Sinusitis

 

What is it?

Sinusitis is an infection of one or more sinuses (or air-filled chambers). There are several sets of sinuses in the bones of the face:

  • a maxillary sinus within each cheekbone.
  • a frontal sinus in the forehead behind each eyebrow.
  • an ethmoidal sinus, which is small and situated between nose and eye on each side.
  • one sphenoidal sinus, deep behind the nose.

The maxillary sinus is the largest, and also the most common sinus to become infected.

Sinusitis is very common and is thought to complicate from a half to two per cent of all colds. It can occur at any age, but is more common in middle-aged people.

 

How does it occur?

Sinuses normally drain their mucus through narrow channels into the cavity of the nose. Drainage is helped by the movement of delicate hair-shaped cells called cilia, which line the sinus walls and beat in a direction that sweeps mucus out. However, fluid can collect in a sinus, especially if there is a blockage to the drainage of mucus. For example, this may occur if there are nasal polyps, or a deviated nasal septum (an abnormality of the shape of the partition between the nostrils). If infection then sets in, as it may do after a cold, then symptoms of sinusitis can develop.

Some people are more prone to sinusitis than others for a number of possible reasons:

  • their sinus openings are narrow or blocked, which may simply be due to the architecture of their skull, ie the shape of their skull and the channels within it.
  • they produce excess mucus (this includes smokers).
  • they may have defective cilia (as in Kartagener's syndrome, a rare inherited disorder).
  • they have problems clearing mucus, such as in cystic fibrosis.
  • there is an immune deficiency (including AIDS).
  • they have dental problems (such as apical abscesses in the upper jaw).

In many cases, there may be no obvious underlying cause for the sinusitis. It may simply be that a viral infection, such as a cold, has caused swelling of the lining of the passages of the nose and sinuses, resulting in restriction of the drainage channels that would normally allow the catarrh to drain away. This means that the catarrh is likely to become infected with a bacterium, thus resulting in acute sinusitis.

 

What causes sinusitis?

The cause of sinusitis, in most cases, is a build up of catarrh in the sinuses which becomes infected. The infection can be either a virus (such as one called a rhinovirus) or a bacterium. This congestion, followed by infection, explains why many people describe two phases to their symptoms. These consist of an initial phase where they have nasal congestion and the symptoms of a cold, followed by a second phase where they develop sinus pain and the other symptoms of sinus infection as detailed below.

What are the symptoms?

Sinusitis usually causes the following symptoms:

  • facial pain, sometimes only on one side, which is worse when bending down
  • facial tenderness
  • toothache
  • post-nasal drip (a feeling of catarrh running down the back of the throat)
  • sometimes a green nasal discharge
  • reduced sense of smell
  • a raised temperature
  • a general feeling of being unwell

A heavy cold can also cause many of these symptoms, so it can be hard to diagnose sinusitis.

 

What is the difference between acute and chronic sinusitis?

Acute sinusitis is infection of the sinuses, giving rise to all or some of the above symptoms, but which lasts for less than four weeks. If someone suffers from the symptoms of sinusitis and the symptoms either last for more than three months, or they get three or four episodes of acute sinus infection a year, they are said to suffer from chronic sinusitis. Sinus infection lasting between four weeks and three months is sometimes called relapsing sinusitis, but this term is rarely used.

The main significance of this difference is that people with chronic sinusitis are more likely to be investigated either by their GP or a specialist for any possible causes or alternative explanations for their symptoms.

How is sinusitis diagnosed?

In the vast majority of cases, sinusitis is diagnosed on the history (the description of the symptoms) given by the patient. Sometimes the doctor will examine the patient to look for signs of tenderness of the sinuses, or to detect possible aggravating factors such as nasal polyps or a deviated nasal septum (see above).

The only test that will definitely confirm sinusitis is puncturing the sinus with a needle and finding pus and bacteria, but this is very rarely done.

X-rays can help, especially if they show fluid in the sinus, although fluid can be present without symptoms of sinusitis and does not confirm infection. Computerised tomography (CT) or magnetic resonance imaging (MRI) scanning (special x-rays which give very detailed images) of the sinuses can sometimes be helpful, especially in cases where the diagnosis is in doubt or to look for possible causes of chronic sinusitis. So, in practical terms, doctors usually rely on the symptoms and on examining the patient to make the diagnosis.

 

What are the complications?

Complications are rare, but sometimes infection can spread from a severe case of sinusitis into the tissues under the skin, causing cellulitis, or into the bones of the orbit (around the eye). Both of these complications need antibiotic treatment, usually at a high dose. Rarely, the infection in the sinuses can spread to other areas such as into the brain causing an abscess or meningitis, or can cause something called a venous sinus thrombosis, which is clotting in a blood-filled area at the base of the skull. Obviously, these complications require urgent hospital treatment and are usually signified by a person with sinusitis suddenly becoming extremely unwell.

Another complication of sinusitis is the formation of cysts inside the sinuses, that can occasionally cause persistent headaches and may interfere with the movements of the eye(s), resulting in double vision.

As mentioned above, sometimes sinusitis fails to settle completely and the condition becomes chronic, with persistent symptoms. If so, referral to an ear, nose and throat (ENT) specialist may be needed to rule out any underlying blockage or other problem.

 

What is the treatment?

There are several drug treatments, and a patient may be prescribed all three during an attack:

  • painkillers for discomfort.
  • antibiotics.
  • decongestants to relieve blockage and excess mucus.

Painkillers such as paracetamol or ibuprofen can be very helpful in the relief of pain from sinusitis. In some cases, stronger prescription-only painkillers are required for a short period.

Decongestants can be taken by mouth or in the form of nose drops or nasal spray. They tend to work better if used directly on the nose, but can only be used for a short time. The lining of the nose gets accustomed to the drug, so when treatment stops, problems can be worse than they were in the first place. This is sometimes called a rebound effect. Because of this, the maximum length of treatment is usually set at seven days.

Although decongestants by mouth (either in tablet or syrup form) are often suggested, there is in fact no proof as yet, that they make any difference in the treatment of sinusitis. Also, although inhaling steam is a traditional method of relieving symptoms, this is unproven as an effective method of treatment. However, one could take the attitude that it may be worth trying these things anyway.

Antibiotics are often given but there is much debate as to whether they help. Many cases of sinusitis improve on their own or with simple treatments and, as yet, there is no evidence that antibiotics reduce the complication rate or the chances of developing chronic sinusitis.

 

What about surgery?

Surgery can be very useful in preventing further attacks of sinusitis when there is a blockage, an anatomical problem, or nasal polyps. Nowadays, much sinus surgery can be done telescopically through an endoscope (something called FESS - functional endoscopic sinus surgery). Unfortunately, surgery for nasal polyps is not always successful in the long-term because polyps can recur, but removal of polyps may result in significant short-term relief of symptoms lasting months or even years.

Can it be prevented?

There area number of ways to help decrease the risk of getting sinusitis. For example:

  • If you have any dental problems ensure they are treated.
  • Exercise regularly.
  • Drink plenty of fluids, especially water.
  • Do not smoke and avoid smoky environments.
  • Reduce your stress levels.
  • Have an annual flu vaccine.
  • If you have an allergy then make sure you take the appropriate medication on a regular basis or as prescribed by your doctor.
 

Are there alternative therapies?

Homeopathy is sometimes used for the treatment of sinusitis. You may wish to consult you doctor to discuss these.