The sinuses are small, air filled spaces inside our cheekbones and forehead. They make mucus, which drains into the nose through small channels. This mucus than makes it way to the back of our nose from where it goes to our throat and we swallow it.

Sinusitis means inflammation of a sinus and is usually caused by an infection. The cheekbone (maxillary) sinuses are the most commonly affected. When this infection develops rapidly over a few days and lasts a short time, it is called Acutesinusitis. Many cases of acute sinusitis last a week or so but it is not unusual for it to last 2-3 weeks. A mild bout of acute sinusitis is common and many people will have some degree of sinusitis with a cold.

Infrequently the sinusitis becomes persistent and lasts for longer than 3 months, when it is called chronic sinusitis.

In most people, acute sinusitis develops after a viral cold or flu. In few people after the virus has started the infection, bacteria can add on. This can make the infection worse and last longer.

People who smoke, or have asthma, nasal allergy or nasal polyps are prone to blockage of sinuses that can lead to sinusitis. People with cystic fibrosis or weak immune system also have higher risk. Rarely dental infection can spread to your maxillary sinus.

When you have acute sinusitis you are likely to have pain over the infected sinus that is throbbing and worse when you bend your head forward. You are also likely to have blocked nose on both sides of your nose with reduced smell and a runny nose. You can have fever and may feel generally unwell.

We usually diagnose acute sinusitis from listening to your typical symptoms and the duration of problems. Investigations are not usually needed to diagnose acute sinusitis but if needed may include blood tests, X-rays or scans.

Because most cases of acute sinusitis are due to a viral infection, your immune system usually clears the virus and symptoms generally go within a couple of weeks. Even if bacteria cause the infection, the immune system will usually clear it away. So, for most people with acute sinusitis, antibiotics are not needed. Remember, antibiotics have no effect on viruses! However, we may prescribe a course of antibiotics in some cases, for example:

• If your symptoms are severe or if you are very unwell

• If you have another illness such as cystic fibrosis, heart problems or a weakened immune system

• If your symptoms are not settling within 7 days, or are worsening

• If you are old and have additional serious medical problems, such as diabetes.

Treatment to relieve symptoms

In most cases, treatment to relieve your symptoms whilst waiting for your immune system to clear the infection; is all that is required. These include the following:

• Painkillers such as paracetamol or ibuprofen. They will also help to bring down your fever. Sometimes stronger painkillers are needed.

• Decongestant nasal sprays or drops are sometimes used as they may briefly relieve a blocked nose. Remember you should not use a decongestant spray or drops for more than 7 -10 days at a time. If they are used for longer than this, they may cause a worse rebound congestion in the nose.

• Have plenty of water

• Warm face packs held over the sinuses may help to ease pain.

• Saltysolutions for nasal washout may help to relieve congestion and blockage in the nose.

• Steam inhalationmay give temporary relief

However, if you experience any of following I would advise seeking our opinion urgently

  • Severe forehead headache, forehead swelling,
  • Feeling drowsy, nauseous with aversion to light as it can indicate meningitis
  • Disturbance in sight, seeing double or swelling around your eye
  • If you are known to have weak immunity
  • If you experience problems ONLY on ONE side of your nose especially if you are aware of a mass or bloodstained discharge (could be a tumour!)
  • If you get 3 or more attacks per year or have persistent symptoms despite an adequate course of second-line antibiotics.

Very rarely if medicines fail to have any effect and if your condition is getting worse, surgical intervention may be required to drain the sinuses of infected material. This may be

• Sinus puncture and irrigation.

• Endoscopic Sinus surgery is preferred now

Most cases of chronic sinusitis develop following an acute sinusitis infection.

We divide chronic rhino sinusitis into three different categories, depending upon the features that are present.

• Chronic rhinosinusitis without polyps — This is the most common type of rhinosinusitis where inflammation is due to allergy, irritation or structurally narrow drainage path from your sinuses.

• Chronic rhinosinusitis with polyps —In some people, for poorly understood reasons, the lining of the nose and sinuses become so swollen that they appear like pale grapes. These common polyps are NOT cancer and do NOT develop into a cancer. The polyps can become large and numerous enough to clog the sinuses, causing symptoms.

• Chronic rhinosinusitis with fungi —Fungi is normal in air around us and most of us can breathe in air containing fungi without problems. However, in some people fungi causes the sinus lining to make thick, dense mucus that fills the sinuses and we can see fungi in the mucus under the microscope.

The most prominent symptom is usually a blocked nose (nasal obstruction). One or more of the following may also occur:

• A runny nose. The discharge may be green/yellow

• A blocked sensation when breathing in through the nose

• A reduced sense of smell.

• Pain over the affected sinus or head is NOTcommon (unlike acute sinusitis). In many cases, it is more of a feeling of facial fullness or mild discomfort rather than pain.

You may develop episodes of acute sinusitis over the chronic sinusitis making symptoms worse again.

We usually diagnose chronic sinusitis based on your symptoms along with examination of your nose with special instruments called nasal endoscopes. They allow us to see any obvious abnormalities or deviation of the bones in your nose, sinus drainage passage and to look for any other problems, such as nasal polyps. As a general rule, X-Rays or scans are NOT used for diagnosis of chronic sinusitis. This is because studies have shown that many people who have NO sinusitis, have some findings on sinus scans! CT scan if requested, is usually done to help us plan surgery (not for sinusitis diagnosis) if medical treatment has failed.

Several studies have shown that if CT scans are done in people WITHOUT any nose or sinus problems, it will show some swelling or fluid collection in half of them. This is commonly due to

  • healthy mucus circulating through their nose or sinuses that looks like collection in sinuses
  • swelling of their sinus lining that we know can occur normally at interval in healthy sinuses
  • slightly different but clinically unimportant shape of their drainage passage

Therefore, CT scan without endoscopic examination of the nose is generally NOT used to diagnose sinusitis. The diagnosis of sinusitis is primarily made by the presence of above mentioned symptoms and finding features of inflammation or infection when we look inside the nose with endoscopes.

Treatment of any underlying problem

This may mean treatment for allergic rhinitis, treatment of a dental infection, treatment of asthma, treatment of a fungal infection, etc.

Avoidance of things that may make your symptoms worse

This would include avoiding smoking or things that you are allergic to such as dust, pollen or grass.You should also practice good dental hygiene.

Medical treatments :

Medical treatment is the first step and this cures vast majority of people. However, usually a long course i.e. 4-12 week treatment is recommended for chronic sinusitis

The medicines that are recommended include the following:

1. Steroids applied to the nasal lining using sprays or drops to help reduce inflammation. Initially a course of steroid tablets by mouth may be suggested for 10-14 days.

2. Prolonged courses (4-8 weeks) of specific antibioticsat lower dose are sometimes helpful.

3. A saline nasal solution is very useful to relieve congestion and blockage

4. Rarely antifungal medicines may be needed if you have a fungal infection

In addition, at times the medicines mentioned above for acute sinusitis will help for managing the symptoms.

Surgical treatments :

Surgery is used mainly if the condition does not improve with the above medical treatments. The main purpose of surgery is to improve the drainage of the affected sinus. The most common operation is called functional endoscopic sinus surgery (FESS).

FESS refers to surgery inside your nose and sinuses with specially designed instruments while we look inside with an endoscope. The endoscope used for this procedure is a thin rigid instrument that contains lenses that allows a detailed magnified view of inside the nose. We can see the opening of the sinus drainage channels and remove any tissues that are blocking the drainage of the affected sinus to improve sinus drainage and ventilation and help to restore normal function to the sinus. This operation does not require any cut or scar on your face/nose, is minimally invasive (causes little damage) and usually has a high success rate in relieving symptoms of chronic sinusitis. You can follow this link to learn more about FESS.

A more recently developed operation is called balloon catheter dilation of paranasalsinus openings. This involves pushing a small balloon through a flexible tube in the nostril, into the blocked sinus. The balloon is inflated which pushes wide the blocked area. The balloon is then deflated and removed. Following this procedure there is a good chance that the sinus drainage channel is widened and the sinus can drain properly.

Surgery may also sometimes be needed to remove nasal polyps or to correct problems with deviated bones inside the nose.

Chronic sinusitis can be unpleasant but serious complications are very uncommon. Rarely, a sinus infection may spread to nearby areas, such as around an eye, into adjoining bones, into the blood, or into the brain.

Children are more prone to complications than adults and you must seek urgent specialist opinion if there is swelling or redness of an eyelid or cheek

This is an uncommon infection that is mostlyseen in patients withuncontrolled diabetes or weak immunity. There are two distinct clinical pictures:

  • Non-invasive fungal sinusitis: this is usually seen in healthy persons and is because of allergy to the fungi or due to accumulation of fungi in your sinuses.

  • Invasive fungal sinusitis: In this the fungus can spread directly to your eyes or brain or through blood to other parts of your body. You are more likely to have this if you have uncontrolled diabetes or a weak immune system. In some patients this may take on an acute, aggressive character when it is associated with a high mortality rate, unless recognised and treated early.

In addition to clinical examination blood test (Serum total fungus-specific IgE concentrations may be elevated in patients with allergic fungal sinusitis) and CT and or MRI imaging are required for diagnosis. Microbiology and histology provide the final diagnosis.

The treatment for fungus sinusitis is by endoscopic sinus surgery followed by medications.

The aim is to remove the infected mucus and tissue. The extent of operation ranges from simple opening and washout of your sinuses to removal of most of the tissue in your nose and sinuses. Antifungal treatment is used where there is invasive infection. Steroids are usually given after the operation if you have allergic fungal sinusitis.

In addition intensive regular washout of the nose and sinuses with special solution is required.

Most patients do well. However about half of those withaggressive invasive fungal sinusitis die, even with aggressive surgical and medical treatment. The infection may come back after treatment, so it is not unusual for some patients to need long term/lifelong antifungal medications.

Nasal polyps are grape like swelling arising from the lining of the nose or the sinuses. They are almost always on both sides, though the size may be different in one nostril from the other (polyps on ONE side only may be nasal tumours!). If they occur in children, tests for cystic fibrosismust be done.

Cause

In most cases, we do NOT know what causes these polyps! In some cases it can be due to chronic sinusitiswhile in others it can be due to imbalance of normal chemicals inside the nose. It is more common if you have asthma, aspirin allergy, Cystic fibrosis or allergic fungal sinusitis. Nasal polyps are not associated with allergy.

Associated clinical problems

The problems due to polyps depends on their size (small polyps may be asymptomatic). Blocked nose is the commonest problem and is usually associated with reduced or absent sense of smell and food flavor. Most people are also bothered by runny nose, the discharge is mostly watery and clear. Green secretions suggest infection. Blood-tinged secretion are usually NOT seen with nasal polyps and if from only one side, it can indicate other problems such as tumour, foreign body, nose picking, or misapplication of nasal spray. Similarly pain is NOT seen with nasal polyps though you may experience heaviness or dull headaches. Large polyps can lead to snoring and obstructive sleep symptoms.

Diagnosis

Nasal polyps are easily seen on nasal examination with nasal endoscopy.Usually no additional tests are required for diagnosis.

CT scans are recommended if you require an operation or if there are unusual features such as polyps only on one side as it may be a sign of tumour.

Treatment

Medication is the first-line treatment, unless the nature of the polyp is uncertain (egsuspected malignancy).

Steroids are the most effective medicines for most patients as they shrink polyps and improve symptoms. However due to risks and potential side effects/complications steroid tablets are NOT safe for more than a week or two. Thereafter a course of steroid drops may be given for a few weeks. These too have side effects if taken for longer period. Therefore, for most patients, after the above mentioned course, steroid sprays are given. These are known to have negligible absorption and effect elsewhere in your body and can be taken for months or years!

In addition, steroids are also beneficial after operation as some studies have shown that they reduce the risk of polyps coming back.

Nasal drops should be used in the 'head upside down' position (see diagram).

Nasal washout with salty water is also beneficial and is best used immediately beforethe use of steroid drops or sprays.

Surgery for nasal polyps

Surgery is recommended if your symptoms and polyps persist after medical treatment mentioned above. This is done endoscopically to remove the polys from your nose and sinuses with special instruments. We also open up the sinuses and make their ventilation easy.

However, you must remember that the polyps can come back even after they are completely removed during your operation. Therefore, we advocate a course of steroid medication (mentioned above) after the surgery. You may need repeat operations in future if the polyps recur. There is NO treatment that can guarantee cure of nasal polyps with no risk of their recurrence. People who have asthma and intolerance to aspirin have higher chance of polyps coming back and may require multiple operations during their life.

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