Sinusitis

Introduction

Sinus disease is a significant health condition impacting 15% of the US population at one time or another. Sinusitis is defined as inflammation of the sinuses, which are air-filled cavities within the face.  A bacterial sinus infection often starts because of inadequate drainage from these cavities. This can happen when there is a preceding viral upper respiratory tract infection,  narrow sinus openings, chronic nasal and sinus inflammation from allergies, a weak immune system, or some combination of all of the above. Sinusitis is becoming more prevalent. There is also an association between chronic sinusitis and asthma.

Types of sinusitis

Sinusitis can be divided into acute and chronic sinusitis. Acute sinusitis resolves completely within 12 weeks, whereas chronic sinusitis persists beyond this time. Acute sinusitis is often triggered initially by a viral respiratory infection, with persistent symptoms beyond 10 days, suggesting a secondary bacterial infection. Chronic sinusitis can be divided into 2 subtypes based on the presence or absence of nasal polyps: chronic rhinosinusitis without nasal polyps (CRSsNP), and chronic rhinosinusitis with nasal polyps (CRSwNP). Nasal polyps are pale gray, gelatinous-like structures that are associated with extreme nasal congestion and often the complete loss of the ability to smell. The presence or absence of nasal polyps has significant implications in regards to treatment.

Symptoms of sinusitis

Some of the symptoms of sinusitis include postnasal drip, yellow-green nasal discharge, nasal congestion, facial tenderness, and reduction or loss of the sense of smell. Sinusitis is more common in patients that have asthma. Treatment of sinusitis may improve asthma control. Allergic and non-allergic rhinitis may also cause sinusitis. In chronic sinusitis, the symptoms may be diffuse or there may be a single symptom such as a headache or postnasal drip.

Treatment of sinusitis

The treatment of sinusitis encompasses both symptomatic relief and the treatment of the underlying infection. Topical and oral decongestants can decrease congestion. Topical nasal steroid sprays, and occasionally oral steroids, can provide additional symptom relief. Antibiotics are also used to address bacterial growth in the sinuses and decrease the inflammation. Treatment of chronic sinusitis sometimes requires prolonged courses of antibiotics. A useful strategy may be to treat for a week beyond complete symptom resolution. Another strategy may be to use prophylactic or preventative macrolide antibiotics such as azithromycin on a chronic basis, and/or through the viral season. If nasal polyps are present, the use of nasal steroids is typically recommended. Evaluation by an ENT surgeon is often recommended and surgery may be needed. Biologic medications such as Dupixent, Tezspire, Nucala, and Xolair are also approved for the treatment of nasal polyps and are often very effective at reducing the polyp burden, improving/minimizing symptoms, improving the sense of smell, and preventing regrowth of polyps after they have been surgically removed. The presence of nasal polyps might indicate a condition called aspirin exacerbated respiratory disease (AERD).  In some cases, an immunodeficiency workup may be obtained, especially if there is a history of other chronic or recurrent infections, such as pneumonias or ear infections.