Sinusitis FAQ's

Martin J. Citardi, M.D.

What is sinusitis?

How common is sinusitis?

What causes sinusitis?

How can sinusitis be diagnosed?

How can sinusitis be treated?

Who treats sinusitis?

When is surgery needed?

Where can I find additional information?

What is sinusitis?
Strictly speaking, "sinusitis" is any inflammation of the sinuses. From a practical standpoint, sinusitis refers to the infection of the paranasal sinuses by bacteria.

Respiratory tract viral infections also can produce inflammation within the sinuses. It is unclear whether these viruses directly infect the sinuses. Alternatively, these may infect the nose, producing rhinitis (inflammation of the nose), and then this rhinitis blocks the sinus ostia, producing inflammation in the sinuses. In any case, a viral respiratory tract infection (viral rhinitis) may produce the conditions that lead to a bacterial infection of the sinuses.

Nasal allergies are not sinusitis. Direct allergy events have not been conclusively demonstrated in the sinuses themselves. Nasal allergies can produce symptoms that resemble the symptoms of sinusitis. Additionally, nasal allergies can produce rhinitis (nasal inflammation), which then can block the sinus ostia producing sinusitis.

Other conditions can also produce sinusitis. For example, fungal infections can occur.

In 1996, the Task Force on Rhinosinusitis, which was sponsored by the American Rhinologic Society, the American Academy of Otolaryngology-Head and Neck Surgery and the American Academy of Otolaryngic Allergy, proposed that the term "rhinosinusitis" replace the term "sinusitis." The central idea here is that the nose ("rhino-") and sinuses are closely related:

First, rhinitis typically precedes sinusitis, as described above.
Secondly, sinusitis without rhinitis is very, very rare. Rhinosinusitis is an inflammatory condition that involves the lining of the nose and the lining of the sinuses.

The Task Force on Rhinosinusitis also defined the following types of rhinosinusitis:

Acute rhinosinusitis (present for less than 4 weeks)
Subacute rhinosinusitis (present for more than 4 weeks, but less than 12 weeks)
Chronic rhinosinusitis (present for greater than 12 weeks)
Recurrent acute rhinosinusitis (more than 4 acute episodes over 1 year)
Acute exacerbation of chronic rhinosinusitis (an acute infection superimposed over a chronic infection, producing a sudden worsening of the patient's baseline symptoms)

For the purpose of this discussion, the term "sinusitis" shall refer to bacterial infection, because that is the typical convention.

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How common is sinusitis?
Sinusitis is the most common chronic illness in America. It is estimated that more than 35 million Americans suffer from sinusitis. Interestingly, many people with this disease do no receive treatment, because they do no know they have sinusitis, or because the sinusitis is overlooked.

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What causes sinusitis?
The central event in sinusitis is blockage of the sinus ostium so that the sinus secretions collect in the sinuses. Bacteria then can infect the blocked sinus. Inflammatory cells, which fight infection, are attracted to the blocked sinus.

Many different types of bacteria can infect the paranasal sinuses. These bacteria are most often cultured from acute sinusitis:

Streptococcus pneumoniae
Hemophilus pneumoniae
Moraxella catarrhalis

In chronic sinusitis, other bacteria, such as Staphylococcus aureus, are more often cultured. Over the past several years, it has become increasingly common to culture gram negative bacteria, such as Pseudomonas aeriginosa, especially from patients who have received extensive sinusitis treatments. Traditionally, it was felt that such gram negative sinus infections were exceedingly rare; however, today that is no longer true.

A variety of factors may contribute to the development of sinusitis:

Viral infection (As described above, viral infection may produce blockage of the sinus ostia-the first step in the development of sinusitis. This may represent the most common initial step in the development of sinusitis.)
Nasal allergy (This was also described above. Nasal allergy may also produce blockage of the sinus ostia.)
Anatomic obstruction (In some patients, the sinus ostia may be anatomically blocked. This is relatively rare; after all, the ostia are normally very small, and most people do not get sinusitis. Other factors seem to predominate.)
Congenital diseases, such as cystic fibrosis (Certain congenital conditions, including cystic fibrosis, seem to be associated with sinusitis.)
Immunodeficiency (Immunodefiency refers to the situation where the normal mechanisms which fight infection are not effective. AIDS is perhaps the best known example of immunodeficiency; many other conditions also produce immunodeficiency of varying severity.)
Reactive airway disease, such as asthma (Patients with asthma and especially patients with asthma, nasal polyps and aspirin sensitivity, seem to have more frequent and more severe sinus disease. These patients seem to have altered metabolism of leukotrienes, an important messenger for inflammation.)
Previous surgery (Sinus surgery, whose goal is to "open" the sinuses, may actually produce blockage of the sinuses. When this happens, a detailed evaluation is necessary to determine the precise cause. Often repeat surgery will be necessary. If so, it should be performed by a surgeon with extensive experience in revision sinus surgery.)
Trauma (Facial injuries may also block the sinus drainage pathways.)
Inflammatory diseases (Certain inflammatory diseases, such as sarcoidosis and Wegener's granulomatosis, typically have nasal components, including sinusitis.)

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How can sinusitis be diagnosed?
The diagnosis of sinusitis, especially chronic sinusitis, can be very difficult. The symptoms of sinusitis are often overlooked, or the symptoms may be mistaken for another condition.

Physicians rely upon the patient history and physical examination to make this diagnosis. Doctors will ask questions to determine exactly what symptoms trouble the patient. An examination of the nasal cavity also can be helpful.

Of course, X-rays can be obtained. It is important to remember that the role of plain X-rays for the diagnosis of sinusitis is somewhat controversial. Simply put, plain films can miss significant disease; as a result, some experts have questioned their utility as a routine test for sinusitis.

CT scans (CAT scans) have emerged as the preferred radiologic study for sinusitis. CT scans can demonstrate the anatomy in fine detail, and they can show signs of infection that are not seen on plain films. Not all patients who seem to have sinusitis need a CT scan. In fact, CT scans are usually reserved for patients who continue to have symptoms after medical treatment.

Over the past two decades, nasal endoscopy has been introduced. Slender optical devices (either rigid nasal telescopes or flexible fiberoptic scopes) can be passed into the nose to examine the tiny spaces of the nose and sinus cavities. The lining of the nose can be seen. Mucus with an infected appearance can be samples for culture. Like CT scans, nasal endoscopy is reserved for selected patients who do not do well with initial treatment with antibiotics.

Most people can describe the most common symptoms of a sinus infection. These symptoms include:

Nasal drainage that is thick and has a yellow or green color (Patients may describe so-called postnasal drip, which is actually this mucus as it drains down the back of the throat. The nasal drainage may also come from the front of the nose.)
Facial pain that usually feels like pressure (This pain will be localized right over the involved sinus. For example, in maxillary sinusitis, there is pain over the cheek and sometimes over the upper teeth on the same side.)
Nasal congestion and/or obstruction
Cough, which is probably produced by the postnasal drip (Although most patients can relate the cough to the postnasal drip, in some patients, there is a significant cough, but the patient does not report postnasal drip.)
Fever
Ear discomfort (The Eustachian tube, which runs from the space behind the ear drum to the back of the nose, helps to equalize the pressure behind the ear drum. If the eustachian tube's opening in the nose is inflamed [from postnasal drip, for instance], then the tube may not work well, causing ear pressure, popping, fullness, and similar symptoms.)

Most of the symptoms of sinusitis are really not unique to sinusitis. For example, nasal congestion, can be caused by several different processes, including allergies and viruses, as well as sinusitis. In recognition of this problem, the Taskforce on Rhinosinusitis (described above) also focused upon the difficulty of making the diagnosis of sinusitis. This group proposed a rhinosinusitis symptom complex, which includes both major and minor factors. The major factors are as follows:

Facial pain/pressure (It should be noted that facial pain/pressure alone is not a suggestive history, unless anther major nasal symptom or sign is also present.)
Facial congestion/fullness
Nasal obstruction/blockage
Infected nasal drainage (thick and green/yellow) that goes down the back of the throat or comes from the nostril
Decreased or absent sense of smell
Pus in the nose on physical examination
Fever (It should be noted that in acute sinusitis, fever alone is not a strong sign unless another nasal symptom or sign is also present. Also, fever is considered to be a sign of acute sinusitis only.)

The minor factors are as follows:

Headache
Fever
Bad breath (halitosis)
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness

The Task Force also defined a strong history of sinusitis as one of the following situations:

Two major factors
One major factor and two minor factors
Pus in the nose on examination

According to this approach, patients with a strong history have sinusitis and should be treated. It should be noted that even patients with only one major factor or only two minor factors may have sinusitis. In addition, fever or pain alone without other symptoms does not suggest sinusitis.

The Task Force also said that the type of sinusitis is determined by the duration of symptoms:

Acute rhinosinusitis (present for less than 4 weeks)
Subacute rhinosinusitis (present for more than 4 weeks, but less than 12 weeks)
Chronic rhinosinusitis (present for greater than 12 weeks)
Recurrent acute rhinosinusitis (more than 4 acute episodes over 1 year)
Acute exacerbation of chronic rhinosinusitis (an acute infection superimposed over a chronic infection, producing a sudden worsening of the patient's baseline symptoms)

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How can sinusitis be treated?
After sinusitis develops, there are several possible outcomes:

Resolution without treatment (The body is able to fight off the infection completely without medical treatment.)
Resolution with treatment (The patient seeks medical treatment, and with treatment, the infection clears.)
Persistence (The infection does not improve completely, or it quickly returns.)
Complication (Rarely, the infection may get very worse and spread to other structures, including the brain and the eye.)

The mainstay of treatment for bacterial sinusitis is an appropriate antibiotic. Many potent antibiotics are available today for the treatment of sinusitis. A physician will base his choice of antibiotics on many factors. These factors include:

The most likely type of bacterium causing the infection
Potential resistance of the bacterium to certain antibiotics
Results of sinus cultures, if they are available
Patient allergies
Other medications that the patient is also taking
The patient's other medical conditions
Previous treatment

The physician will consider each of these factors prior to choosing an antibiotic.

Often other medications and treatments will be prescribed. These include the following:

Oral decongestants
Mucus thinning drugs
Topical nasal steroids
Systemic steroids
Nasal saline washes

The duration of treatment is variable. For acute sinusitis, treatment is usually for 10-14 days. Some physicians will recommend treatment for as little as 3 days, but this is more usual. If the sinusitis has been present for several weeks or longer, then treatment will be prolonged. In this case, the treatment usually is at least 4 weeks and can be up to 8-12 weeks (or even longer).

Antibiotics are used to treat bacterial sinusitis. If the symptoms are caused by an infection with a virus, then the antibiotics are useless. For example, the common cold, which is viral, can seem like bacterial sinusitis; however, antibiotics should never be used for the common cold, because they are useless for this condition. Obviously, the diagnosis of sinusitis must be accurate. Because the diagnosis can be difficult, it is critical that a physician, who is skilled in this area, direct the patient's treatment.

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Who treats sinusitis?
Sinusitis is a common disease, and many types of physicians are involved in the treatment of sinusitis. Primary care physicians, family practice doctors, internists, allergists and pulmonologists all treat sinusitis. In addition, physician extenders (physician assistants, nurse practitioners, etc.) also treat sinusitis.

Lastly, ear, nose, and throat doctors (ENT doctors, also known as otolaryngologists) treat many different nose and sinus conditions. ENT physicians provide a full range of treatment alternatives, including medications and surgery. Other specialists cannot offer such comprehensive evaluation and treatment. Primary care physicians, internists and other medical specialists will send their most severe sinusitis patients to an ENT specialist.

Some otolaryngologists have chosen to specialize further in rhinology; that is, they focus their practices on diseases of the nose and paranasal sinuses. The American Rhinologic Society is an organization dedicated to the field of rhinology.

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When is surgery needed?
Sinus surgery is performed for chronic sinusitis that does not resolve with medical treatment. As described above, such treatment can last for at least several weeks. It must be remembered that sinusitis is primarily a medical disease, and it needs to be treated aggressively with medicines before considering surgery.

For patients who have received appropriate treatment, sinus surgery is an excellent option. Today, this surgery is typically performed using the principles of functional endoscopic sinus surgery (FESS). The goal of FESS is to restore normal function (mucus drainage) to the blocked sinuses. During a FESS procedure, the surgeon is able to open the small drainage passageways for the sinuses. The entire operation is almost always performed through the nostril; external incisions are usually avoided. Nasal telescopes, which are slender, tubular optical devices, are passed through the nostril; by looking through the telescope (or an image provided by a camera attached to the telescope) the surgeon is able to see the nose and sinus passageways. Because of this view, this delicate surgery can be performed.

Occasionally, a sinus infection can spread to structures outside the sinuses; when this happens, the infection spreads to the eye or brain. This complication of sinusitis is a medical and surgical emergency. Often surgery will be required to drain the pocket of pus in the sinus. Such complications are rare, but when they do occur, immediate treatment is necessary. The treatment of such complications is beyond the scope of this presentation.

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Where can I find additional information?
As you have probably already discovered, the Internet provides a great deal of medical information. Please refer to the Links section for additional information.

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