Learning Center: Sinusitis

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What is sinusitis?

Sinusitis, also known as paranasal sinusitis, or rhinosinusitis, is inflammation of the mucous membranes that line the sinuses resulting in symptoms.  Common symptoms include thick nasal mucus, resistance to nasal airflow, and facial pain.  Other signs and symptoms may include fever, headaches, a poor sense of smell, sore throat, and a cough.  The cough is often worse at night. Serious complications are rare.  It is defined as acute sinusitis if it lasts less than 4 weeks, and as chronic sinusitis if it lasts for more than 12 weeks.

Most infections causing sinusitis are caused by a virus, and the infection and symptoms usually come and go within a week. As the duration of symptoms increases, the statistical likelihood that the infection is bacterial increases. Occasionally, symptoms of a viral sinusitis begin to improve, and then bacteria seize the opportunity to thrive in the inflamed sinuses, leading to a bacterial superinfection, with.a corresponding worsening of symptoms.

Treating acute (new onset) bacterial sinusitis

Usually, the determining that a sinus infection is bacterial is a matter of waiting for what may be a virus to pass. After about 10 days, the statistical likelihood of the infection being due to bacteria is high enough to treat it as such, meaning using an antibiotic.

• Link to an evidence based article on Treating Acute Bacterial Rhinosinusitis on the ENTHealth website.

maximal medical therapy regimen

Usually, before considering surgery, a best effort to clear a sinus infection is made. While there is not one and only one “maximal” medical regimen for all situations, we do know that treating a sinus infection with multiple simultaneous pathways is more effective than using one medicine at a time. For example, a maximal medical regimen for sinusitis might consist of the following:

  1. Nasal/Sinus saline irrigation

  2. A short course of oxymetazoline (Afrin), 2 sprays each nostril twice a day for only 3 days

  3. A longer course of a nasal steroid spray [e.g., fluticasone (Flonase) 2 sprays in each nostril twice a day for 30 days

  4. A mucus thinner, like guaifenesin (Robitussin, Mucinex) 600-800 mg twice a day for a week, being sure to stay well-hydrated during this time

  5. An antibiotic chosen by your physician

  6. An oral steroid taper (a decreasing dose of an anti-inflammatory steroid over several days)—this is not routine

  7. A medicine to lessen the acidity of the stomach contents, which can help protect the stomach when taking oral steroids and also reduce any contribution reflux (which is common!) may have on promoting sinus infections.

Some of the above items may be excluded from an individual patient’s regimen, while others, such as adding medication to the nasal/sinus rinse or testing and possibly treating for allergies, may be included.

If maximal medical therapy fails to yield sustained and sufficient improvement in symptoms, sinus surgery may become an option.

medicated nasal rinse

In some circumstances, your physician may recommend using a sinus rinse with one or more medications mixed into the salt water solution. This may include medications to fight bacteria or fungus, and may include a steroid to reduce inflammation. Sometimes, a patient will receive a pre-mixed solution from the pharmacy and simply transfer some of that liquid to the squeeze bottle for each use. Other times, the pharmacy may provide a capsule that the patient opens and adds the powder into a salt water mixture in the squeeze bottle. These solutions require preparation by a compounding pharmacy, and the cost may not be covered by your insurance. Typically, the pharmacy will call you before making your preparation to verify your willingness to proceed based on their charge.

Migraine headaches

Migraine headaches are common and since symptoms of migraine headaches are similar to sinusitis, determining if one, the other, or both are occurring in an individual can be tricky. Some of the typical hallmarks of migraine headache include the pain being on one side of the head, pulsating in nature, and lasting from a few hours to three days. Associated symptoms can include nausea/vomiting, and worsened headache with bright lights, certain smells, and/or loud noises, and the sense that relief can be obtained by lying down in a quiet, dark place. Some migraine sufferers also have an aura, which is a visual disturbance that can occur prior to onset of the headache itself. Specific symptoms of sinusitis, in contrast, may include significant production of nasal mucus out of the nostrils (not just “post-nasal drip”), a decreased sense of smell, and decreased airflow through the sinuses. The term “migraine headache” does not mean a severe headache; instead, migraine headache is its own type of headache and best treatment of it is specific for migraines. A primary care physician or a neurologist typically manages migraines. The book, Heal Your Headache, by David Buchholz, M.D. is an excellent source of help for those affected by migraine headaches.

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