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Sinusitis

Topic Overview

What is sinusitis?

Sinus infections often follow a cold and cause pain and pressure in your head and face.

Sinusitis can be either acute (sudden) or chronic (long-term). With chronic sinusitis, the infection or inflammation does not completely go away for 12 weeks or more.

What causes sinusitis?

Sinusitis can be caused by three things:

  • Viruses.
  • Bacteria.
  • Fungi.

The same viruses that cause the common cold cause most cases of sinusitis.

When the lining of the sinus cavities gets inflamed from a viral infection like a cold, it swells. This is viral sinusitis. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat. If the fluid cannot drain and builds up over time, bacteria or fungi (plural of fungus) may start to grow in it. These bacterial or fungal infections can cause more swelling and pain. They are more likely to last longer, get worse with time, and become chronic.

Nasal allergies or other problems that block the nasal passages and allow fluid to build up in the sinuses can also lead to sinusitis.

What are the symptoms?

The main symptoms of sinusitis are a runny or stuffy nose and pain and pressure in your head and face. You may also have a yellow or green drainage or drip from your nose or down the back of your throat (postnasal discharge). Where you feel the pain and tenderness depends on which sinus is affected.

Other common symptoms of sinusitis may include:

  • A headache.
  • Bad breath.
  • A cough that produces mucus.
  • A fever.
  • Pain in your teeth.
  • A reduced sense of taste or smell.

How is sinusitis diagnosed?

Your doctor can tell if you have sinusitis by asking questions about your past health and doing a physical exam. You probably won't need any other tests.

How is it treated?

Viral sinus infections usually go away on their own within 10 to 14 days. Antibiotics don't work for viral infections. But there are some things you can do at home to help relieve your symptoms:

  • Drink plenty of fluids.
  • Put a hot, damp towel or gel pack on your face for 5 to 10 minutes at a time, several times a day.
  • Breathe warm, moist air from a steamy shower, a hot bath, or a sink filled with hot water.
  • Use saline nose drops and sprays to keep the nasal passages moist and use saline nasal washes to help keep the nasal passages open and wash out mucus and bacteria.
  • Try over-the-counter medicine to help relieve pain and pressure in your head and face.

Home treatments may help drain mucus from the sinuses and prevent a more serious bacterial or fungal infection.

Bacterial infections can be treated with antibiotics. You will probably feel better in a few days, but some symptoms may last for several weeks. You may need to take the medicine for a longer time if you have chronic sinusitis.

If you have a fungal infection—which is not common—antibiotics won't clear up your sinusitis. With this type of infection, you may need treatment with antifungal medicines, steroid medicines, or surgery.

If you have taken antibiotics and other medicines for a long time but still have sinusitis symptoms, you may need surgery. You may also need surgery if the infection is likely to spread or if you have other problems, such as a growth (polyp) blocking the nasal passage.

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Cause

Sinusitis is most often the result of a viral infection that causes the mucous membrane lining the inside of the nose and the sinuses to become inflamed.

  • The mucous membrane swells when it becomes inflamed, blocking the drainage of fluid from the sinuses into the nose and throat.
  • Mucus and fluid build up inside the sinuses, causing pressure and pain.
  • Bacteria are more likely to grow in sinuses that are unable to drain properly. Bacterial infection in the sinuses often causes more inflammation and pain.

Colds usually trigger this process, but any factor that causes the mucous membrane to become inflamed may lead to sinusitis. Many people with nasal allergies (allergic rhinitis), for instance, are likely to have recurring or long-term (chronic) sinus infections. Nasal polyps, foreign objects (usually in children), structural problems in the nose such as a deviated septum, and other conditions can also block the nasal passages, increasing the risk of sinusitis.

Fungal infections may also cause sinusitis. This is especially true in people with impaired immune systems. Fungal sinusitis tends to be chronic and harder to treat than bacterial sinusitis.

Symptoms

Pain and pressure in the face along with a stuffy or runny nose are the main symptoms of sinusitis. You also may have a yellow or greenish discharge from your nose. Leaning forward or moving your head often increases facial pain and pressure.

The location of pain and tenderness may depend on which sinus is affected.

Other common symptoms of sinusitis include:

  • Headache.
  • Yellow or greenish discharge from the nose or down the back of the throat.
  • Bad breath.
  • Stuffy nose.
  • Cough that produces mucus.
  • Fever.
  • Tooth pain.
  • Reduced sense of taste or smell.

Acute (sudden) sinusitis is usually caused by a viral infection and often develops rapidly. It usually lasts for 4 weeks or less, and the symptoms often begin to clear up within a week without any treatment. Acute sinusitis caused by a bacterial infection is less likely to clear up on its own and may lead to chronic sinusitis or to complications in which the infection spreads beyond the sinuses. Nasal discharge that contains pus and gets worse after 5 days or persists for more than 10 days may be a sign of acute sinusitis caused by a bacterial infection.

Chronic (long-term) sinusitis is usually caused by a bacterial or fungal infection. These infections may be difficult to treat. If chronic sinusitis is not cured after trying two or more different antibiotics, you may want to talk with your doctor about surgery or allergy testing. Chronic sinusitis can lead to permanent changes in the mucous membranes that line the sinuses and may make you more prone to sinus infections.

Symptoms of sinusitis in children include coughing, nasal discharge that lasts more than 7 to 10 days, and complaints of headache and facial pain. Many children age 2 or older with chronic sinusitis may also have allergies and frequent ear infections.

Other conditions that have symptoms similar to sinusitis may include allergies, toothaches, and colds or other upper respiratory infections. But if you've had a cold that returns or gets worse after 7 days, you may have a sinus infection rather than a cold or other upper respiratory infection.

What Happens

There are two types of sinusitis: acute (sudden onset) and chronic (long-term). Sinusitis often develops after a cold or viral infection. Most sinus infections improve on their own, but sometimes they develop into a bacterial infection—swelling, inflammation, and mucus production caused by the cold can lead to blockage in the nasal passages, which may encourage the growth of bacteria.

Acute sinusitis, whether viral or bacterial, may develop into chronic inflammation or infections that may last 12 weeks or longer. Chronic sinusitis can lead to permanent changes in the mucous membranes that line the sinuses. As a result of these changes, you may become prone to having more sinus infections that may become more difficult to treat.

Complications of sinusitis (such as meningitis or an infection of the facial bones called osteomyelitis) are rare. But when complications occur, they may be life-threatening and often require extensive medical or surgical treatment.

What Increases Your Risk

Your risk of sinusitis increases if you have recently had a cold, another viral or bacterial infection, or an upper respiratory tract infection. Also, chronic nasal allergies (allergic rhinitis) can lead to sinusitis.

Sometimes a deviated septum, broken nose, or growths such as nasal polyps can make you more susceptible to sinus infections. Problems with nasal structure can prevent the proper flow of mucus from the sinuses into the nose.

Other factors that increase your risk for getting sinus infections include having asthma, smoking, air pollution, overuse of decongestant sprays, cold weather, rapid air pressure changes (such as from flying or scuba diving), and swimming in contaminated water. Also, using continuous positive airway pressure (CPAP) to treat sleep apnea may increase the risk of sinusitis.

When should you call your doctor?

Call your doctor if sinusitis does not improve after 2 days of home treatment and you have symptoms such as:

  • Pain in the face or upper teeth.
  • Pain extending from the bridge of the nose to the lower eyelid.
  • Headache that is not relieved by an over-the-counter pain medicine, such as acetaminophen or ibuprofen.
  • Fever.
  • Nasal discharge that starts out clear and later becomes thick and discolored (yellow or green).
  • Cold symptoms that last longer than 10 days or get worse after the first 7 days.
  • Mild or chronic pain in the face that lasts longer than a month, has changed, or has not been checked by a doctor.
  • Not feeling any better within 3 to 5 days after starting antibiotics for your sinus infection.

Watchful waiting

Watchful waiting is okay if you have symptoms of an early sinus infection (such as pain and pressure in your head along with a stuffy or runny nose). An early sinus infection can often be treated at home if you are in good health. If you develop symptoms of a sinus infection, start home treatment. This includes drinking lots of fluids and breathing steam from a warm shower. Use the guidelines above to decide whether you need to call a doctor.

Exams and Tests

Diagnosis of sinusitis is usually based on your medical history and physical exam. A detailed history of the problem often can be of more value to the diagnosis than a physical exam. If the symptoms and physical findings are typical of sinusitis, further testing is usually not needed.

Additional tests may be done if:

  • The diagnosis is not clear.
  • Antibiotic treatment has failed to clear up the problem.
  • Complications (such as a bone infection) are suspected.
  • Surgery is being considered.

Imaging tests may be used when symptoms of sinusitis persist or recur despite treatment, or to look for tumors or other growths when there is bleeding or bloody discharge from the nose. They include:

  • Computed tomography (CT) scan of the head and face, which provides a detailed image of sinus structures. A CT scan may help evaluate severe or chronic sinusitis, identify suspected complications of sinusitis, or rule out other conditions. It is not used to diagnose acute sinusitis.
  • Sinus X-ray, which may be done to confirm a suspected case of sinusitis. An X-ray produces a picture of dense tissues inside the body. But a CT scan provides better information.

Less often, other tests may be done by an ear, nose, and throat (ENT) specialist (also called an otolaryngologist) or by an allergist. These tests may include:

Treatment Overview

Sinusitis is treated with medicines and home treatment, such as applying moist heat to your face. The goals of treatment for sinusitis are to:

  • Improve drainage of mucus and reduce swelling in the sinuses.
  • Relieve pain and pressure.
  • Clear up any infection.
  • Prevent the formation of scar tissue, and avoid permanent damage to the tissues lining the nose and sinuses.

For more information, see Home Treatment and Medications.

At first while being treated for acute or chronic sinusitis, you may begin to feel better from antibiotics and home treatment, but sometimes your symptoms become worse and additional treatment may be needed.

For acute sinusitis

Short-term (acute) sinusitis usually lasts less than 4 weeks. Up to two-thirds of people with acute sinusitis improve on their own without antibiotic treatment.footnote 1 Sinus infections are commonly caused by viral infections, which do not respond to antibiotics. Talking with your doctor will help you determine whether treatment with antibiotics is needed for your acute sinus infection.

Most people recover completely when treated with an antibiotic for acute sinusitis that is caused by a bacterial infection. The number of days you take antibiotics depends on the antibiotic and how bad the infection is. When you are prescribed an antibiotic, be sure to take it until it is gone, even if you feel better. Always take an antibiotic exactly as your doctor tells you, or the infection may not go away completely.

For chronic sinusitis

Sinusitis that lasts 12 weeks or longer is called chronic sinusitis. It is more difficult to treat and responds more slowly to antibiotics than acute sinusitis.

Antibiotic therapy is usually recommended for chronic sinusitis and may require a longer course of treatment. You may need to try more than one antibiotic. A corticosteroid nasal spray that reduces inflammation and swelling of the lining of the nasal passages may also be used during treatment.

In some people, a sinus infection may be caused by a fungus or a bacterium other than those normally associated with sinusitis. People who have an impaired immune system are at risk for these unusual infections. It also may include people who must use an oral or inhaled corticosteroid medicine (such as prednisone). Fungal sinusitis, which accounts for a significant number of chronic sinusitis cases, does not respond to antibiotic treatment and may need treatment with antifungal medicines, corticosteroids, or surgery.

Surgery may be required if you have taken antibiotics for an extended period of time but still have symptoms or when complications (such as infection of facial bones) are likely.

What to think about

Sinusitis may be difficult to diagnose, because it often causes the same symptoms as a cold or other viral illness, especially in its early stages. It can be particularly difficult to identify sinusitis in children. If your child or you have frequent sinus infections, learn what signs to watch for, and begin home treatment immediately.

Symptoms of chronic sinusitis are often vague and may not respond well to treatment. It may take time and patience to find a successful treatment.

Prevention

There are several ways you may reduce your chance of getting sinusitis:

  • Treat stuffiness (nasal congestion) caused by colds or allergies promptly. This can help you prevent a bacterial infection from developing in your sinuses.
  • Avoid contact with people who have colds and other viral upper respiratory infections. If you do have contact with people who have these infections, wash your hands often, especially after being in contact with those who are infected.
  • Avoid cigarette, cigar, and pipe smoke in your home and workplace. Smoke causes and further irritates inflamed membranes in your nose and sinuses.
  • If you have allergies, avoid the things that trigger your allergy attacks. Consider talking to your doctor about immunotherapy, such as allergy shots. For more information, see the topic Allergic Rhinitis.
  • Avoid breathing dry air. Consider using a humidifier at home and work to increase the moisture in the air.

Make sure your child gets all the recommended immunizations. Some immunizations, such as pneumococcal conjugate vaccine, may help prevent ear and sinus infections.

Home Treatment

Home treatment may relieve symptoms of pain and pressure associated with short-term (acute) sinusitis. Home treatment may improve drainage of mucus from the sinuses and prevent the need for antibiotics.

  • Drink plenty of fluids to help keep your mucus thin.
  • Apply moist heat (using a hot, damp towel or gel pack) to your face for 5 to 10 minutes, several times a day.
  • Breathe warm, moist air from a steamy shower, a hot bath, or a sink filled with hot water. Avoid extremely cool, dry air. Consider using a humidifier to increase the moisture in the air in your home.
  • Use saltwater nasal washes (saline lavage or irrigation) to help keep the nasal passages open and wash out mucus and bacteria. You can purchase saline nose drops or sprays at a pharmacy or make your own saline solution at home. If you make saline at home, use distilled water or water that has been boiled and then cooled. People who have postnasal drip and are around age 8 and older may also find it helpful to gargle often with warm salt water. This can help prevent a sore throat.
  • If you need to blow your nose, do it gently. Forceful blowing may force thick mucus back into your sinuses and block them. Keep both nostrils open when blowing your nose.
  • Avoid alcohol. It causes swelling of the tissue lining the nose and sinuses.
  • Try over-the-counter medicines to relieve pain or stuffy nose. Be safe with medicines. Read and follow all instructions on the label. Do not use the medicine longer than the label says.

If you have chronic sinusitis, you'll probably need to continue the above home treatment measures for a long period of time to keep your sinuses clear.

Medications

Medicines may be needed when symptoms of sinusitis are severe or do not improve. The goals of treatment with medicine are to:

  • Treat the infection, which is usually caused by bacteria if your symptoms have lasted more than 7 to 10 days.
  • Relieve pressure and pain caused by poor sinus drainage.
  • Reduce inflammation of the nose and sinuses.

Medicine choices

Medicines are used and sometimes combined to treat sinusitis. Be safe with medicines. Read and follow all instructions on the label.

  • Antibiotics kill bacteria. Examples of antibiotics used are amoxicillin with clavulanate and cefdinir.
  • Decongestants reduce the swelling of the mucous membranes in the nose. Some examples may include oxymetazoline (for example, Afrin) and phenylephrine (for example, Neo-Synephrine).
  • Analgesics relieve pain. Some examples include acetaminophen (for example, Tylenol) and ibuprofen (for example, Advil).
  • Corticosteroids reduce inflammation in the nasal passages. Some examples include beclomethasone (Beconase) or mometasone (Nasonex). Most of the time, they come in the form of a nasal spray.
  • Mucolytics thin mucus. Some examples include guaifenesin (for example, Robitussin).

What to think about

If you are taking antibiotics for a sinus infection, do not stop taking the antibiotics early just because you feel better. Take the entire course of antibiotics. The infection may not go away if you do not take all of the antibiotics prescribed by your doctor.

Antibiotic treatment is successful in most cases of short-term (acute) sinusitis when it is caused by bacteria. You should notice improvement within 3 to 4 days after you begin taking an antibiotic.

Chronic sinusitis may last 12 weeks or longer and usually requires 3 to 4 weeks of antibiotic treatment. Symptoms may persist or return despite adequate antibiotic treatment. A different antibiotic may be needed to treat the infection. Referral to an ear, nose, and throat (ENT) specialist (also called an otolaryngologist) may be needed if symptoms of sinusitis do not go away despite long-term antibiotic treatment.

Surgery

The goal of surgery is to make drainage of the sinuses better, usually by removing the blockage and draining the mucus. This may mean removing:

  • Infected, swollen, or damaged tissue.
  • Bone, to create a wider opening for drainage of mucus from the sinuses.
  • Growths (polyps) inside the nose or sinuses.
  • A foreign object that is blocking a nasal or sinus passage. This usually occurs in children.

Surgery may be the only means of getting a badly blocked, infected sinus to drain properly. But surgery does not always completely eliminate sinusitis. Some people may need a second operation.

Surgery is most successful when used along with medicine and home treatment to prevent future sinusitis. A second surgery and future sinusitis may be avoided if antibiotics are taken to prevent reinfection.

Surgery choices

Endoscopic surgery is preferred over traditional surgery for most cases of chronic sinusitis that require surgery. It is less invasive, less expensive, and has a lower rate of complications.

  • Endoscopic surgery may be done to remove small amounts of bone or other material blocking the sinus openings or to remove growths (polyps). Normally, a thin, lighted tool called an endoscope is inserted through the nose so the doctor can see and remove whatever is blocking the sinuses.
  • Sinus surgery may be done when complications of sinusitis—such as the development of pus in a sinus, infection of the facial bones, or brain abscess—have occurred. In this type of surgery, the doctor makes an opening into the sinus from inside the mouth or through the skin of the face.

What to think about

Very few people need surgery to treat sinusitis. But you may need surgery ifALL of these are true:

  • Your doctor says that you have chronic sinusitis.
  • You've followed what's called "maximum medical treatment" for 4 to 6 weeks. This means that you've taken medicines and followed home treatment for at least 4 to 6 weeks. This treatment includes antibiotics, a steroid nasal spray, and other prescription medicines.
  • You've had a CT scan of your sinuses after the 4 to 6 weeks of treatment. It is very important to have the CT scan done after this treatment. Reducing the swelling and infection as much as possible lets your doctor see what could be causing your infections.
  • The CT scan shows that something, such as nasal polyps, is keeping your sinuses from draining as they should.

You also may need surgery if:

  • You have a sinus infection caused by a fungus. Infections caused by fungus cannot be cleared up with antibiotics.
  • You have a serious problem such as an infection that spreads beyond your sinuses. This is rare.

The extent of the blockage and other problems determine how extensive your surgery will need to be. Surgery may be limited to removal of infected tissue or small growths (polyps) inside the nose. More extensive surgery involves removing pieces of bone to create a wider opening to allow a sinus to drain.

Sinus surgery is always performed by an ear, nose, and throat (ENT) specialist (also called an otolaryngologist).

References

Citations

  1. Ah-See K (2015). Sinusitis (acute rhinosinusitis). BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/0511/overview.html. Accessed April 14, 2016.

Other Works Consulted

  • Chow AW, et al. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases, 54(8): e72–e112.
  • Rosenfeld R, et al. (2015). Clinical practice guideline (updated): Adult sinusitis. Otolaryngology–Head and Neck Surgery, 152(2S): S1–S39. Accessed June 16, 2015.
  • Rubin MA, et al. (2015). Sore throat, earache, and upper respiratory symptoms. In DL Kasper et al., eds., Harrison's Principles of Internal Medicine, 19th ed., vol. 1, pp. 225–235. New York: McGraw-Hill Education.

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