Sinus

Nose Denver.jpgVestibulitis vs. Inflammation of the nasal mucous membrane is called rhinitis. The symptoms include sneezing and runny and/or itchy nose, caused by irritation and congestion in the nose. There are two types: allergic rhinitis and non-allergic rhinitis.

Allergic Rhinitis

This condition occurs when the body’s immune system over-responds to specific, non-infectious particles such as plant pollens, molds, dust mites, animal hair, industrial chemicals (including tobacco smoke), foods, medicines, and insect venom. During an allergic attack, antibodies, primarily immunoglobin E (IgE), attach to mast cells (cells that release histamine) in the lungs, skin, and mucous membranes. Once IgE connects with the mast cells, a number of chemicals are released. One of the chemicals, histamine, opens the blood vessels and causes skin redness and swollen membranes. When this occurs in the nose, sneezing and congestion are the result.

Seasonal allergic rhinitis or hayfever occurs in late summer or spring. Hypersensitivity to ragweed, not hay, is the primary cause of seasonal allergic rhinitis in 75 percent of all Americans who suffer from this seasonal disorder. People with sensitivity to tree pollen have symptoms in late March or early April; an allergic reaction to mold spores occurs in October and November as a consequence of falling leaves.

Perennial allergic rhinitis occurs year-round and can result from sensitivity to pet hair, mold on wallpaper, houseplants, carpeting, and upholstery. Some studies suggest that air pollution such as automobile engine emissions can aggravate allergic rhinitis. Although bacteria is not the cause of allergic rhinitis, one medical study found a significant number of the bacteria Staphylococcus aureus in the nasal passages of patients with year-round allergic rhinitis, concluding that the allergic condition may lead to higher bacterial levels, thereby creating a condition that worsens the allergies. 

Patients who suffer from recurring bouts of allergic rhinitis should observe their symptoms on a continuous basis. If facial pain or a greenish-yellow nasal discharge occurs, a qualified ear, nose, and throat specialist can provide appropriate sinusitis treatment.

Non-Allergic Rhinitis: This form of rhinitis does not depend on the presence of IgE and is not due to an allergic reaction. The symptoms can be triggered by cigarette smoke and other pollutants as well as strong odors, alcoholic beverages, and cold. Other causes may include blockages in the nose, a deviated septum, infections, and over-use of medications such as decongestants.

Rhinosinusitis: Clarifying The Relationship Between The Sinuses And Rhinitis

Recent studies by otolaryngologist–head and neck surgeons have better defined the association between rhinitis and sinusitis. They have concluded that sinusitis is often preceded by rhinitis and rarely occurs without concurrent rhinitis. The symptoms, nasal obstruction/discharge and loss of smell, occur in both disorders. Most importantly, computed tomography (CT scan) findings have established that the mucosal linings of the nose and sinuses are simultaneously involved in the common cold (previously, thought to affect only the nasal passages). Otolaryngologists, acknowledging the inter-relationship between the nasal and sinus passages, now refer to sinusitis as rhinosinusitis.

The catalyst relating the two disorders is thought to involve nasal sinus overflow obstruction, followed by bacterial colonization and infection leading to acute, recurrent, or chronic sinusitis. Likewise, chronic inflammation due to allergies can lead to obstruction and subsequent sinusitis.

Other medical research has supported the close relationship between allergic rhinitis and sinusitis. In a retrospective study on sinus abnormalities in 1,120 patients (from two to 87 years of age), thickening of the sinus mucosa was more commonly found in sinusitis patients during July, August, September, and December, months in which pollen, mold, and viral epidemics are prominent. A review of patients (four to 83 years of age) who had surgery to treat their chronic sinus conditions revealed that those with seasonal allergy and nasal polyps are more likely to experience a recurrence of their sinusitis.

Sinusitis

Sinus Facts

Have you ever had a cold or allergy attack that wouldn't go away? If so, there's a good chance you actually had sinusitis. Experts estimate that 37 million people are afflicted with sinusitis each year, making it one of the most common health conditions in America. That number may be significantly higher, since the symptoms of bacterial sinusitis often mimic those of colds or allergies, and many sufferers never see a doctor for proper diagnosis and treatment with an antibiotic.

What is Sinusitis?

Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician's diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.

Normally, mucus collecting in the sinuses drains into the nasal passages. When you have a cold or allergy attack, your sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Diagnosis of acute sinusitis usually is based on a physical examination and a discussion of your symptoms. Your doctor also may use x-rays of your sinuses or obtain a sample of your nasal discharge to test for bacteria.

When Acute Sinusitis Becomes Chronic

When you have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.

Treating Sinusitis

Bacterial sinusitis: Therapy for bacterial sinusitis should include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart), be sure to see your doctor for diagnosis. In addition to an antibiotic, an oral or nasal spray or drop decongestant may be recommended to relieve congestion, although you should avoid prolonged use of nonprescription nasal sprays or drops. Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.

Antibiotic Resistance

Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections, such as sinusitis, challenging to treat. You can help prevent antibiotic resistance. If the doctor prescribes an antibiotic, it is important that you take all of the medication just as your doctor instructs, even if your symptoms are gone before the medicine runs out.

Chronic Sinusitis

If your doctor thinks you have chronic sinusitis, intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.

Sinus Surgery

Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease. Surgery can be performed under the upper lip, behind the eyebrow, next to the nose or scalp, or inside the nose itself.

Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope, the surgeon can look directly into the nose, while at the same time, removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor, depending on your individual circumstances.

Before surgery, be sure that you have realistic expectations for the results, recovery, and postoperative care. Good results require not only good surgical techniques, but a cooperative effort between the patient and physician throughout the healing process. It is equally important for patients to follow pre- and postoperative instructions.

Preventing Sinusitis

As always, an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack, keep your sinuses clear by:

    * using an oral decongestant or a short course of nasal spray decongestant
    * gently blowing your nose, blocking one nostril while blowing through the other
    * drinking plenty of fluids to keep nasal discharge thin
    * avoiding air travel. If you must fly, use a nasal spray decongestant before take-off to prevent blockage of the sinuses allowing mucus to drain
    * If you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks 

Allergy testing, followed by appropriate allergy treatments, may increase your tolerance of allergy-causing substances. If you believe you may have sinusitis, see our tips for sinusitis sufferers.

When to See a Doctor

Because the symptoms of sinusitis sometimes mimic those of colds and allergies, you may not realize you need to see a doctor. If you suspect you have sinusitis, review these signs and symptoms. If you suffer from three or more, you should see your doctor.

Children & Sinusitis

Your child's sinuses are not fully developed until age 20. However, children can still suffer from sinus infection. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Sinusitis is difficult to diagnose in children because respiratory infections are more frequent, and symptoms can be subtle. Unlike a cold or allergy, bacterial sinusitis requires a physician's diagnosis and treatment with an antibiotic to prevent future complications.

The following symptoms may indicate a sinus infection in your child:

    * a "cold" lasting more than 10 to 14 days, sometimes with low-grade fever
    * thick yellow-green nasal drainage
    * post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
    * headache, usually not before age 6
    * irritability or fatigue
    * swelling around the eyes 

If despite appropriate medical therapy these symptoms persist, care should be taken to seek an underlying cause. The role of allergy and frequent upper respiratory infections should be considered.

Symptoms Of Sinusitis

Pain in the sinus area does not automatically mean that you have a sinus disorder. On the other hand, sinus and nasal passages can become inflamed leading to a headache. Headache is one of the key symptoms of patients diagnosed with acute or chronic sinusitis. In addition to a headache, sinusitis patients often complain of:

    * Pain and pressure around the eyes, across the cheeks and the forehead
    * Achy feeling in the upper teeth
    * Fever and chills
    * Facial swelling
    * Nasal stuffiness
    * Yellow or green discharge 

However, it is important to note that there are some cases of headaches related to chronic sinusitis without other upper respiratory symptoms. This suggests that an examination for sinusitis be considered when treatment for a migraine or other headache disorder is unsuccessful. 

Emergence Of Increasing Drug Resistance In Chronic Sinusitis
Chronic sinusitis patients have frequent infections. There are several studies that demonstrate increased antibiotic resistance, and the emergence of gram negative and fungal species. We are studying whether there are approaches that can decrease the use of empiric antibiotics in chronic sinus patients. Several studies continue at CSI in this area. These include:

  • Use of culture-directed therapy for acute infections in chronic sinus patients.
  • Randomized study of post-operative antibiotics after sinus surgery.
  • Microbiology of acute infections in chronic sinus patients.

Use Of Anti-Fungals In The Management Of Allergic Fungal Sinusitis
Allergic Fungal Sinusitis can lead to extensive and recurrent sinus disease. The use of nebulized antifungals, antifungal nasal rinses, and oral antifungals are recommended. Side effects, failure rate and outcome data of these different approaches are being studied.

Psychological Impact Of Chronic Sinusitis On Patients
All chronic diseases can lead to significant impact on the quality of life and psychological functioning of patients. Quality of life outcomes are conducted on all sinus patients at CSI. Retrospective studies (via outcome surveys) on the impact of several therapies include:

  • Impact of longer endoscopic and culture-directed therapy,
  • Impact of revision endoscopic sinus surgery with surgical navigation,

Impact of nebulized therapies on psychological outcome measures.

Sinusitis and Children

Sinusitis is the inflammation of one or more of the sinuses that drain into the nose. Everyone has four sets of sinuses. In children, the ethmoid sinuses are most commonly affected.

A common cold may start a sinus infection. Also, unusual little things such as a peanut, a raisin or a bead pushed into the nose may cause a nasal infection.

When an infection begins, the lining of the sinuses may become swollen blocking the passage where normal sinus mucous drains. This results in a back up of mucus which can not get out. When this mucous remains in the sinus too long it can become infected.

Signs of  Sinusitis and children 

Many of the signs of childhood sinusitis are the same as the common cold. When the symptoms of a cold last longer than seven or ten days it is time to consider a sinus infection. Common sinus infection symptoms include:

  • fever
  • yellow or green nasal drainage
  • cough
  • headache
  • facial pain or facial pressure
  • congestion
  • swelling around the eyes
  • sneezing "attacks"

How will doctor know if sinusitis is my child's problem? 

Often your doctor is able to diagnose sinusitis from your description of the problem. Sometimes your physician will need an X-ray (CAT scan) of the sinuses to exactly identify the problem. 

How will my child be treated? 

Antibiotics are the primary medication for the treatment of sinusitis. Other medications include:

  • decongestants to decrease mucous
  • mucolytics to thin the mucous
  • cortisone nasal spray to reduce nasal swelling

It is very important to finish all of the medication even if the symptoms of the infection seem to have gone away. 

Sometimes the medications do not completely clear away the infection. The child then requires a re-evaluation. It is very important for you to keep in contact with your physician. Your child depends on you.

Howard Levine, M.D.
Mt. Sinai Nasal-Sinus Center, Cleveland, OH 

Treatment For A Sinus Headache

Sinus headaches are associated with a swelling of the membranes lining the sinuses (spaces adjacent to the nasal passages). Pain occurs in the affected region – the result of air, pus, and mucus being trapped within the obstructed sinuses. The discomfort often occurs under the eye and in the upper teeth (disguised as a headache or toothache). Sinus headaches tend to worsen as you bend forward or lie down. The key to relieving the symptoms is to reduce sinus swelling and inflammation and facilitate mucous drainage from the sinuses.

There are several at-home steps that help prevent sinus headache or alleviate its pain. They include:

    * Breathe moist air: Relief for a sinus headache can be achieved by humidifying the dry air environment. This can be done by using a steam vaporizer or cool-mist humidifier, steam from a basin of hot water, or steam from a hot shower.
    * Alternate hot and cold compresses: Place a hot compress across your sinuses for three minutes, and then a cold compress for 30 seconds. Repeat this procedure three times per treatment, two to six times a day.
    * Nasal irrigation: Some believe that when nasal irrigation or rinse is performed, mucus, allergy creating particles and irritants such as pollens, dust particles, pollutants and bacteria are washed away, reducing the inflammation of the mucous membrane. Normal mucosa will fight infections and allergies better and will reduce the symptoms. Nasal irrigation helps shrink the sinus membranes and thus increases drainage. There are several over-the-counter nasal rinse products available. Consult your ear, nose, and throat specialist for directions on making a home nasal rinse or irrigation solution.
    * Over-the-counter medications: Some over-the-counter (OTC) drugs are highly effective in reducing sinus headache pain. The primary ingredient in most OTC pain relievers is aspirin, acetaminophen, ibuprofen, naproxen, or a combination of them. The best way to choose a pain reliever is by determining which of these ingredients works best for you.
    * Decongestants: Sinus pressure headaches caused by allergies are usually treated with decongestants and antihistamines. In difficult cases, nasal steroid sprays may be recommended.
    * Alternative medicine: Chinese herbalists use Magnolia Flower as a remedy for clogged sinus and nasal passages. In conjunction with other herbs, such as angelica, mint, and chrysanthemum, it is often recommended for upper respiratory tract infections and sinus headaches, although its effectiveness for these problems has not been scientifically confirmed.

If none of these preventative measures or treatments is effective, a visit to an ear, nose, and throat specialist may be warranted. During the examination, a CT scan of the sinuses may be ordered to determine the extent of blockage caused by chronic sinusitis. If no chronic sinusitis were found, treatment might then include allergy testing and desensitization (allergy shots). Acute sinusitis is treated with antibiotics and decongestants. If antibiotics fail to relieve the chronic sinusitis and accompanying headaches, endoscopic or image-guided surgery may be the recommended treatment.

Acute
Recurrent
Nasal rinses
Saline
Other rinses
Common medications used to treat sinusitis including antibiotics and antifungals, steroids, etc