Sinusitis

Sinusitis is inflammation of the sinuses.

Sinusitis is one of the most common disorders affecting older people. It may last only for a brief period (acute sinusitis) or may persist for 3 months or longer (chronic sinusitis).

Sinusitis is categorized as infectious or allergic. Sinusitis in older people most frequently occurs with rhinitis as part of the common cold and so is caused by a virus. The nasal congestion that results blocks the sinuses, preventing drainage of mucus into the nose and mouth. The sinus mucus then builds up and thickens, and infection in the sinuses becomes more likely. Infectious sinusitis can also be caused by a bacterial infection or sometimes by a fungal infection (particularly in people with poor immune functioning, such as those receiving chemotherapy for cancer or those with diabetes).

Allergic sinusitis is caused by an allergic reaction to dust, mold, pollen, or another substance in the environment. Some people develop an allergic reaction to harmless fungi that can grow in their sinuses if they have fleshy growths (polyps) or other obstructions in the nose (allergic fungal sinusitis).

Sinusitis does not become more common with aging because of aging itself but rather because the conditions that predispose a person to sinusitis increase with aging. For example, older people are more likely to develop sinusitis because of tooth or gum infections, nosebleeds, nasal polyps, an aging immune system, or dryer nasal secretions that do not drain well.

Symptoms and Diagnosis

Sinusitis causes nasal and sinus congestion, nasal discharge, sinus pain or pressure, headache, and sometimes pain or tingling in the upper teeth. Fever may occur if an infection is present. Bacterial sinusitis sometimes causes a foul smell or bad breath due to pus draining down the back of the throat.

A diagnosis of sinusitis is usually made on the basis of symptoms. Computed tomography (CT) can be used when sinusitis is not relieved by the use of appropriate drugs or is relieved but keeps recurring after treatment. A doctor can also diagnose sinusitis by inserting an endoscope (a flexible viewing tube) into the nose to inspect the sinus openings and to obtain samples of sinus drainage to detect and identify bacteria. This procedure is useful when the diagnosis of sinusitis is uncertain, when the type of infection must be identified, or when sinusitis recurs.

Treatment

Infectious sinusitis is treated according to the type of infection believed to be causing it. Often, antibiotics are needed.

Viral sinusitis, which doctors typically assume is the cause, does not respond to antibiotics. Salt water may be sprayed into the nose to improve drainage of the thick mucus. A nasal rinse may be used: A solution containing salt water, with or without other additives, is irrigated into the nose until the solution begins to run down the back of the throat. Although some people find this process unnerving, most people tolerate it well and obtain considerable relief. Decongestant nasal sprays or pills may be taken to lessen congestion. Acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, may be taken by mouth to lessen pain. Guaifenesin may be taken by mouth to thin mucus secretions. Drinking fluids, which keeps secretions thin, is encouraged.

When symptoms do not subside after 5 to 7 days despite treatment, doctors suspect a bacterial infection and may prescribe antibiotics. People whose condition does not improve after taking antibiotics may be given stronger antibiotics or corticosteroid nasal sprays. They may undergo a sinus x-ray to help doctors identify the precise problem. Sinusitis involving the maxillary sinus may, on rare occasions, require puncturing of the sinus wall to allow for drainage.

Invasive fungal sinusitis is treated with antifungal drugs given intravenously and by surgery that opens existing passageways or that creates new passageways that allow sinuses to drain (surgical drainage).

Allergic sinusitis is treated with corticosteroid sprays or antihistamines taken by mouth. Newer antihistamines, such as fexofenadine, cetirizine, and loratadine, should be used. Older antihistamines, such as diphenhydramine and chlorpheniramine, can cause many side effects and should not be taken. Antihistamines taken as sprays are also effective. Guaifenesin, which is taken by mouth, can thin secretions and thereby improve drainage. Allergic fungal sinusitis is treated surgically. Fungal material and any obstruction caused by nasal polyps are removed. Treatment may also involve the use of corticosteroid sprays or, sometimes, pills. Allergy shots may help. Antifungal drugs given as mist treatments may also be of use but are unproven.

Outlook

The outlook for most kinds of sinusitis is generally good. Bacteria can occasionally cause chronic infection that is not easily treated with antibiotics. Although uncommon, a bacterial infection can spread from the sinuses to the orbit around the eye, causing pain, difficulty moving the eye, and even vision loss and blindness. Rarely, a bacterial infection can spread into the central nervous system, causing meningitis or clotting of blood vessels in the brain (cavernous sinus thrombosis). Fungal infections can be difficult to treat and require long-term treatment with corticosteroid and antifungal drugs, which sometimes requires that the person continue to receive the drug intravenously at home for a while.