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Sinusitis

Highlights

Sinusitis

Sinusitis is inflammation or infection of the sinuses, the air-filled chambers in the skull that are located around the nose. Symptoms of sinusitis include thick nasal discharge, facial pain or pressure, fever, and reduced sense of smell. Depending on how long these symptoms last, sinusitis is classified as acute, subacute, chronic, or recurrent. Viruses are the most common cause of acute sinusitis, but bacteria are responsible for most of the serious cases.

Non-Drug Treatment of Sinusitis

Home remedies such as saline (salt) washes or sprays are helpful for removing mucus and relieving congestion. Steam inhalation is also beneficial. Patients with sinusitis should drink plenty of fluids to avoid dehydration. Water, which helps lubricate the mucous membranes, is the best fluid to drink.

Drug Treatment of Sinusitis

Medication depends on the type of sinusitis and its cause. Nonprescription pain relievers such as acetaminophen and ibuprofen can help mild-to-moderate pain. Decongestants may help relieve congestion, but they do not cure sinusitis. Antihistamines can dry the mucus and sometimes worsen the condition. Cough or cold medication is not recommended for children younger than age 4.

Because many cases of acute sinusitis resolve within 2 weeks with nonprescription treatments and home remedies, doctors generally wait at least 7 to 14 days before prescribing an antibiotic.

For chronic sinusitis, antibiotics and nasal corticosteroids are the main treatments, but this condition is difficult to treat and does not always respond to these drugs. Other drugs may also be prescribed. If drugs are ineffective, some patients with chronic sinusitis may need surgery.

Guidelines for Managing Acute Bacterial Sinusitis

According to guidelines from the Infectious Diseases Society of America (IDSA):

  • Bacterial sinusitis can be difficult to distinguish from sinusitis caused by a viral infection. It is important to know the difference, because viral infections do not respond to antibiotic treatment.
  • Bacteria cause only 2 to 10% of acute sinusitis cases. Viruses, such as those from the common cold, are the main cause of acute sinusitis. Most cases of acute sinusitis resolve on their own within a few weeks.
  • Doctors distinguish bacterial from viral sinusitis based on how symptoms start, how they progress, and how long they last.
  • When an antibiotic is prescribed, the IDSA recommends amoxicillin-clavulanate as a first choice. Many types of antibiotics formerly used for acute bacterial sinusitis are no longer effective or recommended.

Guidelines for Children with Acute Bacterial Sinusitis

In 2013, the American Academy of Pediatrics updated its guidelines for diagnosing and treating acute bacterial sinusitis in children. The new guidelines recommend that doctors use "watchful waiting" before prescribing antibiotics to children with symptoms lasting more than 10 days. However, antibiotics are recommended for children with severe or worsening symptoms (nasal discharge, fever, cough).

Introduction

Sinusitis (also called rhinosinusitis) is inflammation of the mucous lining of the nasal passages and sinus cavities. The sinuses are air-filled chambers in the skull (behind the forehead, nasal bones, cheeks, and eyes) that are lined with mucous membranes.

Four pairs of sinuses, known as the paranasal air sinuses, connect to the nasal passages (the two airways running through the nose):

  • Frontal sinuses (behind the forehead)
  • Maxillary sinuses (behind the cheekbones)
  • Ethmoid sinuses (behind the nose)
  • Sphenoid sinuses (behind the eyes)

Sinusitis occurs if obstruction or congestion causes the paranasal sinus openings to become blocked. When the sinus openings become blocked or too much mucus builds up in the chambers, bacteria and other germs can grow more easily, leading to infection and inflammation.

Sinusitis is classified as acute, subacute, chronic, or recurrent. The classification is based on how long symptoms last:

  • Acute: Less than 4 weeks
  • Subacute: 4 to 12 weeks
  • Chronic: 12 weeks or longer
  • Recurrent: 3 or more acute episodes in 1 year

Sinusitis is always accompanied (and usually preceded) by rhinitis, which is inflammation of the mucous membrane of the nasal cavities. The two conditions share common symptoms such as nasal obstruction and discharge.

Causes

Acute sinusitis can be caused by viral, bacterial, or fungal infections. Allergens and environmental irritants are other possible causes. In most cases, acute sinusitis is caused by an upper respiratory tract viral infection, such as the common cold, and usually resolves on its own.

Chronic sinusitis refers to long-term swelling and inflammation of the sinuses. Chronic sinusitis can result from recurring episodes of acute sinusitis, or it can be caused by other health conditions, like:

  • Asthma and allergic rhinitis
  • Immune disorders
  • Structural abnormalities in the nose, like a deviated septum or nasal polyps

Viral, Bacterial, and Fungal Infections

Viruses. Viruses cause 90 to 98% of acute sinusitis cases. Acute sinusitis typically starts with the common cold virus. A cold can set the stage for sinusitis by causing inflammation and congestion in the nasal passages, leading to obstruction in the sinuses.

Bacteria. A small percentage of acute sinusitis, and possibly chronic sinusitis cases, are caused by bacteria. Bacteria are normally present in the nasal passages and throat and are usually harmless. However, when a cold or other viral upper respiratory infection blocks the nasal passage and prevents the sinuses from draining, bacteria can multiply within the mucous lining of the sinuses, causing sinusitis. Streptococcus pneumonia, Haemophilus influenzae, and Moraxella catarrhalis (a common cause of childhood illnesses) are the bacteria most often linked to acute sinusitis. These bacteria plus other strains, such as Staphylococcus aureus, are also associated with chronic sinusitis. (The role of bacteria in chronic sinusitis is still being debated.) Bacterial sinusitis usually causes more severe symptoms and lasts longer than viral sinusitis.

Fungi. An allergic reaction to fungi is a cause of some chronic rhinosinusitis cases. Aspergillus is the most common fungus associated with sinusitis. Fungal infections tend to occur in people with sinusitis who also have diabetes, leukemia, AIDS, or other conditions that impair the immune system. Fungal infections can also occur in patients with healthy immune systems, but they are far less common.

Allergies, Asthma, and Immune Response

Allergies, asthma, and sinusitis often overlap. Seasonal allergic rhinitis and other allergies that cause mucus blockage may predispose people to develop sinusitis. Many of the immune factors observed in people with chronic sinusitis resemble those that appear in allergic rhinitis, suggesting that in some people sinusitis is due to an allergic response. Asthma is also strongly associated with sinusitis and many people have both conditions. Some studies suggest that sinusitis may worsen asthma symptoms.

Chronic sinusitis and recurrent acute sinusitis are also associated with disorders that weaken the immune system or produce airway inflammation or persistent thickened stagnant mucus. These conditions include diabetes, AIDS, cystic fibrosis, Kartagener syndrome, and Wegener granulomatosis.

Structural Abnormalities of the Nasal Passage

Structural abnormalities in the nose can cause a blockage, thereby increasing the risk for chronic sinusitis. Some abnormalities include:

  • Polyps (small benign growths) in the nasal passage block mucus drainage and restrict airflow. Polyps can result from previous sinus infections that caused overgrowth of the nasal membrane.
  • Enlarged adenoids can lead to sinusitis.
Adenoids

Adenoids are masses of tissue located high on the posterior wall of the pharynx. They are made up of lymphatic tissue, which trap and destroy germs in the air that enter the nasopharynx.

  • Cleft palate
  • Tumors
  • Deviated septum (a common structural abnormality in which the septum, the center section of the nose, is shifted to one side, usually the left)
Deviated septum

Click the icon to see an image of a septal deviation.

Risk Factors

Sinusitis is one of the most common diseases in the United States, affecting about 30 million Americans each year.

Young Children and Sinusitis

Before the immune system matures, all infants are susceptible to respiratory infections. Babies catch a cold about every 1 to 2 months. Young children are prone to colds and may have 8 to 12 bouts every year. Smaller nasal and sinus passages make children more vulnerable to upper respiratory tract infections than older children and adults. Ear infections such as otitis media are also associated with sinusitis.

The Elderly and Sinusitis

Older people are at heightened risk for sinusitis. Their nasal passages tend to dry out with age. In addition, the cartilage supporting the nasal passages weakens, causing airflow changes. They also have diminished cough and gag reflexes and weakened immune systems and are at greater risk for serious respiratory infections than are young and middle-aged adults.

People with Asthma or Allergies

People with asthma or allergies are at increased risk for inflammation in the sinuses. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter, or ASA, triad) are at very high risk for chronic or recurrent acute sinusitis.

Hospitalization

Some hospitalized patients are at higher risk for sinusitis, particularly those with:

  • Head injuries
  • Conditions requiring insertion of tubes through the nose
  • Breathing aided by mechanical ventilators
  • Weakened immune system

Other Medical Conditions Affecting the Sinuses

A number of medical conditions put people at risk for chronic sinusitis. They include:

  • Diabetes (types 1 and 2)
  • Gastroesophageal reflux disease
  • Nasal polyps or septal deviation
  • AIDS and other disorders of the immune system
  • Oral or intravenous steroid treatment
  • Hypothyroidism (underactive thyroid gland)
  • Cystic fibrosis, a genetic disorder in which the mucus is very thick and builds up
  • Kartagener syndrome, a genetic disorder that impairs function of cilia, the hair-like structures that normally move mucus through the respiratory tract

Miscellaneous Risk Factors

Dental Problems. Bacteria associated with infections from dental problems or procedures can trigger cases of maxillary sinusitis.

Changes in Atmospheric Pressure. People who experience changes in atmospheric pressure, such as while flying, climbing to high altitudes, or scuba diving, risk sinus blockage and therefore face an increased risk of developing sinusitis. (Swimming also increases the risk for sinusitis.)

Cigarette Smoke and Other Air Pollutants. Air pollution from industrial chemicals, cigarette smoke, or other pollutants can damage the cilia responsible for moving mucus through the sinuses. It is still not clear whether air pollution is an important cause of sinusitis and which specific pollutants are critical factors. Cigarette smoke, for example, poses a small but definite risk for sinusitis in adults. Secondhand smoke does not appear to have any significant effect on adult sinuses, although it may pose a risk for sinusitis in children.

Complications

Bacterial Infections

Bacterial sinusitis is nearly always harmless (although uncomfortable and sometimes even very painful). If an episode becomes severe, antibiotics generally eliminate further problems. In rare cases, however, bacterial sinusitis can cause very serious infections.

Infection of the Frontal Bone. Osteomyelitis is infection of the bones. In rare cases, sinusitis can lead to infection of the forehead and other facial bones. In such cases, the patient usually experiences headache, fever, and a soft swelling over the bone known as Pott puffy tumor.

Infection of the Eye Socket. Infection of the eye socket (orbital cellulitis), which causes swelling and subsequent drooping of the eyelid, is a rare but serious complication of ethmoid sinusitis. In these cases, the patient loses movement in the eye, and pressure on the optic nerve can lead to vision loss, which is sometimes permanent. Fever and severe illness are usually present.

Brain Infection. The most dangerous complication of sinusitis, particularly frontal and sphenoid sinusitis, is the spread of infection by anaerobic bacteria to the brain, either through the bones or blood vessels. Abscesses, meningitis, and other life-threatening conditions may result. In such cases, the patient may experience mild personality changes, headache, altered consciousness, visual problems, and, finally, seizures, coma, and death.

Blood Clots

Blood clots are another danger, although rare, from ethmoid or frontal sinusitis. If a blood clot forms in the sinus area around the front and top of the face, symptoms are similar to infection of the eye socket. In addition, the pupil may be fixed and dilated. Although symptoms usually begin on one side of the head, the process usually spreads to both sides.

Increased Asthma Severity

Many people with moderate-to-severe asthma also have sinusitis and allergic rhinitis. The relationship between sinusitis and asthma is not clear, but sinusitis appears to predispose people to more severe asthma attacks. Evidence suggests that treating one condition can have a beneficial impact on the other.

Effect on Quality of Life

Pain, fatigue, and other symptoms of chronic sinusitis can have significant effects on quality of life. This condition can cause emotional distress, impair normal activity, and reduce attendance at work or school. According to the American Academy of Allergy, Asthma, and Immunology, the average patient with sinusitis misses about 4 work days a year, and sinusitis is one of the top 10 medical conditions that most adversely affect American employers.

Symptoms

General Symptoms of Acute Sinusitis

Sinus symptoms are very common during a cold or the flu. In most cases, they are due to the effects of the infecting virus and resolve when the infection does. General symptoms of acute sinusitis (both viral and bacterial) include:

  • Nasal congestion or discharge
  • Headache
  • Facial pain or pressure
  • Cough or scratchy throat
  • Fever
  • Diminished or absent sense of smell
  • Other symptoms, such as ear pain or pressure, dental pain, bad breath, and fatigue

Acute Bacterial Sinusitis Symptoms

It is important to differentiate between inflamed sinuses associated with cold or flu virus and sinusitis caused by bacteria, but it can be difficult to do so. In general, with viral sinusitis symptoms usually last 7 to 10 days and then improve. Acute bacterial sinusitis, in contrast to viral sinusitis, usually takes one of the following three paths:

  • Persistent symptoms that last more than 10 days and do not improve. Nasal discharge (either clear or colored) and daytime cough are common.
  • Severe symptoms, with a high fever (at least 102oF) and thick, green nasal discharge or facial pain that lasts for at least 3 to 4 days starting from the beginning of the illness. (With viral sinusitis, fever usually disappears within the first day or two and green discharge does not appear until after the fourth day.)
  • Worsening symptoms following a typical viral upper respiratory infection. Symptoms appear to improve but are then followed suddenly by another set of worsening symptoms (return of fever, cough, severe headache, or increase in nasal discharge) after 5 to 6 days ("double-sickening").

If symptoms suggest acute bacterial sinusitis, antibiotic treatment is warranted. Bacterial sinusitis is not as common as viral sinusitis, but bacteria are responsible for most serious cases of sinusitis.

Children. In children, the most common signs and symptoms of acute bacterial sinusitis are daytime cough (which may worsen at night), nasal discharge, and fever. Bad breath, fatigue, headache, and decreased appetite are also common symptoms in young children, but they do not necessarily indicate sinusitis.

The American Academy of Pediatrics recommends that doctors diagnose acute bacterial sinusitis when a child with an upper respiratory infection has:

  • Symptoms that last more than 10 days
  • Severe onset of symptoms (including fever and nasal discharge) lasting at least 3 days in a row
  • Symptoms (like nasal discharge, fever, or cough) that get worse after initially improving

Children with worsening or severe symptoms should be treated with antibiotics. For other children, watchful waiting is appropriate to see if the infection clears up on its own.

Chronic Sinusitis Symptoms

With chronic sinusitis:

  • Any of the sinusitis symptoms listed previously may be present
  • Symptoms are more vague and generalized than with acute sinusitis
  • Fever may be absent or low-grade
  • Symptoms of sinusitis last 12 weeks or longer
  • Symptoms occur throughout the year, even during nonallergy seasons

Symptoms Indicating a Medical Emergency

Rare complications of sinusitis can produce additional symptoms, which may be severe or even life-threatening. Symptoms indicating a medical emergency include:

  • Increasing severity of symptoms
  • Eyes that are red, bulging, or painful (if the sinus infection occurs around the eyes)
  • Swelling and drooping eyelid
  • Loss of eye movement (possible infection in the eye socket)
  • Vision changes
  • Fixed or dilated pupil
  • Symptoms spreading to both sides of face (may indicate blood clot)
  • Development of severe headache, altered vision
  • Mild personality or mental changes (may indicate spread of infection to brain)
  • Soft swelling over the bone (may indicate bone infection)

Other Causes of Sinusitis Symptoms

Allergies. Symptoms of both sinusitis and allergic rhinitis include nasal obstruction and congestion. The conditions often occur together. People with allergies and no sinus infection may have:

  • Thin, clear, and runny nasal discharge
  • Itchy nose, eyes, or throat (these symptoms do not occur with bacterial sinusitis)
  • Recurrent sneezing
  • Symptoms of allergies that appear only during exposure to allergens

Migraine and Other Headaches. Many primary headaches, particularly migraine or cluster headaches, may closely resemble sinus headache. Migraine and sinus headaches may even coexist in many cases. Sinus headaches are usually more generalized than migraines. But it is often difficult to tell them apart, particularly if headache is the only symptom of sinusitis.

Trigeminal Neuralgia. In some cases, headache that persists after successful treatment of chronic sinusitis may be due to neuralgia (nerve-related pain) in the face.

Other Conditions. A number of other conditions can mimic sinusitis, including:

  • Dental problems
  • A foreign object in the nasal passage
  • Temporal arteritis (headache caused by inflamed arteries in the head)
  • Persistent upper respiratory tract infections
  • Temporomandibular disorders (problems in the joints and muscles of the jaw hinges)
  • Vasomotor rhinitis, a condition in which the nasal passages become congested in response to irritants or stress. It often occurs in pregnant women.

Diagnosis

See your doctor if you have sinusitis symptoms that do not clear up within a few days, are severe, or are accompanied by high fever or sudden generalized illness.

The first goal in diagnosing sinusitis is to rule out other possible causes of symptoms, and then determine:

  • The site where the infection has occurred
  • Whether the condition is acute or chronic
  • The organism causing the infection (if possible)

Diagnostic Approach to Acute Sinusitis

Medical History. The patient should describe all symptoms, such as nasal discharge and specific pain in the face and head, including eye and tooth pain.

The doctor will evaluate the symptoms and take a thorough medical history, including:

  • Any history of allergies, asthma, or headaches
  • Recent upper respiratory infections (colds, flu, and infection) and how long they lasted
  • History of sinusitis episodes that did not respond to antibiotic treatment. (In such cases, the doctor will usually diagnose chronic or recurrent acute sinusitis and may refer the patient to a specialist for more advanced testing.)
  • Exposure to cigarette smoke or other environmental pollutants
  • Recent travel (especially by air), scuba diving
  • Recent dental procedures
  • Medications (particularly decongestants)
  • Any known structural abnormalities in the nose and face
  • Injury to the head or face
  • History of medical conditions that can produce tender areas in the face or sinus regions, and nonspecific symptoms of ill health
  • Any family or personal history of immune disorders, cystic fibrosis, or Kartagener (immotile cilia) syndrome
  • In small children with sinusitis, whether they attend a day care center or nursery school

Physical Examination

The doctor will press the forehead and cheekbones to check for tenderness and other signs of sinusitis, including yellow to yellow-green nasal discharge. The doctor will also check the inside of the nasal passages using a device with a bright light to look for mucus and any structural abnormalities.

Nasal Endoscopy (Rhinoscopy)

Nasal endoscopy, or rhinoscopy, involves the insertion of a flexible tube with a fiberoptic light on the end into the nasal passage. Rhinoscopy allows detection of even very small abnormalities in the nasal passages. It can evaluate structural problems of the nasal septum, as well as the presence of soft tissue growths such as polyps. Rhinoscopy may also identify small amounts of pus draining from the opening of a sinus. Bacterial cultures can be taken from samples removed using endoscopy. (Endoscopy is also used for treating sinusitis.)

Imaging Techniques

Computed Tomography. Computed tomography (CT) scanning is the best method for viewing the paranasal sinuses. There is little relationship, however, between symptoms in most patients and abnormal findings on a CT scan. Therefore, CT scans are not recommended for most cases of uncomplicated acute bacterial sinusitis. They are only recommended for acute sinusitis if there is a severe infection, complications, or a high risk for complications, especially those that may affect the eyes or central nervous system.

CT scans can be useful for diagnosing chronic or recurrent acute sinusitis and for planning operations. They show inflammation and swelling and the extent of the infection, including in deeply hidden air chambers x-rays and nasal endoscopy miss. They may also detect fungal infections.

X-Rays. X-rays used to be commonly used, but they are not as accurate as endoscopy and CT scans for identifying abnormalities in the sinuses, particularly the ethmoid sinuses.

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) is not as effective as CT in viewing the paranasal anatomy, and is therefore not typically used to image the sinuses for suspected sinusitis. MRI is also more expensive than CT. However, it can help rule out fungal sinusitis and it may help differentiate between inflammatory disease, malignant tumors, and complications within the skull. It may also be useful for showing soft tissue involvement.

Sinus Puncture and Bacterial Culture

Sinus puncture with bacterial culture is the gold standard for diagnosing a bacterial sinus infection. It is invasive and is performed only when patients are at risk of having unusual infections or serious complications, or if antibiotics have not worked. Sinus puncture involves using a needle to withdraw a small amount of fluid from the sinuses. It requires a local anesthetic and is performed by a specialist. The fluid is then cultured to determine what type of bacteria is causing sinusitis.

Prevention

The best way to prevent sinusitis is to avoid colds and influenza. If you are unable to avoid them, the next best way to prevent sinusitis is to effectively treat colds and influenza.

Good Hygiene and Preventing Transmission

Cold and flu viruses spread when an infected person coughs or sneezes. These viruses can also be transmitted by shaking hands. Everyone should always wash their hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleansers that contain an alcohol-based gel are also effective. Antibacterial soaps add little protection, particularly against viruses. Wiping surfaces with a solution that contains 1 part bleach to 10 parts water is very effective in killing viruses.

Vaccines

Influenza Vaccine. Doctors recommend that most people receive annual influenza vaccinations in October or November. Because influenza viruses change from year to year, influenza vaccines are redesigned annually to match the anticipated viral strains.

Flu vaccines are now recommended for virtually everyone over 6 months of age, except for those allergic to eggs or other vaccine compounds.

Pneumococcal Vaccines. Pneumococcal vaccines protect against S. pneumoniae (also called pneumococcal) bacteria, the most common bacterial cause of respiratory infections. Pneumococcal vaccination is recommended for all children and for all adults age 65 and older. The vaccine is also recommended for adults younger than age 65 who have health conditions that compromise their immune system or raise their risk for infection, as well as for smokers and patients with asthma.

Treatment

General Treatment Approaches

General treatment goals for sinusitis aim to:

  • Reduce swelling
  • Stop infection
  • Drain the sinuses
  • Ensure that the sinuses remain open

Most patients with sinusitis do not require aggressive treatment. Home remedies can be very helpful.

Bacterial sinusitis, which is treated with antibiotics, accounts for only 2 to 10% of acute sinusitis cases. Most cases of sinusitis are caused by viruses, which do not respond to antibiotics. Acute viral sinusitis generally clears up on its own within 7 to 10 days.

It is important to reserve antibiotics for illnesses caused by bacteria. The intense and widespread use of antibiotics has led to a serious global problem of antibiotic-resistant bacteria.

Treatment of Acute Sinusitis:

  • Saline nasal irrigation, steam inhalation, good hydration, and decongestants are appropriate for a minimum of 7 to 10 days for patients with mild-to-moderate symptoms, and may be used for longer.
  • A diagnosis of acute bacterial sinusitis is based on how symptoms progress or worsen, and if they last longer than 10 days. Symptoms such as high fever and thick, colored nasal discharge may indicate a bacterial infection.
  • For patients with acute bacterial sinusitis that requires antibiotic treatment, amoxicillin, with or without clavulanate, is usually the first choice.
  • For children who have symptoms for more than 10 days, doctors may wait and watch for an additional 3 days before prescribing antibiotics to see if the infection clears up on its own. Children who have severe or worsening symptoms should receive immediate treatment with antibiotics.

Treatment of Chronic Sinusitis:

  • Chronic sinusitis typically results from damage to the mucous membrane from a past, untreated acute sinus infection. The role of antibiotic treatment for chronic sinusitis is controversial. Special types of antibiotics may be used, and treatment may be needed for a longer time.
  • Corticosteroid nasal spray is a helpful treatment. Some doctors also recommend oral corticosteroids (such as prednisone) for patients who do not respond to nasal corticosteroids or for patients who have nasal polyps or allergic fungal sinusitis.
  • Saline nasal irrigation may be used on an ongoing basis.
  • If there is no improvement, surgery may be considered. For some people with chronic sinusitis the condition is not curable, and the goal of treatment is to improve the quality of life.
  • A thorough diagnostic workup should be performed to rule out any underlying conditions, including allergies, asthma, immune problems, gastroesophageal reflux disorder, and structural problems in the nasal passages. If a primary trigger for chronic sinusitis can be identified, it should be treated or controlled, if possible.

Hydration

Home remedies that open and hydrate the sinuses are often the only treatment necessary for mild sinusitis that is not accompanied by signs of acute infection.

  • Drinking plenty of fluids and getting lots of rest is still the best advice for easing mild symptoms. Water is the best fluid because it helps lubricate the mucous membranes. (There is no evidence that drinking milk will increase or worsen mucus, although milk is a food and should not serve as fluid replacement.)
  • Chicken soup helps with congestion and aches. The hot steam from the soup may be its chief advantage, although other ingredients in the soup may have anti-inflammatory effects. In fact, any hot beverage may have similar soothing effects from steam. Ginger tea or any hot tea with honey and lemon can be helpful.
  • Spicy foods that contain hot peppers or horseradish may help clear sinuses.
  • Inhaling steam 2 to 4 times a day is extremely helpful, costs nothing, and requires no expensive equipment. The patient should sit comfortably and lean over a bowl of boiling hot water (no one should ever inhale steam from water as it boils) while covering the head and the bowl with a towel so the steam remains under the cloth. The steam should be inhaled continuously for 10 minutes. A mentholated or other aromatic preparation may be added to the water. Long, steamy showers, vaporizers, and facial saunas are alternatives.

Nasal Wash

A nasal wash can be helpful for removing mucus from the nose and relieving sinusitis symptoms. A saline (salt water) solution can be purchased in a spray bottle at a drug store or made at home. (Mix 1 teaspoon of table, Kosher, or sea salt with 2 cups of warm water. Some people add a pinch of baking soda.) If you prepare your own saline solution, use bottled or boiled water, not plain tap water. Perform the nasal wash several times a day.

A simple method for administering a nasal wash is:

  • Lean over the sink head down.
  • Pour some solution into the palm of the hand and inhale it through the nose, one nostril at a time.
  • Spit out the remaining solution.
  • Gently blow the nose.

Neti pots have also become popular in recent years for prevention and treatment of sinusitis. To do nasal irrigation with a saline solution through a Neti pot:

  • Lean over the sink with your head tilted to one side.
  • Insert the spout of the Neti pot into the upper nostril.
  • Slowly pour the salt water into your nose while continuing to breathe through your mouth.
  • The water will flow through the upper nostril and out through the lower nostril.
  • When the water finishes dripping out, blow your nose.
  • Reverse the tilt of your head and repeat the process with the other nostril.

Managing Sinusitis in Patients with Allergies

Patients often have various combinations of allergies, sinusitis, and asthma. Treating each condition is important for improving them all. In addition to decongestants, pain relievers, and expectorants, other remedies are available for people who have nonbacterial sinusitis during allergy season.

  • Anti-Inflammatory Drugs. Nasal spray corticosteroids (commonly called steroids) reduce the inflammatory response in the nasal passages and airways. They are important in the treatment of asthma, and are considered to be the most effective measure for preventing allergy attacks. Leukotriene-antagonists are also useful for sinusitis symptoms.
  • Antihistamines. Antihistamine tablets relieve sneezing and itching and can prevent nasal congestion before an allergy attack. Many brands are available by prescription and over the counter. Because they thicken mucus and make it harder to drain out from the sinuses, they should not be used for sinusitis.
  • Immunotherapy. Immunotherapy may be considered for patients with severe seasonal allergies that do not respond to treatment. Immunotherapy is the only treatment that affects the cause of allergies. Immunotherapy is most commonly given by injection, but some types of pollen can be treated with under-the-tongue (sublingual) tablets.
  • All drug treatments have side effects. Some side effects are very unpleasant and, rarely, serious. Patients may need to try different drugs until they find one that relieves symptoms without producing excessively distressing side effects.

Emergency Treatment

Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull need emergency care. High-dose antibiotics are administered intravenously, and emergency surgery is almost always necessary in such cases.

Sinusitis caused by severe fungal infections is a medical emergency. Treatment is aggressive surgery, and high-dose antifungal chemotherapy with a drug such as amphotericin B can be life-saving.

Medications

Antibiotics

Antibiotic drugs are used to treat bacterial, not viral, infections. Unfortunately, because of the overuse and improper use of antibiotics, many types of bacteria no longer respond to antibiotic treatment. The bacteria have become resistant to these drugs. Due to the problem of bacterial resistance, doctors have had to switch to different or stronger types of antibiotics to treat bacterial infections.

Amoxicillin, a type of penicillin, is the main antibiotic used for mild-to-moderate acute bacterial sinusitis, but due to bacterial resistance it has become less effective. Amoxicillin-clavulanate (Augmentin, generic) may be used as an alternative to amoxicillin for treating acute bacterial sinusitis in both children and adults, especially for patients with moderate-to-severe illness. It is a type of penicillin that works against a wide spectrum of bacteria.

Patients who have a history of penicillin allergy cannot take amoxicillin-clavulanate:

  • For adults with sinusitis and penicillin allergies, doctors recommend either doxycycline or the fluoroquinolones levofloxacin or moxifloxacin.
  • Children should not take doxycycline because it can cause tooth discoloration. They should be treated with either a cephalosporin antibiotic (cefdinir, cefuroxime, or cefpodoxime) or the quinolone antibiotic levofloxacin. Children who are vomiting and can't take oral antibiotics may need an injection of ceftriaxone.

Other types of antibiotics, such as macrolides and trimethoprim-sulfamethoxazole, have also become ineffective for treating acute bacterial sinusitis and are no longer recommended.

Side Effects. Side effects of antibiotics vary according to the specific drug and the patient's individual response. Many patients experience few side effects, but they may include:

  • Upset stomach.
  • Vaginal infections (taking supplements of acidophilus or eating yogurt with active cultures may help restore healthy bacteria that offset the risk for such infections).
  • Allergic reactions can occur with all antibiotics, but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, and even life-threatening anaphylactic shock.
  • Certain drugs, including some over-the-counter medications, interact with antibiotics. Inform your doctor of all medications you are taking and of any drug allergies.

Corticosteroids

Nasal-spray corticosteroids, commonly called steroids, are effective drugs for treating allergic rhinitis. Although they are not approved for treating sinusitis, they may be helpful for patients with sinusitis (either chronic or acute) who have a history of allergic rhinitis. Nasal spray steroids can help reduce inflammation and mucus production. Oral (systemic) corticosteroids are not helpful for treating sinusitis.

Corticosteroids that are available in nasal spray form and are approved for treating nasal allergy symptoms include:

  • Triamcinolone (Nasacort Allergy HR) is the only nasal steroid available without a prescription.
  • Mometasone furoate (Nasonex)
  • Fluticasone (Flonase, generic)
  • Beclomethasone (Beconase, Vancenase), flunisolide (Nasalide, generic), and budesonide (Rhinocort)
  • These nasal sprays are also approved for children (ages vary depending on brand)

Side Effects. Corticosteroids are powerful anti-inflammatory drugs. Although oral steroids can have many side effects, the nasal-spray form affects only local areas, and the risk for widespread side effects is very low unless the drug is used excessively. Side effects of nasal corticosteroids may include:

  • Dryness, burning, stinging in the nasal passage
  • Sneezing
  • Headaches and nosebleed (these side effects are uncommon, but should be reported immediately to your doctor)

Decongestants

Decongestants are drugs that help reduce nasal congestion. They are available in both pill and nasal spray forms. However, decongestants will not cure sinusitis. They may actually worsen sinusitis by increasing sinus inflammation.

Due to the lack of evidence for the benefit of nasal decongestants in treating sinusitis, the FDA ordered manufacturers of over-the-counter (OTC) nasal decongestant products to remove all references to sinusitis from their labeling. The Infectious Diseases Society of America does not recommend nasal or oral decongestants for patients with acute bacterial sinusitis.

Your doctor may still recommend that you take either an OTC or prescription nasal decongestant to help relieve blockage symptoms associated with sinusitis. If you think you have sinusitis, check with your doctor before taking a decongestant. Do not try to treat sinusitis by yourself.

Decongestants should never be used in infants and children under age 4, and some doctors recommend not giving them to children under age 14. Children are at particular risk for central nervous system side effects, including convulsions, rapid heart rate, loss of consciousness, and death.

Antihistamines

Antihistamines such as diphenhydramine (Benadryl, generic) are included in many cold and allergy medications. Because they dry and thicken nasal secretions, they make sinus drainage difficult and may worsen sinusitis. Patients with sinusitis should not take antihistamines.

Surgery

Surgery can unblock the sinuses when drug therapy is not effective or if there are other complications, such as structural abnormalities or fungal sinusitis.

Insertion of a Drainage Tube

The simplest surgical approach is to insert a drainage tube into the sinuses, followed by an infusion of sterile water to flush out the sinuses.

Functional Endoscopic Sinus Surgery

Functional endoscopic sinus surgery (FESS) is the standard procedure for most patients requiring surgical management of chronic sinusitis or polyposis. The procedure allows correction of obstructions, including polyps, ventilation, and drainage to aid healing.

Candidates for the Procedure. In general, patients should have tried and failed extensive medical therapy before undergoing surgery. This usually includes several prolonged courses of broad-spectrum antibiotics, nasal corticosteroids, nasal saline irrigation, allergy testing and immunotherapy (when appropriate), and sinus drainage (when appropriate).

Patients who may benefit from endoscopy include those with:

  • Nasal or sinus polyps who have not responded to intranasal or oral corticosteroids
  • Congenital anatomic abnormalities
  • Evidence of bone involvement
  • HIV/AIDS or other immune system impairments who have chronic or recurrent sinusitis

Procedure. The surgery generally proceeds as follows:

  • Adults need only a local anesthetic, although children need a general anesthetic.
  • Before the procedure, a computed tomography (CT) scan is taken to help the surgeon plan the procedure and to guide the surgery.
  • A flexible tube, miniature camera, and fiberoptic light are inserted through a single small opening.
  • The surgeon uses special instruments to remove diseased bone or tissue and clear obstructions. Shavers are used to gently remove soft tissue. Bone cutters are sometimes used to open the floor of the frontal sinus and restore drainage (called the modified Lothrop procedure). Lasers may be used to remove bone, coagulate the passageways, or clear obstructions.

Complications. Serious complications of FESS are very rare, but may include cerebrospinal fluid leakage, meningitis, hemorrhage, or infection.

Postsurgical Care. Postsurgical care involves the following:

  • The patient will experience a dull ache around the nose and sinus cavity that can be treated with pain medication.
  • Following surgery, the patient should flush the sinuses twice daily with a saline or alkaline solution.
  • Antibiotics may be prescribed for several weeks until postnasal drip has stopped. Corticosteroid sprays and antihistamines may be needed.

Success Rates. It may take several months for the mucous membranes to completely recover, but 85 to 90% of patients have good-to-excellent relief of their symptoms after surgery. Children may need a second procedure 2 to 3 weeks after the first surgery to remove crusty matter.

Balloon Sinuplasty

A newer type of surgical procedure threads a small balloon through the sinus passages. As the balloon is gently opened, the sinus passages expand, allowing drainage to occur. The procedure is best suited for select patients with sinusitis disease in the maxillary (behind the cheekbones), frontal (behind the sides of the forehead), and sphenoid (behind the eyes) sinus regions. It is inappropriate for patients with disease in the ethmoid (between the eyes) sinuses because of the risk of eye injury.

Invasive Conventional Surgery

Endoscopy is now used in most cases of chronic sinusitis, but in severe cases, invasive surgery using conventional scalpel techniques may be required to remove infected areas. This may be the case with acute ethmoid sinusitis in which pus breaks through the sinus and threatens the eye, very severe frontal sinusitis, invasive fungal sinusitis, or when cancer is present in the sinuses.

Resources

References

Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW Jr, Mäkelä M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014 Feb 11;2:CD000243.

Ah-See KL, MacKenzie J, Ah-See KW. Management of chronic rhinosinusitis. BMJ. 2012;345:e7054.

Anon JB. Upper respiratory infections. Am J Med. 2010;123(4 Suppl):S16-S25.

Brook I. Acute and chronic bacterial sinusitis. Infect Dis Clin North Am. 2007;21(2):427-48, vii.

Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.

DeMuri GP, Wald ER. Clinical practice: acute bacterial sinusitis in children. N Engl J Med. 2012;367(12):1128-1134.

Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol. 2010;125(2 Suppl 2):S103-S115.

Hamilos DL. Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol. 2011;128(4):693-707; quiz 708-709.

Hersh AL, Jackson MA, Hicks LA; American Academy of Pediatrics Committee on Infectious Diseases. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013;132(6):1146-54. Epub 2013 Nov 18.

Jarvis D, Newson R, Lotvall J, et al. Asthma in adults and its association with chronic rhinosinusitis: the GA2LEN survey in Europe. Allergy. 2012;67(1):91-98.

Ling FT, Kountakis SE. Important clinical symptoms in patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. 2007;117(6):1090-1093.

Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc. 2011;86(5):427-443.

Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009;80(10):1117-1119.

Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(3 Suppl):S1-S31.

Ryan MW, Marple BF. Allergic fungal rhinosinusitis: diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2007;15(1):18-22.

Sacks PL, Harvey RJ, Rimmer J, Gallagher RM, Sacks R. Topical and systemic antifungal therapy for the symptomatic treatment of chronic rhinosinusitis. Cochrane Database Syst Rev. 2011;(8):CD008263.

Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2012;9:CD007909. 2013 Jul;132(1):e262-80.

Wald ER, Applegate KE, Bordley C, Darrow DH, Glode MP, Marcy SM, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. Published online June 24, 2013.

Venekamp RP, Thompson MJ, Hayward G, Heneghan CJ, Del Mar CB, Perera R, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2014;3:CD008115.

Zalmanovici Trestioreanu A(1), Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;12:CD005149.


Review Date: 6/24/2013
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital, Boston, MA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team. A.D.A.M. Editorial Update: 09/29/2014.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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