chronic sinusitis

What is chronic sinusitis

Chronic sinusitis is an inflammatory disease of the paranasal sinuses that lasts for 12 weeks or longer and is usually caused by prolonged inflammation, rather than a longstanding infection.

Chronic sinusitis also known as chronic rhinosinusitis, this condition interferes with drainage and causes mucus buildup. Breathing through your nose might be difficult. The area around your eyes and face might feel swollen, and you might have facial pain or tenderness.

Chronic sinusitis (chronic rhinosinusitis) occurs in 1% to 5% of the U.S. population 1). It may significantly decrease quality of life.

Chronic sinusitis (chronic rhinosinusitis) is defined by the presence of at least two out of four cardinal symptoms (i.e., facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction) for at least 12 consecutive weeks, in addition to objective evidence. Objective evidence of chronic rhinosinusitis may be obtained on physical examination (anterior rhinoscopy, endoscopy) or radiography, preferably from sinus computed tomography.

Chronic sinusitis can be brought on by an infection, by growths in the sinuses (nasal polyps) or by a deviated nasal septum. The condition most commonly affects young and middle-aged adults, but it also can affect children.

Chronic sinusitis lasts for a longer period of time than acute sinusitis and is likely caused by different things. Acute sinusitis is diagnosed when symptoms last up to 4 weeks. It is usually caused by viruses or bacteria. Chronic sinusitis is defined as lasting for 12 weeks or longer and is usually caused by prolonged inflammation, rather than a longstanding infection. Infection can be a part of chronic sinusitis, especially when it worsens from time to time, but is not usually the main cause.

Treatment is directed at enhancing mucociliary clearance, improving sinus drainage/outflow, eradicating local infection and inflammation, and improving access for topical medications. Because chronic sinusitis is caused more by inflammation than infection, the treatments for chronic sinusitis are meant to control the inflammation. First-line treatment is nasal saline irrigation and intranasal corticosteroid sprays. Salt water nasal irrigation and/or nasal steroid sprays are the main treatments for the symptoms of chronic sinusitis. It may help to look for other factors that can go along with chronic sinusitis and possibly make the problem worse, and have them treated too. Some of these factors are allergies, nasal polyps, asthma, and problems with the body’s ability to fight infections.

Making your own saline nasal irrigation solution

There are many over-the-counter saline (salt water) solutions available, but you can make your own saline solution at home:

  • 1 quart (4 cups) boiled or distilled water
  • 1 teaspoon baking soda
  • 1 teaspoon non-iodized salt

If you make your own rinse, use water that’s contaminant-free — distilled, sterile, previously boiled and cooled, or filtered using a filter with an absolute pore size of 1 micron or smaller — to make up the irrigation solution. Also be sure to rinse the irrigation device after each use with contaminant-free water, and let air-dry.

There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection. If medical management fails, endoscopic sinus surgery may be effective. Patients not responding to first-line medical therapy should be referred to an otolaryngologist, and selected patients with a history suggestive of other comorbidities (e.g., vasculitides, granulomatous diseases, cystic fibrosis, immunodeficiency) may also benefit from referral to an allergist or pulmonologist.

Surgery for the sinuses is done when the symptoms can’t be controlled with medications and other treatments. The most common type of surgery for the sinuses is called endoscopic sinus surgery, because a pencil-sized scope (“endoscope”) is used to see inside the nose and sinuses and guide the surgery. The purpose of the surgery is to widen the natural drainage pathways between the sinuses and the nose, allowing mucus to get out of the sinuses and air to get in. Medications that are delivered to the surface of the nose and sinuses, like sprays and irrigations, can get into the sinuses better after surgery as well.

The sinuses

The paranasal sinuses are spaces in the bones of the skull which are mainly full of air. The paranasal sinuses include:

  • the sphenoid sinus – in the centre of the head;
  • the maxillary sinuses – situated in the cheekbones;
  • the frontal sinuses – above the eyes; and
  • the ethmoidal sinuses – on either side of the nose.

The lining of the sinuses produces clear fluid – mucus – which cleans them. This fluid passes through narrow drainage passages into the back of the nose and throat, from where it is swallowed. This happens continually, although we are usually unaware of it.

Because the drainage holes from the sinuses are narrow, they block up easily. So any excess mucus production can cause a blockage, and pressure builds up in the sinuses.

The 2 main causes of excess mucus production are:

  • Infection; and
  • Allergy.

Figure 1. Paranasal sinuses

Paranasal sinusesParanasal sinuses - medial aspect

Complications of chronic sinusitis

Chronic sinusitis complications include:

  • Meningitis. This infection causes inflammation of the membranes and fluid surrounding your brain and spinal cord.
  • Other infections. Uncommonly, infection can spread to the bones (osteomyelitis) or skin (cellulitis).
  • Partial or complete loss of sense of smell. Nasal obstruction and inflammation of the nerve for smell (olfactory nerve) can cause temporary or permanent loss of smell.
  • Vision problems. If infection spreads to your eye socket, it can cause reduced vision or even blindness that can be permanent.

Chronic sinusitis causes

The cause of chronic rhinosinusitis is mostly unknown, but it is not caused by an infection. Instead, it is thought to be caused by your immune system overreacting to something in the sinuses.

More than 50% of individuals with allergic rhinitis (hay fever or seasonal allergies) have clinical 2) or radiographic 3) evidence of chronic sinusitis and conversely, 25–58% of individuals with sinusitis have aeroallergen sensitization 4). Elevated total IgE (immunoglobulin E are antibodies produced by the immune system) is a risk factor for the presence of severe chronic sinusitis 5) and both sensitivity to multiple allergens and sensitivity to perennial allergens (e.g., dust mites) are independently associated with increased likelihood of having chronic sinusitis 6). Together, these studies support the concept that chronic sinusitis could be an atopic disease driven by IgE sensitization to aeroallergens.

Very rarely, it may be caused by another condition such as a poor immune system, swelling of blood vessels, cystic fibrosis, or primary ciliary dyskinesia.

Common causes of chronic sinusitis include:

  • Nasal polyps. These tissue growths can block the nasal passages or sinuses.
  • Deviated nasal septum. A crooked septum — the wall between the nostrils — may restrict or block sinus passages.
  • Other medical conditions. The complications of cystic fibrosis, gastroesophageal reflux, or HIV and other immune system-related diseases can result in nasal blockage.
  • Respiratory tract infections. Infections in your respiratory tract — most commonly colds — can inflame and thicken your sinus membranes and block mucus drainage. These infections can be viral, bacterial or fungal.
  • Allergies such as hay fever. Inflammation that occurs with allergies can block your sinuses.

Risk factors for Chronic sinusitis

You’re at increased risk of getting chronic or recurrent sinusitis if you have:

  • A nasal passage abnormality, such as a deviated nasal septum or nasal polyps
  • Asthma, which is highly connected to chronic sinusitis
  • Aspirin sensitivity that causes respiratory symptoms
  • An immune system disorder, such as HIV/AIDS or cystic fibrosis
  • Hay fever or another allergic condition that affects your sinuses
  • Regular exposure to pollutants such as cigarette smoke

Prevention of chronic sinusitis

Take these steps to reduce your risk of getting chronic sinusitis:

  • Avoid upper respiratory infections. Minimize contact with people who have colds. Wash your hands frequently with soap and water, especially before meals.
  • Manage your allergies. Work with your doctor to keep symptoms under control.
  • Avoid cigarette smoke and polluted air. Tobacco smoke and air contaminants can irritate and inflame your lungs and nasal passages.
  • Use a humidifier. If the air in your home is dry, such as it is if you have forced hot air heat, adding moisture to the air may help prevent sinusitis. Be sure to keep the humidifier clean and free of mold with regular, thorough cleaning.

Chronic sinusitis symptoms

At least two of the four primary signs and symptoms of chronic sinusitis must be present for at least 12 consecutive weeks with confirmation of nasal inflammation for a diagnosis of the condition. They are 7):

  • Thick, discolored discharge from the nose or drainage down the back of the throat (postnasal drainage)
  • Nasal obstruction or congestion, causing difficulty breathing through your nose
  • Pain, tenderness and swelling around your eyes, cheeks, nose or forehead
  • Reduced sense of smell and taste in adults or cough in children

Other signs and symptoms can include:

  • Ear pain
  • Aching in your upper jaw and teeth
  • Cough that might worsen at night
  • Sore throat
  • Bad breath (halitosis)
  • Fatigue or irritability
  • Nausea

Chronic sinusitis and acute sinusitis have similar signs and symptoms, but acute sinusitis is a temporary infection of the sinuses often associated with a cold. The signs and symptoms of chronic sinusitis last longer and often cause more fatigue. Fever isn’t a common sign of chronic sinusitis, but you might have one with acute sinusitis.

When to see a doctor

See a doctor immediately if you have any of the following, which could indicate a serious infection:

  • High fever
  • Swelling or redness around your eyes
  • Severe headache
  • Confusion
  • Double vision or other vision changes
  • Stiff neck

Chronic sinusitis diagnosis

Your doctor will feel for tenderness in your nose and face and look inside your nose.

Other methods for diagnosing chronic sinusitis include:

  • Nasal endoscopy. A thin, flexible tube (endoscope) with a fiber-optic light inserted through your nose allows your doctor to see the inside of your sinuses. This also is known as rhinoscopy.
  • Imaging studies. Images taken using a CT scan or MRI can show details of your sinuses and nasal area. These might pinpoint a deep inflammation or physical obstruction that’s difficult to detect using an endoscope.
  • Nasal and sinus cultures. Cultures are generally unnecessary for diagnosing chronic sinusitis. However, when the condition fails to respond to treatment or is worsening, tissue cultures might help determine the cause, such as bacteria or fungi.
  • An allergy test. If your doctor suspects that the condition might be triggered by allergies, he or she might recommend an allergy skin test. A skin test is safe and quick and can help pinpoint the allergen that’s responsible for your nasal flare-ups.

Chronic sinusitis treatment

The goal of treating chronic sinusitis is to:

Reduce sinus inflammation
Keep your nasal passages draining
Eliminate the underlying cause
Reduce the number of sinusitis flare-ups

How to treat chronic sinusitis

These treatments include:

Saline nasal irrigation, with nasal sprays or solutions, reduces drainage and rinses away irritants and allergies.

Nasal corticosteroids. These nasal sprays help prevent and treat inflammation. Examples include fluticasone (Flonase, Veramyst), triamcinolone (Nasacort 24), budesonide (Rhinocort), mometasone (Nasonex) and beclomethasone (Beconase AQ, Qnasl, others).

If the sprays aren’t effective enough, your doctor might recommend rinsing with a solution of saline mixed with drops of budesonide (Pulmicort Respules) or using a nasal mist of the solution.

Oral or injected corticosteroids. These medications are used to relieve inflammation from severe sinusitis, especially if you also have nasal polyps. Oral corticosteroids can cause serious side effects when used long term, so they’re used only to treat severe symptoms.

Aspirin desensitization treatment, if you have reactions to aspirin that cause sinusitis. Under medical supervision, you’re gradually given larger doses of aspirin to increase your tolerance.

Antibiotics

Antibiotic therapy for chronic sinusitis is controversial and may be most appropriate for acute exacerbation of chronic sinusitis. Medical therapy should include both a broad-spectrum antibiotic and a topical intranasal steroid to address the strong inflammatory component of this disease. Antibiotic therapy might need to be continued for 4 to 6 weeks 8). The antibiotics of choice include agents that cover organisms causing acute sinusitis but also cover Staphylococcus species and anaerobes. These include amoxicillin-clavulanate, cefpodoxime proxetil, cefuroxime, gatifloxacin, moxifloxacin, and levofloxacin. Currently used topical intranasal steroids such as fluticasone (Flonase), mometasone (Nasonex), budesonide (Rhinocort AQ), and triamcinolone (Nasacort AQ) have a favorable safety profile and indications for the pediatric age group. A short course of oral steroids may be used for extensive mucosal thickening and congestion or nasal polyps.

Immunotherapy

If allergies are contributing to your sinusitis, allergy shots (immunotherapy) that help reduce the body’s reaction to specific allergens might improve the condition.

Chronic sinusitis home remedies

These self-help steps can help relieve sinusitis symptoms:

  • Rest. This will help your body fight inflammation and speed recovery.
  • Drink fluids, such as water or juice. This will help dilute mucous secretions and promote drainage. Avoid beverages that contain caffeine or alcohol, which can be dehydrating. Drinking alcohol also can worsen the swelling of the lining of the sinuses and nose.
  • Moisturize your sinus cavities. Drape a towel over your head as you breathe in the vapor from a bowl of medium-hot water. Keep the vapor directed toward your face. Or take a hot shower, breathing in the warm, moist air to help ease pain and help mucus drain.
  • Apply warm compresses to your face. Place warm, damp towels around your nose, cheeks and eyes to ease facial pain.
  • Rinse out your nasal passages. Use a specially designed squeeze bottle (Sinus Rinse, others), saline canister or neti pot to rinse your nasal passages. This home remedy, called nasal lavage, can help clear your sinuses. If you make your own rinse, use water that’s contaminant-free — distilled, sterile, previously boiled and cooled, or filtered using a filter with an absolute pore size of 1 micron or smaller — to make up the irrigation solution. Also be sure to rinse the irrigation device after each use with contaminant-free water, and let air-dry.
  • Sleep with your head elevated. This will help your sinuses drain, reducing congestion.

Chronic sinusitis surgery

In cases resistant to treatment or medication, endoscopic sinus surgery might be an option. For this procedure, the doctor uses a thin, flexible tube with an attached light (endoscope) to explore your sinus passages.

Depending on the source of obstruction, the doctor might use various instruments to remove tissue or shave away a polyp that’s causing nasal blockage. Enlarging a narrow sinus opening also may be an option to promote drainage.

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