One of the most common afflictions in modern life is sinusitis, with literally tens of millions of Americans afflicted every year. Billions and billions of dollars are spent on over-the-counter medications, prescriptions, and lost worker productivity. It appears that the incidence of sinusitis, like that of the related disease asthma, is increasing dramatically. Appropriate therapy can greatly reduce the symptoms and frequency of sinus attacks in the great majority of sufferers.
Dr. John Burgoyne, Dr. Calvin Knapp, and Dr. Chad Ruffin are highly experienced in the diagnosis and treatment of sinus disorders, including the treatment of allergies. The most up-to-date advances in sinus surgery are available through our center.
What are Sinuses?
The sinuses are large, air-filled cavities within the bony structure of the face surrounding the nose. Normally humans have four sets of sinuses. The frontal sinuses are in the forehead.
The maxillary sinuses are behind the cheekbones and are the most well-known sinuses. The ethmoid sinuses are between the eyes and eye-sockets in the middle of the face. The ethmoid sinuses are actually a honeycomb of a dozen or so compartments connected together. The sphenoid sinuses are at the back of the nose, behind the eye sockets, nearly in the center of the head.
The sinuses are lined with mucosa. Like the mucosa elsewhere in the nose, the sinus mucosa has thousands of tiny hair-like structures called cilia, which beat rhythmically about 1,000 times a minute, sweeping the mucus produced by the sinuses out into the nasal passages and backward into the throat where it is swallowed. Normally, humans will produce about a quart and a half of thin, watery mucus every day. This is not usually noticed unless it becomes thickened or infected. The constant flow of mucous sweeps the bacteria and dust particles out of the sinus, and keeps them clean and nearly sterile.
The openings of sinuses are generally very small, and problems occur when the mucosa lining the openings thickens to the point of blocking that opening. Mucous and bacteria are trapped in the sinus, and an infection starts. The infection, in turn, will lead to more swelling and can develop into a cycle that is hard to break. It is interesting that most of the sinuses drain out through the small area behind the middle turbinate. The openings can also become blocked if the middle turbinate is too large, or is pushed to the side in front of the openings by a deviated septum.
In some patients, the mucosa will swell up so much that it will hang down in large folds or bags of tissue. These are called polyps. Nasal and sinus polyps are rarely actual growths and thus are almost never cancerous or malignant. Polyps contribute to sinus problems by either blocking the openings into the sinuses, thus worsening the cycle of infection or by being large enough to block the nasal airway.
What is Sinusitis?
When bacteria are growing inside the sinuses, that is called sinusitis. It is almost always due to a blockage of the drainage opening in the sinus. A person’s susceptibility to sinusitis is based on the size and shape of their sinus openings, and also to their propensity for thickening of the tissues of the nose and sinus. If the lining tissue thickens due to a cold, allergies, or other irritants, then the openings can become blocked, thus trapping bacteria in the sinuses, causing an infection. The infection itself will lead to more swelling, and a vicious cycle can develop – swelling leads to infection, which leads to more swelling which leads to more infection.
Common symptoms of sinus infection are headache, face ache, or toothache; thick discharge, often yellow or green; nasal congestion or stuffiness; fatigue; postnasal drip and cough or hoarseness; flare-up of asthma, bronchitis, or pneumonia; ear pressure; decreased sense of smell or taste; feeling of a lump in the throat; bad breath; worsening of snoring; and disequilibrium.
When sinusitis goes on for a while, the lining tissue may become permanently thickened, so that the openings are always partially or completely blocked. With time, the entire sinus system can fill up with thickened tissue. This thickened tissue may hang down into the nose. These are called polyps. People with asthma are particularly prone to developing polyps.
Rare complications of sinusitis come when the infection spreads into the surrounding organs, namely the eyes or brain. Meningitis, brain abscesses, and eye-socket abscesses can occur.
Sinusitis is defined as acute if it lasts less than 6 weeks. Some patients have recurrent attacks of acute sinusitis, but their sinuses clear out completely in between attacks. If the symptoms last for more than 12 weeks, or if the sinuses don’t clear completely between acute attacks (as evaluated by physical exam or CT Scans), it is referred to as chronic sinusitis.
Evaluation of the Sinus Patient
The evaluation of the nose and sinuses starts with medical history. The pattern of nasal obstruction, infections, pressure, etc., are all important and contribute to understanding the disease process.
The examination consists of looking into the nose, first from the front using a headlight or reflecting mirror. This gives information regarding the size and shape of the turbinates, as well as the shape of the septum. Sometimes a decongestant spray is used to shrink the mucosa and allow a better view.
Nasal endoscopes are used to look farther into the nose, and to look at the openings of the sinuses. Endoscopes are special telescopes that show the insides of the nose in greater detail.
A CT scan is a special type of x-ray that gives a cross-sectional view of the nose and sinuses. This gives a very detailed picture of the anatomy, and can show if there is any septal deviation, enlarged or abnormal turbinates, and most importantly allow the physician to evaluate whether there is ongoing thickening of the sinus mucosa, or any polyps or fluid.
The Seattle Sinus and Allergy Center has all of the equipment, including CT Scan, which is needed for the complete evaluation of the sinuses. In most cases, the entire evaluation can be completed during the initial visit.
Treatment of Sinus Problems
The goal of medical treatment for nasal and sinus problems is to prevent or reverse abnormal swelling of the mucosa and eliminate the infection.
Nasal steroids (Rhinocort Aqua®, Nasacort®, Flonase®, Nasonex®, and others) are medicines that are sprayed into the nose. They will shrink swelling from any cause and are safe for long-term use. Steroids (prednisone, Medrol®, and others) may also be taken by mouth. These drugs may dramatically shrink swollen tissues, but are not suitable for prolonged use because of serious side effects.
Antihistamines, either orally (Allegra®, Claritin®, Clarinex®, Zyrtec®, Benadryl®, and others) or sprayed into the nose (Astelin) will help prevent swelling due to allergies.
Over-the-counter 12-hour nose sprays such as Afrin® or Dristan® will shrink the turbinates well but are only safe to use for a very short time. Prolonged use will lead to rebound swelling that will lead to dependency on the sprays and complete obstruction of breathing if they are withdrawn. We usually only use these in very short-term situations, such as around the time of surgery, or before airplane flights, or sometimes right at the start of treatment for an infection.
A large range of antibiotics are available and are very helpful in fighting sinus infections. These are frequently most effective when used in combination with some of the other treatments. A several-week course is needed for severe or chronic infection.
Saltwater (saline) rinses are useful for washing thick or infected mucus out of the nose. Normally, almost none of a saline rinse actually gets into the sinuses.
Allergy testing is very useful for treatment planning. Between one-third and one-half of all people will have some degree of allergy, and the proportion is higher in those with chronic sinusitis. Things to which we are allergic are called allergens.
Skin testing is an accurate method of determining a patient’s allergies. Blood tests are best for testing some types of allergies. At the Minor & James ENT, we use a combination of these methods.
Allergy treatment usually will include avoiding or eliminating the allergens by environmental control, which can include special air cleaners or filters, mattress covers, and cleaning.
Antihistamines are also used to control allergies.
Many allergens are difficult or impossible to avoid, and immunotherapy, or allergy shots, are used. These are made from the specific antigens that the patient had reactions to, and are given weekly for a period of time. Immunotherapy is effective because it actually reduces the body’s response to the allergens.
If nasal obstruction or sinus symptoms persist despite the medical treatments, surgery may be needed.