Sinusitis is 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. Nonprescription pain relievers such as acetaminophen and ibuprofen can help mild-to-moderate pain. 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.
Because many cases of acute sinusitis resolve within 2 weeks with nonprescription treatments and home remedies, doctors generally wait at least 7 to 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.
Guidelines for Managing Acute Bacterial Sinusitis
According to guidelines from the Infectious Diseases Society of America (IDSA):
Guidelines for Children with Acute Bacterial Sinusitis
In 2013, the American Academy of Pediatrics updated its guidelines for diagnosing and treating acute bacterial sinusitis in children. The new guidelines recommend that doctors use "watchful waiting" before prescribing antibiotics to children with symptoms lasting more than 10 days. However, antibiotics are recommended for children with severe or worsening symptoms (nasal discharge, fever, cough).
Sinusitis (also called rhinosinusitis) is inflammation of the mucous lining of the nasal passages and sinus cavities. The sinuses are air-filled chambers in the skull (behind the forehead, nasal bones, cheeks, and eyes) that are lined with mucous membranes.
Four pairs of sinuses, known as the paranasal air sinuses, connect to the nasal passages (the two airways running through the nose):
Sinusitis occurs if obstruction or congestion causes 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, chronic, or recurrent. The classification is based on how long symptoms last:
Sinusitis is always accompanied (and usually preceded) by rhinitis, which is inflammation of the mucous membrane of the nasal cavities. The two conditions share common symptoms such as nasal obstruction and discharge.
Acute sinusitis can be caused by viral, bacterial, or fungal infections. Allergens 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:
Viral, Bacterial, and Fungal Infections
Viruses. Viruses cause 90 to 98% of acute sinusitis cases. Acute sinusitis typically starts with the common cold virus. A cold can set the stage for sinusitis by causing inflammation and congestion in the nasal passages, leading to obstruction in the sinuses.
Bacteria. A small percentage of acute sinusitis, and possibly chronic sinusitis cases, are caused by bacteria. Bacteria are normally present in the nasal passages and throat and are usually 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 mucous lining of the sinuses, causing sinusitis. Streptococcus pneumonia, Haemophilus 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 chronic rhinosinusitis cases. 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 associated with disorders that weaken the immune system or produce airway inflammation or persistent thickened stagnant mucus. These conditions include diabetes, AIDS, cystic fibrosis, Kartagener syndrome, and Wegener granulomatosis.
Structural Abnormalities of the Nasal Passage
Structural abnormalities in the nose can cause a blockage, thereby increasing the risk for chronic sinusitis. Some abnormalities include:
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 germs in the air that enter the nasopharynx.
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 to 2 months. Young children are prone to colds and may have 8 to 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.
The Elderly and Sinusitis
Older people are at heightened 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 increased risk for inflammation in the sinuses. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter, 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:
Other Medical Conditions Affecting the Sinuses
A number of medical conditions put people at risk for chronic sinusitis. They include:
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 scuba diving, risk sinus blockage and therefore face an increased risk of developing sinusitis. (Swimming also increases the risk for sinusitis.)
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. It is still not clear whether air pollution is an important cause of sinusitis and which specific pollutants are critical factors. Cigarette smoke, for example, poses a small but definite risk for sinusitis in adults. Secondhand 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, bacterial sinusitis can cause very serious infections.
Infection of the Frontal Bone. Osteomyelitis is infection of the bones. In rare cases, sinusitis can lead to infection 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 puffy tumor.
Infection of the Eye Socket. Infection of the eye socket (orbital cellulitis), 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.
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.
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 infection of the eye socket. 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.
Increased Asthma Severity
Many people with moderate-to-severe asthma also have sinusitis and allergic rhinitis. The relationship between sinusitis and asthma is not clear, but sinusitis appears to predispose people to more severe asthma attacks. Evidence suggests that treating one condition can have a beneficial impact on the other.
Effect on Quality of Life
Pain, fatigue, and other symptoms of chronic sinusitis can have significant effects on 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. 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:
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 to 10 days and then improve. Acute bacterial sinusitis, in contrast to viral sinusitis, usually takes one of the following three paths:
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 serious cases of sinusitis.
Children. In children, the most common signs and symptoms of acute bacterial sinusitis are daytime cough (which may worsen at night), nasal discharge, and fever. Bad breath, fatigue, headache, and decreased appetite are also common symptoms in young children, but they do not necessarily indicate sinusitis.
The American Academy of Pediatrics recommends that doctors diagnose acute bacterial sinusitis when a child with an upper respiratory infection has:
Children with worsening or severe symptoms should be treated with antibiotics. For other children, watchful waiting is appropriate to see if the infection clears up on its own.
Chronic Sinusitis Symptoms
With chronic sinusitis:
Symptoms Indicating a Medical Emergency
Rare complications of sinusitis can produce additional symptoms, which may be severe or even life-threatening. Symptoms indicating a medical emergency include:
Other Causes of Sinusitis Symptoms
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:
Migraine and Other Headaches. Many primary headaches, particularly migraine or cluster headaches, 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, including:
See your doctor if you have sinusitis symptoms that do not clear up within a few days, are severe, or are accompanied by high fever or sudden generalized illness.
The first goal in diagnosing sinusitis is to rule out other possible causes of symptoms, and then determine:
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.
The doctor will evaluate the symptoms and take a thorough medical history, including:
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 look for mucus and 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. It can evaluate structural problems of the nasal septum, as well as the presence of soft tissue growths such as polyps. Rhinoscopy may also identify small amounts of pus draining from the opening of a sinus. Bacterial cultures can be taken from samples removed using endoscopy. (Endoscopy is also used for treating sinusitis.)
Computed 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 abnormal findings on a CT scan. Therefore, CT scans are not recommended for most cases of uncomplicated acute bacterial sinusitis. They are only recommended for acute sinusitis if there is a severe infection, complications, or a high risk for complications, especially those that may affect the eyes or central nervous system.
CT scans can be useful for diagnosing chronic or recurrent acute sinusitis and for planning operations. They show inflammation and swelling and the extent of the infection, including in deeply hidden air chambers x-rays and nasal endoscopy miss. They may also detect fungal infections.
X-Rays. X-rays used to be commonly used, but they are not as accurate as endoscopy and CT scans for identifying abnormalities in the sinuses, particularly the ethmoid sinuses.
Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) is not as effective as CT in viewing the paranasal anatomy, and is therefore 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 it 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 and is performed only when patients are at risk of having unusual infections or serious complications, or if 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
Cold and flu viruses spread when an infected person coughs or sneezes. These viruses can also be transmitted by shaking hands. Everyone should always wash their hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleansers that contain an alcohol-based gel are also effective. Antibacterial soaps add little protection, particularly against viruses. Wiping surfaces with a solution that contains 1 part bleach to 10 parts water is very effective in killing viruses.
Influenza Vaccine. Doctors recommend that most people receive annual influenza vaccinations in October or November. Because influenza viruses change from year to year, influenza vaccines are redesigned annually to match the anticipated viral strains.
Flu vaccines are now recommended for virtually everyone over 6 months of age, except for those allergic to eggs or other vaccine compounds.
Pneumococcal Vaccines. Pneumococcal vaccines protect against S. pneumoniae (also called pneumococcal) bacteria, the most common bacterial cause of respiratory infections. Pneumococcal vaccination is recommended for all children and for all adults age 65 and older. The vaccine is also recommended for adults younger than age 65 who have health conditions that compromise their immune system or raise their risk for infection, as well as for smokers and patients with asthma.
General Treatment Approaches
General treatment goals for sinusitis aim to:
Most patients with sinusitis do not require aggressive treatment. Home remedies can be very helpful.
Bacterial sinusitis, which is treated with antibiotics, accounts for only 2 to 10% of acute sinusitis cases. Most cases of sinusitis are caused by viruses, which do not respond to antibiotics. Acute viral sinusitis generally clears up on its own within 7 to 10 days.
It is important to reserve antibiotics for illnesses caused by bacteria. The intense and widespread use of antibiotics has led to a serious global problem of antibiotic-resistant bacteria.
Treatment of Acute Sinusitis:
Treatment of Chronic Sinusitis:
Home remedies that open and hydrate the sinuses are often the only treatment necessary for mild sinusitis that is not accompanied by signs of acute infection.
A nasal wash can be helpful for removing mucus from the nose and relieving sinusitis symptoms. A saline (salt water) 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.) If you prepare your own saline solution, use bottled or boiled water, not plain tap water. Perform the nasal wash several times a day.
A simple method for administering a nasal wash is:
Neti pots have also become popular in recent years for prevention and treatment of sinusitis. To do nasal irrigation with a saline solution through a Neti pot:
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 have nonbacterial sinusitis during allergy season.
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.
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.
Antibiotic drugs are used to treat bacterial, not viral, infections. Unfortunately, because of the overuse and improper use of antibiotics, many types of bacteria no longer respond to antibiotic treatment. The bacteria have become resistant to these drugs. Due to the problem of bacterial resistance, doctors have had to switch to different or stronger types of antibiotics to treat bacterial infections.
Amoxicillin, a type of penicillin, is the main antibiotic used for mild-to-moderate acute bacterial sinusitis, but due to bacterial resistance it has become less effective. Amoxicillin-clavulanate (Augmentin, generic) may be used as an alternative to amoxicillin for treating acute bacterial sinusitis in both children and adults, especially for patients with moderate-to-severe illness. It is a type of penicillin that works against a wide spectrum of bacteria.
Patients who have a history of penicillin allergy cannot take amoxicillin-clavulanate:
Other types of antibiotics, such as macrolides and trimethoprim-sulfamethoxazole, have also become ineffective for treating acute bacterial sinusitis and are no longer recommended.
Side Effects. Side effects of antibiotics vary according to the specific drug and the patient's individual response. Many patients experience few side effects, but they may include:
Nasal-spray corticosteroids, commonly called steroids, are effective drugs for treating allergic rhinitis. Although they are not approved for treating sinusitis, they may be helpful for patients with sinusitis (either chronic or acute) who have a history of allergic rhinitis. Nasal spray steroids can help reduce inflammation and mucus production. Oral (systemic) corticosteroids are not helpful for treating sinusitis.
Corticosteroids that are available in nasal spray form and are approved for treating nasal allergy symptoms include:
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 widespread side effects is very low unless the drug is used excessively. Side effects of nasal corticosteroids may include:
Decongestants are drugs that help reduce nasal congestion. They are available in both pill and nasal spray forms. However, decongestants will not cure sinusitis. They 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 ordered manufacturers of over-the-counter (OTC) nasal decongestant products to remove all references to sinusitis from their labeling. The Infectious Diseases Society of America does not recommend nasal or oral decongestants for patients with acute bacterial 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 never be used in infants and children under age 4, and some doctors recommend not giving them to children under age 14. Children are at particular risk for central nervous system side effects, including convulsions, rapid heart rate, loss of consciousness, and death.
Antihistamines such as diphenhydramine (Benadryl, generic) are included in many cold and allergy medications. Because they dry and thicken nasal secretions, they make sinus drainage difficult and may worsen sinusitis. Patients with sinusitis should not take antihistamines.
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 to insert a drainage tube into the sinuses, followed by an infusion of sterile water to flush out the sinuses.
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 polyps, ventilation, and drainage to aid healing.
Candidates for the Procedure. In general, patients should have tried and failed extensive medical therapy before undergoing surgery. This usually includes several prolonged courses of broad-spectrum antibiotics, nasal corticosteroids, nasal saline irrigation, allergy testing and immunotherapy (when appropriate), and sinus drainage (when appropriate).
Patients who may benefit from endoscopy include those with:
Procedure. The surgery generally proceeds as follows:
Complications. Serious complications of FESS are very rare, but may include cerebrospinal fluid leakage, meningitis, hemorrhage, or infection.
Postsurgical Care. Postsurgical care involves the following:
Success Rates. It may take several months for the mucous membranes to completely recover, but 85 to 90% of patients have good-to-excellent relief of their symptoms after surgery. Children may need a second procedure 2 to 3 weeks after the first surgery to remove crusty matter.
A newer 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. The procedure is best suited for select patients with sinusitis disease in the maxillary (behind the cheekbones), frontal (behind the sides of the forehead), and sphenoid (behind the eyes) sinus regions. It is inappropriate for patients with disease in the ethmoid (between the eyes) sinuses because of the risk of eye injury.
Invasive Conventional Surgery
Endoscopy is now used in most cases of chronic sinusitis, but in severe cases, invasive surgery using conventional scalpel techniques may be required to remove infected areas. This may be the case with acute ethmoid sinusitis in which pus breaks through the sinus and threatens the eye, very severe frontal sinusitis, invasive fungal sinusitis, or when cancer is present in the sinuses.
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