Sinusitis

Sinus Anatomy and the Definition of Sinusitis

The sinuses are air-filled cavities located within the bones of the skull. They occur in four pairs:

• Maxillary sinuses (in the cheeks, beneath the eyes)
• Frontal sinuses (in the forehead region)
• Ethmoid sinuses (between the eyes, in a honeycomb-like structure)
• Sphenoid sinuses (at the very back of the nose, close to the base of the brain)

Each sinus opens into the nasal cavity through a narrow channel. Like the rest of the airways, they are lined with a thin layer of mucosa. This mucosa produces approximately 1 litre of mucus per day; the mucus is continuously transported towards the nose by the beating of the ciliated cells in the mucosa, from where it is swallowed.

The sinuses reduce the weight of the head, contribute to the resonance of the voice, absorb impact during facial trauma, and humidify and warm the air that is breathed in.

Sinusitis (in current terminology, rhinosinusitis) is inflammation of this sinus mucosa. The mucosa swells, the channels become blocked, mucus drainage is impaired, and trapped fluid and secretions accumulate within the sinuses. This build-up creates the basis for pressure, pain, congestion and infection.

Classification: Acute, Subacute, Chronic

Sinusitis is classified according to its duration, and this classification is the single most important factor in determining treatment.

• Acute sinusitis: A condition lasting under 4 weeks. It usually begins following a viral upper respiratory tract infection.
• Subacute sinusitis: A condition lasting between 4 and 12 weeks.
• Chronic sinusitis: A condition lasting longer than 12 weeks that returns when medication is stopped or never fully resolves. Depending on whether polyps are present, it is divided into CRSwNP (with polyps) and CRSsNP (without polyps).
• Recurrent acute sinusitis: Four or more acute episodes within a year, with the patient being entirely well in between.

The significance of classification is this: while acute sinusitis is largely resolved with medical treatment, chronic sinusitis often requires medication + sinus surgery + long-term maintenance treatment.

When Is Sinusitis Considered? Indications

The classic picture in which an ENT physician makes a preliminary diagnosis of sinusitis consists of at least two main symptoms:

• Nasal congestion
• Nasal or postnasal discharge (from the front or the back)
• Facial pain / pressure
• Reduced sense of smell

These may be accompanied by the following findings:

• Toothache (particularly in the upper back molars)
• Headache that increases on bending forward, and a feeling of fullness in the forehead and beneath the eyes
• Fatigue, mild fever
• Coughing at night, particularly a dry cough in children
• Bad breath, a sensation of postnasal drip

Upper respiratory tract infections that last longer than 10 days, worsen rather than improve, or briefly improve and then flare up again are interpreted as indicating sinusitis.

Symptoms and Causes

Causes of acute sinusitis

The most common cause of acute sinusitis is viral infection — it can be thought of as a continuation of the common cold. Only a small proportion of cases become bacterial. Important risk factors:

• An ongoing upper respiratory tract infection
• Flare-ups of allergic rhinitis
• Air pollution, cigarette smoke
• Gum / upper molar tooth infections (particularly maxillary sinusitis)
• Anatomical narrowing (septal deviation, turbinate enlargement)
• Pressure changes (flying, diving)

Causes of chronic sinusitis

Chronic sinusitis is rarely explained by a single bacterium; it is most often the product of the triad of prolonged inflammation + impaired drainage + individual predisposition. Typical triggers:

• Septal deviation and turbinate hypertrophy (which mechanically narrow the sinus openings)
• Nasal polyps
• Allergy (particularly year-round allergic rhinitis)
• Asthma and eosinophilic airway diseases
• Aspirin/NSAID intolerance (Samter’s triad)
• Dental maxillary sinusitis
• Fungal sinusitis (requires particular caution in immunosuppressed patients)
• Smoking, air pollution, occupational irritants
• Immune deficiency, cystic fibrosis, ciliary dyskinesia

The Diagnostic Process

The diagnosis of sinusitis is a clinical diagnosis; that is, it is largely made through history and examination. Imaging is not required in every patient.

1. History. The duration of complaints (critical for distinguishing acute from chronic), frequency of recurrence, response to medication, accompanying allergy or asthma, smoking, and previous surgery.
2. Facial examination. Sinus tenderness and sensitivity beneath the eyes and in the forehead region.
3. Anterior rhinoscopy. The state of the mucosa, the character of the discharge, and the presence of polyps.
4. Nasal endoscopy. A thin endoscope provides a clear view of the middle meatus, the sinus openings, and any polyps or purulent discharge. It is the standard examination tool when chronic sinusitis is suspected.
5. Paranasal sinus CT. Essential in chronic cases for assessing the degree of opacification of the sinuses, anatomical variations (concha bullosa, agger nasi, etc.), the state of the bony walls, and surgical mapping. Routine CT is not requested in acute sinusitis.
6. Allergy tests / blood investigations. Eosinophilia, IgE and, if necessary, an immune panel.
7. Dental consultation. This must always be considered in unilateral, foul-smelling maxillary sinusitis.
8. Culture. A culture taken endoscopically helps with the correct choice of antibiotic in resistant or recurrent cases.

Treatment Approaches: From Acute to Chronic

1. Treatment of acute sinusitis

The majority of acute sinusitis does not require antibiotics, because the underlying picture is viral. In these cases, 7–10 days of supportive treatment is recommended:

• Plenty of saline rinses / saline spray
• Short-term decongestant spray (for a maximum of 3–5 days)
• Painkillers / antipyretics as needed
• Intranasal steroid spray
• Rest and fluid intake
• Avoiding cigarette smoke

When findings suggesting bacterial sinusitis are present (symptoms that exceed 10 days without improving, that worsen, high fever, unilateral purulent discharge, or “double sickening” — improving and then deteriorating again), antibiotics are started. The treatment duration is typically 7–14 days.

2. Treatment of chronic sinusitis

In chronic sinusitis, antibiotics alone are not the solution. Treatment has multiple components and requires management lasting months:

• Intranasal corticosteroid spray daily and long-term. Correct spray technique is essential.
• Saline rinses (particularly high-volume, pressurised rinses) clear inflammatory secretions and enhance the effect of the spray.
• Short courses of corticosteroids during flare-ups, more frequently if polyps are present.
• Antibiotics only during acute bacterial flare-ups; in some resistant cases, a low-dose, long-term macrolide may be tried in selected patients.
• Antihistamines if there is an allergic component.
• Parallel treatment of accompanying conditions such as asthma, reflux and allergy.
• Biologic medications in resistant chronic rhinosinusitis with polyps, following joint evaluation with respiratory medicine.

3. Surgical treatment (FESS)

In cases that do not respond adequately to medical treatment, that flare up frequently, that involve polyps, or that present with complications threatening the eye or orbit, Functional Endoscopic Sinus Surgery (FESS) is performed.

FESS is carried out without any external incision, through the nostrils under endoscopic guidance. Its aim is to:

• Open the blocked sinus openings
• Clear the diseased tissue
• Preserve the healthy mucosa
• Enable medical treatment to reach the sinuses

If accompanying septal deviation, turbinate enlargement or polyps are present, they are addressed together in the same session.

The critical point to understand here is that in chronic sinusitis, surgery does not eradicate the disease on its own. Spray and rinse treatments must be continued without interruption after surgery. Surgery removes the mechanical obstacles standing in the way of the medication working more effectively.

The Process and Recovery (After FESS)

The typical course of recovery after FESS:

• 0–24 hours: Observation in hospital for the same day or 1 night. If packing is used, dissolvable types are preferred.
• Days 1–7: Mild blood-tinged, serosanguineous discharge, dryness in the throat and nasopharynx, and crusting are normal. Saline rinses are started early.
• Week 2: Accumulated crusts are carefully cleared at an endoscopic check-up. This check-up is one of the most important steps for a successful outcome.
• Weeks 3–6: The mucosa heals; congestion and headache decrease markedly.

Practical rules for the patient:

• No forceful nose-blowing.
• Saline rinses should be performed regularly 2–3 times a day.
• Strenuous exercise, sauna, diving and bending-over work are restricted for the first 2 weeks.
• Cigarette smoke must be strictly avoided.
• Spray treatment is continued without interruption.

Quality of Life and Long-Term Follow-Up

Well-managed sinusitis makes a major difference to quality of life:

• Better-quality sleep and less snoring
• Clearer thinking and higher energy during the day
• Gradual improvement in the sense of smell and taste
• Reduction in headaches and facial fullness
• Milder colds

Long-term follow-up has two priorities:

1. Managing triggers. Parallel control of allergy, smoking, air pollution, dental problems, reflux and asthma markedly reduces the recurrence of sinusitis.
2. Adherence to maintenance treatment. Continuous use of the spray, making saline rinses a daily routine, and not skipping follow-up examinations.

Chronic sinusitis should be regarded as a managed condition like cardiovascular disease or asthma; approaching it with the mindset of “one treatment and it’s over” is not correct.

Sinusitis in Children

Sinusitis in children has some important differences from that in adults. Because the sinuses are not fully developed at birth, different sinuses come to the fore depending on age: the maxillary and ethmoid sinuses are present from infancy, whereas the frontal and sphenoid sinuses develop during school age. For this reason, childhood sinusitis typically originates from the maxillary / ethmoid sinuses.

In children, the most common triggers are viral upper respiratory tract infection and accompanying adenoid (adenoid tissue) enlargement. The adenoid creates the basis for sinusitis both as a bacterial reservoir and as a mechanical obstacle. For this reason, assessment of the adenoid is very important in recurrent childhood sinusitis; in some children, adenoidectomy alone markedly relieves the sinusitis picture.

There are certain warning signs that must be watched for in childhood sinusitis: if there is swelling or redness of the eyelid, a vision problem, severe headache, high fever or altered consciousness, urgent assessment is required, because complications of sinusitis can progress more rapidly in children than in adults.

Common Misconceptions About Sinusitis

• “Every case of sinusitis needs antibiotics.” Not true. The vast majority of cases are viral in origin; unnecessary antibiotics create resistance and side effects.
• “Sinusitis is cured with surgery.” Surgery addresses not the sinusitis itself but the drainage problems and mechanical obstacles. Maintenance spray treatment must be continued.
• “Nasal spray is addictive.” This is not true for corticosteroid sprays; it is decongestant sprays that are habit-forming. It is important to distinguish between the two.
• “Sinusitis is contagious.” Sinusitis itself is not contagious; however, an underlying viral cold may be.
• “Children don’t have sinuses.” Children do have sinuses; they simply develop with age.

When Should an ENT Specialist Be Consulted?

Consultation with an ENT specialist is recommended if one of the following pictures is present:

• An upper respiratory tract infection that does not improve or that worsens despite more than 10 days passing
• Four or more acute sinusitis episodes per year
• Nasal congestion, facial fullness or postnasal discharge lasting longer than 12 weeks
• Progressive loss of smell
• Unilateral, purulent or blood-stained discharge
• Unilateral sinusitis together with upper toothache (which may be dental sinusitis)
• Swelling or redness of the eye, a change in vision, or severe headache (urgent assessment)
• Sinus complaints together with a history of asthma, allergy or an aspirin reaction

When correctly classified and treated with the appropriate stepwise approach, sinusitis is a condition that can largely be brought under control and that directly improves quality of life. The key is to evaluate the underlying basis (anatomy, allergy, asthma, environment) holistically, rather than becoming trapped in an “antibiotic–corticosteroid–antibiotic” cycle.