Chronic Sinusitis

What are sinuses?

The sinuses are small, air filled spaces inside the cheekbones and forehead. They make some mucus which drains into the nose through small channels.

What is sinusitis?

Sinusitis means inflammation of a sinus. Most bouts of sinusitis are caused by an infection. The cheekbone (maxillary) sinuses are the most commonly affected.

Acute sinusitis means that an infection develops quickly (over a few days) and lasts a short time. Most cases last no more than a week or so but some last longer. Acute sinusitis is common and is dealt with more fully in a separate leaflet.

Chronic sinusitis means that a sinusitis is persistent. Symptoms can last for several months or longer. The strict medical definition of chronic sinusitis is a condition where "symptoms persist for more than 90 days, and may be due to prolonged or repeated infections leading to changes in the mucosal lining of the sinuses." Chronic sinusitis is uncommon.

The rest of this leaflet is only about chronic sinusitis. See a separate leaflet for details of acute sinusitis which is much more common.

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 four weeks, often much sooner. In some cases the symptoms do not go and become 'chronic'.) The following are causes of acute sinusitis that may progress into a chronic sinusitis.

  • In most cases, acute sinusitis develops from a cold or flu-like illness. Colds and flu are caused by viruses which may spread to the sinuses. The infection may remain 'viral' before clearing. In some cases, bacteria 'add-on' to an infection that started with a virus. This can make the infection worse, last longer, and may cause more damage or changes to the lining of the sinus.
  • In some cases, infection spreads to a maxillary sinus from an infected tooth.
  • In a few cases, one or more factors are present that cause the sinuses to be more prone to infection. These cases may be more likely to progress into chronic sinusitis as there is an underlying problem. These include:
    • Allergic rhinitis (nose allergy). The allergy may cause swelling of the tissues on the inside lining of the nose and block the sinus drainage channels. See separate leaflet called 'Allergic Rhinitis'.
    • Other causes of a blockage to the sinus drainage channels such as nasal polyps, objects pushed into the nose (especially in children such as peas or plastic beads), facial injury or surgery, and certain congenital abnormalities in children.
    • 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 such as Aspergillus or Cryptococcus 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 rhinitis (nose inflammation).
    • Primary ciliary dyskinesia / Kartagener's syndrome.
    • Rare tumours of the nose.

However, chronic sinusitis is not simply due to an infection that does not clear. (This is why chronic sinusitis is not easily treated with a normal course of antibiotics.) The persisting symptoms may be due to a combination of factors after being initially triggered by an infection. 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 other factors may cause or contribute to the development of chronic sinusitis. For example, a persisting allergy that causes inflammation in a sinus and swelling or blockage of the drainage channel.

What are the symptoms of chronic sinusitis?

The most prominent symptom is usually a blocked nose (nasal obstruction). One or more of the following may also occur.

  • A runny nose. The discharge is often greeny/yellow.
  • A reduced sense of smell.
  • Pain over the affected sinus. However, pain is often not a main feature of chronic sinusitis (unlike acute sinusitis). In many cases it is more of a feeling of 'facial fullness' or mild discomfort rather than pain.

The severity of symptoms may wax and wane. They may be worst during an initial acute sinusitis. They may then ease off and not be as severe. For example, you may just have 'nasal stuffiness' rather than a fully blocked nose with some mild facial discomfort.

Other symptoms that sometimes occur include: headache, bad breath, toothache, cough, a feeling of pressure or fullness in the ears, and tiredness. In children, symptoms may include irritability, snoring, mouth breathing, feeding difficulty, and 'nasal' speech.

What are the treatments for chronic sinusitis?

If you develop chronic sinusitis you are likely to be referred to an Ear Nose and Throat specialist. He or she may do various tests to see if there is an underlying cause which makes you more prone to develop sinusitis (mentioned above). For example, a scan of the sinuses or a detailed look into the nose cavity. Treatments are classed as 'medical' or 'surgical'.

Medical treatments
The sort of treatments that may be considered include the following.

  • A long course of a steroid nasal spray or steroid nasal drops may be advised. (For example, a three month course.) Steroids reduce inflammation. In particular, a steroid spray or drops may help where an allergy is thought to play a role. For example, if you have allergic rhinitis.
  • A longer than normal course of antibiotics may be advised (for example, a 2-3 week course). This may work but, as mentioned, chronic sinusitis is not just a simple ongoing infection. A long course of antibiotics may protect the affected sinus from recurring infection to allow any chronic inflammatory changes to gradually return to normal.
  • Anti-fungal medicines are needed if you have a fungal infection of a sinus (rare).
  • If you have asthma then good control of asthma may improve chronic sinusitis symptoms, and vice versa.
  • If you smoke, then stopping smoking may help.
  • Painkillers such as paracetamol or ibuprofen to ease any pain. Sometimes stronger painkillers such as codeine are needed for a short time.
  • Dental treatment may be advised if a dental cause is diagnosed.

Surgical treatments
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 commonest 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 nasal cavities). The surgeon can then 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 restore normal function to the affected sinus. This operation is 'minimally invasive' (causes little damage) and has a high success rate in relieving the symptoms of chronic sinusitis.

Are there any complications from chronic sinusitis?

Living with untreated chronic sinusitis can be unpleasant with the persistent symptoms. However, serious complications are rare. For example, rarely, a sinus infection may spread to nearby areas such as around an eye, into bones, into the blood, or into the brain. Complications are more common with infection of the frontal sinus. Children are more prone to complications than adults. Swelling or redness of an eyelid or cheek in a child with sinusitis should be reported to a doctor urgently.

Scuba divers with nasal or sinus problems should be aware of possible serious consequences of sinus barotrauma (tissue injury resulting from pressure differences when diving). Divers with chronic sinusitis should seek specialist advice, as recurrent barotrauma to sinuses can cause 'knock on' complications such as serious infection and damage to nerves in the face and eye.

Flying in an aeroplane may cause an increase in pain if there is blockage of the sinus drainage channel. This is because 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 decending to land.