Chronic sinusitis is an inflammatory process of the nasal passages and paranasal sinuses that lasts for more than 12 weeks. Recurrent sinusitis is defined as greater than four episodes of sinusitis within one year. It is possible to have either or both.
Chronic sinusitis is a complex, often lifelong, condition.
Patients who have chronic sinusitis can often have persistent post-nasal drip, copious nasal mucus, and congestion, with loss of smell and taste.
Best treatment practices include a comprehensive approach to medications, surgery, and possible allergy or immunologic treatments.
Most commonly, patients who have chronic sinusitis already know whether they have nasal polyps and if they have allergic fungal rhinosinusitis.
Treatment of chronic sinusitis involves a spectrum of medical management. Without fully embracing all aspects of treatment, chronic sinusitis tends to have a negative connotation for both patients and healthcare providers because using only one aspect of treatment, such as surgery, may not solve all of the patient’s problems in every case.
Misconceptions abound since so many patients with chronic sinusitis have either persistent problems or worsening symptoms. Until recently, many chronic sinusitis sufferers either lived with a certain level of symptoms and discomfort or accepted the need for multiple rounds of medications such as antibiotics and repeated surgeries.
But things have changed for the better.
What causes chronic sinusitis, and do I have chronic sinusitis?
It is important to understand that acute sinusitis – something many people experience at some point in their lives – is completely different from chronic sinusitis. Most people with an episode of acute sinusitis recover uneventfully. However, acute sinusitis or recurrent acute sinusitis sufferers often misconstrue their infections as being chronic.
But the opposite is not always true. Patients who have chronic sinusitis can often have persistent post-nasal drip, copious nasal mucus, and congestion, with loss of smell and taste, and they can have worse cases of more severe acute sinusitis. In other words, chronic sinusitis patients can have both acute and chronic sinusitis.
Chronic sinusitis patients are believed to have a different disease process, which is multifactorial. Patients with chronic sinusitis can have a complex mixture of structural problems in the nose and sinuses, particularly in the openings to the sinuses, nasal polyps, infections, genetic conditions, immune deficiencies, and environmental and food allergies.
The point is that the diagnosis of chronic sinusitis has to be established first. Next, a full gamut of medical and possible surgical management needs to be employed. Surgery has the connotation of being a complete fix in most patients’ minds, but although many patients do improve dramatically after sinus surgery, patients still need care over the long term.
How does chronic sinusitis occur?
Your sinuses, including four paired sinus cavities, filter air when you inhale. For the filtration to work so unwanted things are expelled, the sinuses must drain properly. The drainage system must work perfectly or there can be the development of inflammation, infection, and lower oxygen tension.
The sinuses are arranged in three dimensions in the front part of your face, and some extend as far as the center of your head. To put it in perspective, the sinuses are like several containers spanning large expanses. Interestingly, all of these sinuses have limited capacities to drain, as most drain into only one specific area called the osteomeatal complex, located high in the nasal cavity.
To make matters worse, the sinuses have tiny hair cells called cilia. Ciliary dysfunction along with structural abnormalities can worsen the drainage process.
How do I know I have chronic sinusitis?
Most chronic sinusitis patients have these three cardinal symptoms:
- Purulent (green or yellow) nasal discharge
- Facial pain which can include dental pain or pressure-like pain
- The nasal obstruction which causes difficulty breathing out of one or both sides of the nose and mouth-breathing
Many patients also have:
- Decreased sense of smell
- Halitosis (bad breath)
Fever can occur in about half of chronic sinusitis patients and it is a crucial factor in determining the severity of the disease.
How is chronic sinusitis treated in most patients?
The key word here is “most.” There is no consensus on how to treat every patient with chronic sinusitis.
Treatment goals focus on improving sinus drainage. Better sinus drainage is vital, and it includes:
- Eliminating infection
- Reducing inflammation
- Modulating or eliminating triggers if the allergy is present
- If there is an underlying medical condition, therapy should be targeted to that problem
Nasal steroids should be used with or without nasal saline irrigation. The treatment should be lifelong in many patients. ENT specialists will suggest various levels of dosing depending on the patient.
Nasal saline irrigation can serve as a useful adjunct to nasal steroids. High-volume nasal saline irrigation was found to be more effective than low-volume nasal spray techniques. There are many options available, most of which are available over the counter.
Antihistamines should only be used if an allergic component is suspected. Antihistamines can cause drying of the nasal lining and the eyes. In some patients, antihistamines can hinder the sinuses from draining properly instead of helping.
Decongestants can be used for symptomatic relief, but decongestant use must be done with caution. Decongestants can cause unwanted side effects such as hypertension and anxiety. The main issue is that decongestants may open the sinus passageways when taken, but the sinus passageways do not stay open.
Antibiotics can be given for an extended period. Some patients do well with up to six weeks of certain antibiotics. There is no agreement as to the length of antibiotic therapy or the choice of antibiotics. As expected, antibiotic use is fraught with problems such as antibiotic resistance, gastrointestinal problems that can be severe, and the fact that even if the infection in the sinuses is eliminated, there still may be poor sinus drainage.
Oral steroids can be used. However, their use is not routinely indicated. Steroid use must be carefully considered since it has the potential for many other problems, particularly if used long-term.
Anti-fungal treatments are only for specific patients with that particular problem.
Chronic sinusitis with polyps should be treated with topical nasal steroids. If severe or unresponsive to therapy after 12 weeks, a short course of oral steroids can be considered.
Leukotriene antagonists such as montelukast, zafirlukast or zileuton can be considered.
Biologics, a new class of treatment, has been introduced for some patients with severe chronic sinusitis. Biologics are medicinal products produced by a biological process. Monoclonal antibodies are one type. These products show great promise in reducing symptoms and the extent of sinus disease.
Functional endoscopic sinus surgery (FESS) can be considered for patients who fail medical management. In more complicated cases, it is necessary to combine medical and surgical treatment.
FESS is done as an outpatient. There are other options now including balloon sinuplasty where a small balloon is inflated in the openings to the sinuses.
The goals of this surgery are to:
- Relieve obstruction of sinus drainage
- Restore sinus drainage and mucociliary clearance
- Ventilate the sinuses
Treatment of chronic sinusitis involves a spectrum of medical management, including everything from nasal irrigation to medications and endoscopic surgery. Chronic sinusitis can be a lifelong condition for many people.