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Sinusitis

OVERVIEW

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You're coughing and sneezing and tired and achy. You think that you might be getting a cold. Later, when the medicines you've been taking to relieve the symptoms of the common cold are not working and you've now got a terrible headache, you finally drag yourself to the doctor. After listening to your history of symptoms, examining your face and forehead, and perhaps doing a sinus X-ray, the doctor says you have sinusitis.

Sinusitis simply means your sinuses are infected or inflamed, but this gives little indication of the misery and pain this condition can cause. Health care experts usually divide sinusitis cases into

• Acute, which last for 3 weeks or less
• Chronic, which usually last for 3 to 8 weeks but can continue for months or even years
• Recurrent, which are several acute attacks within a year

Health care experts estimate that 37 million Americans are affected by sinusitis every year. Health care providers report nearly 32 million cases of chronic sinusitis to the Centers for Disease Control and Prevention annually. Americans spend millions of dollars each year for medications that promise relief from their sinus symptoms.

WHAT ARE SINUSES?

Sinuses are hollow air spaces in the human body. When people say, "I'm having a sinus attack," they usually are referring to symptoms in one or more of four pairs of cavities, or sinuses, known as paranasal sinuses . These cavities, located within the skull or bones of the head surrounding the nose, include the

• Frontal sinuses over the eyes in the brow area
• Maxillary sinuses inside each cheekbone
• Ethmoid sinuses just behind the bridge of the nose and between the eyes
• Sphenoid sinuses behind the ethmoids in the upper region of the nose and behind the eyes

Each sinus has an opening into the nose for the free exchange of air and mucus, and each is joined with the nasal passages by a continuous mucous membrane lining. Therefore, anything that causes a swelling in the nose—an infection, an allergic reaction, or another type of immune reaction—also can affect the sinuses. Air trapped within a blocked sinus, along with pus or other secretions, may cause pressure on the sinus wall. The result is the sometimes intense pain of a sinus attack. Similarly, when air is prevented from entering a paranasal sinus by a swollen membrane at the opening, a vacuum can be created that also causes pain.

SYMPTOMS

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The location of your sinus pain depends on which sinus is affected.

• Headache when you wake up in the morning is typical of a sinus problem.
• Pain when your forehead over the frontal sinuses is touched may indicate that your frontal sinuses are inflamed.
• Infection in the maxillary sinuses can cause your upper jaw and teeth to ache and your cheeks to become tender to the touch.
• Since the ethmoid sinuses are near the tear ducts in the corner of the eyes, inflammation of these cavities often causes swelling of the eyelids and tissues around your eyes, and pain between your eyes. Ethmoid inflammation also can cause tenderness when the sides of your nose are touched, a loss of smell, and a stuffy nose.
• Although the sphenoid sinuses are less frequently affected, infection in this area can cause earaches, neck pain, and deep aching at the top of your head.

Most people with sinusitis, however, have pain or tenderness in several locations, and their symptoms usually do not clearly indicate which sinuses are inflamed.

Other symptoms of sinusitis can include

• Fever
• Weakness
• Tiredness
• A cough that may be more severe at night
• Runny nose (rhinitis) or nasal congestion

In addition, the drainage of mucus from the sphenoid or other sinuses down the back of your throat (postnasal drip) can cause you to have a sore throat. Mucus drainage also can irritate the membranes lining your larynx (upper windpipe). Not everyone with these symptoms, however, has sinusitis.

On rare occasions, acute sinusitis can result in brain infection and other serious complications.

SOME CAUSES OF ACUTE SINUSITIS

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Most cases of acute sinusitis start with a common cold, which is caused by a virus. These viral colds do not cause symptoms of sinusitis, but they do inflame the sinuses. Both the cold and the sinus inflammation usually go away without treatment in 2 weeks. The inflammation, however, might explain why having a cold increases your likelihood of developing acute sinusitis. For example, your nose reacts to an invasion by viruses that cause infections such as the common cold or flu by producing mucus and sending white blood cells to the lining of the nose, which congest and swell the nasal passages.

When this swelling involves the adjacent mucous membranes of your sinuses, air and mucus are trapped behind the narrowed openings of the sinuses. When your sinus openings become too narrow, mucus cannot drain properly. This increase in mucus sets up prime conditions for bacteria to multiply.

Most healthy people harbor bacteria, such as Streptococcus pneumoniae and Haemophilus influenzae , in their upper respiratory tracts with no problems until the body's defenses are weakened or drainage from the sinuses is blocked by a cold or other viral infection. Thus, bacteria that may have been living harmlessly in your nose or throat can multiply and invade your sinuses, causing an acute sinus infection.

Sometimes, fungal infections can cause acute sinusitis. Although fungi are abundant in the environment, they usually are harmless to healthy people, indicating that the human body has a natural resistance to them. Fungi, such as Aspergillus , can cause serious illness in people whose immune systems are not functioning properly. Some people with fungal sinusitis have an allergic-type reaction to the fungi.

Chronic inflammation of the nasal passages also can lead to sinusitis. If you have allergic rhinitis or hay fever, you can develop episodes of acute sinusitis. Vasomotor rhinitis, caused by humidity, cold air, alcohol, perfumes, and other environmental conditions, also may be complicated by sinus infections.

Acute sinusitis is much more common in some people than in the general population. For example, sinusitis occurs more often in people who have reduced immune function (such as those with primary immune deficiency diseases or HIV infection) and with abnormality of mucus secretion or mucus movement (such as those with cystic fibrosis).

CAUSES OF CHRONIC SINUSITIS

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It can be difficult to determine the cause of chronic sinusitis. Some investigators think it is an infectious disease but others are not certain. It is an inflammatory disease that often occurs in patients with asthma. If you have asthma, an allergic disease, you may have chronic sinusitis with exacerbations. If you are allergic to airborne allergens, such as dust, mold, and pollen, which trigger allergic rhinitis, you may develop chronic sinusitis. An immune response to antigens in fungi may be responsible for at least some cases of chronic sinusitis. In addition, people who are allergic to fungi can develop a condition called "allergic fungal sinusitis." If you are subject to getting chronic sinusitis, damp weather, especially in northern temperate climates, or pollutants in the air and in buildings also can affect you.

If you have an immune deficiency disease or an abnormality in the way mucus moves through and from your respiratory system (e.g., primary immune deficiency, HIV infection, and cystic fibrosis) you might develop chronic sinusitis with frequent flare-ups of acute sinusitis due to infections. In otherwise normal individuals, sinusitis may or may not be infectious. In addition, if you have severe asthma, nasal polyps (small growths in the nose), or a severe asthma attacks caused by aspirin and aspirin-like medicines such as ibuprofen, you might have chronic sinusitis

DIAGNOSIS

Because your nose can get stuffy when you have a condition like the common cold, you may confuse simple nasal congestion with sinusitis. A cold, however, usually lasts about 7 to 14 days and disappears without treatment. Acute sinusitis often lasts longer and typically causes more symptoms than just a cold.

Your doctor can diagnose sinusitis by listening to your symptoms, doing a physical examination, taking X-rays, and if necessary, an MRI or CT scan (magnetic resonance imaging and computed tomography).