What is Sinusitis?
Sinusitis is an inflammation or infection of the air pockets on either side of and behind the nose. It can be caused by bacteria, viruses, fungi (molds) and possibly by allergies. About 15-20 % of the population has a chronic sinusitis (meaning lasting longer than 3 weeks). It can cause a tremendous amount of suffering. I had sinusitis for years. I kept working but felt like I wanted to die. I felt like no one understood what I was going through, my wife would always say: "I can't believe you complain so much about something as trivial as a sinus infection", and then she got one... and she started complaining!
Sinusitis causes a wide variety of symptoms which can often be confused with other medical problems or dismissed as being due to a "cold". There may commonly be single symptoms such as a post nasal drip, stuffiness, or pressure around the nose, but can also be a combination of the these symptoms associated with a runny nose, clear or coloured mucus, a cough, a sore or irritated throat, pain in the teeth, headache, or fever. Additional symptoms which sometimes occur are hoarseness, a decreased sense of smell, and fullness of the ears, but they can be extremely varied as you will see in the FAQ section.
Sinus infections must first be diagnosed accurately, and then subsequently need to be treated with antibiotics, and prescription nasal sprays, as well as decongestants and often medications to thin the mucus. I also suggest that people use a vaporizer at night, and occasionally nasal irrigation, as well as Aspirin (if you can tolerate it), and I am sure that your friends and relatives will attempt to force you to take all kinds of non-drug remedies. Believe me, it gets overwhelming . We will try to sort it out for you.
If sinus infections are not treated early, they may become chronic. Early means no later than 2-3 weeks after the symptoms first start - the cold that lingers may not be just a cold. The longer you wait to treat sinus problems, the more difficult they become to treat, the more likely complications will ensue, and the more likely surgery may be necessary as opposed to medical treatment. So
Sinusitis Treatment Regimen
In the past 10-15 years it seems sinus infections have gotten progressively worse. More and more people suffer for longer and longer periods of time. I am one of those sufferers. My sinus infections started as a result of not being adequately treated for a cold. Over the course of three years they got progressively worse. As a result I ended up having to have surgery (twice) and now have been essentially cured, but that doesn't mean that I don't still get occasional episodes of sinusitis. The sinusitis is much easier to treat, however. Fortunately, most patients are able to be treated without surgery. Ninety to 95% of patients with chronic sinusitis can be effectively treated with medical therapy.
You may then ask, if 95% of people with sinusitis get better, why haven't my symptoms gone away? The reason is very simple. Sinusitis is very difficult to treat. As a result, patients typically don't get better quickly, and if they're not treated correctly they may never improve. If you're not getting better it doesn't mean that you're not getting good care, but it may mean you're not getting the very best care. Unfortunately most doctors don't understand the best way to treat it.
I would like for you to be able to understand how I treat patients in my office so that you can get the best treatment for your sinusitis wherever you can go for treatment. If you have read this far, you probably have spent much time, energy and money trying to get better. If you haven't had to spend that much, you are lucky. It is hard for most people to understand that a sinusitis specialist has special skills (and I'm not including surgery) which allow them to be successful in treating a difficult problem like sinusitis. That concept may be difficult to convey here, but by the time you've finished browsing through this website, I hope I will have achieved it. It is like a patient with chest pain going to see a cardiologist if the internist can't take care of the problems initially.
Probably as a result of having sinus problems myself, I have made many changes in the way I treat sinus infections-not so much in the medications or dosages, but in terms of the approach to treatment. When I had sinus infections, I felt like life wasn't worth living any more, between the exhaustion, pain and just feeling miserable. I was scared of having complications from the sinus infections, but even more scared of having surgery. I had side effects from the medications that nobody had heard of, and it seemed like there was just one problem after another. I think having gone through that made me 1) appreciate much more about how patients suffer with sinus infections, 2) understand more about how patients need to be treated as well as 3) empathize better with what they are going through.
The first time a patient comes into my office we have them fill out some forms, and then I will go over their history in detail. The history is probably the most important part of my evaluation. We get a strong suspicion not only of whether a sinusitis is brewing but also clues to treatment and factors which may worsen it. I spend a lot of time going through my patient's history (you can't do it in 5 minutes) and then do an examination. I was trained as an internist, so I don't just look at my patient's nose, but also listen to their heart and lungs as well as whatever else is necessary. It takes a long time (often 1-2 hours)to review all of the problems as well as the kinds of treatments that are used. We don't just treat the initial symptoms, we want to get you better permanently. It isn't easy. It means taking medications and sometimes altering various things about your lifestyle. It could be as simple as getting a vaporizer and putting it by your bedside so your nose and throat don't get dried out at night, or it may mean keeping a glass of water by your bedside. But sometimes it means making major lifestyle changes.
People often ask how long they have to take medications. It is often for weeks or months, but after a while, you usually can taper off the medications. Some people do need to have ongoing treatment, but obviously we would like to try to minimize that if at all possible. I talk to my patients about what can be done in order to do that. What is critically important though, is to get you over your sinusitis completely if it is at all possible.
Of the commonly used medications, the ones we like to use as briefly as possible are the antibiotics. Long term use can cause resistant bacteria (a very serious problem now), allergy and side effects. Other medications we use commonly include mucus thinners, decongestants, steroid nasal sprays, and anti-inflammatory agents. We also sometimes use antifungal agents.
In the course of the rest of the website we will discuss most of the medications that need to be used to treat sinusitis. Because of the number of requests, we have included a partial list here. It is important to realize that some or all of them may need to be used in each patient. Please discuss the medications with your doctor. Please do not send emails asking about specific medications as those must be discussed with your doctor. In some cases we have included hyperlinks explaining the medications. In others you must use the search engine Please read through the website so that you can better understand what the various treatments can do:
The most important treatments are in bold.
Steroid Nasal Sprays
decongestant nasal spray
Why do we have sinuses?
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.
What causes sinusitis?
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.
How common is sinusitis?
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.
Why is sinusitis increasing?
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.
How is sinusitis diagnosed?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.