Chronic sinusitis Overview
Chronic sinusitis is a common condition in which the cavities around nasal passages (sinuses) become inflamed and swollen for at least eight weeks, despite treatment attempts.
Also known as chronic rhinosinusitis, this condition interferes with drainage and causes mucus to build up. If you have chronic sinusitis, it may be difficult to breathe through your nose. The area around your eyes and face may feel swollen, and you may have throbbing facial pain or a headache.
Chronic sinusitis may be caused by an infection, but it can also be caused by growths in the sinuses (nasal polyps) or by a deviated nasal septum. Chronic sinusitis most commonly affects young and middle-aged adults, but it also can affect children.
How do you get Chronic Sinusitis?
Most cases of chronic sinusitis develop following an acute sinusitis infection. Most cases of acute sinusitis go away within 2-3 weeks, often much sooner. In some cases the symptoms do not go and become persistent (chronic). The following are causes of acute sinusitis that may progress into a chronic sinusitis:
- Cold or flu-like illnesses – in most cases, acute sinusitis develops from a cold or flu-like illness. Colds and flu are caused by germs called viruses which may spread to the sinuses. The infection may remain viral before clearing, causing a viral sinus infection. In a small number of cases, germs called bacteria add on to an infection that started with a virus. This can cause a bacterial sinus infection which can make the infection worse, last longer and may cause more damage or changes to the lining of the sinus.
- Dental infections – in some cases, infection spreads to a cheekbone (maxillary) sinus from an infected tooth.
- Other risk factors for sinus infection – in a few people, one or more factors are present that may cause their sinuses to be more prone to infection. Acute sinusitis may be more likely to progress into chronic sinusitis as there is an underlying problem. Such factors include:
- Nasal allergy (allergic rhinitis). The allergy may cause swelling of the tissues on the inside lining of the nose and block the sinus drainage channels. This makes the sinuses more susceptible to infection. See separate leaflets called Hay Fever and Persistent Rhinitis which discuss allergic rhinitis in more detail.
- Other causes of a blockage to the sinus drainage channels, such as:
- Growths (nasal polyps).
- Objects pushed into the nose (especially in children, such as peas or plastic beads).
- Facial injury or surgery.
- Certain congenital abnormalities. (‘Congenital’ means you are born with these abnormalities.)
- Cystic fibrosis.
- A poor immune system for example, people with HIV, people on chemotherapy, etc. A poor immune system makes you more prone to any infection. Fungal infections are rare causes of sinusitis and occur most commonly in people with a poor immune system.
- Inflammatory disorders such as Wegener’s granulomatosis or sarcoidosis.
- Pregnancy, which makes you more prone to nasal inflammation (rhinitis).
- Primary ciliary dyskinesia/Kartagener’s syndrome.
- Rare tumours of the nose.
- Sniffing substances that irritate the lining of the nose (for example, cocaine).
- Previous injury to the nose or cheeks.
If you develop chronic sinusitis after an acute sinus infection, you may continue to get symptoms even though the infection has gone. (This is why treating chronic sinusitis with a normal course of antibiotics does not often work.) After being initially triggered by an infection, the persisting symptoms may be due to a combination of factors. For example:
- Poor drainage of the affected sinus: the sinus drainage channel may become fully or partially blocked.
- A build-up of mucus in the sinus.
- Inflammatory changes to the lining of the sinus that result from infection.
- A flare-up of infection from time to time as a result of these changes.
Sometimes, a persisting allergy can cause inflammation in a sinus and swelling or blockage of the drainage channel.
Who Gets Chronic Sinusitis?
About 37 million Americans suffer from at least one episode of sinusitis each year. People who have the following conditions have a higher risk of sinusitis:
- Nasal mucous membrane swelling as from a common cold
- Blockage of drainage ducts
- Structural differences that narrow the drainage ducts
- Nasal polyps
- Conditions that result in an increased risk of infection such as immune deficiencies or taking medications that suppress the immune system.
In children, common environmental factors that contribute to sinusitis include allergies, illness from other children at day care or school, pacifiers, bottle drinking while lying on one’s back, and smoke in the environment.
In adults, the contributing factors are most frequently infections and smoking.
Acute vs. Chronic Sinusitis
The sinuses are small cavities in the skull that are normally filled with air. They produce mucus, which helps keep the nasal passages clear of allergens and pollutants.
Sinusitis is an inflammation of the tissue that lines these cavities. In some cases, this swelling blocks off the sinuses, trapping mucus and air inside them. This can cause pain and pressure; sometimes, it can lead to bacterial infection. There are two basic types of sinusitis.
- Acute sinusitis lasts up to four weeks.
- Chronic sinusitis lasts more than twelve weeks and can linger for years. The cause of chronic sinusitis can be hard to pin down and hard to treat.
The initial inflammation of sinusitis might be initially triggered by a cold or allergies. In people who have compromised immune systems, sinusitis can be caused by fungus. Sometimes, chronic sinusitis results from defects in the structure of the nasal passages or a growth like a nasal polyp which can block the sinuses and prevent them from draining normally.
The symptoms of acute and chronic sinusitis are similar:
- Facial pressure and pain
- Thick discolored mucus
Symptoms of Chronic Sinusitis
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. At least two of the following signs and symptoms must be present for a diagnosis of chronic sinusitis:
- Drainage of a thick, yellow or greenish discharge from the nose or down the back of the throat
- 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
Other signs and symptoms can include:
- Ear pain
- Aching in your upper jaw and teeth
- Cough, which may be worse at night
- Sore throat
- Bad breath (halitosis)
- Fatigue or irritability
The signs and symptoms of chronic sinusitis are similar to acute sinusitis, except they last longer and often cause more significant fatigue. Fever isn’t a common sign of chronic sinusitis, as it may be with acute sinusitis.
What are the treatments for chronic sinusitis?
Treatment of any underlying problem
If you have an underlying problem that may have caused or contributed to your chronic sinusitis, treating this will usually help your symptoms. For example, this may mean treatment for nasal allergy (allergic rhinitis), treatment of a dental infection, treatment of asthma, treatment of a fungal infection, etc.
Avoidance of things that may make your symptoms worse
If you have chronic sinusitis and you are a smoker, you may find that if you stop smoking your symptoms improve. This may especially be the case if you have allergies as well. You should also practise good dental hygiene if you are prone to chronic sinusitis, as it can be caused by a dental infection.
Scuba divers with nasal or sinus problems should be aware of the possible serious consequences of sinus barotrauma. (This is damage to your sinuses resulting from pressure differences when diving.) Recurrent barotrauma to sinuses can cause knock-on complications, such as serious infection and damage to nerves in the face and eye. If you have had chronic sinusitis and wish to dive, you should seek advice from your doctor.
Flying in an aeroplane may cause an increase in pain if there is blockage of the sinus drainage channel. With the change in air pressure in an aeroplane, the pressure does not equalise between the sinus and outside, due to the blockage. Pain tends to be worse when the aeroplane is descending to land.
The sort of medicines that may be considered include the following:
- Steroids applied to the nasal lining using sprays ( such as beclometasone nasal spray) or drops are recommended for all types of chronic sinusitis. This is because they help to reduce inflammation. A long course may be advised for example, for three-months. Occasionally, if symptoms are severe, a course of steroid tablets by mouth may be suggested. However, these are more likely to produce side-effects. See separate leaflet called Oral Steroids for more detail.
- Prolonged courses of antibiotics (3-4 weeks) are sometimes helpful but are best prescribed after full assessment by an Ear, Nose and Throat specialist .
- Antifungal medicines are needed if you have a fungal infection of a sinus (rare).
If you have a flare-up of more acute sinusitis symptoms on top of your background symptoms, one or more of the following may be helpful:
- Painkillers, such as paracetamol or ibuprofen, will usually ease any pain. Sometimes stronger painkillers, such as codeine, are needed for a short time.
- Decongestant nasal sprays or drops are sometimes used. You can buy these from pharmacies. They may briefly relieve a blocked nose. You should not use a decongestant spray or drops for more than 5-7 days at a time. If they are used for longer than this, they may cause a worse rebound congestion in the nose.
- Warm face packs held over the sinuses may help to ease pain.
- A saline nasal solution may help to relieve congestion and blockage within the nose.
- A short course of antibiotics may sometimes be advised by your doctor if they suspect germs (bacteria) have caused an infection.
Surgery is used mainly if the condition does not improve with the above medical treatments. The main purpose of surgery is to improve the drainage of the affected sinus.
The most common operation is called functional endoscopic sinus surgery (FESS). This involves a surgeon inserting an endoscope into the nose. The endoscope used for this procedure is a thin rigid instrument that contains lenses. The endoscope allows a detailed magnified view of inside the nose. The surgeon can see the opening of the sinus drainage channels. He or she can then remove any tissues that are blocking the drainage of the affected sinus. This can improve sinus drainage and ventilation and help to restore normal function to the sinus. This operation causes little damage (is minimally invasive). It usually has a high success rate in relieving symptoms of chronic sinusitis.
A more recently developed operation is called balloon catheter dilation of paranasal sinus ostia. This involves a surgeon pushing a small balloon through a flexible tube in the nostril, into the blocked sinus. The balloon is inflated which pushes wide the blocked area. The balloon is then deflated and removed. Following this procedure there is a good chance that the sinus drainage channel is widened and the sinus can drain properly.
Surgery may also sometimes be needed to remove nasal growths (polyps) or to correct problems with deviated bones inside the nose.