Sinusitis is an infection or inflammation of the sinuses, the air-filled chambers in the skull that are located around the nose. Bacteria are the most common cause of sinusitis, but there can be other causes as well. 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.
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 mucus 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. Antihistamine 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 on their own within 2 weeks, 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.
The skull contains a number of air-filled spaces called sinuses. They perform the following functions:
- Reduce the weight of the skull
- Provide insulation for the skull
- Provide resonance for the voice
Four pairs of sinuses, known as the paranasal air sinuses, connect to the nasal passages (the two airways running through the nose). These sinuses are the following:
- Frontal sinuses (behind the forehead)
- Maxillary sinuses (behind the cheekbones)
- Ethmoid sinuses (between the eyes)
- Sphenoid sinuses (behind the eyes)
Sinusitis occurs in these four areas.
Healthy sinuses are sterile and contain no bacteria. (The nasal passage, on the other hand, normally contains many bacteria.)
The Disease Process. Sinusitis is an infection that occurs if obstruction or congestion leads to bacterial growth in the paranasal sinuses. Among the many causes of such obstruction or congestion are the common cold, allergies, certain medical conditions, abnormalities in the nasal passage, and change in atmosphere. In any of these cases, sinusitis can develop as follows:
- Mucus drainage and airflow are blocked.
- Secretions build up, encouraging the growth of certain bacteria.
- The resulting infection, swelling, and inflammation create further blockage, which may cause the sinuses to close up completely.
Forms of Sinusitis. 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
Bacteria are the most common direct cause of acute sinusitis. (Other organisms might be the infecting cause in less common cases.) The ability of bacteria or other organisms to infect the sinuses, however, must first be set up by conditions that create a favorable environment in the sinus cavities. Sinusitis is most often an acute condition, which is self-limiting and treatable. In some cases, however, the inflammation in the sinuses is lasting, or is chronic to begin with. The causes for such chronic sinusitis cases are sometimes unclear.
Upper Respiratory Infections
The typical process leading to acute sinusitis starts with a cold virus. Over 85% of people with colds have inflamed sinuses. These inflammations are typically brief and mild, however, 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. This creates a hospitable environment for bacterial growth, which is the direct cause of sinus infection. In fact, rhinitis is the precursor to sinusitis in so many cases that doctors now refer to most cases of sinusitis as rhinosinusitis.
Rhinosinusitis tends to involve the following sinuses:
- The maxillary sinuses (behind the cheekbones) are the most common sites.
- The ethmoid sinuses (between the eyes) are the second most common sites affected by colds.
- The frontal (behind the forehead) and sphenoid (behind the eyes) sinuses are involved in about a third of cold-related cases.
Conditions That Cause Chronic or Recurrent Sinusitis
Chronic or recurrent acute sinusitis typically results from one of the following conditions:
- Untreated acute sinusitis that results in damage to the mucus membranes
- Chronic medical disorders that cause inflammation in the airways or persistent thickened stagnant mucus (such as diabetes, AIDS, other disorders of the immune system, hypothyroidism, cystic fibrosis, Kartagener's syndrome, and Wegener's granulomatosis)
- Structural abnormalities
- Allergic reaction to fungi
Chronic or recurrent acute sinusitis can be a lifelong condition.
Inflammatory Response, Allergies, and Asthma
The absence of bacterial organisms as factor in many cases suggests that some instances of chronic sinusitis may be due to a continuing inflammatory condition. Many of the immune factors observed in people with chronic sinusitis resemble those that appear in allergic rhinitis, suggesting that sinusitis in some individuals is due to an allergic response.
Allergies, asthma, and sinusitis often overlap. Those with allergic rhinitis (so-called hay fever) often have symptoms of sinusitis, and true sinusitis can develop as a result of the mucus blockage it causes. A causal association, however, has not been proved, and many doctors believe allergies themselves rarely predispose to sinusitis. People with chronic sinusitis may also have an allergic reaction to fungal organisms.
Abnormalities of the Nasal Passage
Abnormalities in the nasal passage can cause blockage and thereby increase the risk for chronic sinusitis. Some abnormalities include:
- Polyps (small benign growths) in the nasal passage block mucus drainage and restrict airflow. Polyps themselves may be consequences of previous sinus infections that caused overgrowth of the nasal membrane.
- Enlarged adenoids can lead to sinusitis.
- 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)
The Role of Bacteria. The role of bacteria or other infectious organisms is complicated in chronic sinusitis. They may have a direct, or an indirect, role. Bacteria may be living in the sinuses without causing an infection (called colonization) In some patients, infectious organisms play no role at all:
The bacteria most commonly implicated in sinusitis include:
- Streptococcus pneumoniae. This bacterium is found in up to 45% of adults and children with sinusitis.
- H. influenzae (a common bacterium associated with many upper respiratory infections). This bacterium causes about 25% of sinusitis cases in children. Studies have reported the presence of this bacterium in up to a third of adult sinusitis patients.
- Moraxella catarrhalis. Over 75% of all children harbor this bacterium, which causes about 25% of sinusitis cases.
Other possible bacterial culprits include:
- Other streptococcal strains
- Staphylococcus aureus
- P. aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter species, and Escherichia coli
- Fusobacterium nucleatum and Prevotella intermedia)
While fungi are an uncommon cause of sinusitis, the incidence of such infections is increasing. At least 5 - 10% of chronic rhinosinusitis patients may actually have allergic fungal sinusitis.
Many patients with chronic sinusitis may be colonized with fungi, but this does not necessarily mean the patient has a fungal infection causing their symptoms. Studies suggest that some people who suffer from chronic sinusitis have an immune and inflammatory response to fungi and may benefit from anti-fungal treatment.
Fungi involved in sinusitis include:
- Aspergillus is the most common cause of all forms of fungal sinusitis.
- Other fungi include Curvularia, Bipolaris, Alternaria, Dreschslera, Cryptococcus, Candida, Sporothrix, Exserohilum, and Mucormycosis.
- There have been a few reports of fungal sinusitis caused by Metarrhizium anisopliae, which is used in biological insect control.
There are four categories of fungal sinusitis:
- Acute or invasive fungal sinusitis. This infection is most likely to affect people with diabetes and compromised immune systems.
- Chronic or indolent fungal sinusitis. This form is generally found outside the U.S., most commonly in the Sudan and northern India.
- Fungus ball (mycetoma). This fungal sinusitis is noninvasive and occurs usually in one sinus, most often the maxillary sinus.
- Allergic fungal sinusitis. This form typically occurs because of an allergy to the fungus Aspergillus (rather than being caused by the fungus itself). In such cases, a peanut butter-like fungal growth occurs in the sinus cavities that may cause nasal passage obstruction and the erosion of the bones.
Fungal infections can be very serious, and both chronic and acute fungal sinusitis require immediate treatment. Fungal ball is not invasive and is nearly always treatable.
Fungal infections should be suspected 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.
Sinusitis is one of the most common diseases in the United States, affecting about 1 in 7 adults each year. About 31 million Americans are diagnosed with sinusitis each year.
Young Children and Sinusitis
Before the immune system matures, all infants are susceptible to respiratory infections, with a possible frequency of one cold every 1 - 2 months. Young children are prone to colds and may have 8 - 12 bouts every year. Smaller nasal and sinus passages also 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. Some doctors believe it is greatly overdiagnosed in this population.
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 faltering 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. (Such patients may have a significantly higher risk for maxillary sinusitis.)
- Patients who had a 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 predispose the patient to sinusitis (fungal infections are especially risky)
- Oral or intravenous steroid treatment
- Hypothyroidism -- causes congestion that clears up when the condition is treated
- Cystic fibrosis -- a genetic disorder in which the mucus is very thick and builds up
- Kartagener's syndrome
Miscellaneous Risk Factors
Dental Problems. Anaerobic bacteria are associated with infections from dental problems or procedures, which precipitate about 10% of 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 chance 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.
Symptoms Suggesting a Bacterial Infection
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. It is important to differentiate between inflamed sinuses associated with cold or flu virus and sinusitis caused by bacteria.
The signs and symptoms that are associated with the diagnosis of sinusitis include one to two of the following:
- Nasal congestion and discharge that typically is thick and becomes yellowish to yellow-green
- Facial pain, pressure, congestion, or fullness (that is also accompanied by other symptoms of sinusitis)
- Symptoms that continue for 10 days or more after the start of a cold or flu
- Symptoms worsen after 5 - 7 days, or return after initial improvement in a cold (called double sickening)
- Reduced or absent sense of smell
- Fever, although should also be accompanied by other symptoms of sinusitis
Other symptoms of sinusitis that usually occur in adults include one to two of the following:
- A persistent cough (particularly during the day)
- Ear pain, pressure, or fullness
- Halitosis (bad breath)
- Dental pain
However, many studies have shown that symptoms used to diagnose sinusitis often do not predict prognosis or response to antibiotic treatment.
Sneezing, sore throat, and muscle aches may be present, but they are rarely caused by sinusitis itself. Muscle aches may be caused by fever, sore throat by post-nasal drip, and sneezing from cold or allergies.
Rare complications of sinusitis can produce additional symptoms, which may be severe or even life threatening.
Symptoms Indicating Medical Emergency
- Increasing severity of symptoms
- Eyes may be red, bulging, or painful if the sinus infection occurs around the eyes
- Swelling and drooping eyelid
- Loss of eye movement (possible orbital infection, which is in the eye socket)
- Vision changes
- Pupil fixed or dilated
- Symptoms spreading to both sides of face (may indicate blood clot)
- Development of severe headache, altered vision
- Mild personality or mental changes (may indicate spread of infection to brain)
- A soft swelling over the bone (may indicate bone infection)
Symptoms in Children
Children are most likely to develop infection in the ethmoid sinuses, located between the eyes. Children with sinusitis are also less likely to experience facial pain over the affected sinus and headache, which are the primary signs in adults. Symptoms of bacterial sinusitis in children may be less specific than in adults and include:
- Persistent nasal discharge (of any type) and day time cough for more than 10 days, or
- Severe symptoms last for at least 3 - 4 days in a row and include thick, greenish nasal discharge plus a fever of at least 102 F
Other symptoms in children may include:
- Gagging on mucus
Recurrent acute sinusitis and chronic sinusitis tend to take the following course:
- Any of the sinusitis symptoms listed previously may be present
- Symptoms are more vague and generalized than acute sinusitis
- Fever may be absent or just low grade
- Symptoms of sinusitis last 12 weeks or longer
- Symptoms occur throughout the year, even during nonallergy seasons
Other Causes of Sinusitis Symptoms
It is often difficult to tell when a viral infection converts to a bacterial infection. Studies have found that 40 - 85% of patients with the common cold show signs of inflamed sinuses on x-rays or CT scans. A cold, however, unlike sinusitis, typically clears up without treatment within a week. (Only about 0.5 - 2% of adults with viral colds or flus actually develop bacterial infections.)
Allergies. Symptoms of both sinusitis and allergic rhinitis include nasal obstruction and congestion. The conditions often occur together. People with allergies and no sinus infection may have:
- Thin, clear, and runny nasal discharge
- Itchy nose, eyes, or throat (do not occur with bacterial sinusitis)
- Recurrent sneezing
- Symptoms of allergies appear only during exposure to allergens
Migraine and Other Headaches. Many primary headaches, particularly migraine or cluster, may closely resemble sinus headache. Migraine and sinus headaches may even coexist in many cases. Sinus headaches are usually more generalized than migraines, but it is often difficult to tell them apart, particularly if headache is the only symptom of sinusitis.
Trigeminal Neuralgia. In some cases, headache that persists after successful treatment of chronic sinusitis may be due to neuralgia (nerve-related pain) in the face.
Other Conditions. A number of other conditions can mimic sinusitis. They include:
- Dental problems
- A foreign object in the nasal passage
- Temporal arteritis (headache caused by inflamed arteries in the head)
- Persistent upper respiratory tract infections
- Temporomandibular disorders (problems in the joints and muscles of the jaw hinges)
- Vasomotor rhinitis, a condition in which the nasal passages become congested in response to irritants or stress. It often occurs in pregnant women.
Patients should see a doctor if they have sinusitis symptoms that do not clear up within a few days, are severe, or are accompanied by high fever or acute illness. However, only one-half to two-thirds of patients with such symptoms actually have sinusitis.
Some doctors believe that too many patients are diagnosed with true sinusitis and given unnecessary antibiotics when their symptoms would actually resolve easily in days with over-the-counter medications or no drugs at all.
The first goal in diagnosing sinusitis is to rule out other possible causes of symptoms, and then determine:
- The site where the infection has occurred
- Whether the condition is acute or chronic
- The organism causing the infection (if possible)
Diagnostic Approach to Acute Sinusitis
Medical History. The patient should describe all symptoms such as nasal discharge and specific pain in the face and head, including eye and tooth pain.
After assessing symptoms, the doctor should take a thorough medical history of the patient:
- Any history of allergies or headaches
- Recent upper respiratory infection (colds, flus, infection) and how long they have lasted
- History of sinusitis episodes that is unresponsive to antibiotic treatment. (In such cases, the doctor will usually diagnose chronic or recurrent acute sinusitis and may refer the patient to a specialist for more advanced testing.)
- Exposure to cigarette smoke or other environmental pollutants
- Recent travel
- Recent dental procedures
- Medications being taken (particularly decongestants)
- Any known structural abnormalities in the nose and face
- Injury to the head or face
- History of medical conditions, such as chronic fatigue syndrome or fibromyalgia, which can produce tender areas in the face or sinus regions and nonspecific symptoms of ill health
- Any family history of allergies, immune disorders, cystic fibrosis, or immotile cilia syndrome
- In small children with sinusitis, whether they attend a day care center or nursery school
The doctor will press the forehead and cheekbones to check for tenderness and other signs of sinusitis, including yellow to yellow-green nasal discharge. The doctor will also check the inside of the nasal passages using a device with a bright light to check the mucus and look for any structural abnormalities.
Nasal Endoscopy (Rhinoscopy)
Nasal endoscopy, or rhinoscopy, involves the insertion of a flexible tube with a fiberoptic light on the end into the nasal passage. Rhinoscopy allows detection of even very small abnormalities in the nasal passages and can better evaluate structural problems of the nasal septum, as well as the presence of soft tissue masses such as polyps. It may also identify small amounts of pus draining from the opening of a sinus. Bacterial cultures can also be taken from samples removed using endoscopy. (Endoscopy is also used for treating sinusitis.)
Computer Tomography. Computed tomography (CT) scanning is the best method for viewing the paranasal sinuses. There is little relationship, however, between symptoms in most patients and findings of abnormalities on a CT scan. CT scans are recommended for acute sinusitis only if there is a severe infection, complications, or a high risk for complications. CT scans are useful for diagnosing chronic or recurrent acute sinusitis and for surgeons as a guide during surgery. They show inflammation and swelling and the extent of the infection, including in deeply hidden air chambers missed by x-rays and nasal endoscopy. Often, they can detect the presence of fungal infections.
X-Rays. Until the availability of endoscopy and CT scans, x-rays were commonly used. They are not as accurate, however, in identifying abnormalities in the sinuses. For example, more than one x-ray is needed for diagnosing frontal and sphenoid sinusitis. X-rays do not detect ethmoid sinusitis at all. This area can be the primary site of an infection that has spread to the maxillary or frontal sinuses.
Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) is not as effective as CT in defining the paranasal anatomy and therefore is not typically used to image the sinuses for suspected sinusitis. MRI is also more expensive than CT. However, it can help rule out fungal sinusitis and may help differentiate between inflammatory disease, malignant tumors, and complications within the skull. It may also be useful for showing soft tissue involvement.
Sinus Puncture and Bacterial Culture
Sinus puncture with bacterial culture is the gold standard for diagnosing a bacterial sinus infection. It is invasive, however, and is performed only when antibiotics have not worked. Sinus puncture involves using a needle to withdraw a small amount of fluid from the sinuses. It requires a local anesthetic and is performed by a specialist. The fluid is then cultured to determine what type of bacteria is causing sinusitis.
The best way to prevent sinusitis is to avoid colds and influenza. If you are unable to avoid them, the next best way to prevent sinusitis is to effectively treat colds and influenza.
Good Hygiene and Preventing Transmission
Colds and flu are spread primarily when an infected person coughs or sneezes near someone else. A very common method for transmitting a cold is by shaking hands. Everyone should always wash their hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleaners that contain an alcohol-based gel are also effective for every day use and may even kill cold viruses. (They are less effective, however, if extreme hygiene is required. In such cases, alcohol-based rinses are needed.) Antibacterial soaps add little protection, particularly against viruses. Wiping surfaces with a solution that contains one part bleach to 10 parts water is very effective in killing viruses.
Influenza Vaccine. Because influenza viruses change from year to year, influenza vaccines are redesigned annually to match the anticipated viral strains. Doctors recommend that people receive annual influenza vaccinations in October or November.
Although flu vaccines are safe and appropriate for anyone over 6 months of age, the vaccines are now recommended for:
- All healthy children ages six months to 18 years.
- All adults ages 65 years or older;
- Other adults who are at high risk for developing serious medical complications from influenza, and health care workers and others who care for individuals who are at high risk for influenza complications. [For more information, see In-Depth Report #94: Colds and influenza.]
Pneumococcal Vaccines. The pneumococcal vaccine protects against S. pneumoniae (also called pneumococcal) bacteria, the most common bacterial cause of respiratory infections. There are two effective vaccines available, one called a 23-valent polysaccharide vaccine (Pneumovax, Pnu-Immune) for adults and a 7-valent conjugate vaccine (Prevnar or PCV7) for infants and young children. Doctors are now recommending that more people, including healthy elderly people, be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria. [For more information, see In-Depth Report #90: Immunizations.]
General Treatment Approaches
The primary objectives for treatment of sinusitis are reduction of swelling, eradication of infection, draining of the sinuses, and ensuring that the sinuses remain open. Fewer than half of patients reporting symptoms of sinusitis need aggressive treatment. Home remedies can be very useful.
Treatment of Acute Sinusitis.
- Support treatment with only saline nasal irrigation, decongestants, antihistamines, and expectorants are appropriate for a minimum of 7 - 10 days for patients with mild-to-moderate symptoms, and may be used for longer.
- Antibiotics are not helpful for patients with mild-to-moderate symptoms, so they should not be prescribed for at least the first 7 days.
Treatment of Chronic Sinusitis.
- A broad-spectrum antibiotic (one that can eliminate a wide range of bacteria) may be helpful. Some patients benefit from prolonged therapy.
- A corticosteroid nasal spray. Some doctors also recommend oral corticosteroids (such as prednisone) for patients who do not respond to nasal corticosteroids or for those patients who have nasal polyps. Prednisone is also used for patients who have allergic fungal sinusitis.
- Saline nasal irrigation is often needed on an ongoing basis.
- If the condition dramatically improves after 1 - 2 months, antibiotics are stopped. The patient should continue with both the steroid and saline nasal solutions. If there is no improvement after this time, surgery may be considered. For some people with chronic sinusitis, however, the condition is not curable, and the goal of treatment is to improve the quality of life.
- A thorough diagnostic work-up should be performed to rule out any underlying conditions, including but not limited to allergies, asthma, any immune problems, gastroesophageal reflux disorder, and structural problems in the nasal passages. If a primary trigger for chronic sinusitis can be identified, it should be treated or controlled if possible.
Home remedies that open and hydrate sinuses may, indeed, be the only treatment necessary for mild sinusitis that is not accompanied by signs of acute infection.
- Drinking plenty of fluids and getting lots of rest when needed is still the best bit of advice to ease the discomforts of the common cold. Water is the best fluid and helps lubricate the mucus membranes. (There is NO evidence that drinking milk will increase or worsen mucus, although milk is a food and should not serve as fluid replacement.)
- Chicken soup does, indeed, help congestion and aches. The hot steam from the soup may be its chief advantage, although laboratory studies have actually reported that ingredients in the soup may have anti-inflammatory effects. In fact, any hot beverage may have similar soothing effects from steam. Ginger tea, fruit juice, and hot tea with honey and lemon may all be helpful.
- Spicy foods that contain hot peppers or horseradish may help clear sinuses.
- Inhaling steam 2 - 4 times a day is extremely helpful, costs nothing, and requires no expensive equipment. The patient should sit comfortably and lean over a bowl of boiling hot water (no one should ever inhale steam from water as it boils) while covering the head and the bowl with a towel so the steam remains under the cloth. The steam should be inhaled continuously for 10 minutes. A mentholated or other aromatic preparation may be added to the water. Long, steamy showers, vaporizers, and facial saunas are alternatives.
A nasal wash can be helpful for removing mucus from the nose. A saline solution can be purchased in a spray bottle at a drug store or made at home. (Mix 1 teaspoon of table, Kosher, or sea salt with 2 cups of warm water. Some people add a pinch of baking soda.) Perform the nasal wash several times a day. Researchers have reported that daily irrigation of the nasal passages with a hypertonic saline solution relieves sinusitis symptoms and also reduces antibiotic use and the occurrence of acute exacerbations.
A simple method for administering a nasal wash is:
- Lean over the sink head down.
- Pour some solution into the palm of the hand and inhale it through the nose, one nostril at a time.
- Spit out the remaining solution.
- Gently blow the nose.
Neti pots have also become popular in recent years for prevention and treatment of sinusitis. Nasal irrigation with a saline solution through a neti pot involves:
- Lean over the sink with your head tilted to one side.
- Insert the spout of the neti pot in the upper nostril.
- Slowly pour the salt water into your nose while continuing to breathe through your mouth.
- The water will flow through the upper nostril and out through the lower nostril.
- When the water finishes dripping out, blow your nose.
- Reverse the tilt of your head and repeat the process with the other nostril.
Antibiotic Use in the Treatment of Sinusitis
Overview on Antibiotics and Their Overuse. Sinusitis is the fifth most common diagnosis for antibiotic prescriptions. But there is much evidence that antibiotics are inappropriately prescribed for many patients:
- Most acute sinusitis cases clear up on their own.
- Antibiotics generally help only a very small number of children with persistent nasal discharge for at least 20 days. Even when antibiotics are helpful, benefits are modest in reducing duration of the infection.
- The intense and widespread use of antibiotics (not only for sinusitis but also for ear infections and other upper respiratory tract infections) has led to a serious global problem, which is bacterial resistance to common antibiotics.
When to Use Antibiotics. Antibiotics should usually be reserved for select patients who are at higher risk for developing bacterial infections. Because up to 80% of sinusitis cases resolve on their own within 2 weeks, doctors generally wait 7 - 14 days before prescribing antibiotics. Some doctors feel that antibiotics still should not be prescribed if symptoms last longer than 10 days. However, antibiotics may be prescribed sooner if severe symptoms develop. These symptoms include:
- Fever greater than 39 C (102.2 F)
- Facial pain or headache
- Severe swelling around the eyes
Chronic sinusitis is often the result of damage to the mucus membrane from a past, untreated acute sinus infection. The aerobic and anaerobic bacteria present in chronic sinusitis are often different from those that cause the acute form. The role of antibiotic treatment for chronic sinusitis is controversial. Special types of antibiotics may be used, and treatment may be needed for a longer time.
Some patients with chronic sinusitis may need intravenous antibiotic therapy, particularly those with underlying medical disorders that can worsen their condition. This therapy is typically given 2 weeks before surgery and continued for about a month afterwards.
- The standard first-line antibiotic treatment for acute uncomplicated bacterial sinusitis is a 10 - 14 day course of amoxicillin. Trimethoprim-sulfamethoxazole is an alternative choice.
- For more complicated illnesses (chronic illness, chronic sinusitis, symptoms lasting longer than 30 days, children in day care or younger than 2 years old, smokers, recent antibiotic use, or unresponsiveness to initial antibiotic course), the doctor may prescribe a different type of antibiotic, such as amoxicillin-clavulanate, cephalosporin, or a macrolide.
- If the patient does not respond after 21 - 28 days, the doctor may switch to another broad-spectrum antibiotic, such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime. Other choices include clarithromycin or azithromycin (macrolides) or levofloxacin (a fluoroquinolone).
Side Effects of Antibiotics. Most antibiotics have the following side effects (although specific antibiotics may have other side effects or fewer of the standard ones):
- The most common side effect for nearly all antibiotics is gastrointestinal distress.
- Antibiotics double the risk for vaginal infections in women. Taking supplements of acidophilus or eating yogurt with active cultures may help restore healthy bacteria that offset the risk for such infections.
- Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening, anaphylactic shock.
- Certain drugs, including some over-the-counter medications, interact with antibiotics; patients should inform the doctor of all medications they are taking and of any drug allergies.
Managing Sinusitis in Patients with Allergies
Patients often have various combinations of allergies, sinusitis, and asthma. Treating each condition is important for improving them all. In addition to decongestants, pain relievers, and expectorants, other remedies are available for people who suffer from nonbacterial sinusitis during allergy season.
- Anti-Inflammatory Drugs. Nasal spray corticosteroids (commonly called steroids) are important for reducing the inflammatory response in the nasal passages and airways. They are important in the treatment of asthma and are now considered to be the most effective measure for preventing allergy attacks. Leukotriene-antagonists are also useful for sinusitis symptoms.
- Antihistamines. Antihistamine tablets relieve sneezing and itching and can prevent nasal congestion before an allergy attack. Many brands are available by prescription and over the counter. Because they thicken mucus and make it harder to drain out from the sinuses, they should not be used for sinusitis.
- Immunotherapy. Immunotherapy, commonly referred to as allergy shots, may be considered for patients with severe seasonal allergies that do not respond to treatment. Immunotherapy is the only treatment that affects the cause of allergies.
- All drug treatments have side effects, some very unpleasant and, rarely, serious. Patients may need to try different drugs until they find one that relieves symptoms without producing excessively distressing side effects.
Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull need emergency care. High dose antibiotics are administered intravenously, and emergency surgery is almost always necessary in such cases.
Severe Fungal Sinusitis. Sinusitis caused by severe fungal infections is a medical emergency. Treatment is aggressive surgery, and high-dose antifungal chemotherapy with a drug such as amphotericin B can be life saving.
Decongestants are drugs that help reduce nasal congestion. They are available in both pill and nasal forms. However, decongestants will not cure sinusitis. Nasal decongestants may actually worsen sinusitis by increasing sinus inflammation. Due to the lack of evidence for the benefit of nasal decongestants in treating sinusitis, the FDA ruled ordered manufacturers of over-the-counter (OTC) nasal decongestant products to remove from their labeling all references to sinusitis.
Your doctor may still recommend that you take either an OTC or prescription nasal decongestant to help relieve blockage symptoms associated with sinusitis. If you think you have sinusitis, check with your doctor before taking a decongestant. Do not try to treat sinusitis by yourself.
Decongestants should not be used at all in infants and children under the age of 4 years, and some doctors recommend not giving them to children under the age of 14. Children are at particular risk for central nervous system side effects including convulsions, rapid heart rates, loss of consciousness, and death.
Expectorants are drugs that cause mucus to be coughed up from the lungs. The most common type is guaifenesin, which is found in many over-the-counter (OTC) cough syrups as well as prescription products. Expectorants used to be recommended for treatment of sinusitis-associated cough, but some recent guidelines advise against their use. Like decongestants, cough medicines should not be given to children younger than age 4 years.
According to the American College of Chest Physicians (ACCP), expectorants and cough suppressants do not help treat cough. The ACCP recommends that adults instead take a decongestant or antihistamine to relieve cough. The ACCP also recommends against OTC cold and cough medicine for children ages 14 years and younger. Parents should talk with their childs pediatrician for advice on treating cough.
Specific Antibiotics Used for Sinusitis
Penicillins. Amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation) has been the most widely prescribed antibiotic for acute sinusitis. This penicillin is both inexpensive and at one time was highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly, both among S. pneumoniae and H. influenzae, and penicillin is no longer as reliable as it once was.
Amoxicillin-clavulanate (Augmentin) is a type of penicillin that works against a wide spectrum of bacteria. An extended release form has been approved for treating adults with sinusitis infections that have become resistant to penicillin.
Cephalosporins. They are often classed by generation:
- First generation includes cephalexin (Keflex), cefadroxil (Duricef, Ultracef), and cephradine (Velosef).
- Second generation include cefaclor (Ceclor), cefuroxime (Ceftin), cefprozil (Cefzil), and loracarbef (Lorabid).
- Third generation include cefpodoxime (Vantin), cefdinir (Omnicef) cefditoren (Sprectracef), cefixime (Suprax), and ceftibuten (Cedex). Ceftriaxone (Rocephin) is an injected cephalosporin. These are effective against a wide range of bacteria.
- Cephalosporins are usually safe for patients with mild penicillin allergies (rash), but should be avoided in patients with high-grade penicllin allergies (hives, airway swelling, collapse).
Macrolides. Macrolides are often used to treat mild-to-moderate bacterial sinusitis in patients who are allergic to penicillin. Some of the most common macrolids are azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). An extended-release form of azithromycin (Zmax) is available as a single dose treatment for mild-to-moderate acute bacterial sinusitis. These antibiotics are also effective against many strains of S. pneumoniae and M. catarrhalis, but macrolide-resistance is common. Erythromycin is not effective against H. influenzae.
Macrolides have anti-inflammatory actions, which may have benefits for some patients with chronic sinusitis.
Trimethoprim-Sulfamethoxazole. Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) is another first-line antibiotic for sinusitis. It is less expensive than amoxicillin and particularly useful for patients with mild sinusitis who are allergic to penicillin. It is no longer effective, however, against certain streptococcal strains. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious.
Fluoroquinolones (Quinolones). Fluoroquinolones (also simply called quinolones) interfere with the bacteria's genetic material so they cannot reproduce.
Newer generation fluoroquinolones, which include levofloxacin (Levaquin), gatifloxacin (Tequin), and moxifloxacin (Avelox), are currently the most effective antibiotics against the common bacteria that cause sinusitis. They are recommended for adults with moderate sinusitis who have already been treated with antibiotics within 6 weeks or who are allergic to beta-lactam antibiotics.
Some of the newer fluoroquinolones only need to be taken once a day, which make compliance easier. Some, but not all, quinolones cause photosensitivity. S. pneumoniae strains resistant to the quinolones have been uncommon in the U.S. but their numbers are increasing.
Lincosamides. Lincosamides prevent bacteria from reproducing. The most common lincosamide is clindamycin (Cleocin). This antibiotic is useful against many S. pneumoniae bacteria but not against H. influenzae.
Tetracyclines. Tetracyclines inhibit bacterial growth. They include doxycycline, tetracycline, and minocycline. They can be effective against S. pneumoniae and M. catarrhalis, but bacteria that are resistant to penicillin are also often resistant to doxycycline. Tetracyclines have unique side effects among antibiotics, including skin reactions to sunlight, possible burning in the throat, and tooth discoloration. They should not be used by children or pregnant women.
Corticosteroids for Chronic Sinusitis
Benefits of Corticosteroid Nasal Sprays. Nasal-spray corticosteroids, most commonly called steroids, are effective drugs for treating allergic rhinitis. They also help in the treatment of chronic sinusitis and are sometimes used for acute sinusitis. Some studies have reported that, when combined with antibiotics, they speed recovery and improve healing rates of complicated or chronic sinusitis compared to antibiotics alone. Nasal spray steroids are safe and have the following benefits:
- They reduce inflammation and mucus production.
- They improve night sleep and daytime alertness in patients with perennial allergic rhinitis.
- They appear to be beneficial in treating polyps in the nasal passages.
Nasal-Spray Brands. Corticosteroids available in nasal spray form include:
- Triamcinolone (Nasacort). Approved for children over age 6.
- Mometasone furoate (Nasonex). Approved for use in patients as young as age 3.
- Fluticasone (Flonase, Flounce). Approved for children over age 4.
- Beclomethasone (Beconase, Vancenase), flunisolide (Nasalide), and budesonide (Rhinocort). Approved for children over age 6.
Side Effects. Corticosteroids are powerful anti-inflammatory drugs. Although oral steroids can have many side effects, the nasal-spray form affects only local areas, and the risk for wide spread side effects is very low unless the drug is used excessively.
- Dryness, burning, stinging in the nasal passage
- Headaches and nosebleed (these side effects are uncommon but should be reported to your doctor immediately)
[For information on more serious complications of corticosteroids, see In-Depth Report #77: Allergic rhinits.]
Antifungals for Chronic Sinusitis
Scientists are investigating whether antifungal drugs may help treat chronic sinusitis. One such drug, Amphotericin B (SinuNase), is currently in Phase III trials for patients who have had sinus surgery but are still experiencing recurrent sinusitis.
Surgery can unblock the sinuses when drug therapy is not effective or if there are other complications, such as structural abnormalities or fungal sinusitis.
Insertion of a Drainage Tube
The simplest surgical approach is the insertion of a drainage tube into the sinuses followed by an infusion of sterile water to flush them out.
Functional Endoscopic Sinus Surgery
Functional endoscopic sinus surgery (FESS) is the standard procedure for most patients requiring surgical management of chronic sinusitis or polyposis. The procedure allows correction of obstructions, including any polyp and ventilation and drainage to aid healing.
Candidates for the Procedure.
- In general, patients should have tried and failed extensive medical therapy. This usually includes several prolonged courses of broad-spectrum antibiotics, nasal corticosteroids, nasal saline irrigation, allergy testing and immunotherapy where appropriate, and sinus drainage where appropriate.
- Patients with nasal polyps or sinus polyps who have failed intranasal and possibly oral corticosteroids generally require surgery.
- Patients with congenital anatomic abnormalities.
- Patients with evidence of bone involvement.
- Patients with HIV who have chronic or recurrent sinusitis.
Surgery may not be as effective for patients with the fungal infections or severe chronic sinusitis, although endoscopy is proving to be beneficial even for these conditions with the use of more powerful instruments.
Procedure. The surgery generally proceeds as follows:
- Adults need only a local anesthetic for the procedure, though a general anesthetic is needed for children.
- Before the procedure, a computed tomography (CT) scan is taken for use by the surgeon in planning the procedure and as a guide to the sinuses during surgery.
- A flexible tube, a miniature camera, and a fiberoptic light source are inserted through a single small opening.
- Instruments are then used to remove diseased bone or tissue and clear obstructions. For instance, shavers are used to gently remove soft tissue. Bone cutters are sometimes employed to open the floor of the frontal sinus and restore drainage (called the modified Lothrop procedure). Lasers may be used to remove bone, coagulate the passageways, or clear obstructions.
Complications. Serious complications of FESS are very rare, but the following have been reported in a few cases:
- Cerebrospinal fluid leak is the most common major complication, but it occurs in only 0.2% of cases and is usually easily repaired during surgery.
- Other very rare complications include meningitis, hemorrhage, infection, or vision loss.
- Patients can develop infections afterward that are very difficult to treat. Interesting studies are reporting good-to-excellent results in these patients by spraying antibiotics into the nasal passages using a nebulizer.
Postsurgical Care. Postsurgical care involves the following:
- The patient will experience a dull ache around the nose and sinus cavity that can be treated with pain medication.
- Following surgery, the patient should flush the sinuses twice daily with a saline or alkaline solution.
- Antibiotics may be prescribed for several weeks until postnasal drip has stopped, and corticosteroid sprays and antihistamines may be needed.
Success Rates. It may take several months for the mucus membranes to completely recover, but 85 - 90% of patients have good to excellent relief of their symptoms after surgery. Children may need a second procedure 2 - 3 weeks after the first surgery to remove crusty matter.
A new type of surgical procedure threads a small balloon through the sinus passages. As the balloon is gently opened, the sinus passages expand, allowing drainage to occur. Some doctors think that this procedure is only appropriate for select patients with sinusitis disease in the maxillary (behind cheek bones), frontal (behind the sides of the forehead), and sphenoid (behind the eyes) sinus regions. It may not work for patients with disease in the ethmoid (between the eyes) sinuses, even though sinusitis commonly occurs in this location. More long-term studies are needed.
Invasive Conventional Surgery
Endoscopy is now used in most cases of chronic sinusitis, but in severe cases, invasive surgery using conventional scalpel techniques to remove infected areas may be required. This may be the case with acute ethmoid sinusitis in which pus breaks through the sinus and threatens the eye, with very severe frontal sinusitis, with invasive fungal sinusitis, or when cancer is present in the sinuses.
- www.entnet.org -- American Academy of Otolaryngology - Head and Neck Surgery
- www.aaaai.org -- American Academy of Allergy, Asthma, and Immunology
- www.acaai.org -- American College of Allergy, Asthma, and Immunology
- www.niaid.nih.gov -- National Institute of Allergy and Infectious Disease
- www.american-rhinologic.org -- American Rhinologic Society
- www.cdc.gov/vaccines -- National Immunization Program
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Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.