Understanding Chronic Sinus Disease

Understanding Chronic Sinus Problems

Sinusitis is one of the most common health problems that patients of all ages experience.  The incidence in adults in the United States, as per census data, is 14.1% for adults who suffer at least once yearly from sinusitis. The American Academy of Otolaryngology (ENT) research shows that treating sinusitis costs U.S. patients $3.4 billion yearly, and chronic rhinosinusitis patients have 18 to 22 million doctor visits yearly.

We use the word Rhinosinusitis instead of sinusitis, because the sinus infection is usually preceded by inflammation in the nose.  The condition Rhinosinusitis covers nasal inflammation as well as inflammation and infection of the four pairs of paranasal sinuses, the frontal (behind the eyebrows) the maxillary (behind the cheekbones) the ethmoid (beside the upper part of the nose on each side), and the sphenoid (up above the back of the nose, at the base of the skull).  The location of sinuses and nasal obstruction is important, and the regions where the sinuses drain into the nasal cavity can be blocked by inflammation or anatomic obstruction which can lead to stagnation of sinus secretions and the creation of conditions where infection can develop.  Unfortunately it is sometimes difficult to know early on if the condition is inflammatory or infectious.  Those of us treating rhinosinusitis look for major criteria, such as facial pain, nasal obstruction, decreased sense of smell, fever, and an infected sinus drainage.  We also assess our patients for minor criteria which include tooth pain, cough, fatigue and headache.  Despite these symptoms and physical exam findings, the gold standard for diagnosis of a persistent sinus infection after treatment is a CT scan of the sinuses. 

Based on the duration of rhinosinusitis signs and symptoms we classify the condition as acute if symptoms last up to four weeks with total resolution of symptoms.  Subacute rhinosinusitis is defined as sinus symptoms persisting for over four but less than 12 weeks, and chronic rhinosinusitis is defined as the condition when a patient has signs and symptoms for greater than 12 weeks despite treatment.

How do we treat chronic rhinosinusitis?

Because the causes often are multifactorial, the condition does not respond with antibiotics alone.  There are several predisposing factors which affect the patient in addition to a possible bacterial infection.  We check our patients for viral illness, anatomic obstruction of the sinus drainage areas, exposure to irritants such as cigarette smoke, viral, fungal and bacterial infection, and even gastroesophageal reflux.  Our search for the factors causing our patient’s chronic rhinosinusitis is key to developing an appropriate treatment.

Frequently a combination of measures is necessary to help a patient with chronic rhinosinusitis.  Some treatments are meant to improve sinus ventilation and drainage, such as having our patient drink enough water and use saline nasal irrigation.  The use of intranasal saline has been shown to decrease nasal symptoms and improve quality of life, counteracting the effects of allergens and irritants.  Patients with chronic rhinosinusitis are often asked to do the saline irrigations regularly, even before worsening of symptoms.  If one of the symptoms is persistent thick postnasal drainage, mucolytics such as guaifenisin and topical nasal steroid sprays can help relieve symptoms.  There are other treatments designed to reduce inflammation such as corticosteroids, anti-leukotrienes, antihistamines, and macrolides.  Finally there are medical antibiotic and antifungal treatments which can be taken systemically or used topically with irrigation.  Often the key to success in treating a chronic rhinosinusitis patient is aggressively combining antibiotics with therapies directed at the predisposing conditions for a length of time to adequately allow healing of the mucous membranes of the nose and sinuses, and recovery of local immunity.

What about allergy and irritants and their role in chronic rhinosinusitis?

Up to 30% of adult patients are allergic to at least one common allergen, and the percentage is much greater in patients with a history of chronic nasal and sinus problems.  Allergy is the second most common predisposing cause of chronic sinusitis in children (after viral upper respiratory tract infection), and the most common predisposing factor in adults.  This condition causes mucosal inflammation and hypertrophy leading to blockage of the natural sinus drainage areas into the nose.   All chronic rhinosinusitis patients should have a good allergy history and formal allergy evaluation; treating the inflammatory response is key in these patients.

When is surgery necessary? 

The most common indication for sinus surgery is a failure of the medical treatment of chronic rhinosinusitis.  About 200,000 patients undergo surgery in the United States to alleviate chronic sinusitis.  The relative indications include persistent obstructions to normal aeration of the sinus, specific areas of recurring sinus disease and chronic or recurrent acute rhinosinusitis who have not responded to medical therapy.  Absolute, often emergency reasons for patients to undergo sinus surgery include complications like brain abscess, meningitis, suspected cancer of the sinuses, mucocele or pyocele and serious fungal sinus infections in immuocompromised patients. Over 80 percent of chronic rhinosinusitis patients respond to aggressive medical therapy however when this fails, the natural drainage passages of the sinuses can be enlarged with balloons, and obstructing tissue such as polyps or bony abnormalities can be removed safely with minimally invasive techniques. These sinus surgeries are done under endoscopic visualization often with image guidance after careful treatment planning based on examination of the patient and study of the CT scan showing the extent of disease.  Children with chronic rhinosinusitis are often treated with adenoidectomy and maxillary sinus dilation which is a limited procedure showing predictably improved outcomes. The physicians at West Suburban Ear Nose and Throat Center are all available to consult with you about your sinus or nasal problems. We treat children and adults for these problems, and are committed to the best practices in caring for you whether your sinus condition requires medical or surgical therapy.