Doc, I've got sinus!

  

By: E. Scott Elledge, MD – ENT Associates of Alabama

 

These words are commonly uttered by patient's presenting to our ear nose and throat office. While I understand where they're coming from, the patient may have a wide variety of problems that we label "sinusitis."

 

A better way to think of it, and then this will help one understand treatment options, is to divide it up into two categories --- sinusitis and rhinitis.

 

The term sinusitis applies to inflammation or infection in the paranasal sinus cavities that surround the nose. There are frontal, ethmoid, maxillary, and sphenoid sinuses. These sinuses can be involved in disease processes individually or multiple sinuses.

 

Rhinitis is the term for inflammation of the nose. When the patient has rhinitis they may or may not have sinusitis. Usually, however, when patients have sinusitis they do have some component of rhinitis or nasal inflammation.

 

Understanding the purpose of the nose and sinuses helps us to understand disease processes as well as their treatment. The nose is primarily responsible for filtering out infections and irritants such as dust as well as the very important function of humidifying the air we breathe into our lungs. The nose produces approximately 1.5 Liters of fluid in order to accomplish this per day. Also, whether you're in 0°cold or 110° heat, by the time the inspired air enters the lung it is body temperature, quite an amazing feat!

Symptoms of rhinitis include excessive drainage or post nasal drip, congestion, facial pain pressure, and headaches. Symptoms of sinusitis include the same. Therefore, by symptoms alone, it can be difficult to distinguish between the two.

 

An important structure inside the nose to understand is the turbinates. There are three turbinates on the lateral wall of the nose that contain glandular tissue that produce most of the mucus that provides filtering and humidification function. When the turbinates get inflamed, excessive mucus is produced (i.e. drainage and post nasal drip) and they may swell giving you congestion, facial pain and pressure.

Sinusitis is usually a consequence of an earlier form of rhinitis. Examples of rhinitis include infectious rhinitis (the common cold), allergic rhinitis, and chronic rhinitis from irritants such as smoking or chemicals.

 

Treatment of rhinitis focuses on the symptoms. Decongestants such as Sudafed are used to treat the congestion which also causes the facial pain and pressure. Antihistamines such as Allegra or Benadryl are used to treat the excessive drainage. Other treatments include nasal steroid sprays such as Flonase which reduce the inflammation in the turbinates thereby addressing both the congestion and drainage problem. We also now have spray antihistamines, such as Astepro, which address the drainage problem. Many medications are packaged as an antihistamine combined with Sudafed for example Allegra-D. In severe cases of rhinitis, short-term anti-inflammatory steroids may be used to provide quick relief.

 

In the case of sinusitis, the natural drainage mechanism from the sinus into the nose becomes inflamed or occluded and allows for infection from the nose to then secondarily infected sinuses. Treatment of the sinusitis therefore must also rectify the rhinitis problem as well as address the infection with antibiotics. Saline rinses are also very helpful in the case of rhinitis as well as sinusitis. They provide irrigation benefit to wash away infection but also improve the hydration of the nose and saline is actually a mild decongestant.

 

Treatment guidelines would be to treat rhinitis symptoms with over-the-counter products and if the rhinitis continues for more than 5-7 days then one is at higher risk of the rhinitis transitioning into a sinusitis. Medical intervention with your doctor would be valuable at that point. If rhinitis is occurring frequently or is prolonged then maintenance medications such as the nasal steroid sprays are needed under the guidance of a medical professional.

 

Sinusitis treatments are based on history and physical exam findings and possibly X-rays. Occasional sinusitis can be treated based on clinical symptoms whereas X-rays, to include CT scans, are utilized to evaluate patients with prolonged or severe symptoms. And in some cases the sinusitis simply cannot be cleared and drainage of the sinus needs to be performed in order to recover. These procedures can be done utilizing endoscopes through the nose to identify the sinus drainage systems and open them up and irrigate the sinus. This has traditionally been done in an operating room setting however recent technology advances, such as Balloon Sinuplasty, allow ear nose and throat physicians to open and irrigate the sinuses in the office with topical anesthesia.

 

So as you can see, when one says "Doc, I've got sinus" to me that can mean many different problems requiring a wide variety of solutions.

 

And finally, for a bit of humor, here in Alabama some of my patients pronounce sinusitis as "sign-Unitas" to which I have always wanted to respond " Isn't that what the Colts did in '55..........?"