Sinusitis is inflammation of the lining (mucosa) of the sinuses. The sinuses are located in the forehead), between the eyes, behind the cheeks, and further back in the center of the head. Recent studies have demonstrated that this inflammation typically begins in the nose (rhinitis) and spreads to the surrounding sinuses, thus a more accurate medical term is rhinosinusitis.
The time course of the inflammation determines whether rhinosinusitis is acute (less than 4 weeks), subacute (4-12 weeks), or chronic (more than 12 weeks). Recurrent acute sinusitis is frequent bouts of sinus infections that resolve with medications, but recur soon after finishing medications. Acute exacerbations of chronic sinusitis occur when a flare up occurs in addition to a patient’s baseline chronic symptoms.
Sinusitis is one of the most common chronic illnesses in the US, afflicting over 15% of the population. It seems to be more common in women, and certain geographic areas (such as the Southeast) have a higher incidence of sinusitis. Sinusitis resulted in 12 million visits to doctor’s offices in 2013. The prevalence of sinusitis has soared in the last 1-2 decades, possibly due to increased pollution or other environmental factors.
The underlying causes/mechanisms of chronic sinusitis are not completely understood. One of the central events is swelling of the sinus lining that leads to obstruction of the sinus openings. This leads to retained secretions in the sinuses and the potential for subsequent bacterial infection.
Polyps blocking left nasal cavity.
It is currently thought that certain individuals may have a hyperactive or “revved up” immune system. This predisposes them to have significant inflammation in the sinus lining triggered by certain environmental factors. This can be thought of as “asthma of the nose.” When patients are exposed to these environmental “triggers” a flare-up may occur and patients can experience significant congestion, drainage, and swelling in their mucosa. This can result in facial pain/pressure, headache, and fatigue when the sinuses are obstructed.
The external triggers differ for each individual, but may include environmental allergies (pollens, trees, dust, molds, etc.), viral, bacterial, or fungal infections, or even pollution or tobacco smoke. Once a susceptible patient is exposed to an external trigger, a cycle of inflammation begins. Often the resultant swelling and congestion leads to a secondary bacterial infection that further exacerbates the inflammation. Severe, prolonged inflammation can result in nasal polyp formation (see picture on right).
Other causes of sinus obstruction can include trauma or previous surgery. Scarring from prior sinus surgery may actually lead to blockage of the sinuses. When this happens, a detailed evaluation is needed by a surgeon with extensive experience in revision sinus surgery, as repeated surgery may be needed.
Less common causes of sinusitis include diseases such as cystic fibrosis, Wegener’s granulomatosis, sarcoidosis, and immunodeficiency. These are highly complex cases and usually require the care of a sinus specialist.
The diagnosis of sinusitis is based primarily on clinical symptoms and physical exam. Many of the symptoms of sinusitis may be seen in other conditions, making it essential that an accurate diagnosis is made. Recent guidelines have defined sinusitis as the presence of two or more symptoms. One of those symptoms should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip) and can also include facial pain/pressure or reduction or loss of smell.
Thick mucus drainage in right nasal cavity.
Fever or pain alone without other symptoms does not typically suggest sinusitis. The diagnosis and treatment of each patient must be individualized depending upon the specifics of their case. A CT scan (CAT scan) or X-ray are not usually obtained in order to make the diagnosis of sinusitis, unless there is concern for a potential complication.
In addition to taking a thorough history, ENT physicians are able to examine the lining of the nose/sinuses with a small nasal telescope. This painless procedure greatly enhances our ability to evaluate and treat patients with sinus problems. In addition to looking at the condition of the nasal lining, we can obtain very specific bacterial culture swabs if needed.
Sinusitis is a very common disease that is treated by a variety of physicians. Most patients begin by seeing their primary care providers (internists, pediatricians, family practice doctors, or physician assistants/nurse practitioners). Patients with significant asthma may see a pulmonologist or allergist. Others are often referred to ear, nose, and throat (ENT) doctors (also known as otolaryngologists). ENT physicians are able to provide both comprehensive medical and surgical treatments for sinusitis. ENT surgeons who subspecialize have completed fellowships of at least one year and focus exclusively upon one area. Sinus specialists are called rhinologists and MUSC has two fellowship-trained rhinologists.
While small sinuses in the maxillary (cheek) and ethmoid (between the eyes) regions are present at birth, the sinuses in children are not fully developed until their teenage years or early 20s. Unfortunately, children can still suffer from sinusitis, and it may be more difficult to diagnose in children. Due to their immature immune systems, children usually get 6-8 viral infections each year. While some of the symptoms are similar to adults with sinusitis, children may suffer more often from cough, irritability, and swelling around the eyes. Treatment of chronic sinusitis in children is similar to that of adults, beginning with reducing exposure to known environmental allergies and irritants (tobacco smoke, daycare, acid reflux) and progressing to the use of medications. Fortunately, children respond to medical therapy even better than adults with chronic sinusitis. In those rare cases where surgery is needed, an adenoidectomy is often successful as an initial approach, especially in children younger than 6 years old. This removes enlarged tissue in the back of the nose that can cause many of the symptoms of chronic sinusitis. FESS is reserved for the most refractory cases.
Polyps are non-cancerous, grape-like growths that can occur in the nose or sinuses. They are unrelated to polyps that may occur elsewhere in the body (colon or bladder). While the exact cause is unknown, polyps represent the body’s response during an extremely vigorous inflammatory response. They often occur in patients with asthma or allergies. Patients with polyps can suffer from nasal obstruction, decrease in taste or smell and other symptoms of chronic sinusitis. The best medication for treating polyps is oral or topical steroids. These medications can reduce or stabilize the size of the polyps. Unfortunately, once the oral steroids are stopped, the polyps often recur. Surgery (FESS) can be used to remove polyps, but when used alone, it also may be a temporary solution. The best results are generally seen with surgery to remove the bulk of the obstructing polyps and then daily steroid irrigations. Our center has a number of clinical trials investigating novel methods of delivering steroid to the sinus cavity (link). Intermittent bursts of oral steroids after surgery may also be used to minimize the chances for recurrence. Patients with polyps and asthma will usually have better control of their asthma once their polyps and chronic sinusitis are adequately managed.
Allergic fungal rhinosinusitis (AFRS) is common in the south. Patients are generally younger and may have more severe erosion of the bone around their eyes or up towards their brain. This type of nasal polyposis actually responds quite well to complete surgery and steroid irrigations. Unfortunately immunotherapy alone or anti-fungal medications have been of limited benefit.
Aspirin exacerbated respiratory disease (AERD), aspirin triad or Samter’s triad are all names for patients who have polyps and asthma that is exacerbated when they take aspirin or other non-steroidal medications, such as ibuprofen. These patients improve most often with surgery, postoperative steroid irrigations and consideration of aspirin desensitization. Aspirin desensitization is typically done only at select centers.
Patients can still have significant sinus inflammation and mucosal thickening without developing obvious nasal polyps. These patients often have diffuse inflammation on both sides of their nose, but this type of sinusitis is not associated with asthma and allergies as often as sinusitis with nasal polyps. Treatment does not rely as heavily upon steroids and instead may focus more upon antibiotics.
Other causes for sinusitis without nasal polyps should be looked for, such as dental infections that spread to the sinuses or isolated fungus balls. Another form of chronic sinusitis without nasal polyps is mucoceles. This occurs when the opening to a sinus is blocked. Mucus production continues behind this blockage and the sinus expands, similar to a water balloon. The prognosis for most of these isolated forms of sinusitis is quite good and the surgical cure rate is high.
Most patients with cystic fibrosis (CF) have involvement of both the upper and lower airway. Mucus is extremely viscous and build up of this thick mucus permits bacterial infections with Pseudomonas and/or Staph Aureus most often. Indications for surgery are typically severe sinus symptoms or sinus infections that lead to impaired lung function. Initial therapies consist of saline rinses, possibly containing antibiotics, oral or IV antibiotics and at times, steroids. Sinus surgery is not curative, but creates large openings that permit irrigations to get into the sinuses for cleaning as well as delivery of medications. CF patients require a multi-disciplinary team to take care of lung, gastrointestinal and ENT problems.
Patients are treated with medications first, in an attempt to clear the infection and reduce the inflammation. This treatment may include antibiotics (often guided by bacterial cultures), oral/topical steroids, mucus thinners, and saline nasal irrigations. If allergies are present, anti-histamines and/or allergy shots may be added.
Nearly all cases of acute sinusitis and the vast majority of patients with chronic sinusitis can be successfully treated with appropriate medical therapy alone. The typical duration of treatment for acute sinusitis is 7-14 days (with some recent research suggesting as few as 3-5 days may be possible). Chronic sinusitis usually requires longer courses of therapy depending upon the patient and other underlying conditions. The majority of patients with sinusitis respond to medications and DO NOT require surgery.
Headache is a common problem that is often associated with sinusitis. Unfortunately, sinusitis is only one of a large number of causes for headaches and it may be difficult to determine the exact cause of a patient’s pain. The true cause for a patient’s headache may be difficult to determine, because sometimes headaches occur with sinusitis and sometimes not. Generally, patients with sinus headaches will have other symptoms, such as nasal congestion or thick, discolored drainage and these symptoms will improve with appropriate medical therapy (see above: How is sinusitis diagnosed?). Most often the headaches will be over the areas of the underlying infected sinus (forehead, around/between the eyes, cheek areas). Sinus headaches cause pain as a result of air, pus, and mucus being trapped within the obstructed sinus.
Non-sinus headaches can also occur in similar locations, but they usually will not be accompanied by nasal symptoms. When a headache is the only symptom, it is rarely sinus related and other causes should be looked for, because pain in the sinus area does not automatically mean that you have a sinus disorder. On the other hand, if patients have undergone unsuccessful treatments for migraine or other headache disorders, consideration should be given to an examination for sinusitis.
Antibiotics are used in many cases of sinusitis. The particular antibiotic that is chosen and the length of therapy are based upon many factors. These include any culture information, the most likely bacteria causing the infection, potential drug resistance of the bacteria, patient drug allergies, other medical conditions, current medications and previous treatments.
Oral steroids (prednisone, medrol) are very useful, especially in patients with significant inflammatory environmental triggers, such as nasal polyps, allergies or asthma. These are typically prescribed in a tapering fashion over a course of 2-8 weeks, depending upon the individual patient. This class of drugs can have significant side effects (such as bone loss, weight gain, irritability, diabetes, etc.) if taken on a daily basis for an extended period of time.
Topical nasal steroids are very useful in most cases of chronic sinusitis. They reduce the inflammation in the lining of the nose and sinuses with very few side effects. Some patients may experience minor nose bleeds from time to time, but these medications are generally very well-tolerated.
Widely open sinuses in patient 3 months after sinus surgery.
Nasal saline irrigations are useful in most patients. They help to flush the nose/sinuses and remove viral particles, pollen, irritants, bacterial and fungal debris. There are few significant side effects from saline washes. Some physicians prescribe sterile saline from the pharmacy, while others permit patients to make their own saline at home. Regardless of the source, any devices used to irrigate the nose (such as Neti Pots, squeeze bottles or Water Pik type devices) must be cleaned or replaced regularly to avoid the risk of contamination with mold or fungus. At times, ENT surgeons place medications, such as steroids or antibiotics, into irrigations. This enables delivery of medication directly to the affected sinuses, especially after surgery has been performed to open the sinuses widely (see endoscopic picture on right).
Mucus thinners, such as guaifenesin, can provide symptom relief in patients who experience thick post-nasal drainage or phlegm in the back of the throat. These medications are very safe and can be used long-term.
Oral and topical decongestants are generally prescribed on an as-needed basis. Short term (3-5 days) use may alleviate some of the symptoms of congestion and nasal obstruction seen in sinusitis. There is the potential for side effects, such as high blood pressure, hyperactivity, insomnia, and recurrent nasal congestion, with long-term use.
Antihistamines can be very useful in patients with documented environmental allergies (see Allergy section). They may cause thickening of secretions in the nose and mouth, drowsiness, urinary retention and constipation, thus non-allergic patients should probably refrain from using them.
Allergy shots or drops (immunotherapy) are also useful in patients with proven allergies (See Allergy section). Patients require weekly shots for the first year and a tapering schedule after that, but allergy shots may provide patients with significant long-term relief without the need for chronic medications.
Other treatments for chronic sinusitis include leukotriene inhibitors and aspirin desensitization. These treatments are for selected patients and may not have proven efficacy. You should discuss these with your sinus specialist if you have further questions.
Once a patient has been treated with medications (generally for a minimum of 4 weeks), a CT scan may be obtained. Doctors can evaluate all sinuses with a screening CT scan, such as the one shown that demonstrates the maxillary and ethmoid sinuses. This will give the doctor an idea of the sinus anatomy that may be contributing to the problem and also permits evaluation of areas of the sinuses that are not visible using the endoscope. The majority of patients with sinusitis respond the medications and DO NOT require surgery.
Large polyp with surrounding thick secretions indicating active infection.
Evaluation and treatment: Patients with sinus symptoms, such as nasal congestion, post nasal drip or headache, should be evaluated by an ENT doctor to determine if their symptoms are actually coming from sinusitis or another similar condition, such as allergies, migraine headaches or acid reflux. The evaluation and treatment of sinus patients usually involves nasal endoscopy, examining the inside of the nasal passages with a small telescope and treatment with medications for a minimum of 4 weeks. At the end of that timeframe, if symptoms persist, a CT scan may be obtained. This will give the doctor an idea of the sinus anatomy that may be contributing to the problem and also permits evaluation of areas of the sinuses that are not visible using the endoscope. The diagnosis of chronic sinusitis must be based upon an assessment by your doctor, as other problems can cause symptoms similar to those found with sinus disease. The majority of patients with sinusitis respond the medications and DO NOT require surgery. The MUSC Sinus Center is actively involved in several clinical trials investigating medical treatment of patients with chronic sinusitis.
Surgery is generally needed for the minority of people with chronic sinus problems who do not respond to medical therapy. The diagnosis of chronic sinusitis must be based upon an assessment by your doctor, as other problems can cause symptoms similar to those found with sinus disease. The majority of people with sinusitis DO NOT require surgery. Their sinus symptoms can usually be successfully treated medically. This includes antibiotic therapy and other medications, treatment of allergies, and environmental control. The type of medical therapy used is based upon your doctor’s assessment of the cause.
When medications fail to work and persistent disease is seen on the CT, surgery is an option. Surgery may be needed if an infected or inflamed area does not clear with antibiotic therapy or other medications, the symptoms return when antibiotics are stopped, or for other reasons. You should discuss your CT and the need for sinus surgery with your doctor.
One way FESS differs from traditional sinus surgery is that a thin rigid optical telescope, called an endoscope, is used in the nose to view the nasal cavity and sinuses. This technique has revolutionized the surgical treatment of chronic sinusitis. FESS generally eliminates the need for an external incision. The endoscope allows for better visualization and magnification of diseased or problem areas. This endoscopic exam, along with CT scans, may reveal a problem that was not evident before.
Another difference is that FESS focuses on treating the underlying cause of the problem. The ethmoid sinuses are usually opened. This permits direct visualization of the maxillary, frontal, and sphenoid sinuses and diseased or obstructive tissue can be removed if necessary. There is often less removal of normal tissue and surgery can frequently be performed on an outpatient basis without the need for painful packing that was used in the past. Generally, there are not external scars, little swelling, and only mild discomfort.
The goal of FESS is to open the sinuses more widely. Normally the openings to the sinuses are long narrow bony channels covered with mucosa or the lining of the sinuses. If this lining swells from inflammation, the sinuses can become blocked and an infection can develop. FESS removes some of these thin bony partitions and creates larger openings into the sinuses. After FESS, patients can still develop inflammation from allergies or viruses, but hopefully when the sinus lining swells, the sinus will still remain open. This will permit easier treatment of subsequent exacerbations with more rapid resolution and less severe infections.
Powered instrumentation can be useful during FESS to precisely remove polyps and other diseased tissue, while sparing the surrounding normal sinus lining and adjacent structures. The latest generation of hand instruments allows the surgeon to meticulously open the sinuses, while avoiding the “grab and tear” techniques of the past. Once the diseased tissue is removed and the inflammation subsides, the injured sinus lining often returns to a normal state with time.
Computer guidance during sinus surgery.
Computer assisted surgical navigation is a relatively new tool used in select cases. These devices provide information on the anatomic location of instruments within the sinuses during surgery and can also be used to perform 3D reconstructions that may be helpful to your surgeon. It is typically indicated for revision cases, nasal polyposis, or skull base tumors where normal surgical landmarks have been removed or altered. As with all equipment, image-guided systems can be wrong from time to time and surgeons cannot rely solely on the technology. They must correlate the image-guided information with their training, experience, and knowledge of the anatomy in order to avoid complications due to human or technical errors.
Balloon sinuplasty is a newer technology which uses balloons to stretch and dilate the openings to some of the sinuses, rather than removing tissue. This may be appropriate for some patients with limited inflammation, but is probably not indicated for patients with polyps or scar tissue that must actually be removed.
Most patients do not experience significant pain and are able to return to work in a few days. The MUSC Sinus Center is conducting research using novel intraoperative treatments and dissolvable materials to improve symptoms and outcomes after FESS. After FESS, patients can still develop inflammation from allergies or viruses, but when the sinus lining swells, the sinus should still remain open. This will permit easier treatment of subsequent exacerbations with more rapid resolution and less severe infections. Oftentimes, physicians are able to treat such flare ups with topical medications in sinus irrigations. These medications can now reach the sinuses that were previously blocked by polyps or scar.
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