By Dr. Richard K. Caldwell, M.D.

Sinusitis

The term sinusitis refers to inflammation of the para-nasal sinuses, the sinuses associated with or connected to the nose. The inflammation can be caused by infection (viral, bacterial, fungal), allergies, chemical irritation or injury, or others such as sarcoid or Wegener’s disease. For this discussion the focus will be infection.

The sinuses require ventilation and drainage into the nose to be healthy. Mucus and other secretions create a protective blanket for the nose and sinuses and is constantly being cleared into the nose and is then expelled or swallowed. Anything that interferes with proper ventilation and drainage can cause inflammation and infection.

Sinusitis is always among the top 8 reasons people in the United States see a physician and is the 5th most common reason for antibiotic prescriptions. Sinusitis is the 3rd most common reason Americans purchase over the counter medications. 14% of adults self-diagnose with sinusitis each year. The annual cost of sinusitis in 2006 was estimated to be $3.4 billion. Quality of life and productivity of affected patients are significantly affected.

Symptoms

Typical symptoms of sinusitis include nasal congestion, facial/head pressure, nasal drainage or discharge, sore throat, headache, and cough. Lack of energy, fever, sneezing, and swelling of face, eyelids, and forehead may also be significant symptoms.

Upper respiratory viral infections such as the common cold and upper respiratory allergy such as hay fever are the two most common predisposing factors for developing sinusitis. Membrane swelling in the nose then leads to obstruction of the sinus ventilation and drainage pathways. This disruption of ventilation and drainage is thought to be the single most important factor leading to sinusitis.

In children sinusitis can be different than in adults as sinus development depends on the age of the child. Symptoms can also be different in children. Often in children enlarged adenoid tissue contributes to nasal obstruction and sinusitis.

Untreated sinusitis has the potential to develop severe complications and the consequences can be devastating. The potential for life threatening complications exists even today although they are rare compared to the pre-antibiotic era. Sinus infections that spread to involve the eye or base of the brain can cause blindness, meningitis, epidural abscess and death. Sinus infections in immune compromised patients such as diabetes, HIV, patients receiving chemotherapy can be much more difficult to treat.

Treatment

Treatment with conservative measures is usually effective. Oral hydration, nasal saline sprays, and using a cool mist humidifier are of benefit. Over the counter medicines such as decongestants pseudoephedrine and phenylephrine), mucus thinning medicine (guaifenesin), decongestant nasal sprays (Afrin, Neo-Synephrine), and antihistamines (Zyrtec, Allegra) can be helpful. Due to the possible development of dependence the deconges-tant nasal sprays such as Afrin should not be used for more than 5 days. Appropriate antibiotic therapy (based on culture and sensitivity data when possible) may be required. Treatment with antibiotics is more likely to be necessary if symptoms persist more than 10 days and are failing to respond to the aforementioned conservative treatment measures. A case can often be made for including steroid medications either in nasal spray form or as oral or injectable medication. Steroid medications are effective at reducing swelling but remain somewhat controversial because of possible side effects including the possibility of suppressing the patient’s immune system. Use of these medications should be carefully considered by the patient and physician. Antihistamines have the potential to dry and thicken secretions and therefore should also be used carefully in patients with active sinus infection.

If measures discussed thus far fail to adequately address the signs and symptoms and the patient continues to suffer with sinusitis, then surgery may be considered to open and drain affected sinuses. Sinus surgery is most commonly performed endoscopically, though as with any surgery, the risks and benefits need to be carefully considered. Correction of a deviated septum (middle wall of the nose) is sometimes required. Surgery to address enlarged turbinates (normal tissues in the nose that sometimes permanently swell), obstructing polyps, or enlarged adenoids is sometimes required to adequately address chronic or recurring sinusitis. Children tend to have higher rates of spontaneous resolution and tend to respond to medications better than adults therefore indications for surgery in children are more conservative.

In summary, sinusitis is a common condition for which patients seek medical attention. Sinusitis causes many different troublesome symptoms that significantly affect quality of life and productivity in those affected. Often sinusitis results in multiple doctor visits and multiple courses of medication. Although rare, life-threatening complications can occur, medical treatment is usually effective at treating sinusitis. Sometimes more aggressive measures such as surgery can be necessary. Treatment strategies should be tailored to the individual patient.