One of the most difficult diagnoses in medicine, especially in children, is determining whether you have sinusitis. And, even more challenging is the decision as to whether you need antibiotics. A common cold or flu can either be mistaken as sinusitis, lead to sinusitis, or affect you on top of having sinusitis. A stuffy nose and many other symptoms may be due to a bacterial infection, but even then, antibiotics are not always needed. Sometimes the best medicine is no medicine at all.
What are the paranasal sinuses?
The simple answer is that the sinuses act to humidify and filter air as we breathe. The reality is that no one fully knows why we have sinuses, although there is a lot of speculation.
The sinuses have many roles, including:
- Dampening sound for resonance.
- Dampening air pressure changes.
- Making the skulls lighter.
- Absorbing heat Insulation for the brain.
- Adding to the mechanical rigidity of the skull.
- Increasing our ability to smell and taste.
We have several different sinuses, including:
- Maxillary, in the cheeks.
- Ethmoid, between the eyes.
- Frontal, above the eyes.
- Sphenoid, in the center of the heads, near the pituitary gland.
All sinuses drain into the nose and nasopharynx, the upper part of the throat. The design of the drainage system is unfortunately fraught with potential problems and can be highly variable. Almost all issues with sinusitis have to do with faulty drainage.
The structure of the nose and sinuses
The term “up your nose” describes only a small fraction of our nasal anatomy. The nose goes up for a short distance before it goes straight back to our throat. We all have a wall in between both sides of our nose called the septum that can be crooked, called a deviated septum, causing narrowing of both the nasal and sinus drainage pathway.
The nose has a delicate lining along with mucous. We produce over a liter of mucous each day to keep us healthy. Our nasal cavity has a diverse community of microorganisms at all times, and many feel that it protects from infection. Disruption of the natural balance of the nose can lead to exposure to illnesses.
The main area where the sinuses drain is the osteomeatal complex (OMC), where most sinus infections begin. Even with minimal nasal congestion, inflammation, or swelling from a common cold or flu, the OMC may become blocked, causing a sinus infection.
Some of us develop long-standing narrowing of the OMC from thickening of the lining, or what people refer to as nasal polyps. If the natural pathway of the sinuses is already narrow or blocked, it is not too much of a stretch to imagine that even a minor common cold can bring on a sinus infection.
Do I need an antibiotic?
Here is where the rubber meets the road.
Many who suffer from nasal congestion, sneezing, cough, fever, headache, ear pressure, altered sense of smell, cough, fatigue, or bad breath think right away it is a sinus infection. When we feel terrible, and it happens quickly, the immediate thought is that treatment is required.
For years, both adults and parents have sought medical care when they or their children have these symptoms, thinking it must be a “full-blown” sinus infection. One of the hardest things to do as a doctor is to convince a patient, or worse, a mother of a small child, to wait a few days to see if the symptoms subside before prescribing an antibiotic.
Both patients and health care professionals are frustrated by this. There is no definitive test for sinusitis. The reality is that most people do not immediately need an antibiotic, but some do. It remains a challenge to decide who needs treatment for a bacterial infection.
More recently, because of the blatant overuse of antibiotics in these and other instances, the pendulum has shifted back to conservativism, meaning supportive care such as rest, analgesics, saline nasal spray, and decongestants before resorting to antibiotics. Health care providers have become more cautious in waiting for the patient’s symptoms to subside naturally before resorting to the big guns - antibiotics.
In healthy people, no matter how they treat their upper respiratory infection, in most cases, they are better within a few days. It is those patients who do not get better who need more assistance. After all, even if the diagnosis is sinusitis, the cause may still be a virus, which does not require antibiotics.
Types of sinusitis
There are distinct types of sinusitis, and to make matters more complicated, it is often the result of several risk factors. These include:
- Prior infections, such as a cold or flu or even systemic infections.
- Structural abnormalities in the nose or sinuses that predispose someone to sinusitis.
- Immune system abnormalities.
- Environmental exposure to toxins or other substances.
Sinusitis can be acute, chronic, or recurrent. Each category has its subcategories and there is considerable overlap.
- Acute sinusitis usually results after symptoms last a week or more despite conservative therapy. Hints that treatment of the infection may require an antibiotic may be characteristic changes, such as signs of true infection, like pus, in the openings to the sinuses.
- Chronic sinusitis is an entirely different entity. It can be described as a series of separate topics on its own. There is no one best antibiotic for chronic sinusitis. Many patients require more aggressive anti-inflammatory agents such as steroids. Others require surgical treatment and there are new medications called biologics that work on the immune system.
Generally, most people develop acute sinusitis. One of the most common complaints is that the person cannot breathe through their nose, or they are producing too much mucous.
Often it is not that there is a lot of mucous being produced, but rather the result of so much swelling is there is nowhere for the mucous to go. The swelling affects not just the ability to breathe, but also the ability of the sinuses to drain. And that is where we get into trouble.
One of the reasons short courses of antibiotics, such as azithromycin, works so well is that the antibiotic itself reduces the swelling and is anti-inflammatory. The person gets better not because some evil bacteria has been extinguished, but because the sinuses can mechanically drain better. As a result, the problem subsides. Even if the offending bacteria are gone and the sinuses are still blocked, the infection can either persist or become recurrent.
Sinusitis: Final thoughts
The bottom line is whether acute, recurrent, or chronic, sinusitis results from poor drainage pathways. Microorganisms, such as bacteria, just complicate that lack of drainage. Antibiotics only solve part of the problem.
A clear path to health is sinuses that drain the way they should.
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