What is sinusitis?

The sinuses are air-filled cavities inside the facial bones that open into the nasal cavity (see CT scan below).  Sinusitis is an inflammation of the mucous membranes (or lining) of one or more of the paranasal sinuses.  Acute sinusitis is common and is often associated with viral or bacterial nasal infections that spread to the sinuses.  When the sinus openings become blocked the cavities fill with fluid, producing pain and a feeling of pressure over the affected sinuses. The pain is often made worse by bending, straining, sneezing or coughing.  Other symptoms of acute sinusitis are fever, fatigue and postnasal drainage.  Chronic sinusitis is a sinus problem that usually follows a single attack or repeated attacks of acute sinusitis.  Postnasal or nasal drainage, and nasal congestion are the most common symptoms of chronic sinusitis. Nasal polyps are associated with chronic sinusitis.  Most patients who suffer an acute attack of sinusitis get better by themselves without antibiotics and if they do take antibiotics the majority of patients have no further problems.  Treatment of acute sinusitis is designed to prevent complications and to keep the acute process from becoming chronic. Oral antibiotics, decongestants and analgesics are prescribed. Bed rest, local heat and increased fluids are useful in controlling the systemic symptoms.  Many patients with chronic sinus can be successfully treated medically. A course of Prednisone and a prolonged antibiotic course is frequently useful. Treatment may include treatment for allergies or environmental control (stopping smoking).

Is your condition sinusitis?

A major difficulty in treating sinusitis is accurate diagnosis.  Many nasal symptoms are rightly or wrongly attributed to the sinuses.  A third of the population have abnormalities on their sinus CT scans and yet have no major symptoms.  Many patients who have facial pain particularly over the frontal and maxillary sinuses in the absence of other sinus symptoms do not in fact have sinusitis.  Logically when you have had sinusitis then you should have other sinus symptoms apart from facial pain such as infected nasal discharge or nasal congestion and there should be evidence of significant sinus disease on your CT scan. The other puzzle is that some patients with relatively normal sinus CT scans get an improvement in pain symptoms after they have had surgery for about three months and then the pain comes back.  One sees a similar problem in people after low back surgery.

There are a large number of other causes of facial pain apart from sinusitis.  Many of these may need to be excluded before considering surgery.  I will if required discuss other causes excluding
- neck and shoulder problems
- nutritional issues (some people's sinus symptoms respond to exclusion diets, particularly dairy exclusion)
- vitamin D and vitamin B12 deficiencies.

Allergic symptoms such as nasal discharge and nasal blockage are also often attributed to sinuses. The situation is complicated by the fact that a patient may have more than one problem.  For example, patients with allergic rhinitis are more likely to get sinusitis.

The Consultation

At the consultation I try to work out largely on your history whether you do have sinusitis or another condition mimicking sinusitis (usually a neck problem). Unfortunately there is no simple test that can tell whether you have sinusitis or not.  Important guides in your history are the pain distribution if pain is present, whether you can blow infected mucus from your nose, whether you have a sore throat prior to an attack of sinusitis and whether your problems get better with antibiotics.

Patients with neck problems mimicking sinus disease usually have pain at the base of their necks, referred pain to the ears and the pain may be made worse with exposure to cold and made better with heat.  They may also have low back pain.  Irritable bowel symptoms can also provide a clue as to whether diet may be a contributory factor.

At the consultation, I will probably spray your nose with local anaesthetic and pass a small telescope into your nose.  This is usually not uncomfortable.  I will also palpate your neck and shoulders looking for tender muscles. These tender muscles can easily mimic the pain of sinusitis.  I may palpate other muscles in your body looking for evidence of muscle tenderness elsewhere.

Understanding a CT scan:

To understand a sinus CT scan one has to think that your head has been put through a bread slicer and the scan represents one slice.  By looking at the slices one can then build up a three dimensional picture as to what is happening. White represents bone and grey represents soft tissue.  R on the CT scan represents the right side and L represents the left side.  This CT scan is a slice through the eyes and maxillary sinuses.  The grey at the top represents the brain. The eyes are below on either side.  The black under the eyes is air in the maxillary sinuses.

Are there any other treatments apart from surgery and antibiotics?

The treatment of sinusitis is difficult to evaluate because of difficulties in diagnosis (the patient may not have had sinusitis in the first place) and patients often get better themselves regardless of treatment.

Saline and the Nose:
It used to be an old wife’s tale that salt water was good for the nose but there is good evidence that a saline nasal spray is useful in controlling allergic symptoms. The exact recipe varies but I recommend a half a teaspoon of salt and half a teaspoon of baking soda in a pint (600mls) of water. 

Some authorities recommend using rock salt saying that iodised salt is more likely to sting. Www.ent-consult.com is a useful website.
Other authorities recommend using a teaspoon of salt to a pint of water and increasing it by half a teaspoon of salt each week up to three teaspoons of salt to a pint of water.

Vitamin D
Vitamin D is one of my major research interests.  Vitamin D helps make a powerful natural antibiotic in the body which helps fight infection.  I try to get most of my patient’s vitamin D levels above 100nmol/L.

Scragg R, Bartley J.  Vitamin D – how de we define deficiency and what can we do about it in New Zealand.  NZ Med J 2007; 120: U2735 (Editorial - no abstract available)

Bartley J. Prevalence of Vitamin D deficiency in a tertiary multidisciplinary pain clinic. NZ Med J 2008; 121(1286): 57-62.[Abstract]

Bartley J, Reid DR, Morton RP. Prevalence of Vitamin D Deficiency Among Patients Attending a General Otolaryngology Clinic in South Auckland. Annals of Otology, Rhinology and Laryngology 2009; 118: 326-8. [Abstract]

Bartley J. Vitamin D, innate immunity and upper respiratory tract infection.  JLO 209 (in press)

Ultrasound
The ultrasound treatment of sinusitis is another one of my research interests.Bacteria are now recognised as existing in two forms – free floating (planktonic) or in sophisticated communities called biofilms. Bacteria within biofilms are difficult to culture and highly refractory to antibiotic treatment. Biofilms could explain some of the paradoxes associated with chronic rhinosinusitis. As antibiotics are largely ineffective in the treatment of bacterial biofilms, alternative therapeutic strategies including blocking molecular communication (quorum sensing) between bacteria, inhibiting biofilm matrix production and interventions that damage bacterial membranes are being explored as treatment options.

In the laboratory setting ultrasound enhances the killing of bacteria in biofilms both in vitro and in animal models. Ultrasound appears able to do this also in humans and may be a useful adjunctive treatment in sinusitis.

Bartley J, Young D. Ultrasound as a treatment for chronic rhinosinusitis. Medical Hypotheses 2009; 73(1): 15-7. [Abstract]

Young D, Morton RP, Bartley J. Therapeutic ultrasound for the treatment of chronic rhinosinusitis – preliminary observations JLO 2010 [Epub ahead of print] [Abstract]

Is surgery necessary?

Any decision to have surgery is a quality of life issue. One has to weigh up the misery of surgery versus the misery of sinusitis. Surgery is only recommended in a small percentage of patients.  This may be because of an infection or an inflamed area, which does not clear with antibiotics or one, which keeps returning when the antibiotics are stopped.

The goal of surgical treatment is to return the nose and sinuses to normal function.  Surgery is now frequently done with small telescopes and long instruments.  This surgery differs somewhat from the conventional surgery in trying to identify the underlying cause of the problem. This is frequently in the anterior ethmoid sinuses.  This location is in the area of the openings of the maxillary or frontal sinuses.  The principle is that if the underlying cause of the disease is identified and corrected, secondary disease in the maxillary and frontal sinuses will be improved spontaneously.  There is often less removal of normal tissues and the surgery can be performed on an outpatient basis without the need for nasal packing.

Surgery

The operation can be performed under general anaesthetic or local anaesthetic with an anaesthetist providing monitored sedation. Usually there is little or no pain in the postoperative period. Although there are potentially very serious risks from the surgery in this area, the incidence is low.

Risks of Surgery:

Complications are rare with endoscopic sinus surgery but do occur.

Bleeding:
Although the risk of bleeding is reduced on rare occasions significant bleeding may require stopping of the procedure and the placement of packing. This occurs in less that 1% of patients.
Spinal fluid leak:
All operations carry a rare chance of creating a spinal fluid leak (the fluid that surrounds the brain). Should this rare complication occur, it would extend your hospitalisation and it might require further surgery for its closure. This complication is extremely rare.
Damage to the tear duct:
This complication too is extremely rare; if it happens then it can be corrected with further surgery.
Anaesthetic risks:
The endoscopic techniques can be performed under local anaesthetic with intravenous sedation. If general anaesthetic is required, you are subject to the usual risks of general anaesthetic.

Is the surgery effective?

Surgery is only able to effect structural changes and removes critical areas of disease improving drainage and aeration of the sinuses allowing them to return to normal. In some patients there may be persisting ongoing medical management for symptoms such as nasal allergy. In general terms surgery offers only a 30% chance of total cure but a 95% chance of a significant improvement in symptoms.