes, headache, altered consciousness, visual problems, and, finally, seizures, coma, and death.
Increased Asthma Severity
The relationship between sinusitis and asthma is unclear. A number of theories have been proposed for a causal or shared association between sinusitis and asthma. Successful treatment of both allergic rhinitis and chronic sinusitis in children who also have asthma may reduce symptoms of asthma. It is particularly important to treat any coexisting bacterial sinusitis in people with asthma. Patients might not respond to asthma treatments unless the infection is cleared up first.
Effects on Quality of Life
Pain, fatigue, and other symptoms of chronic sinusitis can have significant effects on the quality of life. This condition can cause emotional distress, impair normal activity, and reduce attendance at work or school. According to the American Academy of Allergy, Asthma, and Immunology, the average patient with sinusitis misses about 4 work days a year, and sinusitis is one of the top 10 medical conditions that most adversely affect American employers.
General Symptoms of Acute Sinusitis
Sinus symptoms are very common during a cold or the flu, but in most cases they are due to the effects of the infecting virus and resolve when the infection does. General symptoms of acute sinusitis (both viral and bacterial) include:
- Nasal congestion or discharge
- Facial pain or pressure
- Cough or scratchy throat
- Diminished or absent sense of smell
- Other symptoms may include ear pain or pressure, dental pain, bad breath, fatigue
Acute Bacterial Sinusitis Symptoms
It is important to differentiate between inflamed sinuses associated with cold or flu virus and sinusitis caused by bacteria but it can be difficult to do so. In general, with viral sinusitis symptoms usually last 7 - 10 days and then improve. Acute bacterial sinusitis, in contrast to viral sinusitis, usually takes one of the following three paths:
- Persistent symptoms that last more than 10 days and do not improve. Nasal discharge either clear or colored and daytime cough are common.
- Severe symptoms, with by a high fever (at least 102 degrees) and thick, green nasal discharge or facial pain that last for at least 3 - 4 days starting from the beginning of the illness. (With viral sinusitis, fever usually disappears within the first day or two and green discharge does not appear until after the fourth day.)
- Worsening symptoms following a typical viral upper respiratory infection. These symptoms appear to improve but are then followed suddenly by another set of worsening symptoms (return of fever, cough, severe headache or increase in nasal discharge) after 5 - 6 days (“double-sickening”)
If symptoms suggest acute bacterial sinusitis, antibiotic treatment is warranted. Bacterial sinusitis is not as common as viral sinusitis, but bacteria are responsible for most of the serious cases of sinusitis.
In children, the most common signs and symptoms of bacterial sinusitis are cough, nasal discharge, and fever. Bad breath is also a common symptom in young children. Headache and facial pain are rare.
Chronic Sinusitis Symptoms
With chronic sinusitis:
Any of the sinusitis symptoms listed previously may be present
Symptoms are more vague and generalized than acute sinusitis
Symptoms Indicating Medical Emergency