Under Pressure: Understanding
Published on: September 24, 2003
By Christine Haran
We've all had cold symptoms that linger on for weeks, leaving us
wondering if we'll ever feel healthy again. Most of the time it's
just a bad cold caused by a virus, or allergies. But nasal congestion
that prevents the sinuses from draining properly can create a perfect
environment for a bacterial infection and the development of sinusitis.
More than 31 million Americans have at least on case of acute sinusitis
each year, and a small portion of those people will go to develop
chronic sinusitis, with symptoms lasting at least 12 weeks. Below,
Dr. Jerry Schreibstein, president of the Massachusetts Society of
Otolaryngology and a practicing ear, nose and throat physician in
Springfield, Massachusetts, reviews the different kinds of sinusitis
and how each type can be prevented and treated.
What are the sinuses?
The sinuses are air-containing spaces in the face that act as cushions
for the brain in the event of trauma and also act to aerate and
humidify the air that we breathe. The sinuses produce mucus that
drains through the nose back down the back of the throat, and we
typically swallow that mucus.
What is sinusitis?
Sinusitis is an infection or inflammation of the sinuses. It typically
occurs a week or 10 days following an upper respiratory tract infection.
The common cold is a viral infection that causes an inflammation
of the nasal membranes. Those membranes, in turn, cause inflammation
of the sinus openings. If the viral inflammation doesn't clear,
the mucus that's produced in the sinuses backs up, the sinus gets
obstructed and bacteria can infect those areas, and you get what
we call a bacterial sinusitis or a bacterial rhinosinusitis, meaning
that the nose and the sinuses are both involved.
Chronic sinusitis is sinusitis with symptoms lasting longer than
12 weeks. Imaging tests such as CT scans are helpful for diagnosis
in this situation. And the patient who gets repeat episodes of acute
sinusitis would be labeled as having recurrent sinusitis or recurrent
What are some of the symptoms of acute and chronic sinusitis?
Acute sinusitis is manifested by pain, pressure, congestion, colored
nasal discharge and pain in the upper molars. Headache, in and of
itself, is not a sign of an acute sinus infection. There are many
different reasons why people get headaches and nasal congestion.
Migraines, tension headaches, trigeminal neuralgia, which is an
inflammation of the nerve that innervates the cheeks, can all cause
pain in the sinus area, but not necessarily be due to an infectious
Chronic sinusitis is the condition where there's a chronic congestion.
There's often postnasal drip, altered sense of taste or smell and
a chronic discharge. And by definition, those are symptoms that
are lasting more than about 90 days. They may be associated more
with pressure symptoms than true severe pain.
What are risk factors for sinusitis other than an upper
Untreated allergy can lead to an infection. When someone has allergic
rhinitis, the nasal membranes get swollen, the nose and sinuses
produce more mucus and the small openings of the sinus get swollen
shut, whether it be from allergy or from a viral upper respiratory
tract infection. If the secretions in the sinus back up, you get
secondary bacterial infection.
Other things that can precipitate infections are anything that can
cause nasal inflammation. This includes pollutants, secondhand smoke,
and in children, chronic adenoid infections. Nasal polyps can cause
obstruction of the outflow track of the sinus. If you have nasal
polyps and you get an acute viral infection, it compromises the
drainage of the sinus and then potentially causes an infection.
How can people prevent sinusitis?
There are ways that people can prevent the development of an acute
sinus infection. You want to do things that help promote drainage
of the sinuses. So you want to use a clean humidifier with a nice,
warm steam mist. Over-the-counter saline sprays that are non-medicated
are very helpful to promote secretions. Topical nasal decongestions,
when used for two or three days, can promote drainage and improve
the nasal obstruction. But when used for more than three days, they
can be addicting and you can get a rebound effect. The other things
that are useful to prevent an acute sinus infection are oral decongestants.
I also recommend avoidance of some of the common over-the-counter
cold preparations that contain antihistamines, which dry the secretions
and prevent the sinuses from draining. I prefer to use antihistamines
only when people have underlying allergy.
For the patient with chronic sinusitis, non-allergic rhinitis due
to environmental irritants such as secondhand smoke and topical
nasal steroids can prevent swelling of the sinuses and the sinus
membranes. And there have been some studies to suggest that using
intranasal steroids is useful for acute sinusitis. But that has
to be done under a physician's supervision.
How is acute sinusitis diagnosed?
The most important thing is always listening to the patient and
taking a good history. The doctor should make sure the patient has
had an upper respiratory tract infection that's lasted for seven
to 10 days or has been worsening after seven days, or that they've
had allergy. When doctors examine the patient, they look for colored
nasal discharge in the nose; pain in their teeth; pain or tenderness
in their cheeks; and pain between the eyes or tenderness on the
frontal sinuses over the eyes. I typically do not recommend X-rays
to make the diagnosis of acute, uncomplicated sinusitis.
Nasal endoscopy, which involves a fiber optic instrument that enables
the doctor to examine the nose and sinuses, is very helpful to make
the diagnosis for a patient if you cannot find nasal discharge on
exam. It's also useful for someone who has had chronic sinusitis
where you want to look at the openings of the sinus and get a culture
to see what is the cause of that infection for someone who's already
been on several antibiotics.
How is sinusitis treated?
Typically, 10- to 14-day course of antibiotics would be given for
an uncomplicated, acute bacterial sinusitis.
The most important thing in treating chronic sinusitis is to try
and identify and eliminate the underlying cause such as an underlying
allergy to pets or mold. Do they have anatomic problems in their
nose that might predispose to chronic sinusitis? These could include
nasal polyps, septal deviation and, in children, adenoid inflammation.
The mainstay of treatment for chronic sinusitis is using saline
washes to flush the nose out, using intranasal steroids when appropriate
and, oftentimes, prolonged courses of antibiotics are indicated
prior to considering surgical intervention.
For patients who have been treated with appropriate medical therapy
and are still having symptoms, endoscopic sinus surgery should be
What are saline washes?
There are several ways to deliver the saline, but I typically have
a patient mix up one to two tablespoons of kosher salt, which is
a little bit purer, a teaspoon of baking soda and eight ounces of
warm water. People can use a little teapot, a syringe or other devices
to instill that saline solution in the nose. What that does is it
helps wash out the thickened mucus, the bacteria and any debris
that might be in the nasal passages, and it helps decongest the
sinus openings to allow the sinuses to drain better.
What is the goal of sinus surgery?
The goal of endoscopic sinus surgery is to reestablish drainage
of the sinuses and to promote natural function of the cilia, which
are the sweepers for the sinuses, so that they drain properly and
that they're open and aerated. So if there is an underlying inflammation,
whether it be allergy or a viral infection, the sinuses will not
It's important to note, though, that endoscopic sinus surgery does
not cure all patients. It is very successful when a properly trained
specialist performs the surgery. However, appropriate medical management
and identification of the underlying risk factors, like allergy,
pollutants and secondhand smoke, is very important in the long-term
management of sinus disease.
Will untreated sinusitis resolve on its own?
There have been some studies to suggest that mild cases of sinusitis
can be treated with decongestants, antiinflammatories and topical
nasal washes. The problem is, is if you have a true bacterial infection,
there is the potential for serious and life-threatening infections.
They are not common, but they do occur. So the main reason to treat
acute sinusitis is to prevent the symptoms of chronic sinusitis
and those acute bacterial complications.
How can sinusitis be different in children?
In children, there are several issues that affect sinusitis. Adenoid
enlargement can be a predisposing factor to sinusitis. Children
with Down syndrome or what they call the craniofacial syndromes
such as Treacher-Collins Syndrome or other conditions where the
structure of the sinuses is affected, are predisposed to sinus infection.
The main risk factor for children is that they get more viral infections
than adults. The average preschool child has six to eight upper
respiratory tract infections a year. But I think the biggest risk
factor for children is secondhand smoke. Secondhand smoke has been
shown to delay the clearance of mucus in the nose, because it affects
the cilia, the natural sweepers for the sinuses, from doing their
What is the biggest misconception people have about sinusitis?
I think the biggest myth is that people think they have a sinus
infection when they're sick for two days and they have colored nasal
discharge. Just because you have colored nasal discharge and sinus
pressure, doesn't mean that it's a bacterial infection that requires
antibiotics. Often with a viral infection, you can still get colored
As specialists, we like to try to prevent the overuse of antibiotics
because that just leads to more resistant infections.
Is there any new research that looks promising?
I think there's a lot of interest in determining what role fungi
plays in the development of chronic sinusitis. Also, I think there's
a lot of immune system research to see why patients who have had
what looks like technically good sinus surgery still can continue
to get infections
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