Sinusitis: It’s nothing to sneeze at.
Each year, about 37 million Americans suffer from sinusitis (sinus infection) resulting in nearly 12 million doctor visits. Adding to the problem is that people often confuse the symptoms of seasonal allergies with sinus infection. To iron out some of the confusion about identifying and treating sinusitis, Well-Being spoke to Dr. Scott Stringer, Professor and Chairman of the Department of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center.
Q. When symptoms are present, what should you look for to determine whether you are experiencing allergies or sinusitis?
A. The symptoms of allergic rhinitis and acute rhinosinusitis, sinus infections, do overlap which can lead to confusion. In general, allergic reactions are characterized by sneezing, a stuffy nose, itchy nose and eyes, and clear nasal drainage. Acute rhinosinusitis usually follows a cold and is characterized by facial pressure or pain, foul or discolored drainage, nasal stuffiness, and possible upper tooth pain. If a cold worsens or does not improve after a week, acute rhinosinusitis is a good possibility.
Q. What are the most common causes of sinusitis?
A. Acute sinusitis, more appropriately called rhinosinusitis, most commonly follows the common cold, which is caused by viruses. If a cold causes the sinuses to become blocked by swelling, bacteria may begin to grow in the sinuses, causing sinusitis. Chronic rhinosinusitis, lasting more than three months, occurs when the sinuses do not completely clear after a sinus infection or repeatedly become infected. There are other common forms of chronic rhinosinusitis related to reactive, inflammatory conditions most commonly manifested by the presence of nasal polyps. The underlying cause of nasal polyposis is sometimes but not always allergies.
Q. Since sinusitis can be triggered by allergies, how do you know when you should see a doctor about treatment?
A. As noted previously, acute sinusitis is more commonly caused by a cold. You should seek medical attention when a cold worsens or does not improve after a week. People with poor immune systems should consult a physician sooner, especially in the presence of fever or significant pain. Allergies do contribute in some cases to the development of chronic rhinosinusitis by keeping the nose swollen and also by direct swelling in the sinus cavities themselves. You should consult your physician if over the counter allergy medications do not give relief in a week or two, both for your comfort and to make sure the diagnosis is correct. There are additional prescription medications that may be required for symptom relief.
Q. If your sinusitis seems to reoccur at the same times of the year, based on allergens that are present at the time, is there anything you can do to preempt the allergic reaction and potential for developing sinusitis.
A. Seasonal allergic rhinitis does typically occur at specific times of the year associated with various pollens. The symptoms of allergic rhinitis can be minimized by taking prescription nasal corticosteroid sprays in advance of and during the season, along with antihistamines. If the seasons are prolonged or multiple, allergy shots are an option for prevention. For very brief seasonal exposures, there is an over the counter medication called cromolyn sodium that can prevent allergy symptoms. Acute rhinosinusitis is more common in the winter due to the high rates of colds during this season. Frequent hand-washing and nasal saline sprays are probably the best methods for minimizing colds and subsequent sinusitis.
Q. What are key factors that can lead to bacterial or viral infections of the sinus, and are there OTC medications that can help prevent the progression?
A. Most viral infections are self-limiting and are more significant in the nasal cavity than the sinus cavities. There is no foolproof method for preventing a cold from turning into a sinus infection, but the most reasonable approach appears to be using nasal saline rinses and getting plenty of rest. Nasal decongestant sprays used for no more than several days may also help. There is also some suggestive evidence that large doses of Vitamin C may help shorten the duration and severity of colds. It is a good idea to check with your physician prior to trying this treatment.
Q. How do you know when to take antihistamines vs. decongestants?
A. Antihistamines are best for sneezing, drainage, and itching. Decongestants are best for relieving nasal congestion. Unfortunately, many cold medications contain both so it is very confusing for the consumer. If you have all of the symptoms mentioned, you might need both an antihistamine and a decongestant. However, if you don’t have a lot of nasal congestion, it is probably safest to take an antihistamine alone. And, a nasal decongestant spray such as oxymetazoline works well without the systemic side effects like elevated blood pressure, sleeplessness, and anxiety. It is important not to use non-prescription nose sprays for more than a few days at a time. Only take as indicated on the label to avoid side effects.
Q. For children (and adults) that are prone to sinusitis, what is the best treatment to avoid overuse of antibiotics or steroids?
A. The best ways to prevent colds that lead to sinusitis include washing your hands frequently and using nasal saline washes. Then it is best to wait 7 to 10 days to see if the cold will go away on its own before taking an antibiotic. If the symptoms are not improving or worsen after that time, an antibiotic is then indicated. Most people mistakenly think that they need an antibiotic every time they get a cold. Colds are caused by viruses, which are not killed by standard antibiotics. Corticosteroid pills or injections are commonly given as part of the treatment for sinus infections, but there is no evidence that they are helpful. They may elevate your energy level, but they don’t help the cold or sinus infection. And, there are risks to taking steroids. Steroids are most helpful in patients with allergies or nasal polyps. It is a good idea to ask your physician if you really need the steroid to treat your routine sinus infection.
Q. For people with chronic sinusitis, how often is it safe to take antibiotics? Steroids?
A. Antibiotics and steroids are both over prescribed. Overuse of antibiotics leads to resistant bacteria and can cause serious damage to the large intestine in rare cases. The most important thing to remember is that antibiotics are only indicated when a cold will not go away or when the infections are very frequent. As a very rough rule of thumb, if you are taking antibiotics more than 3 to 4 times a year for sinusitis you should see an otolaryngologist (ear, nose and throat specialist) to find the underlying cause and consider other treatment options such as minimally invasive sinus surgery. Even a single dose of steroids can have serious side effects. Fortunately this is rare, and steroids are helpful in the right setting. Steroids are best for allergies and nasal polyps. They have a very limited role in chronic sinusitis otherwise. They may be helpful for managing severe allergies and asthma. If you are taking steroids more than twice a year, you should see a specialist to find the correct diagnosis and to consider other alternatives such as allergy shots.
Q. Are there non-medical steps you can take to lessen the effects of sinusitis?
A. A reasonable approach appears to be using nasal saline rinses and getting plenty of rest. Nasal decongestant sprays used for no more than several days may also help. A humidifier may provide some relief by thinning nasal secretions. And, an over the counter analgesic will help decrease the pain associated with sinusitis.
Q. Are there any long-term solutions for people with acute or chronic sinusitis?
A. It is very important to determine the true cause of recurrent acute sinusitis or chronic sinusitis. Nasal endoscopy in the physician’s office, a CT scan, and sometimes allergy testing may be necessary to establish the cause. If allergies are present, the first step is to make sure that the right combination of medications has been tried for an appropriate time period. Many people stop taking their medication too soon for them to work. In some cases, allergy shots may be useful. If no relief occurs, then surgery may be the next best step. Sinus surgery today is nothing at all like your “grandfather’s sinus surgery.” The minimally invasive surgery is done on an outpatient basis, and in some cases even in the office. The days of yards of gauze packing in the nose are over, thankfully, allowing for a much more rapid recovery and return to work. Recovery time is often just a matter of a day or two.
Q. What are the dangers of not treating sinusitis?
A. Untreated acute sinusitis can rarely lead to brain abscess, meningitis, and blindness. Untreated chronic sinusitis also can lead to significant fatigue, decreased quality of life, and loss of smell and taste.
Scott Stringer, M.D., Otolaryngologist, is Professor and Chairman of the Department of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center. He was formerly Professor and Vice-Chairman of the Department of Otolaryngology at the University of Florida College of Medicine. He completed medical school and his otolaryngology residency at the University of Texas Southwestern in Dallas. He received a Master of Science in Administrative Medicine from the University of Wisconsin-Madison in 1998.
Stringer is a recipient of the Honor Award from the American Academy of Otolaryngology-Head and Neck Surgery and is listed in The Best Doctors in America, America’s Top Doctors, and America’s Top Doctors for Cancer publications. Dr. Stringer is the author of over 150 scientific articles and book chapters and 50 published reviews.