Sinusitis (Sinus Infection)

Medications for sinusitis vary depending on the severity of the condition

Sinusitis is inflammation of the air cavities within the passages of the nose (paranasal sinuses). It can be caused by infection (sinus infection) as well as allergy and chemical irritation of the sinuses. A sinus infection (infectious sinusitis) occurs when a virus, bacterium, or fungus grows within a sinus.

• Sinusitis is a common condition that can afflict people throughout their lives.
• Sinusitis frequently occurs when environmental pollens irritate the nasal passages, such as with hay fever.
• Sinusitis can also result from irritants, such as chemicals or the use and/or abuse of over-the-counter (OTC) nasal sprays, and illegal substances that may be snorted or inhaled through the nose.

About 30 million adults have "sinusitis." Colds differ from sinusitis in that they are only caused by viruses and last about seven to 10 days, while sinusitis may have many different causes (infectious and non-infectious) and it usually lasts longer and has more pronounced and variable symptoms.

A sinus is a hollow, air-filled cavity. For this article, a sinus will refer to those hollow cavities in the skull connected to the nasal airway by a narrow hole in the bone (ostium). Normally all sinuses are open to the nasal airway through an ostium.

Humans have four pairs of these cavities:

1. Frontal sinus (in the forehead)
2. Maxillary sinus (behind cheeks)
3. Ethmoid sinuses (between the eyes)
4. Sphenoid sinus (deep behind the ethmoids)

The four pairs of sinuses are often described as a unit called the "paranasal sinuses." The cells of the inner lining of each sinus are mucus-secreting epithelial cells and some cells that are part of the immune system (macrophages, lymphocytes, and eosinophils).

Functions of the sinuses include humidifying and warming-inspired (inhaled) air, insulating surrounding structures (eyes, nerves), increasing voice resonance, and buffering against facial trauma. The sinuses decrease the weight of the skull.

Sinusitis may be classified in several ways, based on its duration (acute, subacute, or chronic) and the type of inflammation (either infectious or noninfectious). The term rhinosinusitis is used to imply that both the nose and sinuses are involved.

• Acute sinus infection (acute sinusitis or acute bacterial rhinosinusitis) usually lasts less than 3-5 days.
• Subacute sinus infection lasts one to three months.
• Chronic sinus infection is greater than three months. Chronic sinusitis may be further sub-classified into chronic sinusitis with or without nasal polyps, or allergic fungal sinusitis.
• Recurrent sinusitis has several sinusitis attacks every year.

There is no medical consensus on the above periods.

• Infected sinusitis usually is caused by an uncomplicated virus infection. Less frequently, bacterial growth causes sinus infection and fungal sinus infection is very infrequent. Subacute and chronic forms of a sinus infection usually are the result of incomplete treatment of an acute sinus infection.
• Noninfectious sinusitis is caused by irritants and allergic conditions and follows the same general timeline for acute, subacute, and chronic as infectious sinusitis.

Sinus infections or sinusitis may be caused by anything that interferes with airflow into the sinuses and the drainage of mucus out of the sinuses. The sinus openings (ostea) may be blocked by swelling of the tissue lining and adjacent nasal passage tissue, for example, by:

• Common colds
• Allergies
• Tissue irritants such as over-the-counter (OTC) nasal sprays, cocaine, and cigarette smoke

Other causes of sinus infections or sinusitis

Tumors or growths also can block the sinuses if they are near the sinus openings.

Dehydration, disease, drying medications, and lack of sufficient humidity can cause sinusitis or sinus infection. The drainage of mucous from the sinuses can also be impaired by thickening of the mucous secretions, a decrease in hydration (water content) of the mucous brought on by disease (for example, cystic fibrosis), drying medications (such as antihistamines), and lack of sufficient humidity in the air. The epithelial cells have small hair-like fibers, called cilia, which move back and forth to help the mucus move out of the sinuses. These small cilia may be damaged by many irritants, especially smoke. This can prevent them from assisting the mucus in draining from the sinuses and thus results in sinus infections or sinusitis.

Stagnated mucus provides an environment for bacteria, viruses, and in some circumstances, fungus (such as in people who have AIDS or are immunosuppressed), to grow within the sinus cavities. In addition, the microbes themselves can initiate and exacerbate sinus blockage. The most commonly infected sinuses are the maxillary and ethmoid sinuses.

Rarely, those who are immunosuppressed or victims of multiple traumas in disasters such as tsunamis, hurricanes, earthquakes, or tornadoes may breathe in fungi from the soil or water. Eventually, in a few days to over a week, the fungi can grow and cut off blood supply to almost any type of tissue, especially in the nose and eyes. These infections, although rare, are serious and can be deadly, and require immediate medical and surgical care. Although the fungal infection may resemble common bacterial sinusitis initially, it is a disease termed zygomycosis or mucormycosis.

Risk factors for sinusitis include:

• Respiratory tract infections
• Seasonal allergies
• Allergies to dust, pollen, and pet dander
• Nasal polyps that can lead to obstruction and inflammation
• Weakened immune system due to human immunodeficiency virus or chemotherapy
• Abnormal sinus structures, such as deviated septum
• Foreign bodies in the noses of children

There are many signs and symptoms of sinusitis and sinus infections. Most patients have several signs and symptoms at the same time. Others may have some intermittent symptoms; most do not have all symptoms at once.

The most common signs and symptoms of a sinus infection or sinusitis include the following:

• Headache due to pressure in partially or completely blocked sinuses. The pain may increase when the person bends down.
• Facial tenderness and/or swelling when facial areas over sinus areas are touched.
• Pressure or pain due to mucus pressing on sinus tissue or inflammation of sinuses.
• Fever due to inflammation of sinus tissues and infection.
• A cloudy, discolored nasal drainage is often seen in bacterial sinus infections.
• Congestion is a feeling of nasal stuffiness and occurs with both infectious and non-infectious sinusitis.
• Postnasal drip is mucus overproduction from sinusitis that flows to the throat and irritates throat tissue.
• Sore throat is inflammation of throat tissue by postnasal drip.
• Cough is a response to post-nasal drip and the body's attempt to clear out throat tissue irritants.
• Tooth pain is caused by pressure on surrounding nerves and tissues.
• Ear pain caused by pressure on surrounding nerves and tissues.
• Eye pain is caused by pressure on surrounding nerves and tissues.
• Fatigue due to fever, immune response, and/or coughing.
• Bad breath usually is due to bacterial infections.
• Itching/sneezing
  • In noninfectious sinusitis, other associated allergy symptoms of itching eyes and sneezing may be common but may include some of the symptoms listed above for infectious sinusitis.
• Nasal drainage usually is clear or whitish-colored in people with noninfectious sinusitis.
• Ulceration can occur with rare fulminant fungal infections with sharply defined edges and a black, necrotic center in the nasal area. Some fungal infections cause dark, black-appearing exudates. This requires immediate medical evaluation.
• Multiple chronic (over one to three months) symptoms usually are a sign of subacute or chronic sinusitis

Experts disagree about the contagiousness of sinus infections (also termed sinusitis and rhinosinusitis).

• Because bacteria and viruses (and occasionally, fungi) are the cause of most sinus infections, some experts say that the bacteria, viruses, or fungi can be transferred from person-to-person, and occasionally cause sinus infections.
• Other experts say that sinus infections, although caused by bacteria and viruses, occur because the conditions in the individual's sinuses are optimal for infection. In addition, infection can be caused by bacteria, viruses, or fungi that are already present in a person, so person-to-person transfer is not required for them to develop.

However, the majority of doctors think that most people do not transmit sinus infections except in rare instances, and conclude that sinus infections are not contagious.

Symptoms that last more than 10 days without improvement and are worsening after you start to improve are cause for concern. If you have symptoms like severe headache or facial pain and a fever that lasts longer than three to four days, you should seek medical care. Your doctor will be able to help diagnose the underlying cause of your symptoms and will provide an active plan of treatment.

Call your doctor if you experience the following:

• Symptoms that worsen even after 7 days of home remedies or medications
• Symptoms that last longer than 7-14 days
• Mucous that changes from clear to yellow or green
• Cough especially at night

Go to an emergency room for evaluation if you experience the following symptoms associated with a possible sinus infection:

• Severe headache that is not relieved by painkillers
• Alteration of mental status or the way a person thinks or acts
• Fever
• Vision changes
• Neck Stiffness
• Nose bleed
• Concern for a foreign body in the nose in children

While sinus infections are common, they can also be life-threatening. If a sinus infection becomes severe and goes untreated, it can spread to the brain.

Many sinus infections can be treated by a primary care physician, an internal medicine doctor, or an emergency medicine specialist. However, it is not unusual to consult an otolaryngologist, also called an ENT (ear, nose, and throat) specialist, infectious disease specialist, or an allergist or immunologist. With some complex sinus infections, a surgeon who specializes in sinus surgery may be necessary to consult.

Sinus infection is most often diagnosed based on the patient's history and examination by a doctor. Because plain X-ray studies of the sinuses may be misleading and procedures such as CT and MRI scans, which are much more sensitive in their ability to diagnose a sinus infection, are so expensive and not available in most doctors' offices, most sinus infections are initially diagnosed and treated based on clinical findings on examination.

These physical findings may include:

• Redness and swelling of the nasal passages
• Purulent (pus-like) drainage from the nasal passages (the symptom most likely to clinically diagnose a sinus infection)
• Tenderness to percussion (tapping) over the cheeks or forehead region of the sinuses
• Swelling about the eyes and cheeks

Occasionally, nasal secretions are examined for secreted cells that may help differentiate between infectious and allergic sinusitis. Infectious sinusitis may show specialized cells of infection (polymorphonuclear cells) while allergic sinusitis may show specialized white blood cells of allergy (eosinophils). Physicians prescribe antibiotics if a bacterial infection is suspected. Antibiotics are not effective against viral infections; many physicians then treat the symptoms.

If sinus infection fails to respond to the initial treatment prescribed, then more in-depth studies such as CT or MRI scans may be performed. Ultrasound has been used to diagnose sinus infections in pregnant women but is not as accurate as CT or MRI. Rhinoscopy or endoscopy, a procedure for directly looking in the back of the nasal passages with a small flexible fiberoptic tube, may be used to directly look at the sinus openings and check for blockage of these openings by either swelling or growths.

It may sometimes be necessary to perform a needle aspiration (needle puncture) of a sinus to get infected material to culture to determine what microbe is causing the sinus infection. Cultures of the nasal passages are rarely helpful in determining what bacteria or fungus is causing a sinus infection since the nasal passages are often normally colonized by non-infecting bacteria. The needle puncture procedure is usually done by an otolaryngologist (ENT, or ear, nose, and throat specialist) when treatments have failed to alleviate the disease. The procedure requires local anesthesia to minimize any discomfort; some patients require general anesthesia. The sinus is aspirated, the contents sent for culture and staining, and the sinus may be flushed with a saline solution. This is technically the most accurate way to diagnose infectious sinusitis.

In addition, both rigid and flexible endoscopy have been used to obtain diagnostic material from sinuses. These procedures are usually done by an otolaryngologist under topical and local anesthesia. Occasionally, there may be a need to sedate the patient. Some investigators suggest that endoscopy specimens are comparable to those obtained by needle puncture.

Fungal infections are usually diagnosed by biopsy procedures and tissue removed by a surgeon, or by fungal culture and microscopic identification by a microbiologist or pathologist trained to identify fungi. Allergic fungal sinusitis (emphasis on allergic) is an inflammatory response to fungal elements in the sinus cavity and is suspected based on certain CT imaging characteristics as well as the history and physical exam.

Drug treatment for sinusitis and sinus infection depends on the type.

Viral sinusitis

Antibiotics are not necessary for sinusitis caused by a virus. Frequently recommended treatments include pain and fever medications, such as:

• Acetaminophen (Tylenol)
• Decongestants and mucolytics are medications that dissolve or break down mucous (for example, guaifenesin)

Bacterial sinusitis

Bacterial infection of the sinuses is suspected when facial pain, nasal discharge resembling pus, and other symptoms last longer than a week and are not responding to over-the-counter (OTC) nasal medications.

Acute sinus bacterial infection usually is treated with antibiotics aimed at treating the most common bacteria known to cause a sinus infection. It is unusual to get a reliable culture without aspirating the sinuses.

The five most common bacteria causing sinus infections include the following:

1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Moraxella catarrhalis
4. Staphylococcus aureus
5. Streptococcus pyogenes

Antibiotic treatment for sinus infections must be able to kill these five types of bacteria.

Amoxicillin (Amoxil) is acceptable for uncomplicated acute sinus infections, but some doctors prescribe a similar medication, amoxicillin-clavulanate (Augmentin) as the first-line antibiotic to treat a possible bacterial infection of the sinuses. Amoxicillin usually is effective against most strains of bacteria.

Other antibiotics may be used as a first choice if you are allergic to penicillin, such as:

• cefaclor (Ceclor)
• loracarbef (Lorabid)
• clarithromycin (Biaxin)
• azithromycin (Zithromax)
• sulfamethoxazole (Gantanol)
• trimethoprim (Bactrim, Septra)
• ciprofloxacin (Cipro)
• levofloxacin (Levaquin)

If you don't improve after 5 days of taking the antibiotic, contact your doctor, who may want to switch antibiotics to one of the five listed above or amoxicillin-clavulanate (Augmentin).

Generally, effective antibiotics need to be continued for a minimum of 10-14 days. However, it is not unusual to treat sinus infections for 14-21 days.

Some antibiotics now are thought to reduce inflammation, independent of the antibacterial activity.

Taking decongestants (pseudoephedrine) and mucolytics (guaifenesin) orally may help assist drainage of sinus infection.

The treatment of chronic forms of sinus infection requires longer courses of medications, such as amoxicillin-clavulanate (Augmentin), and may require a sinus drainage procedure. This drainage typically requires a surgical operation to open the blocked sinus under general anesthesia.

In general, antihistamines should be avoided unless it is thought a sinus infection is due to allergies, such as pollens, dander, or other environmental causes.

The use of a topical nasal steroid spray will likely help reduce swelling in the allergic individual without the drying that is caused by using antihistamines although both are occasionally used.

Oral steroids may be prescribed to reduce acute inflammation and to help with chronic inflammation in cases with or without polyps and allergic fungal sinusitis.

In many people, allergic sinusitis develops first, and later, bacterial infection occurs. For these individuals, early treatment of allergic sinusitis may prevent the development of secondary bacterial sinusitis.

In rare instances or natural disasters, fungal infections (termed zygomycosis or mucormycosis) may develop in debilitated people. Death rates of 50%-85% have been reported for patients with these sinus infections. Treatment relies on early diagnosis followed by immediate surgical debridement, antifungal drugs, (mainly amphotericin B), and stabilizing any underlying health problem such as diabetes.

Common home remedies to treat sinus infections include:

• At-home vaporizer or humidifier: It may help relieve sinus symptoms. Sometimes a hot shower may also relieve sinus symptoms.
• Using lavender essential oil, peppermint essential oil, and eucalyptus oil while breathing steam may relieve nasal pressure.
• A warm compress over the nose and forehead helps relieve sinus pressure.
• Nasal irrigation using a syringe or a neti pot to stream a solution of non-iodized salt, baking soda, and lukewarm distilled (or previously boiled) water through the nostrils to help keep nasal passages clean. Also, a patient may choose a product from a pharmacy that is already prepared and ready to mix from packets.
• Drink warm water to stay hydrated.
• Drinking warm ginger tea with turmeric may help relieve nasal congestion.
• Drinking warm water with apple cider vinegar may help fight a sinus infection. Apple cider vinegar has antibacterial and antifungal properties and is a good source of vitamin A, vitamin E, vitamin B1, vitamin B2, calcium, and magnesium which aids in treating sinus infections. It works by loosening up the mucous and clearing nasal passages.
• Eat a balanced diet that also includes spices, and a diet rich in vitamin C and minerals to help build immunity to fight infection.
• Sleep with the head elevated at night or keeping a humidifier running at home to avoid an arid environment may help relieve sinus pressure.

Sinus infections caused by viruses can use home (over-the-counter, OTC) treatments such as pain and fever medications (acetaminophen [Tylenol]), decongestants, and mucolytics. In addition, some health care professionals suggest nasal irrigation or a sinus rinse solution to help relieve symptoms of sinus infections, even chronic sinusitis symptoms. This irrigation is accomplished with a "neti-pot" or a sinus rinse kit (sometimes termed a nasal bidet).

Bacterial and fungal sinus infections usually require antibiotic or antifungal therapy so home treatments without them are often unsuccessful. However, some home treatments may help reduce symptoms after medical therapy has begun; some healthcare professionals recommend nasal irrigation after sinus surgery.

The signs and symptoms of acute sinusitis usually last around 7-10 days unless there are complications. With appropriate treatment, the symptoms may become more bearable, the recovery may be faster, and chronic sinusitis can be prevented.

The signs and symptoms of chronic sinusitis last at least three months or longer. Patients may experience multiple flare-ups of acute sinusitis.

Potential complications of untreated sinus infection include:

• Chronic sinusitis
• Difficulty breathing
• Hyposmia (reduced sense of smell)
• Anosmia (complete loss of the sense of smell)
• Laryngitis (inflammation of the larynx)
• Dacryocystitis (inflammation or infection of the lacrimal glands)
• Orbital cellulitis or abscess (inflammation of the orbit of the eye)
• Meningitis (inflammation of the meninges)
• Brain abscess (pus-filled pockets inside the brain)
• Frontal bone osteomyelitis (infection of the frontal bone)
• Cavernous sinus thrombosis (formation of blood clot forms inside a hollow space at the base of the brain)

While serious complications are uncommon, it is possible for a sinus infection to cause a direct extension of infection into the brain through a sinus wall, creating a life-threatening emergency (for example, meningitis or brain abscess).

In addition, other adjacent structures can become infected and develop problems, such as osteomyelitis of bones in the skull and infection around the eye (orbital cellulitis). Rarely, these infections (mainly bacterial and fungal organisms) may cause death. The most susceptible individuals to complications are patients with suppressed immune systems, diabetes, and relatively rarely those who have suffered multiple trauma injuries that may occur in natural disasters.

Currently, there are no vaccines designed specifically against infectious sinusitis or sinus infections. However, there are vaccines against viruses (influenza) and bacteria (pneumococci) that may cause some infectious sinusitis. Vaccination against pathogens known to cause infectious sinusitis may indirectly reduce or prevent the chance of getting the disease, but this has not been proven. Fungal vaccines against sinusitis are not available, currently.

If you are prone to recurrent bouts of a "yearly sinus infection" it may be important to consider allergy testing to see if this is the underlying cause of the recurring problem. Treatment of the allergy may prevent secondary bacterial sinus infections. In addition, sinus infections may be due to other problems such as nasal polyps, tumors, or diseases that obstruct normal mucus flow. Treatment of these underlying causes may prevent recurrent sinus infections.