Symptoms of congestion, pain, and tenderness around the eyes, nose, or forehead and postnasal drainage are typically classified as symptoms of sinusitis. It can either be seasonal or perennial (year-round). These symptoms by themselves are not necessarily a sign of an allergy. This is important because assuming that these are allergic in nature can lead to incorrect treatment of sinus related conditions. Although allergy is a common cause, these signs and symptoms can be due to other more chronic diseases such as a chronic sinus infection. It is also common that anatomic abnormalities can lead to exacerbation of these symptoms and without their correct identification and correction symptoms will not improve despite even aggressive medical management.
Dr. Jerome Hester is a San Francisco Bay Area ear, nose, and throat specialist with decades of experience and he obtained his training in Otolaryngology/Head and Neck Surgery at Stanford University. He takes a comprehensive approach with every patient for the best level of care, always assessing the entirety of the symptoms and performing a thorough anatomic inspection of the nasal passages and sinuses as well as a complete history of the individual’s symptoms in order to create a personalized treatment plan. As mentioned, these symptoms can be signs of a chronic sinus infection.
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The sinuses are four paired cavities within the skull. Although there are several theories, the exact reason why we have sinuses is not known. They are not actually in the nose, but rather connect to the nasal cavity through drainage pathways that are narrow tubes that allow for the flow of mucous from the sinuses to the nose and eventually down the back of your throat. If there is no obstruction, this flow is constant with the average adult producing up to a liter of mucous per day. This mucous is pushed by microscopic hair-like cells know as cilia and can trap bacteria, viruses, allergens, and other materials so that the body can either react to them or dispose of them.
Any cause that slows down or stops the flow of mucous can result in a build-up of this material. A common reason for this is swelling that can accompany an infection or in response to an outside irritant. The swelling can cause the opening of the pathways to narrow, thus decreasing or even stopping the flow. Commonly in those situations, the mucous itself will thicken which also leads to obstruction.
In certain patients, reflux of acid from their stomach can actually reach the back of the nasal cavity and cause irritation and swelling in the nose and sinus openings. This can even be true in infants and young children. Since this type of reflux occurs most commonly at night when the patient is lying flat, the diagnosis can be missed as the typical symptoms such as heartburn will not be present.
Some individuals have anatomy that causes a chronic obstruction-for example the natural openings of the sinuses can become narrow either because the patient was born with that problem, or due to repeated infections that leave the openings “scarred.” The chronic obstruction itself can even cause the cilia to stop functioning normally and therefore not transport the mucous. We also know that certain toxins, such as cigarette smoke can alter the function of the cilia. Additionally, a subset of patients forms benign (not cancerous) growths called polyps. These small, grape-like structures are more common in those patients with allergies and typically cause problems by just taking up space, leading to obstruction. Finally, in a disease such as cystic fibrosis, the cilia do not function which leads to problems in the lungs and sinuses.
When the flow of mucous is either slowed or completely blocked, mucous will accumulate in the sinus cavity. This collection of mucous is a great place for bacteria or viruses to grow. The fluid is high in glucose (sugar) and because it is trapped inside the bony walls of the sinus it is hard for the body to use its defenses such as white blood cells to fight any infection. The infection then causes more swelling further blocking any chance of drainage and also causes the mucous to become thicker compounding the problem. This leads to feelings of pain and pressure, thick drainage, and fatigue. Fever is actually uncommon in a sinus infection.
Occasionally the body will overcome these issues and the symptoms will resolve in 3-5 days. Medications such as decongestants, both taken orally and as nasal sprays (although decongestant nasal sprays can only be used for 3-5 days before significant side effects can occur), and drugs that thin mucous (mucolytics such as guaifenesin) can help shorten the duration of the symptoms. Nasal irrigation with salt water can also be helpful and are without side effects.
If symptoms do not resolve in a week or so, or if complications such as severe headache, high fever, or progression of the infection into the chest resulting in bronchitis or pneumonia develop, antibiotics may need to be added. Oral steroids can also be considered to help reduce swelling and improve drainage. If symptoms persist despite the above treatment or if infections clear but recur several times a year, this indicates a more complicated problem. Chronic or recurrent sinus infections not only are associated with the symptoms described above but affect the body in other, potentially more serious ways. Chronic infection can lead to chronic fatigue that goes undiagnosed or is attributed to other issues. Chronic cough can also be due to the chronic drainage from the infection, which can also cause or exacerbate asthma. There have also been studies showing an increased risk of heart disease and stroke in those patients with chronic sinusitis. It is thought that that the chronic inflammation caused by the disease leads to damage to the lining of the blood vessels in the heart and brain, making it more likely for plaques (accumulation of debris) to adhere to the damaged areas and ultimately causing blockage of blood flow to these vital structures.
It is important for the treating physician to start by taking a thorough history. Many times the patient will not realize how often the symptoms are present or for how long they have been suffering. This is especially true if the symptoms have been attributed to allergies or that they just “have a lot of colds,” by either the patient or their doctor. This can lead to the overuse of antibiotics, steroids or other medications that are not truly solving the problem. With over 25 years of experience, Dr. Hester knows the questions to ask to determine the problem that is present which leads to the correct treatment options.
After the history of symptoms is obtained, a thorough examination of the ears, nose, and throat is performed. There is a significant overlap of both cause and effect of these structures in sinus disease. The examination begins with direct examination, however, the use of an endoscope may be necessary to thoroughly evaluate the nose and sinuses. In this case, a small scope that uses magnification and light to see into the recesses of the nose and the openings of the sinuses may give further information.
Ultimately, in order to define the presence of sinus disease and truly define any anatomic problems, Dr. Hester may order a CT, or “CAT” scan. This is a type of X-ray that can actually see “into” the sinuses. Finally, at the end of this thorough history and physical examination, Dr. Hester will outline a comprehensive list of treatment options, including answering questions regarding the risks, benefits, and likely success of each one.
Treatments for Sinusitis
Non- Invasive Sinus Treatments
Although nasal irrigation rarely resolves symptoms completely, they are very safe and can provide some level of improvement. There are various methods of irrigating, but the simplest and best tolerated involves the use of some type of device that will deliver the irrigation with some force.
There are squeeze bottles sold specifically for this purpose as well as powered irrigating devices. Even an infant nasal bulb syringe can work-as well as a turkey baster! The solutions used can also vary. The simplest is a saline solution. These can be purchased, or they can be made at home using approximately 1 tablespoon of table salt in an 8-ounce glass of water. In certain situations, Dr. Hester may suggest adding specific medications to the solution. The technique is to lean slightly forward and place the device slightly into one nostril.
Two to three gentle pumps should cleanse the nasal cavity. It is not necessary for the rinse to come out of the other nostril. By bending slightly forward, the rinsing will still be successful, but will not run down the back of one’s throat- an unnecessary and obnoxious feeling. Also, this can be done in the shower or over a sink to avoid a mess.
The most common medications for the treatment of sinusitis depend on whether one is treating an acute episode or trying to treat the chronic condition. In the acute episode, the use of decongestants to decrease swelling and medications to thin the mucous (mucolytics) is most valuable as a first step. decongestants can be taken orally (for example pseudoephedrine) or by a nasal spray (oxymetazoline). The oral medications can react systemically and although generally tolerated well can cause certain individuals to feel “jittery,” and can raise blood pressure. The nasal sprays typically avoid these systemic issues, but are limited to use for 3-5 days due to the possible development of “rebound.” If the medication is used longer than the recommended duration, the patient will feel the need to use the drug more often in order to feel the same amount of benefit. Soon the patient will be using the nasal spray several times a day and still feel congested. If rebound develops, medical treatment is needed by a specialist.
Mucolytics (such as guaifenesin) thin the mucous and encourage drainage. They are generally very safe and can be taken along with decongestants. Antihistamines are commonly used for sinusitis. However, unless there is a known allergic contribution, they are unlikely to be of benefit and can have the secondary effect of thickening mucous, which is contrary to what one should be trying to accomplish.
If the previous medications are not successful, antibiotics may be added. Certainly, one should be concerned regarding the overuse of antibiotics, but it is not only to prevent the development of resistant bacteria. In addition to this concern is the fact that other serious side effects occur with measurable frequency- such as gastrointestinal issues, breathing difficulties, and severe allergic reactions. For that reason, use should only be considered after a thorough evaluation.
Additionally, if repeated or continuous use is not successful, this is typically a sign of a more complicated case that requires evaluation by a sinus specialist. Oral steroids (prednisone) can be added to decrease inflammation if the antibiotics are not effective. Again, the need for such medication, although generally safe in proper dosages and duration should only be added after a thorough examination.
In chronic situations, the previously mentioned medications can all have a role. However, it is best to have tests such as a CT scan performed in these cases to truly understand what the cause of the chronic condition. Antibiotics and steroids can have a role, but only for acute exacerbation of a chronic problem due to their side effects in long term use.
The successful treatment of allergies can play a significant role in improving some sinusitis symptoms. The added inflammation and swelling along with causing the thinking of the mucous itself can limit the body’s ability to cleanse itself and increase the chance of infection. However, many times further evaluation of sinus symptoms is postponed when symptoms are labeled allergic without proper investigation and confirmation. If an allergy evaluation has not been performed, Dr. Hester can refer you to a qualified allergist to complete this part of your treatment. However, many times even when an allergy is playing a role, other procedures can augment allergy treatment and lead to significant improvement in your quality of life. Dr. Hester can present a thorough list of all treatment options and work with your allergist to get you feeling better.
Minimally Invasive Treatments
Turbinates are normal structures that extend from the lateral wall of the nasal cavity like a shelf. They have a function-due to their design they provide surface area that helps warm and humidify the air we breathe. Although complete removal can cause serious side effects, many times these structures become abnormally enlarged. Although the turbinates may not be directly related to the cause of one’s sinusitis, enlargement of these structures can add to difficulties with normal air and mucous flow. Reducing the turbinates to normal size (and therefore protecting their necessary function of heating and humidifying airflow) can help improve symptoms. In some cases, this simple office-based procedure can be combined with aggressive medical management and nasal irrigations to provide adequate relief without significant downtime or risk.
Like the turbinates, treatment of rhinitis can be additive to the treatment of sinus disease by reducing inflammation and normalizing drainage. Office-based procedures such as the Vivaer, which uses radiofrequency, or Clarifix, which uses cryotherapy (cold) can be performed under local anesthesia with little or no recovery.
The septum is the midline structure that separates the left and right sides of the nasal cavity internally. It is made of bone and cartilage. In a perfect world, it is straight therefore providing an equal passageway on both sides. However, many times the septum is crooked or “deviated” leading to obstruction on one or both sides. This can be a situation the individual was born with, or commonly it is a result of trauma to the nose. Even relatively mild trauma can lead to a deviated septum. The septum can cause significant problems if the deviation happens to be just opposite the normal drainage openings for the sinuses, which can narrow these areas even further and make them even more likely to obstruct even with mild swelling- crating a likely situation for infection to occur.
The surgery to correct a deviated septum is fairly straightforward, does not result in bruising or other cosmetic changes, and allows a return to normal function within a few days.
In those patients where polyps are contributing to the disease, simple removal of the polyps can give relief. This procedure can be done in the office or under light sedation in an outpatient surgery center. Using a small telescope (endoscope), Dr. Hester can look inside the nose and find the offending polyps. They can then be carefully removed. Discomfort and recovery are minimal. Many times this procedure is combined with functional endoscopic sinus surgery in order to provide better long term results.
Functional Endoscopic Sinus Surgery
This is also known as FESS. Originally, the process of sinus surgery was very aggressive and destructive, removing significant amounts of tissue and
creating large openings to allow the sinuses to drain. Some of these procedures even involved incisions on the face or scalp.
With the development of small telescopes or “endoscopes,” it became possible to truly see the sinus anatomy. It was demonstrated that very small, minimally invasive openings could be created by finding the natural drainage pathways and surgically widening these openings just enough to return normal function long term.
The endoscopes and instruments developed for this type of surgery allowed this to be done through the nostrils without any visible incisions. This less traumatic method also allowed restoration of the normal function of the sinuses to occur sooner after surgery and provide longer-term success. It also results in a much easier recovery for the patient with minimal discomfort, no outward bruising or swelling, and very short downtime.
FESS is only performed after a complete evaluation and determination that less invasive treatments have not provided adequate relief for the patient. If surgery is decided to be an option, a CT scan is done to determine which sinuses are affected- sinuses that are actually functioning well are left alone. With over two decades of experience, Dr. Hester will outline for you the most effective surgical approach that will lead safely to success and take the time to answer any and all questions you may have about the surgery and recovery.
Improve Your Quality of Life with Freedom from Sinus Issues
Sinusitis can be a chronic condition that dramatically affects one’s quality of life, energy level, and overall health. It can also lead to the overuse of medications that may not be truly treating the exact issue you have. Dr. Jerome Hester can perform a complete evaluation of your nasal and sinus issues and then provide a detailed description of all treatments that are available. Together, we can find the option that is right for you.