Nose: Chronic Sinusitis

Chronic Sinusitis—A Common Condition

In 1991, evaluation of visits to the physician’s office indicated approximately 12 million Americans visited due to sinus and chronic sinus-related problems. Chronic sinusitis is the fifth leading cause of antibiotic prescriptions and in 1992 there were approximately 2.4 billion dollars attributed to medical costs related to chronic sinusitis. Essentially, approximately 14% of the population in the United States can be affected each year.

What Is Chronic Sinusitis?

Chronic sinusitis is a disease of the sinuses whereby the complex presents for greater than six to eight weeks. Sinus infections that do not last longer than six to eight weeks are described as “acute sinusitis”. There are many underlying factors that predispose one to chronic sinusitis including structural obstruction, allergies, fungal infections, deviated septum, nasal polyposis, etc. The main symptoms that occur include paranasal sinus pressure and pain with nasal drainage, nasal obstruction, and congestion. Particles and mucous within the nose and sinuses become static as it is unable to clear itself from the nose.

How Does One Diagnosis Chronic Sinusitis?

The most important factors in diagnosing chronic sinusitis focus on the characteristic of an individual’s symptoms combined with the anatomy and CT scan findings. Nonetheless, symptoms and complaints are of paramount importance in diagnosing the nasal/sinus and headache problem at hand.

The most common symptoms of chronic sinusitis are that of facial and paranasal sinus pressure and pain with headache. Specifically, this is located in and around the face, nasal area, and around the eyes. Other factors include postnasal drainage that is often times thick and tenacious. Nasal airway obstruction, fatigue, lethargy, cough, dental discomfort, and ear pain all can be associated with sinusitis. Generally a severe debilitating headache without nasal symptoms is not thought to be a hallmark of chronic sinusitis specifically. Headaches can often times be non-sinus related, such as tension headaches and migraines.

Associated Abnormalities

Chronic sinusitis tends to associate itself with a number of other medical conditions. Allergic rhinitis is significantly common and quite commonly associated with chronic sinusitis. Allergic rhinitis is both perennial and seasonal and can instigate, exacerbate, or worsen chronic sinusitis. Nasal polyposis also contributes as it can obstruct the internal nasal cavity, as well as the sinus doorways and ostia. Asthma and chronic obstructive pulmonary disease, as well as other pulmonary conditions can be associated with chronic sinusitis due to the underlying nature of upper airway hypersensitivity problems. Cystic fibrosis tends to be associated with chronic sinusitis in children. Other medical conditions associated with chronic sinusitis include recurrent pneumonia, chronic laryngitis, recurrent laryngospasm, chronic bronchitis and immuno-compromised conditions.

Function of the Sinuses

It is not completely understood why human beings have sinuses to begin with. The function of the sinuses is of minimal significant physiologic benefit. Many clinicians and anatomists feel that the sinuses are present to lighten the skull weight to better help humans move the head. Sinuses are not required to assist in breathing, smell, taste or speech in any significant manner. Over 60 million years ago the dinosaurs roamed the earth and fossil remains suggest significantly large sinuses in dinosaurs, although their underlying function is still a controversy, indicating that this has been a longstanding question. Nonetheless the air-filled bed space of the sinuses lightens the skull, increasing mobilization and agility in daily head movement. Indeed if a dinosaur sinus were filled with simple bone causing dead weight, then the skull would weigh several hundred pounds more than the air-filled sinuses noted on skull examinations.

A minimal warming and humidification occurs in the sinuses. There is a sense of “dampening” of the pressure changes that occur in the nose while blowing it or during sneezing. Others feel that the sinuses act as a shock absorber and protect the brain during facial trauma. Voice resonance also tends to be enhanced with the sinuses intact. However, all of the above functions tend not to have any significant evolutionary benefit. Lightening of the head to increase mobility tends to be the most highly respected cause and may have some evolutionary benefit.

Treatment Goals

Treatment goals of chronic and acute sinusitis are to improve the symptoms that adversely affect the quality of life for individuals who suffer from sinusitis. In addition, there are a number of other aspects that may be improved if the sinusitis is alleviated. Allergies and the consequences of allergies are improved by treating sinusitis. Nasal breathing is also improved. The problems of asthma and chronic obstructive pulmonary disease are improved following successful sinusitis treatment. Lower respiratory tract infections such as bronchitis are minimized or prevented. Forms of chronic laryngitis as well as chronic laryngitis with laryngospasm are significantly improved or alleviated by treating the sinuses alone. Migraines are affected by recurrent and/or chronic sinusitis and can be improved significantly by successfully treating the sinusitis disease. Thus, it is very important to understand that by treating the sinusitis, other systems are improved, particularly the lungs and throat.

Medical Treatment

Medical treatment is implemented immediately following the diagnosis of acute and/or chronic sinusitis. Most individuals will respond to a tincture of time combined with appropriate conservative medical management.

Volume nasal rinses sometimes with an antibiotic such as Bactroban can provide alleviation. Bactroban is an antibiotic solution that helps to fight off a number of bacterial organisms associated with sinusitis. Volume nasal rinses by themselves tend to clean and remove infected secretions and have been shown to improve sinus disease. Topical nasal steroid sprays are important, as they tend to decrease the swelling and inflammation in and around the doorways to the sinuses and in the nasal passages. Systemic steroids are also frequently used to decrease the swelling around the sinuses. Nonetheless, contraindications to steroids should be noted and understood.

Contraindications for steroid use, either topical or orally include diabetes and cataracts.

The common organisms involved with acute sinusitis are aerobic (also known as oxygen loving). These tend to be gram-positive organisms such as staphylococcus, streptococcus, and Moraxella. When sinusitis becomes more chronic and persistent (greater than six to 12 weeks), then anti-aerobic and stronger antibiotics are instituted to treat the more resistant types such as streptococcus. Common antibiotics for chronic sinusitis include Avelox, Levaquin, Augmentin, Clindamycin, etc.

Additional therapy directed towards sinusitis entails addressing allergies. Allergy evaluation, skin testing, and RAST testing can provide better insight into the potential allergy problem that might be instigating the sinusitis.

Sometimes individuals have low-grade immune-compromised conditions such as HIV. These problems predispose to atypical type sinus infections such as fungal sinusitis.

Differential Diagnoses

Chronic sinusitis essentially can be mimicked by other medical conditions that are unrelated to the sinuses. Commonly, a migraine is a recurrent facial pain syndrome that is not at all unlike sinusitis, but is somewhat unrelated. Dental source problems, dental caries, dental infection, and particularly upper dental problems can mask as sinusitis. Ocular or orbital associated pain syndrome can also mimic sinusitis. Neurological problems such as postherpetic trigeminal neuralgia or trigeminal neuralgia are also common conditions that mimic sinusitis. Temporomandibular joint syndrome is joint related pain that extends into the sinus areas.

Evaluation for Sinusitis

Chronic sinusitis should be evaluated meticulously via full history evaluation followed by nasal endoscopic and rhinoscopic evaluation. Commonly, patients with chronic sinusitis have symptoms greater than 12 weeks and specific complaints of particular importance include paranasal sinus pressure and pain, nasal congestion, postnasal drainage, ear discomfort, halitosis, fatigue, cough, and diminished smell and taste. Individuals with chronic sinusitis will often times have a deviated septum, nasal polyps, prominent turbinates, rhinitis and sinus doorway congestion and obstruction.

CT scan evaluation of the sinuses is standard and quite important. For those individuals with chronic problems unresponsive to medical treatment, a CT scan is indicated.

CT scan evaluation is of a “coronal” thin-cut study. One of the most important factors evaluated with CT scan is the “osteomeatal complex”. This is the area in which all the sinuses drain into the nasal cavity. Obstruction of this area is a real source for recurrent and chronic sinus problems.

Sometimes “abnormal CT scans” can occur in asymptomatic patients and “normal CT scans” can occur in symptomatic patients. Traditional CT scans are thought to be abnormal when they are filled with fluid or filled with thickened mucous membranes and thought to be normal when there is simple air in the sinuses. However in recent years, meticulous evaluation of the radiological data suggests that obstruction at the osteomeatal complex (doorway from the sinuses into the nose) is a very significant and important factor when evaluating CT scans. Obstruction in this area is of primary concern and is one of the more important aspects of CT scan/radiologic evaluations even more so than simple opacification of fluid collection of the sinuses. Other aspects noted on radiologic exams include absence or presence of nasal polyps, sinus polyps, or deviated (crooked) nasal septum.

Surgical Options

Functional endoscopic sinus surgery, which was developed in the 1950s, is the mainstay of treatment for refractory and chronic sinusitis, which is quite frustrating. The nasal endoscope has revolutionized sinusitis surgery. Functional endoscopic sinus surgery involves the insertion of the endoscope, which is a very thin fiberoptic tube, into the nose for direct visual examination of the openings of the sinuses. With state-of-the-art micro-telescopes and instruments, abnormally obstructed tissues are easily removed. In the majority of cases the surgical procedure is performed entirely through the nostrils, leaving no external scars.

Endoscopic surgery is less extensive and the specific areas of concern, specifically the doorways of the sinuses, are solely addressed.

Image-Guided Surgery

The sinuses are essentially very close to the eyes and brain, as well as some major arteries. With the growing use of new technology, image-guided endoscopic sinus surgery has developed, which further alleviates the concern for unwanted problems. Image-guided sinus surgery is recommended for severe forms of chronic sinusitis, moderate nasal polyposis, or recurrent and revision sinus surgery. Also, patients who have unusual sinus anatomy will benefit from image-guided sinus surgery.

Image-guidance is a three dimensional mapping system that combines CT scan with real-time information about the exact position of the surgical instruments within the nasal and sinus cavities. In this way, surgeons navigate the instruments through complex sinus passages, providing more exact and precise alleviation of obstruction. Image guidance uses some of the same stealth principles used by the United States Armed Forces to guide bombs to their targets.

Sinus Shaver

Recent technological advances include the sinus shaver. This device helps to meticulously and precisely remove redundant mucosa and small thin bone that can cause obstruction within the nose and sinuses.

Overall Expectations

Endoscopic sinus surgery generally provides very reasonable success for most individuals. Nasal breathing is generally nicely improved. Sinus doorways are nicely opened and the number and frequency, as well as intensity of sinus infections tend to diminish. Specifically, headache related sinus pain can often times be improved with sinus surgery. Four to five days should be reserved for time off work and other activities. Rarely nasal packing is applied. Soft silastic splints are applied in the nose and are gently removed a few days after the surgery. Nasal irrigations are performed routinely after the surgery and nasal cleaning procedures are performed weekly in the office.

Endoscopic sinus surgery with shaving technology concomitant with image-guidance technology has provided patient after patient with significant improvement of the underlying chronic sinus disease process. Nonetheless, there are no guarantees with the surgery, but the majority of patients will have reasonable satisfactory improvement.

Also See: Nasal Septoplasty, Rhinoplasty, and Endoscopic Sinus Surgery