The sinuses are air pockets located inside the bones in the
skull. They are located to either side of the nose (maxillary), behind and
in between the eyes (ethmoid), in the forehead (frontal), and there is one much
further back in the head (sphenoid). (For a better understanding of this, please look at the CT scan page when you finish reading this page.) They are probably present to reduce
the weight of the skull as well as to create resonance to the
voice. The sinuses are lined with very fine hair-like
projections called cilia. The function of the cilia is to
move mucus ( which is normally produced by the sinus) towards the
tiny hole ( the ostium) about the size of a pin hole which provides drainage
for the sinus. Unfortunately, that hole is located at the
top of the largest sinus, and consequently drainage may be
poor.
Sinusitis starts as a result of blockage of the hole (actually a short hairpin shaped tube) into the sinuses, called an ostium. This blockage can occur as a result of an anatomical obstruction, swelling due to a cold or allergy, drying of the mucus, or a foreign body. When this occurs, mucus that normally is expelled from the sinus builds up in the sinus. This can cause pressure or pain. In addition the mucus is an excellent culture medium for bacteria. If the mucus is not cleared immediately, an abscess can develop in the sinus. An abscess is a pus-pocket inside a closed space. Ideally, treatment of an abscess involves opening the abscess up with a knife and allowing the abscess to drain to the outside. Unfortunately, this is obviously not feasible in the case of a sinus infection without doing extensive surgery.
Sinusitis is one of the most common medical problems affecting
approximately 30% of the population at some point. Acute
sinusitis commonly follows a cold and typically lasts for up to
three weeks. After three weeks it becomes defined as a
chronic sinusitis and may become much more difficult to
treat.
Since the Spring of 1990, we have noticed a significant increase in the number of people who have sinus infections. The reason for this is not clear at the present, but it is most likely due to increasing amounts of pollution and ozone. There have been similar increases in other major cities in the United States.
It may be extremely difficult to diagnose a sinus infection early
in the course of the disease. After taking a careful history,
which is extremely valuable in helping diagnose sinusitis, and
doing a physical exam, the diagnosis is typically made by looking
inside the nose with a flexible rubber or rigid steel tube called
an endoscope.
Depending on what is found at the time of the endoscopy, an x-ray (CT scan) of your sinuses may need to be done. Previously, x-rays of the sinuses were done. Now CT scans are ordinarily done because a much greater amount of information can be gleaned from the CT scan, and at a very slight increase in the cost. If you need to have surgery, a CT scan will ordinarily be done prior to surgery. The CT scan is often performed in a special way ( called coronal views) so that certain portions of the sinuses are better seen. Endoscopy and CT scans are now done very commonly for sinus infections. Many doctors and all sinusitis specialists can look inside your nose with the endoscope. It's not painful but might be a little uncomfortable. Don't worry - your nose is sprayed first with a local anesthetic. Believe it or not, I've done it to myself!
There is a section later in this website with CT scans, and an explanation for the layman. Don't be afraid to look at them. By the time you finish, you are likely to know more than your doctor!
What causes mucus to be moved out of the sinuses?
There are tiny hairs in the sinuses called cilia. They beat like waves and move mucus out of the sinuses through a tiny hole (actually a short tube). The tube forms a hairpin turn and is only about 1/6 of an inch in diameter. Obviously it is very easy for this to get blocked.
Why can't the cilia move the mucus out?
Typically, early in the development of a sinus infection, the cilia (tiny hairs lining the sinuses) are lost and mucus becomes increasing thick. Consequently, the mucus is retained in the sinus. If the sinus infection lasts for a long enough period of time, the lining of the sinus may actually physically change, causing an even thicker mucus to develop. The bacteria become trapped in all of the nooks and crannies and proliferate. Once this happens, it is common that patients need to have surgery. Given the above problems, it is obviously important to treat a sinus infection as soon as it starts to occur.
Why do I often have symptoms when I wake up in the morning?
As a result of sleeping, patients will often breathe through their mouth, not be able to clear the mucus from the nose and also not swallow. As a result, mucus is often pooled in the back of the nose and throat causing irritation.
How do I find a doctor to treat my sinus problems?
That is a very difficult question to answer. Assuming that you are not from New York, I would suggest that
you go over the information in the website carefully and discuss it with your doctor. You might want to ask
him to look at the information in the physicians section, or print it out for him or her. Hopefully you can get them to be receptive to the ideas which I have compiled here. If you feel that you are not getting better, and your doctor is not receptive to trying some of the treatments in here, I would suggest that you find an allergist or
otolaryngologist who may be better able to treat you.
If you are located near a medical school, call the department of allergy or otolaryngology and ask to see someone with extensive experience in treatment of sinusitis.
Commonly used antibiotics such as penicillin, erythromycin, and
tetracycline do not generally work because usually the bacteria
are resistant. Antibiotics such as amoxicillin and
sulfa drugs may be used as first line treatment for sinus
infections, but they commonly do not work in patients who
have had infections for more than a short period of time or who
have been on multiple antibiotics previously. We then may have
to use one of the newer antibiotics - they are expensive,
sometimes $100 per week. We commonly may have to use several
different antibiotics until we can find the correct one. It is
important to understand that some people are cured by antibiotics
like penicillin, but it's not as likely to work as one of the
other, newer antibiotics. If you would like a list, see the physicians section.
What other treatments are used?
Although antibiotics are important to use in treatment of sinus
infections, it is extremely important to allow the mucus in the
sinuses to drain adequately. The way this is done is to use nasal
sprays containing small amounts of cortisone to reduce the
inflammation inside the nose and around the ostia (the opening
from the sinuses into the nose). (There is minimal absorption of
any of the cortisone nasal sprays into the body and so they are
very safe). there is a list of the various steroid nasal sprays in the allergy section.
In some cases antifungal treatments need to be used. ( There is a section on fungal sinusitis later in the website.)
We also use decongestants like Sudafed to reduce the
swelling inside the nose, as well as drugs such as guaifenesin (the active ingredient in Robitussin) contained Mucinex ( non-prescription) as well as several prescription medications.
to reduce the thickness of
the mucus. These must be used in high dosages, typically 2400 mg. per day. Discuss that with your doctor because there can be side effects. There used to be another decongestant, phenylpropanolamine, available, but it is no longer available in the United States because of side effects.
What other non drug remedies can be used?
Many patients will report that breathing in eucalyptus oils will
help open the nose. Steam rooms are also often helpful.
Patients often report that after a hot shower their nose seems to
open up and they are more comfortable. Some patients also report
help with garlic. I have even had some patients who stuffed
garlic cloves up their nose!! Chinese herbs have been
used, but we cannot endorse these nor do we know of any studies
showing they are effective. Irrigation, saline nasal sprays, and other medications can be helpful which are listed on the treatment regimen page. If you haven't looked at them, you should do so now. But remember if you choose to use
these non drug treatments, they must be used in conjunction with
prescription medication in order to avoid serious
complications.
How long do I have to take antibiotics?
Because penetration of antibiotics inside the sinuses is poor, an
extended treatment is often necessary. Antibiotics do not
penetrate well into bone and the bacteria in chronic sinusitis are
located inside bone. Typically a minimum of three weeks or
more of antibiotic treatment is necessary for patients with chronic sinusitis. Sometimes 6-8 weeks of
treatment may be necessary. In some cases multiple different
antibiotics need to be used. In some cases where patients do not get better after they have been treated with an adequate course of antibiotics, they will receive intravenous antibiotics instead of, or as preparation for surgery.
What about side effects from medications?
Approximately two-thirds of the patients with sinus infections
that we see have some problems from medications. Common side
effects include lightheadedness, dizziness, spaciness, difficulty
concentrating, jitteriness, being hyper, rapid heart beat,
difficulty sleeping, nausea, bloating, rectal itching, burning on
urination, fatigue, and so forth. A lot of these side effects
can also be due to the sinusitis. And because side
effects occur so commonly, it takes an experienced
physician to be able to deal with the problems.
Can I use an over-the-counter nasal spray?
Judicious use of a decongestant nasal spray such as
Neosynephrine, used according to directions for three to seven
days, is also advisable in many patients. Extreme caution
must be used in order to prevent worsening of symptoms or
addiction to these sprays. Note that there is no risk of
addiction with the prescription nasal sprays, but there can be other side effects - check with your doctor.
It is also extremely important for most people to use a humidifier, especially in the winter. I prefer a hot mist vaporizer, as
long as there isn't any reason not to use one, such as someone
around who might get burned. It should preferably be placed at
your bedside every night, to thin out the mucus. Short of a
vaporizer, breathing in steam on a regular basis by boiling water
can be used but is not as satisfactory. We use a special
apparatus in the office called a Rhinotherm. This machine
blows out a heated mist through a nozzle which patients can then
breathe in their nose. Many patients find it helpful. It is
expensive though and therefore not well suited for home
use. Items such as a personal steamer may be helpful. In patients who are allergic, we like to keep the humidity less than 50 % to prevent mold and dust mite growth. ( See the allergy section for more information.) You can obtain a humidity gauge from a hardware store.
Vaporizers need to be cleaned on a regular basis, to prevent mold accumulation. Hot mist vaporizers are typically less of a problem than cool mist, since the water is boiled before it comes out of the vaporizer.
Can you do a culture to find out what bacteria are causing the
problem?
Unlike most infections ( for example a strep throat), where
it is possible to determine the exact bacteria by doing a simple
culture, it is not possible to simply take a culture from your nose to determine what the cause is of the sinus
infections. The bacteria inside the nose which we could
theoretically culture are not the same as the bacteria
growing in the sinuses unless you have previously had sinus surgery. It is possible to take a culture from the drainage area of the sinuses, but this is something which typically must be done by a specialist using an endoscope. The other way to determine which bacteria
are in the sinuses is to insert a needle into the sinuses through
the nose, obviously an invasive and potentially dangerous
procedure which we would prefer not to do.
Can I use antihistamines to treat sinusitis?
Under some circumstances, antihistamines are used, if allergies play an especially prominent part in the
symptoms. Because of the fact that antihistamines tend to be
drying, we usually try to avoid them in treatment of sinusitis.
The mucus in the sinuses may then get dried out and is plastered
up against the wall of the sinuses. The bacteria love it
because they are trapped inside the sinuses with nowhere to go.
They reproduce like crazy and since the mucus is dried
out, a blockage in the small drainage canal can occur and so
mucus remains inside the sinuses. Unfortunately people feel
better initially because the volume of fluid in the sinuses
initially is reduced, but eventually symptoms return.
How long does sinusitis have to be treated?
Because of the fact that we are dealing with an abscess which can
not be adequately drained without doing a major surgical
procedure, it often takes an extended period of time for the
sinus infection to be completely treated by what we can call
medical drainage. Some physicians often will only treat
patients with sinus infections for a week or ten days and as a
result patients are partially cured, but never get
complete relief of symptoms. It is critical that
treatment occur for a minimum of several weeks, and
commonly patients may need to be treated for several
months. Antifungal agents may need to be used for an even longer period of time. We commonly continue non- antibiotic treatment after stopping antibiotics. If patients don't get better, it is important for them to be evaluated for surgery
by an otolaryngologist.
What is the place of acupuncture in sinusitis?
A wide variety of non-traditional treatments have been used in
treatment of sinusitis. Acupuncture has been used to help open
the sinuses allowing the mucus to drain better. I had
acupuncture before surgery. It helped, but I still had to have
surgery. Most patients we have seen have felt that it has helped
open their sinuses up, but no studies have confirmed this. A CT
scan (x-ray) done before and after on our several of our patients has not shown
any substantial change.
How much water do I have to drink?
It is important to drink a minimum of eight glasses of
water per day. Ideally, 15 or 20 glasses is helpful in order to
thin the mucus out and allow adequate drainage. Some of the
medications tend to make you very thirsty. I was once at a
dinner when I was so thirsty that I drank 12 glasses of
water!
Alcohol very commonly causes worsening of sinusitis, often not so
much because of an allergy, but because alcohol functions as a
diuretic. It often causes patients to become dehydrated, leading
to drying and thickening of the mucus which may, in turn, cause a
blockage of the opening of the sinuses and a worsening of the
infection. In addition, when patients come home after having
several drinks, they often may forget to take their medications
and don't turn on their vaporizer leading to worsening of the
sinus infections. In patients who are allergic to red wine,
yeast, sulfites or other components of the alcohol, that may
compound the problem by causing allergic swelling of the nose.
How often is follow up necessary?
It is important to schedule follow-up visits in order to make
sure that treatment has been adequate. The most common reason
why patients develop future problems with sinus infections is
because they stop the medications too soon. This could be
avoided if they came back for scheduled appointments and had any
other problems addressed.
Why do I have to keep my nose clear? I can breathe through my
mouth.
Believe it or not, your nose is not just a decorative
object found on your face, it really has a purpose. It is
extremely important to keep the nose clear so it is
possible to breath through the nose. It has been found that air
exchange into the sinuses occurs twice as rapidly with nasal
breathing. The air exchange will reduce the likelihood of
bacteria growing in the sinuses.
How fast should I feel better?
We have patients call our office if they do not start feeling
better within several days after coming in. If they're not
feeling better, it usually means they need some change in
medication.
What role does a deviated septum play in sinusitis?
The septum is the bone and cartilage which separates the two
sides of the nose. A deviated septum is simply a crooked septum.
A deviated septum commonly can cause or exacerbate chronic
sinusitis by causing a blockage of the nose and also of the
drainage area from the sinuses. Most people have a somewhat
deviated septum. Just because your septum is deviated, it
doesn't mean that it is causing a problem-but it does need to be evaluated. There are some patients who
have such a severe deviated septum that they need to have surgery.
That may need to be evaluated by an otolaryngologist or sinusitis specialist.
When surgery is done for sinusitis, the deviated septum is often straightened at the same time as the surgery is done on the sinuses.
There is a device called the Breathe Right nasal strip which
you may have seen athletes wear. It looks like a band-aid that goes
across the nose but actually opens up the nose with a spring-like
mechanism which is contained in the Breathe Right strip. Many
patients with a deviated septum find that their nose will open up
if they use it. Unless you're a football player, you will
probably decide not to use it during the daytime, but
since many patients have worsening of symptoms at night, it
can be helpful when used then. There is more information about these mechanical devices on the information page
What kind of effects do tobacco smoke and other irritants have on
the sinuses?
Tobacco smoke and various other irritants may cause worsening of
symptoms. Those irritants include auto exhaust, gasoline fumes,
paint fumes, perfume, roach spray and household chemicals such as
bleach, etc. Cigarette smoke paralyzes the tiny hairs (cilia)
which move mucus out of the sinuses. It also causes irritation
and inflammation in the nose and respiratory tract. There is no
good way to effectively treat these exposures, and as a result
they must be avoided. Sometimes using an air filter will be
helpful in removing them. The most helpful ones typically are
called HEPA filters. (See allergy section later)
What effect do nasal polyps have on sinus problems?
Nasal polyps are not true polyps but rather are probably caused
by inflammation in the nose. They look like peeled grapes but
are basically fluid-filled sacs. They can be found anywhere in
the sinuses or nose and commonly are associated with sinus
infections. They can cause a blockage of the drainage holes
(ostia) from the sinuses, causing a back-up of mucus in the
sinuses. Nasal polyps are often associated with asthma and can
be made worse in some people by ingesting aspirin or related
drugs. Treatment involves steroids, treatment of sinusitis, and treating any allergies. They may sometimes need to be removed surgically, but surgical removal doesn't mean that they won't come back. They are not
precancerous in most cases.
What role do allergies play in sinusitis?
Many patients with chronic sinusitis have
allergies which may partially complicate sinusitis. Allergies
cause swelling and blockage of the tiny holes which allow
drainage of mucus from the sinuses. In addition, the allergies
may cause swelling inside the sinuses and inside the nose. It is
critical that patients with allergies control their environment
in order to control their sinusitis. Because so many patients with sinusitis have allergies, we have included a
section on allergies later in this website as well.
Do allergy shots help with sinus infections?
In patients who have chronic sinus infections, I think it makes
sense to do anything to avoid worsening of symptoms or
surgery. If we find a patient is allergic and has chronic
sinusitis, we often suggest getting allergy shots to desensitize
them to the various things to which they are allergic, in the
hope that it will help with the sinusitis. Because allergy shots
take 6-24 months to work, they must be used in conjunction with
other treatment, including controlling exposure to environmental agents.
What role do food allergies play in sinusitis?
The effects of food allergies in treatment of sinus infections
are very controversial. This is something that the patient needs
to discuss with an allergist well acquainted with treatment of
sinusitis. Briefly, food allergies are much more common in
children than in adults and can sometimes cause problems with
sinusitis, but much less commonly than environmental agents like
dust, molds, pollen, animals and believe it or not: cockroaches. Milk may cause problems in some patients, but probably less than 15% of patients with sinusitis.
When should surgery be considered?
A small percentage of patients with chronic sinusitis will fail
to improve even with the best medical treatment. In most
studies of patients treated by allergists who specialize in treatment of chronic sinusitis, this is less than 10% of patients who have had
optimal medical treatment. It is important to realize,
however, that surgery is frequently performed on patients who have not had
the best medical treatment prior to surgery.
The most well respected medical review organization, called the Cochrane Review, has evaluated medical versus surgical treatment of sinusitis and has found that surgical treatment does not have an advantage over medical treatment. this doesn't mean that people should never have surgery, but I think that it indicates that many patients would do as well with medical treatment.
This web
site is one of many attempts to educate physicians and the public
about the treatment of chronic sinus infections. Although many
physicians, including ear, nose and throat doctors and allergists
treat chronic sinusitis, some physicians do a
better job at it than others. There is an ongoing effort
by a small number of specialists to educate both physicians and
the general public about the best way to treat sinusitis. When
that job has been completed, I will be able to close down this
website and retire. Since I am still in my forties, I don't think
that will be for a while.
What is done if I have to have sinus surgery?
You should first understand that I am not a surgeon, so this is
from the perspective of someone who has seen the surgery, and had
the surgery done, but who doesn't do the surgery himself.
The surgery, called functional endoscopic sinus surgery (FESS),
may be done either under local anesthesia or general anesthesia. Many very experienced sinus surgeons prefer to use local anesthesia.
The operation generally takes approximately 2-3 hours. During
that period of time, the ear, nose and throat doctor will do any
one of a number of things including: straightening the septum
(the bone and cartilage separating the two sides of your nose),
making an opening into the
sinus(es) on either side of the nose so that drainage can occur
more effectively, and possibly remove some of the inflamed lining
of the sinuses. The number of sinuses which need to be opened up
depends on the nature of your problem. (For a better understanding, look at the CT scan section after you finish the FAQ page)
The surgeon uses a rigid tube (endoscope) which is inserted into
the nose. The entire operation is done through the nose.
Previously, the surgery was done using an incision underneath the
lip called a Caldwell-Luc procedure. This caused an extended
post-operative healing time as well as occasional loss of
sensation in the face and was not nearly as effective as the
current surgery.
The current surgery involves opening up the naturally occurring
openings (ostia) from the sinuses into the nose. (They are at the
top of the sinuses). The older procedure involved making a
drainage hole in the bottom part of the nose, with an extensive amount of removal of tissue from inside the nose. It was logical,
but unfortunately it didn't work as well because mucus flows
upwards toward the top of the sinus aided by tiny hairs
called cilia. In addition, removal of the tissue from inside the sinuses caused scarring, so that now very little tissue is removed from inside the sinuses.
Cilia are tiny hairs lining the respiratory tract which beat in a
wave-like fashion to move mucus out. They are paralyzed by
cigarette smoke. Cilia move mucus to the opening of the sinuses
into the nose. Unfortunately that opening is located at the top
of the sinuses. (It worked well for our prehistoric ancestors
who were on all fours, but doesn't work as well for us. Try
it-get down on your hands and knees with your head looking at
the ground and you'll see).
How long is the recovery after surgery?
Generally, patients will remain in the hospital just for the day
of the operation, but sometimes overnight. Patients are usually
out of work for 1-2 weeks. Full recovery may take six weeks,
although for periods of six months to a year patients may become
more sensitive to infection. The surgeon will typically remove crusting on a regular basis from the nose to prevent scarring from occurring. Packing is often not placed nowadays, so that the removal of crusting isn't usually that uncomfortable.
There will be limitations on lifting, blowing the nose, and flying for a short period of time, while the healing occurs. Ask your doctor about irrigating with saline after the first week. Most people don't have a lot of pain, but if you do, ask your doctor for pain medication. Most patients don't have external bruising after the surgery.
Elsewhere in this website, there is a more extended discussion of sinus surgery. We would suggest that you may wish to look at those sections as well.
As we stated earlier, just because you have surgery, it doesn't mean that you won't get sinusitis any more. Surgery is not meant to cure the disease. Once the sinuses have been opened up by surgery, it is possible to wash out the sinuses if necessary, and as a result, sometimes oral antibiotics don't have to be used. It is often possible to do an endoscopy and find out exactly where the cause of the problem is, since it is possible to examine the inside of the sinuses once surgery has been done. Cultures can be done, just as they can be done prior to having surgery, so that antibiotics can be selected based on the findings from the culture.
Elsewhere on this website, there is a section on treatment of sinusitis after surgery.
What if the surgery doesn't help?
First, be patient, recovery from surgery takes weeks (occasionally months). If you aren't better at that point then there are many possibilities including allergies, immune problems, fungal infection of the sinuses, scarring from the original surgery, sinusitis involving sinuses other than those originally operated on, etc. If you have these kinds of problems, it is critical that you see someone who is well experienced with medical treatment of patients after surgery. Unfortunately there are very few doctors in that category. Please review the section of this website on sinusitis after surgery for more information about what happens if you don't get better after surgery..
What other problems happen as a result of sinusitis?
I have seen patients with problems like hives which wouldn't get better, they had no other symptoms. The hives got better immediately with treatment of sinusitis. I was amazed.
Sinus problems may also cause all kinds of allergies to worsen
(it seems that sinusitis turns on the immune system) and can
cause problems with asthma, intestinal symptoms, and a wide
variety of other medical problems. I have had patients who have
toothaches and have numerous dental procedures to no avail.
"Migraines" are an especially common manifestation of sinusitis.
One study found 50% of chronic migraine patients had chronic
sinusitis.
Although rare, serious complications can occur as a result of sinus infections. This includes spread to the brain, eyes, and a blockage of vessels in the head. In addition, erosion of bone can occur as a result of the infection eating through the sinuses. Not a pleasant thought, and more incentive to get it properly treated.
Can sinus problems be due to an immune deficiency?
It is unusual, but sometimes sinus infections are caused by immune problems. In patients who have persistent sinus infections, it is important to have the immune system evaluated by an allergist/immunologist, especially before surgery is done. You may need to have allergy tests done, as well as tests done to make sure that you can form antibodies normally to common bacteria. ( For more discussion, please see the letters section.) Rarely, it can be due to AIDS, but don't jump to conclusions: 99.9% of people with sinusitis don't have AIDS.
Will I get more sinus infections in the future?
Once your sinus infection has been treated, it is important to try to prevent future sinus infections, but they often occur. It is important to provide adequate treatment of colds and allergies in order to try to prevent blockage of the sinuses. We commonly suggest that people start many of the medications, with the exception of antibiotics, at the first sign of development of cold symptoms. You should talk with your doctor about that possibility.
The more frequently that sinus infections occur, the more likely it is that surgery may be needed in the future.
What is the relationship of asthma to sinusitis?
About 70% of people with chronic sinusitis have asthma as well, but it doesn't necessarily have to debilitate you. It has been found that about 15% of Olympic athletes have asthma. For more information, see the section on Asthma in this website.
What is the importance of a fungus in sinusitis?
An article published in the Mayo Clinic Proceedings in September, 1999 by Dr. Gene Kern's group at the Mayo Clinic suggests that fungal sinusitis may be much more common than previously thought. Fungal growth was found in 96% of patients with chronic sinusitis. The difference between those with chronic sinusitis and the normal population was that their eosinophiles ( a type of white blood cell involved in allergic and other reactions) had become activated. The eosinophiles had released a product called Major Basic Protein which attacks the fungus but is very irritating to the lining of the sinuses. It is then speculated that this injury allows the bacteria to proliferate. The concern is whether our treatment of sinusitis should be directed at treatment of the fungus rather than the bacteria. This topic is extremely controversial, but most specialists in sinusitis now agree that it is an important factor in some patients with sinusitis. For more information please go to the separate page on fungal sinusitis, the address of which is below.
Antifungal agents such as Sporanox or Amphotericin B can be used either as oral agents or topically. Both are difficult to use for a variety of reasons, but work is being done on these and other agents. That is an area that requires an extensive amount of work.
Surgery, irrigation, steroids and immunotherapy are helpful, but it can be extremely difficult to treat.
Fungal sinusitis is now thought to contribute to most patients with sinusitis and is a must read