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Chronic Sinusitis

Alternate Names: Chronic rhinosinusitis, Chronic frontal sinusitis, Chronic maxillary sinusitis, Chronic ethmoiditis, Chronic sphenoiditis, Chronic pansinusitis

Definition: Persistent nasal and sinus symptoms lasting three months or longer.

What Is Going on in My Body? There are four pairs of sinuses. The frontal sinuses are in the forehead bone, whereas the maxillaries are below the eyes. The ethmoids are located between the eyes with the sphenoid sinuses situated behind the ethmoids and between the back of the eye sockets (orbits). The ethmoid sinus is a matchbox-sized area filled with seven to ten interconnected bubbles made of very thin-walled bone that are lined with a mucus membrane. Each bubble has its own opening to drain the nasal (nose) cavity. Because the forehead and maxillary sinuses must drain through it into the nose, the front part of the ethmoid is the most crucial of all the sinuses. The posterior ethmoid drains through a separate opening and the sphenoid sinus has its own separate opening in the far back of the nasal cavity. Sinuses are normally air-filled structures lined by a mucous membrane that is covered with microscopic fingers (cilia) that direct the mucus to the drainage openings.

The function of the sinuses is not clearly understood. 1n the average healthy person, the lining of the sinuses and nose makes about one to one and a half pints of mucus per day. So, one of the functions of the nose and sinuses is to moisten, cleanse, and warm the air prior to entering the lungs. The normal nose is a wonderful filter removing 80% of all inspired tiny particles. Most pollen is usually well filtered from the inspired air. Since the sinuses are air-filled, another function may be to make the skull lighter in weight. The sinus linings also make nitrous oxide, a gas that may be important in keeping the small airways in the lungs open.

Chronic sinus disease affects 13% of the population, or about 30-40 million people, according to the National Center for Health Statistics. Chronic sinusitis develops when the natural drainage pathways of the sinuses do not work properly. The mucus glands produce thicker secretions that stay in the cavities increasing bacterial overgrowth and thicken the lining. Less air can pass through causing nasal stuffiness. The microscopic “fingers” (cilia) do not work as effectively, causing the mucous to clear poorly and become infected. The chronic inflammation causes face pain over the sinuses affected. Partial or complete blockage of the sinus openings from a deviated nasal septum or structural problems affecting the sinuses themselves can cause chronic sinusitis. Conditions in the environment like dry air, pollutants, dust, and dirt can damage the microscopic “fingers” (cilia) so that mucus is not cleared with subsequent bacterial overgrowth.

The classic symptoms of chronic sinusitis are nasal stuffiness, increased nasal discharge, and face pain or pressure. Chronic cough and loss of smell may occur. In children, symptoms are slightly different. They have nasal stuffiness, mouth breathing, snoring, cough (worse at night), discolored nasal discharge, frequent ear disease, and irritability. Many people underestimate the impact of chronic sinus symptoms on the patient’s sense of overall wellness. Several studies show that these symptoms significantly impact one’s sense of health and productivity when compared to other chronic illnesses such as low back pain, chronic arthritis, and congestive heart failure.

Risks: People with chronic sinusitis, regardless of the cause, are more likely to develop episodes of acute sinusitis as well. Left untreated, chronic sinusitis can cause a mucocele where the mucus can no longer drain from the sinus and begins to erode the bony sinus walls. In the frontal sinus, mucocele formation can lead to double vision, forehead swelling, brain abscesses and meningitis. In the ethmoid sinus, it can cause abscess or cellulitis around the eye. If the maxillary sinus is involved, nasal obstruction will result. Lastly, in the sphenoid sinus, a mucocele can present with double vision, decrease movement of the eyeball, brain abscess, or meningitis.

Prevention: Individuals who have allergic disease need to avoid the offending allergens and use aggressive treatment to limit the damage to the nasal lining and the sinuses. For environmentally caused disease, avoiding exposure to cold air, keeping the air humidified, and minimizing exposure to pollutants all help. Aggressive treatment of symptoms will help minimize damage to the mucous membranes. For those with structural problems of the nose and sinuses, topical steroids and salt water rinses are the best means of limiting chronic irritation.

Diagnosis: The most important diagnostic tool in chronic sinusitis is the history of the illness with particular attention paid to symptoms, environmental reactions, and response to medications. Since other diseases can act like chronic sinusitis, the history is crucial. For example, migraines can cause headache, nasal stuffiness and drainage. Gastroesophageal reflux causes stomach contents to come up to the back of the throat, thus acting like post-nasal drip.

Physical exam using a rigid nasal endoscope not only accurately diagnoses chronic sinusitis but also is used to follow the medical management of this disorder. CT scans of the paranasal sinuses is the standard means of radiographic diagnosis. However, CT scan should be obtained only after maximum medical treatment has been used. It is used to assess the extent of the disease or to identify any structural problems. Scans must be interpreted with caution since other conditions can look like chronic sinusitis. Conversely, CTs may not identify chronic sinusitis when it does exist. Diagnosis and treatment should not be based purely on x-ray studies but instead should be based on symptoms.

Treatment: Treatment for chronic sinusitis caused by allergies includes antihistamines, decongestants, salt-water rinses, topical nasal steroids, avoiding the allergens, and allergy desensitization. Treatment for chronic bacterial sinusitis includes appropriate antibiotics. As opposed to acute sinusitis, the bacteria causing chronic infections in adults are Staph aureus and anaerobic bacteria. In children, the bacteria are the same in both acute and chronic infections. In addition to antibiotics, nasal steroids, salt-water rinses, decongestants, leukotriene antagonists, and mucus-thinning agents are helpful. For people who do not respond to these treatments or who have structural problems, surgery is the next step in management. The goal of surgery is to reestablish the normal routes of drainage and remove all areas of infection. After surgery, 90% of people have improvement in their headaches, 85% have reduced postnasal drainage, 90% have improved nasal airflow, 90% have a significant reduction in their infections, and over 70% recover the sense of smell. There is very little decline in the results over time.

Side Effects: Side effects depend on the different treatments used. With surgery, complications are infrequent. There is a very rare occurrence of tear duct injury, a disturbance in vision, or leak of spinal fluid. Following successful medical and surgical treatment, symptoms should be controllable and infections greatly reduced.

Monitoring: Monitoring depends on the symptoms. However, any person with progressively worsening symptoms or symptoms of meningitis or eye involvement needs to seek emergent medical care.