City Allergy

Category: Patient Education > Nasal & Sinus  

Chronic Sinusitis

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

***Two of the symptoms in bold suggest a chronic sinus problem.***

What causes chronic sinusitis?

Chronic sinusitis is not one disease. There are different subtypes but whatever started the process by the time it is diagnosed patients always have inflammation and sometimes infection. 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. The causes may be:

• Anatomic obstruction
• Nasal Polyps (see subtype of Aspirin Induced Asthma with polyps)
• Immune deficiency
• Allergies
• Biofilm
• Mold
• Staph Bacteria

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Anatomic Obstruction

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.

The septum divides the nose into left and right nasal passages. If the septum curves to one side it can block the sinuses or cause nasal congestion.

This is an example of localized sinusitis due to anatomic obstruction, in this case it is a spur coming off of the nasal septum.

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Nasal Polyps

Nasal polyps are soft, jelly-like overgrowths of the lining of the sinuses. They may be diffuse and fill the sinus cavities in which case the management is both medical and surgical. If they are localized to one area and do not respond to medical treatment then the polyps may best be treated surgically. When nasal polyps are associated with aspirin sensitivity and asthma it is called the Aspirin Triad. Read more complete information about Nasal Polyps.



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 may contribute to chronic sinusitis though it is more likely a cause for repeated episodes of acute sinusitis. Immune deficiencies causing repeated infections of sinus, ear and lung include IgA deficiency and other antibody deficiency diseases. IgA is the immune protein that helps to protect the respiratory and gastrointestinal tract from infections. 1 in 300 people have an immune defiiency but a significantly higher percentage of chronic sinusitis sufferers have IgA deficiency.
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Allergies

Allergies such as typical hayfever or pet allergy can certainly contribute to the disease process in chronic sinusitis. They are sometimes the principal cause but usually they just are a cofactor contributing to the problem. For some chronic sinus patients there are multiple types of immune response to molds and occasional patients benefit from allergy injections.
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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 antibiotics. There is no routine way in the office to detect biofilms. This is an active area of research and it is unknown how common a problem this is in chronic sinusitis patients.
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Mold

Research in chronic sinusitis suggested that inhaled mold caused an intense inflammatory response in the sinuses in some patients. This led to studies of antifungal treatments sprayed into the nose but the results were disappointing.  Though most sinus patients do not respond to topical antifungal therapy select patients may exhibit a dramatic response.  Sometime the appearance of nasal mucous or the pathology specimen from sinus surgery provides a clue as to who will benefit.  By the time we see a patient with chronic sinusitis, they usually have a mixture of inflammation, nasal polyps and bacterial infection. The bacterial infections need to be cleared first before anything else can be accomplished. If you have already had sinus surgery then many of the topical therapies for sinus disease, including treatment for mold, may enter the sinus cavities.
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Staph Bacteria

This bacterium is usually found on the skin and sometimes in the nose.  Staph produces “superantigen” which can drive the inflammatory response.  Immune responses to Staph may promote the development of nasal polyps.  Some sinus surgeons treat patients for a few months postoperatively with antibiotics to suppress Staph. Sometimes long term low dose antibiotics are prescribed.


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Diagnosis

Allergy skin testing:

Testing and treatment for immediate sensitivity to environmental allergens is important for 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. However, in some cases the inflammation is restricted to the sinus cavities themselves which cannot be viewed directly unless someone has already had nasal surgery to open the passages.  For following patients with established chronic sinusitis, especially those who have had surgery, this is mandatory.

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.  Image-guided CT scans are like a GPS of your head which guide surgeons during sinus surgery.

Antibiotics

Antibiotics are almost always given at some point in chronic sinusitis care, usually when bacteria overgrow in an area. This is often considered a superinfection (bacterial infection superimposed on a chronic sinus problem). Sometimes bacteria are the main cause of the problem. In patients who have had sinus surgery, sometimes a bacterial infection can be managed with an antibiotic nasal spray. In some causes of chronic sinusitis (biofilm) long term antibiotics may be appropriate.

Antifungal

Antifungal agents are antibiotics that kill mold. There are two topical agents available for chronic sinusitis patients through specialty or compounding pharmacies, itraconazole and amphotericin.  The response to these medications is sometimes quite dramatic.

Steroids

Steroids effectively control the inflammatory response in allergy and chronic sinusitis but often steroid nasal sprays are not enough. Steroid tablets (e.g.-prednisone) are often required to control swelling. Sometimes a very low dose of alternate day oral steroids is enough to control the inflammation.  Highly potent nasal sprays are also sometimes given though there is a risk of systemic absorption and side effects.

Leukotriene Modifiers

These drugs, including Singulair and Zyflo CR, block leukotrienes which are potent agents produced by allergic cells. Occasionally patients with nasal polyps have a dramatic response.

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Tags: Chronic Sinusitis, For Patients, Sinusitis