Chronic Sinusitis

What are the sinuses?

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. Many cases of acute sinusitis last a week or so but it is not unusual for it to last 2-3 weeks (that is, longer than most colds). Sometimes it lasts longer. Sinusitis is said to be 'acute' if it lasts no longer than 12 weeks. A mild bout of acute sinusitis is common and many people will have mild sinusitis with a cold. See separate leaflet called 'Acute Sinusitis' for more details.

Chronic sinusitis means that a sinusitis becomes persistent and lasts for longer than 12 weeks. Chronic sinusitis is uncommon. The rest of this leaflet is just about chronic sinusitis.

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 '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 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, 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 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:
  • 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. This makes the sinuses more susceptible to infection. There are separate leaflets on hay fever and persistent rhinitis that discuss allergic rhinitis in more detail.
  • 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.
  • Asthma.
  • 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 rhinitis (nose inflammation).
  • Primary ciliary dyskinesia/Kartagener's syndrome.
  • Rare tumours of the nose.
  • Smoking.

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 - see below.) 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 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 may be 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 your symptoms may wax and wane. They may be worst during an initial acute sinusitis. They may then ease off and not be as severe leaving a 'background' level of symptoms. (For example, you may just have 'nasal stuffiness' rather than a fully blocked nose, as well as some mild facial discomfort.) You may then develop another episode of acute sinusitis making symptoms worse again. For a diagnosis of chronic sinusitis, symptoms must have been present for longer than 12 weeks.

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.

Do I need any investigations?

Your doctor can usually diagnose chronic sinusitis from listening to your typical symptoms. They may ask questions to determine if there could be an underlying problem causing your chronic sinusitis. For example, asthma, allergic rhinitis, chronic dental infection etc. Your doctor may also examine your nose to check for any obvious abnormalities or deviation of the bones in your nose and to look for any other problems such as nasal polyps.

If you develop chronic sinusitis that is not easy to treat with straightforward measures, your doctor may suggest that you are referred to an Ear, Nose and Throat specialist. The specialist 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.

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 allergic rhinitis, treatment of a dental infection, treatment of asthma 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 (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, 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. 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 descending to land.

Medical treatments

The sort of drug 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. Steroid nasal sprays or drops may also sometimes help to shrink nasal polyps. 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 'Steroid Tablets' for more detail.
• 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 and allow any chronic inflammatory changes to return gradually to normal. However, the evidence for giving long courses of antibiotics to treat chronic sinusitis is limited because of a lack of good clinical trials. It is often an Ear, Nose and Throat specialist who is the best person to decide whether a long course of antibiotics may be helpful for you or not.
• Anti-fungal 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 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 nose 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 a bacterial infection.

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 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 is 'minimally invasive' (causes little damage) and 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. (There is a news report with a video showing this procedure being done on the BBC website at: http://news.bbc.co.uk/1/hi/health/8103949.stm )

Surgery may also sometimes be needed to remove nasal polyps or to correct problems with deviated bones inside the nose.

Are there any complications from chronic sinusitis?

Living with untreated chronic sinusitis can be unpleasant with the persistent symptoms but serious complications are uncommon. Rarely, a sinus infection may spread to nearby areas such as around an eye, into adjoining bones, into the blood, or into the brain. 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.