Symptoms
Symptoms of chronic sinusitis may be severe or subtle. Some patients simply have chronic fatigue and a post nasal drip. For others, nasal congestion and poor sense of smell may be the problem. Symptoms seen in chronic sinusitis include:
- Pressure-like pain on your forehead, temples, cheeks, nose, or around or behind your eyes
- Difficulty breathing through your nose
- Thick, yellow or greenish discharge that drains into your nose or down the back of your throat
- Reduced sense of smell
- Aching in upper jaw and teeth
- Headache
- Bad breath
- Ear pain
- Fatigue
- Cough
What causes chronic sinusitis?
- Anatomy
- Nasal Polyps
- Allergies
- Immune deficiency
- Bacterial overgrowth
- Mold (sometimes)
Every patients is different but whatever started the by problem, there is always inflammation, fluid, mucous and usually infection in the sinuses. What we try to do is contain the problem when it is flaring then try to work our way backwards to find the underlying cause.
ANATOMY
Tight nasal passages that restrict drainage may easily lead to sinusitis following colds or allergies. The result usually is recurring infection and inflammation in one particular area. A deviated septum may impinge on a sinus drainage pathway such as seen in the images below.
Nasal Polyps
Nasal polyps are soft, jelly-like overgrowths of the lining of the sinuses. They may be diffuse and fill the sinus cavities or localized to one area. A more severe form of chronic sinusitis occurs in patients with nasal polyps, asthma & aspirin allergy and is termed the Aspirin Triad (also known as Samter’s Triad)
Diagram (above) of polyps (red teardrops) in the nasal cavity. Polyps often are seen in the middle meatus (seen emerging from the cleft) where they can block sinus drainage leading to infection.
Sinus cat scan showing polyps (P) within the sinus cavities. This polyp appears to be blocking the sinus outflow tract potentially causing both recurrent infection and pain.
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Immune deficiency
Immune deficiency sometimes leads to repeated sinus infections which then become chronic. An protein called IgA is the most common immune deficiency and it is more common in people with chronic sinusitis.
Allergies
Allergies such as typical hayfever or pet allergy can cause or aggravate chronic sinusitis.
Biofilm
Biofilms are protective coatings around colonies of bacteria or fungi. An example is dental plaque. It is like a jelly surrounding the bacterial colonies. Antibiotics may treat the infection that spreads beyond the biofilm but cannot penetrate the coating so infections keep returning. This may be one cause of poor response to oral antibiotics which is one reason doctors recommend sinus rinses.
Mold
Inhaled mold can cause typical allergies or a more inflammatory response in the sinuses. Most of the time this can be managed with medications and sinus rinses.
Bacteria
This bacterium is usually found on the skin and sometimes in the nose. Immune responses to Staph may promote the development of nasal polyps. Some sinus surgeons treat patients for a few months after surgery with antibiotics to suppress Staph. Sometimes long term low dose antibiotics are prescribed.
Diagnosis
Allergy skin testing:
Testing and treatment for immediate sensitivity to environmental allergens may help chronic sinus patients.
Nasal Endoscopy:
With an anesthetic nasal spray this is a well-tolerated procedure. For the initial evaluation, a direct look in the nose identifies many things such as anatomic causes of sinusitis, sinus drainage or nasal polyps.
Sinus CAT Scan:
This test is the gold standard for the diagnosis of sinusitis. If the CAT scan does not show swelling within the sinus passages then chronic sinusitis is not the diagnosis. However, this does not rule out a nasal source of sinus pain.
Antibiotics
Oral Antibiotics are almost always given at some point in chronic sinusitis care but this is rarely a long term solution.
Steroids
Nasal steroid and sometimes short term oral steroids are helpful in milder cases. Steroids in a sinus rinse work even better, especially when the sinus cavity openings have been widened surgically.
Leukotriene Modifiers
These drugs, including Singulair (montelukast) are more helpful for allergy symptoms than nasal polyps.
Treatment
Antibiotics
Oral Antibiotics are almost always given at some point in chronic sinusitis care but this is rarely a long term solution.
Steroids
Nasal steroid and sometimes short term oral steroids are helpful in milder cases. Steroids in a sinus rinse work even better, especially when the sinus cavity openings have been widened surgically.
Surgery
Depending on the sinus Cat Scan findings, surgery by a sinus surgeon (ENT) may be indicated. Sometimes, limited surgery is done in the office with a balloon (sinoplasty). Dr. Stadtmauer refers to best sinus surgeons in the city and helps guide patients down the right path.