Definitions

Question: What are the sinuses?
Answer: The sinuses are chambers in the bones of the face and skull that are normally lined with a thin mucus-producing membrane (called mucosa). The four paired sinuses are named the maxillary, ethmoid, frontal, and sphenoid sinuses. Shown here is a view of the sinus anatomy from the nose toward the back of the head, showing the frontal, ethmoid, and sphenoid sinuses (the maxillary is illustrated a little later).

The sinuses communicate with the nasal cavity via narrow openings. Air and mucus enter and exit to and from the sinuses through these openings. Blockage of the small sinus openings from swelling, infection, allergy, and other causes can result in sinusitis.

Question: What is sinusitis, and what causes it?
Answer: Sinusitis means, literally, "inflammation of the sinus cavities." This inflammation is what happens when your nose and sinuses are exposed to anything that might irritate the membranous linings. These irritants may include dust and pollution, cigarette smoke, and other irritants. Allergic reaction to mold, pollen and so forth may also irritate the nasal linings. Furthermore, infection with a virus or bacteria may irritate the nasal linings. Thick abnormal mucus secretions can also block the sinuses further. All of these factors may cause the narrow openings in the nose and sinus cavities to narrow even further or even to shut entirely.

Rhinitis refers to inflammation of the nasal mucosal linings only. Sinusitis refers to inflammation of the mucosal linings of the sinuses and is usually associated with and often preceded by rhinitis. Because the two go together, ear, nose and throat specialists today often use the term rhinosinusitis. However, the words rhinitis, sinusitis, and rhinosinusitis are often used interchangeably. In this website, we will use the term sinusitis to mean inflammation of the sinus and nasal passageways.

Question: Is there a more detailed definition? Give me a more technical, medical definition.
Answer: Experts on sinusitis have tried to precisely define sinusitis. The Rhinosinusitis Task Force of the American Rhinologic Society has defined rhinosinusitis as a condition manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within the cavities, and/or underlying bone. Symptoms associated with rhinosinusitis include nasal obstruction, nasal congestion and discharge, post-nasal drip, facial pressure and pain, cough, and others (Table 1). A strong history consistent with chronic sinusitis includes the presence of two or more major factors or one major and two minor factors for greater than 12 weeks.

TABLE 1:
Factors associated with the diagnosis of chronic rhinosinusitis

What the Sinuses Do, and How They Work

Question: What do the sinuses do?
Answer: The functions of the nose and sinuses include respiration. Anyone who has suffered from nasal obstruction -- for example, when you catch a cold -- appreciates the importance of normal nasal breathing.

The nose and sinuses also play an important role in warming and filtering of inspired air. The nose and sinuses also have an important role in the production of mucus to keep the nasal and upper respiratory passageways moist.

The sense of smell is located in the nose. This important sense does more than allow us to enjoy the sweet smells of flowers -- it alerts us to spoiled food, and also to when something is burning. Loss of sense of smell takes away a surprising number of life's pleasures, and it takes away an important warning system!

The sinuses also may help as "shock absorbers" during head trauma. The paranasal sinuses may have evolved as protection for the brain by providing an air-filled crushable barrier to absorb the energy from a heavy assault. The paranasal sinuses' ability to dissipate great force is akin to the design of modern automobiles that have crushable front and back ends that protect the contents of the passenger compartment. Other hypothetical functions of the paranasal sinus, such as enhancement of vocal tone or depth, have no scientific evidence to support them.

Finally, the presence of the sinuses decreases the weight of the skull, which some believe is an evolutionary development to assist in head balance and flotation.

Question: How do the sinuses work?
Answer: The normal function of the sinuses depends on three essential components: thin, normal mucus secretions, normally functioning microscopic hairs (called "cilia") that move the mucus out of the sinuses, and open sinus drainage openings (called sinus ostiums). These components allow for the continuous clearance of secretions.

The sinuses are mucus factories. People are always surprised to hear that the normal nose and sinuses produce about one liter of mucus every day! The mucus produced in the sinuses is propelled by the microhairs (cilia) through the natural sinus openings (ostium) into the nasal cavity. This blanket of mucus helps to purify, humidify, and warm inspired air. This mucus layer also traps particles such as bacteria and debris and is swallowed imperceptibly every day. The acid found in the stomach then destroys these trapped particles and bacteria.

Anything that interferes with any of the three components of the normal sinuses may predispose the patient to sinusitis. In other words, thick secretions, malfunction of the microhairs, or blockage of the natural sinus openings, may lead to symptoms of sinusitis - such as nasal obstruction, post-nasal drip, facial pressure, and other symptoms.

Question: What causes the sinuses to malfunction?
Answer: When a river is dammed, water flow is slowed or halted and water gathers behind the dam. The water level rises and a reservoir forms. Similarly, if the sinus openings are blocked, a backup of mucus occurs. This can lead to a tepid swamp-like condition that leads to infection.

The "grand central station" of the sinuses is the osteomeatal complex - the most important sinus opening. Any process that causes blockage in this sensitive area can occlude the other sinuses that drain into the osteomeatal complex. When obstruction occurs, the mucus is retained in the sinus cavity. These stagnant secretions thicken and provide a medium for bacterial growth. Obstruction also leads to decreased oxygen levels within the sinus, which exacerbates sinus infections from both aerobic and anaerobic bacteria. These changes lead to damage to the sinus lining. The retained secretions and infection lead to further tissue inflammation, which in turn leads to further blockage. These events demonstrate a vicious cycle that leads to chronic sinusitis.

Question: What is the basic principle underlying treatments that restore normal sinus function?
Answer:We now know that sinus disease can often be resolved or controlled by controlling the sinus problems at the main sinus opening, or osteomeatal complex (OMC). This allows for restoration of normal sinus aeration and mucus clearance.

In general, the OMC can be blocked by mucosal congestion or anatomic obstruction. The causes are commonly reversible with appropriate medical and, at times, surgical management.

Question: What are some specific causes of sinusitis?
Answer: Sinusitis simply means inflammation in the nose. Anything that causes inflammation, by definition, contributes to sinusitis.

There are a number of common causes of nasal irritation and inflammation, including allergens, non-allergic pollutants, cigarette smoke and viruses. These can often lead to obstruction of the osteomeatal complex from mucosal swelling and this leads to secondary bacterial sinusitis, which causes additional inflammation.

In addition, anatomic abnormalities such as polyps, tumors, foreign bodies (especially in children), enlarged adenoids, deviated nasal septum, and aerated middle turbinates (concha bullosa), may cause initial obstruction with the same result. It is common to see more than one contributing factor.

It is important to keep in mind that hormonal reactions associated with puberty, birth control pills, pregnancy, and aging can lead to nasal and sinus difficulties. Acid reflux is also at times a contributor to sinus inflammation. Other factors include self-induced causes such as intranasal cocaine or medication misuse.

Question: What are some additional causative factors in sinusitis?
Answer: These can be considered by categories.

• Inflammatory factors include upper respiratory tract infections, allergic rhinitis, vasomotor rhinitis, recent dental work, barotrauma, and swimming.
• Systemic factors include immunodeficiency, ciliary dyskinesia syndrome, cystic fibrosis, rhinitis of pregnancy, and hypothyroidism.
• Mechanical factors include sinonasal polyps, deviated septum, foreign body, trauma, tumor, nasogastric tube, turbinate hypertrophy, concha bullosa, adenoid hypertrophy, and choanal atresia.

Question: What about immune deficiencies?
Answer: Researchers have recognized that immune deficiencies can be important to a pre-disposition to sinusitis. One notable immune deficiency is called secretory IGA deficiency. It is notable that IGA deficiency is always associated with an IGG subtype deficiency which may be reversed by the monthly administration of an intravenous immunoglobulin. This problem is more likely to be found in elderly patients who have failed to respond to adequate medical and surgical management. These patients should also receive the care of an infectious disease specialist.

Question: I thought sinusitis was an infection?
Answer: Infection is only one of many causes of inflammation of the sinuses. Signs of infection include fever, green and foul-smelling nasal drainage, and facial pain. Infection should be treated with antibiotics.

Is Sinusitis Common?

Question: Is sinusitis common?
Answer: Sinusitis is one of the most common health care complaints in the United States. Approximately one in eight people in the United States will have sinusitis at one time in their lives. The National Center for Disease Statistics reports that sinusitis is now the number one chronic illness for all age groups in the United States. The 1993 National Health Interview Survey found that sinusitis was the most commonly reported chronic disease, affecting approximately 14% of the United States population.

Sinus disease affects roughly 31 million people annually. Between 1990 and 1992, reports indicate that sinusitis sufferers had approximately 73 million days of restricted activity - a 50% increase from 4 years earlier! Sinusitis accounted for nearly 25 million physician office visits in the United States in 1993 and 1994. (Of course, many more cases are unreported and many patients suffer without seeing a physician, so the true incidence of sinusitis is unknown.)

Until recently, sinusitis has been an undertreated disease. Its drastic negative effect on quality of life has been generally unappreciated and unrecognized. Recent studies show that patients score the effects of chronic sinus disease in areas such as bodily pain and social functioning as more debilitating than diseases such as angina, congestive heart failure, emphysema, chronic bronchitis, and lower back pain, to name a few.

It is estimated that 2.2 billion dollars is spent yearly on prescription and non-prescription medication. Overall health expenditures for sinusitis in 1996 were estimated at approximately 5.8 billion dollars, with 1.8 billion of that being spent on children 12 years and younger.

Question: Is sinusitis getting the attention it deserves?
Answer: In the past, many patients were told they would just have to "live with it." Since the introduction of endoscopic techniques for diagnosis of sinus disease in the United States in 1985, increased attention has been directed to this problem.

Medical therapy may be recommended in the face of nasal symptoms and mucosal disease. Typical medications used in the treatment of mucosal disease include oral antibiotics, mucolytics, nasal steroid spray, nasal saline spray, oral decongestants, oral antihistamines, and steroids. The selection of appropriate medications is tailored to each patient.

Question: Is sinusitis on the rise?
Answer: Perhaps because the air we breathe is becoming increasingly more polluted, sinusitis is on the rise.

Question: What are some of the factors that are important in causing the rise in sinusitis?
Answer: A number of factors are felt to be important in the increasing incidence in sinusitis. Irritated air pollutants and inhaled allergens are bad for the sinuses and are increasing. Global warming and the related increases in air pollution have also affected the sinuses. Cigarette smoke is also detrimental to the sinuses - not only for the smokers, but also due to second-hand smoke.

Question: Is there any good news?
Answer: While the incidence of sinusitis is on the rise, there have also been enormous improvements during the past 15 years in the ability to diagnose and treat this problem. This is largely because of technological advances in nasal endoscopy and x-ray imaging, and the development of newer, more powerful medications.

Question: How does sinusitis develop? (In other words, why me?!)
Answer: In many people with sinusitis, the lining of the nose and sinuses is overly sensitive to a variety of factors. This is a problem to which a patient may be genetically predisposed. Factors to which the nose may react include environmental pollution and allergies, temperature changes, and possibly also stress and certain foods.

Environmental pollutants in the air can cause increased irritation of the nasal and sinus passages, particularly in people with hypersensitive nasal lining (mucosa). We are also becoming more aware of the effects of both general outdoor and indoor pollution. Chemicals used in the manufacturing of carpets, furniture, or buildings may also be a problem for sensitive individuals.

If you have allergies, your nose may react to allergy-inducing substances in the air, such as dust or mold. Allergic nasal and sinus swelling may in turn lead to sinusitis. Food allergies (or sensitivities) can also be an unrecognized cause of nasal congestion and swelling. Lastly, certain conditions that exist within your own body can increase your susceptibility to sinus infections. For example, periods of emotional stress can result in swelling of the nasal lining. Many female patients develop nasal swelling during pregnancy.

In patients with this type of hypersensitivity, these factors may cause more marked irritation and swelling, secondary sinus obstruction, and poor clearance of mucus. Should secondary chronic infection develop subsequently, the problem is typically made worse and the hyper-reactivity then further increases. Treatment of the infection, even when it is low-grade, may, over time, result in a significant improvement in the symptoms of hyper-reactivity.

Sinusitis Made Simple

Question: What are the sinuses?
Answer: The sinuses are chambers in the bones of the face and skull that are normally lined with a thin mucus-producing membrane (called mucosa). They communicate with the nasal cavity via narrow openings. Air and mucus enter and exit to and from the sinuses through these openings.

Question: What is sinusitis, and what causes it?

Answer: Sinusitis literally means "inflammation of the sinus cavities." This inflammation is what happens when your nose and sinuses are exposed to anything that might irritate the membranous linings. These irritants may include dust and pollution, cigarette smoke, and other irritants. Allergic reaction to mold, pollen and so forth may also irritate the nasal linings. Furthermore, infection with a virus or bacteria may irritate the nasal linings. All of these factors may cause the narrow openings in the nose and sinus cavities to narrow even further or even to shut entirely.

The "grand central station" of the sinuses is the osteomeatal complex -- the most important sinus opening. Any process that causes blockage in this sensitive area can occlude the other sinuses that drain into the osteomeatal complex. When obstruction occurs, the mucus is retained in the sinus cavity. These stagnant secretions thicken and provide a medium for bacterial growth. These changes lead to damage and dysfunction of the cilia (microhairs) that line the sinuses. The retained secretions and infection lead to further tissue inflammation, which in turn leads to further blockage. These events demonstrate a vicious cycle that leads to chronic sinusitis.

Question: What is the basic principle underlying treatments that restore normal sinus function?
Answer: We now know that sinus disease can often be resolved or controlled by controlling the sinus problems at the main sinus opening, or osteomeatal complex (OMC). This allows for restoration of normal sinus aeration and mucus clearance.

In general, the OMC can be blocked by mucosal congestion or anatomic obstruction. The causes are commonly reversible with appropriate medical and, at times, surgical management.

Question: What are the symptoms of sinusitis?
Answer: The symptoms of sinusitis include nasal blockage (the #1 symptom), facial pressure or pain, snoring, postnasal drainage, bad breath, fatigue, recurrent infections, tooth pain, loss of sense of smell, and others.

Question: Is there a relationship between sinusitis and asthma?
Answer: Sinusitis can actually exacerbate asthma. Many patients who have successful treatment of their sinuses find that their asthma also improves. The post-nasal drainage of diseased sinuses can irritate the reactive airways of asthmatics.

A significant number of asthma/sinusitis patients - nearly 2/3 - find they can decrease or, in some cases, come off of asthma medication after sinus surgery.

Question: What is the appropriate medical therapy for sinusitis?
Answer: Once the diagnosis of sinusitis is made, medical therapy is instituted. The exact therapy chosen by your doctor will depend upon the underlying cause. Therapy is aimed at relieving obstruction of the nose and sinuses, particularly at the osteomeatal complex. In addition, therapy is targeted in such a way as to treat any infection that may be present.

In general, medical management of sinusitis may include one or more of the following: Antibiotics, topical and systemic decongestants, topical nasal lavage, nasal saline sprays, humidification, mucolytics, decongestants, and steroids.

Medical therapy must be undertaken under a doctor's care. Some medications for sinusitis must not be taken if a patient has other medical conditions. For example, if a patient has high blood pressure, or if a patient is pregnant, certain medications must not be taken.

Most cases of chronic sinusitis treated by otolaryngologists are successfully treated with medical therapy. When medical therapy fails, the surgical alternative is a consideration.

Question: When is surgical intervention (FESS) considered?
Answer: Surgical intervention for chronic sinusitis is reserved for those patients in whom maximal medical therapy has failed. Functional endoscopic sinus surgery has become the most widely accepted approach for patients undergoing surgical intervention for chronic sinusitis. The goal is to return the sinuses to as near a normal anatomic state as possible. This surgery is intended to correct conditions that impede mucocilary clearance of the sinuses, especially through the osteomeatal complex. Respect of the normal drainage patterns of the sinuses and elimination or improvement of obstruction of these drainage pathways promotes the resolution of mucosal hypertrophy and infection and the return to a normal disease-free state.

Question: How many sinus surgical procedures are performed each year in the United States?
Answer: Some estimates suggest that more than 200,000 sinus surgical procedures are performed each year.

Question: When should I consider surgery?
Answer: When anatomic abnormalities exist and are contributing to your sinusitis, and when other therapies have failed, these abnormalities can be surgically corrected.

Endoscopic techniques allow otolaryngologists to diagnose and treat these problems more easily than in the past, allowing them to be more proactive in the management of anatomic nasal abnormalities.

Question: When is surgical management indicated?
Answer: Surgical management of sinusitis is considered when medical management fails to relieve the patient of the symptoms of sinusitis, when the patient's condition, unrelieved by medical therapy, is also associated with lower respiratory tract problems such as chronic bronchitis and asthma, and when complications of sinusitis are present or threatening.

In general, patients who fail maximum medical therapy are potential candidates for surgical management.

Question: What are the surgical options?
Answer: FESS (or functional endoscopic sinus surgery) has essentially replaced the traditional "old-fashioned" procedures for the conservative surgical management of sinus disease. Functional endoscopic sinus surgery (FESS) is aimed at restoring patency and normal mucociliary flow of the natural sinus openings.

With nasal endoscopes the narrow anatomical region of the sinus drainage pathways can be visualized and accurately approached surgically.

FESS has brought dramatic positive improvement in the surgical treatment of sinusitis.

Question: What is the key underlying concept behind minimally invasive, functional endoscopic sinus surgery (FESS)?
Answer: The osteomeatal complex, or OMC - the small compartment located in the region between the middle turbinate and the lateral nasal wall in the middle meatus - represents the key region for drainage of the anterior ethmoid, maxillary and frontal sinuses. Obstruction of the OMC causes a vicious cycle of events that lead to chronic sinusitis.

Functional endoscopic sinus surgery opens these natural sinus openings to restore normal sinus functioning.

Question: Tell me more about Functional Endoscopic Sinus Surgery.
Answer: In FESS, an endoscope is used in the nose to view the nasal and sinus cavities. This generally eliminates the need for an external incision. The endoscope allows for better visualization of diseased or problem areas. This endoscopic view, along with detailed X-ray studies, may reveal a problem that was not evident before.

FESS focuses on treating the underlying cause of the problem. The ethmoid area is usually opened, which allows for visualization of the maxillary, frontal and sphenoid sinuses. The sinuses can then be viewed directly and diseased or obstructive tissue removed if necessary. The surgery is commonly performed on an outpatient basis.

Careful postoperative care is essential to the success of this surgery. The patient will be provided postoperative care instructions. It is very important that the patient follow these instructions, as well as any other instructions given by the surgeon, to promote healing and decrease the chance of complications.

Question: Will endoscopic sinus surgery cure sinus problems?
Answer: Overall, the majority of patients have had significant improvement with the combination of surgery and continued medical management. FESS performed as a result of medical therapy failures in acute and chronic sinusitis is associated with a success rate of 75 to 95% according to sources in the literature.

Sinusitis is a chronic problem, and while your symptoms may improve or even disappear after surgery, the patients nose and sinuses still have the potential to be irritated by pollen, dust, pollution, etc It should be realized that some medical therapy is usually continued after surgery, especially if allergy or polyps play a role in the sinus disease. This is necessary to control or prevent recurrence of disease.

It is possible that the disease may not be cured by the operation, or that the disease may recur at a later time. If this should happen, subsequent surgical therapy may be required.

Symptoms of Sinusitis

Question: What symptoms may be associated with sinusitis?
Answer: Factors Associated with the Diagnosis of Chronic Rhinosinusitis:

Question: What causes the SYMPTOMS of sinusitis? In other words, why does the swelling of the sinuses make me feel bad? Why is it a problem?
Answer: You feel SYMPTOMS of sinusitis when the inflammation causes blockage of the small openings of the sinuses.

Question: What can I do about facial pain/headache?
Answer: Facial pain and headaches have many causes. Tension headache, migraine headache, stress headache, cluster headaches, reflex sympathetic dystrophy, and more exist. Sinusitis does contribute to facial pressure and pain, and it can reduce your resistance to other kinds of headaches -- that is, sinusitis can lower your threshold or make you more disposed to another type of headache.

The complete and thorough evaluation of headache includes evaluation by a neurologist and often an ENT specialist. If you feel that your pain is probably more sinus-related, start with the sinus specialist. He/she will examine you thoroughly and search out all of the MANY causes of facial pain that can be treated. If nothing definitive is found, do not lose hope. Your specialist(s) may still be able to offer you effective treatment.

In a rare patient, ENT and neurologic exam finds no cause for the headache. In these cases, a Pain Management Specialist is enlisted to your team, with frequent positive results that are usually a surprise to the patient!

Question: Can sinus problems make my migraines worse?
Answer: YES. Sinusitis can lower your threshold for migraine headaches. In other words, it can cause you to have migraines more easily. It is commonly thought that sinusitis can act in some cases as a "trigger" for migraine headaches. Treatment of sinusitis may in some cases decrease the incidence of migraine headaches.

Question: Will you tell me more about facial pressure and pain in sinusitis?
Answer: The sinuses are hollow, air-filled cavities housed in the facial skeleton. The sinuses are lined by a mucous-producing lining. Mucous is typically swept out of the sinuses into the nasal cavity and then back into the throat where it is swallowed. In patients with sinusitis, the small openings ("ostia") through which the mucous from the sinuses drains are blocked - often by swelling of the sinus lining. When the openings are blocked, the mucous does not drain effectively and a "back-up" occurs. The sinuses then retain secretions and an environment is created where warm, wet, stagnant secretions pool, leading to an influx of inflammatory mediators. Patients with this pooling of mucous and swelling of the sinus lining typically complain of facial pain and pressure associated with the swelling (and, on occasion, infection) in the sinuses (FIGURE 1).

FIGURE 1: The CT scan on the left demonstrates normal, healthy air-filled sinuses. In the CT scan on the right, the patient's sinuses have partial opacification corresponding to a swollen sinus lining and pooled secretions.

Question: What can I do about recurrent infections?
Answer: We must find out why you get recurrent infections and treat this problem! Some causes are unavoidable. For instance, if you have small children in elementary school who bring home cold after cold, you will have to wait until they grow older! (Actually, even in this situation we can often help you with preventive medical treatment).

However, if you have sinus blockage predisposing you to infections, medical and/or surgical therapy can help.

Question: What can I do about nasal blockage?
Answer: Nasal blockage has many causes. It is convenient to divide them into causes that are treated medically and causes that require surgical treatment.

Medical causes include the common cold (viral infection - a temporary cause), bacterial sinusitis, allergy, sensitivity to dust, smoke, pollution and other irritants.

Surgical causes include anatomic abnormalities such as a deviated septum, nasal polyps, obstructed sinuses that do not improve with medication, over-enlarged turbinates, obstructing adenoids, and other causes. Sometimes, scarring from trauma or prior nasal surgery can cause nasal obstruction.

Chronic nasal obstruction must be evaluated by a specialist.

Question: What can I do about snoring?
Answer: There are many causes of snoring. One of them is nasal obstruction. Nasal obstruction causes you to breathe through your mouth; this causes greater vibration of the tissue in the back of your mouth and throat when you are sleeping and may lead to snoring or increased snoring. If you snore, you should check with a specialist to find out the cause. Maybe it is because of nasal blockage, in which case a simple nasal treatment may fix your problem!

Question: What can I do about postnasal drainage?
Answer: Postnasal drainage is a symptom that can be a result of rhinitis or sinusitis: Abnormal swelling of the nasal and sinus membranes causes them to produce thick abnormal mucus. This thick mucus can drain into the back of your throat and cause cough, sore throat, nasal blockage, and so forth.

Treatment of postnasal drainage includes treating the cause of the postnasal drainage. (See Medical Treatment of sinusitis).

Question: Will you tell me more about postnasal drainage in sinusitis?
Answer: Postnasal drainage is a symptom that may result from rhinitis or sinusitis. Abnormal swelling of the nasal and sinus membranes causes them to produce thick, abnormal mucus, which can contribute to nasal blockage, and also can drain into the back of the throat and cause cough, sore throat, and so forth. Treatment of postnasal drainage includes treating rhinitis and sinusitis. Sometimes, the sensation of postnasal drainage may actually come from acid reflux. Acid from the stomach can travel in a retrograde direction - up the esophagus -- and spill onto the voice box (larynx). The irritation to the larynx, and associated throat-clearing and felling of "something stuck in my throat," can contribute to the feeling of postnasal drainage.

An ear nose and throat doctor can quickly and easily evaluate you for this Laryngopharyngeal Acid Reflux with a quick clinic examination. In this case, as in most instances with the sinuses and throat, effective treatment depends on proper diagnosis.

Question: What can I do about bad breath (halitosis)?
Answer: A common cause of bad breath is thick postnasal drip. This thick mucus can be white, yellow or even green. If you have sinusitis, it is stagnant in your sinuses and becomes foul-smelling, then it drips back into your throat to give you bad breath. No mouthwash will take this bad breath away! You need to see a sinus specialist.

Question: What can I do about fatigue?
Answer: Chronic sinusitis - like any chronic illness - can take a lot out of you. It can decrease your energy and make you less productive. If you have fatigue, you should see your primary doctor to evaluate other causes, but if you have sinusitis, you should realize that this can be a contributing factor.

However, if you have sinus blockage predisposing you to infections, medical and/or surgical therapy can help.

Question: What can I do about cough?
Answer: Two of the most common causes of cough are post-nasal drip and acid reflux. If you have a chronic cough, and especially if you smoke, it is critical that a specialist examine your larynx. You might also need a chest x-ray. Treatment of the cause -- postnasal drainage, acid reflux, or both -- should improve it or resolve your cough.

Question: What if my cough persists despite treatment?
Answer: Sometimes a cough can persist even after the cause has been treated. This might be a cough reflex. Often, the cough cycle must be broken by a cough suppressant prescribed by your doctor.

Also, re-examination for other causes is important when a cough persists.

Question: What role do my teeth play in sinusitis?
Answer: Proper care of the maxillary teeth and gums can be a major factor in the prevention of maxillary sinusitis, because the molar teeth are just beneath the sinus floor. Also, sinusitis can irritate the tooth roots and cause tooth pain. In these cases, treating the sinusitis often causes relief from the tooth pain.

Question: Do sinus problems affect my sense of smell?
Answer: Smell and taste sensation go hand-in-hand. If you lose your sense of smell, then you probably also find that food is bland or tasteless. Also, this can be a more serious problem because you cannot tell if food is spoiled; and if something in the house is burning you would not be able to smell it.

The nerves for smell are located in a very small area high in the nasal cavity. Even a small amount of blockage in this location can cause you to lose sense of smell. (That's why you lose sense of smell when you have a cold, for instance). However, there are a number of other problems that can cause a loss of sense of smell, including tumors, and this MUST be evaluated by a specialist.

Question: Does smoking affect my sinuses?
Answer: YES. Environmental pollutants in the air, such as cigarette smoke, can cause increased irritation of the nasal and sinus passages, particularly in people with hypersensitive nasal lining (mucosa). We are also becoming more aware of the effects of both general outdoor and indoor pollution. Chemicals used in the manufacturing of carpets, furniture, or buildings may also be a problem for sensitive individuals.

If you smoke, you should quit promptly. Smoking causes so many health problems besides sinusitis that are not the subject of this discussion. Just read the warning on the cigarette package, and talk to your family doctor. Please stop smoking!

Many surgeons feel that cigarette smoking is a contraindication to sinus surgery. In other words, it is unlikely that the sinus surgery will have much positive effect if you continue to damage your sinus linings with cigarette smoke.

Question: Will you tell me more about halitosis in sinusitis?
Answer: A common cause of halitosis (bad breath) is thick postnasal drip. This thick mucus can be white, yellow, or even green. If a patient has sinusitis, the mucus is stagnant in the sinuses and becomes foul-smelling, then it drips back into the throat to give bad breath. No mouthwash will take this bad breath away. The patient needs to see a sinus specialist. As part of the evaluation of postnasal drainage, the specialist will evaluate the nose and sinuses, as well as the throat.

Question: Will you tell me more about fatigue in sinusitis?
Answer: Patients who experience fatigue should see their primary doctor to evaluate the many possible causes. Thyroid dysfunction, for example, commonly manifests with fatigue. However, chronic sinusitis -- like any chronic illness -- can also take its toll on a patient. It can decrease energy levels and make the individual less productive. Several studies have confirmed that fatigue is a common presentation of patients with sinusitis. If a patient has sinusitis, this can be a contributing factor to fatigue.

Question: Will you tell me more about facial pain and headache in sinusitis?
Answer: Facial pain and headache have many causes: tension headache, migraine headache, stress headache, cluster headaches, reflex sympathetic dystrophy, and more. Sinusitis does contribute to facial pressure and pain, and it can reduce resistance to other kinds of headaches -- that is, sinusitis can lower the threshold or make the patient more disposed to get another type of headache. While some patients develop headache, others may have pain, tenderness and swelling around the eyes, cheeks, nose or forehead.

The complete and thorough evaluation of headache includes evaluation by a neurologist and often an ENT specialist. If a patient's doctor feels that the individual's pain may be more sinus related, the doctor may want to start with a sinus specialist, who will examine the patient thoroughly and will search out all of the many causes of facial pain that can be treated. If the specialist doesn't find anything definitive, there may still be hope of other effective treatment, and a neurologist may also suggest treatments. In a rare patient, ENT and neurologic exams find no cause for the headache. In these cases, a pain management specialist is enlisted into the team, with frequent positive results that are usually a surprise to the patient.

Question: Will you tell me more about facial pain and pressure with airplane travel?
Answer: Nasal congestion, secondary to sinusitis and other conditions, is a relative contraindication to air travel. This means that patients prone to nasal congestive disorders should only travel by airplane if they have first consulted with their physician. The physician may determine that it is not safe to fly or may feel that the patient can fly with proper pretreatment. The risks of flying with nasal congestion include severe facial pain, damage to the eardrums including bleeding and perforation, dizziness or vertigo, sinus bleeding, and other even more serious conditions.

It is recommended that patients with nasal congestion take a systemic decongestant and also spray the nasal passages with a topical long-acting nasal decongestant before the flight and before the descent. Such patients should check with their doctors to make sure that they can take these medications...for instance, patients with high blood pressure may want to avoid these medications. Patients with allergies may also take an antihistamine under a doctor's supervision. In some cases, a doctor may wish to prescribe other medications, such as oral prednisone, a few days prior to travel. Medical care should be available at the patient's destination in case sinusitis develops.

Air travelers with sinusitis are also advised to chew gum, swallow frequently, and learn how to perform the Valsalva maneuver to clear their ears. One way to perform this maneuver is to hold the nose and gently generate pressure against the closed mouth and glottis every 30 seconds.

Question: Will you tell me more about thick nasal discharge in sinusitis?
Answer: Some patients have recurrent infections with thick, sometimes discolored, nasal discharge. Sometimes this thick mucous drains down the back of the throat. The sinus specialist must find out why patients get recurrent infections and treat this problem. Some causes are unavoidable -- for instance, patients with small children in elementary school who bring home cold after cold will have to wait until their children grow older. (Actually, even in this situation the sinus specialist can often help with preventive medical treatment.) Patients with sinus blockage predisposing them to infections may find medical and/or surgical therapy to be helpful. The sinus specialist may need to check the function of the patient's immune status -- while this is usually normal, occasionally a patient has low immune defenses that can be helped.

Question: Will you tell me more about decreased sense of smell in sinusitis?
Answer: Smell and taste sensation go hand in hand. Patients who lose their sense of smell probably also find that food is bland or tasteless. Although annoying, this can actually be a more serious problem because the patient cannot tell if food is spoiled or if there is a household emergency such as fire, which they would not be able to detect. The nerves for smell are located in a very small area high in the nasal cavity. Even a small amount of blockage in this location can cause loss of sense of smell (which is why patients lose sense of smell when they have a cold, for instance).

Sinusitis is a common cause of loss of senses of smell and taste. However, there are a number of other problems that can cause a loss of sense of smell, including tumors, and this must be evaluated by an ENT specialist (FIGURE 3).

FIGURE 3. Nasal and sinus polyps, seen here on endoscopic view, can lead to decrease in sensation of smell and taste. The polyps and their associated inflammation often block the passage of olfactory molecules upwards toward the "smell nerves" housed in the roof of the nose.

Question: Will you tell me more about dental pain in sinusitis?
Answer: The maxillary (cheek) sinuses are located just above the teeth. In fact, the roof of the mouth (where the dental roots live) is the floor of the cheek sinuses. While it is not uncommon for dental problems to lead to infection in the cheek sinuses, an infected cheek sinus may also lead to dental pain. Once the maxillary sinuses are affected, infection can then spread to the adjacent sinuses.

It is important to keep in mind that hormonal reactions associated with puberty, birth control pills, pregnancy, and aging can lead to nasal and sinus difficulties. Acid reflux is also at times a contributor to sinus inflammation. Other factors include self-induced causes such as intranasal cocaine or medication misuse.

Question: If I have a sinus infection, can I travel by airplane?
Answer: Nasal congestion secondary to sinusitis and other conditions is a relative contraindication to air travel. This means that you should only travel by plane if you have first consulted with your physician. Your physician may determine that it is not safe for you to fly, or he or she may feel that you can fly with proper pre-treatment.

The risks of flying with nasal congestion include severe facial pain, damage to the eardrums including bleeding and perforation, dizziness or vertigo, sinus bleeding, and other even more serious conditions.

It is recommended that patients with nasal congestion take a systemic decongestant and also spray the nasal passages with a topical long-acting nasal decongestant before the flight and before the descent. You should check with your doctor to make sure that you can take these medications - for instance, patients with high blood pressure may want to avoid these medications.

Patients with allergies may also take an antihistamine, under a doctor's supervision. In some cases, a doctor may wish to prescribe other medications such as oral prednisone a few days prior to travel. Medical care should be available at the patient's destination in case sinusitis develops.

Air travelers with sinusitis are also advised to chew gum, swallow frequently, and learn how to perform the Valsalva maneuver to clear their ears. One way to perform this maneuver is to hold the nose and gently generate pressure against the closed mouth and glottis every 30 seconds.

Question: What else can be making my sinus problems worse?
Answer: Certain conditions that exist within your own body can increase your susceptibility to sinus infections. For example, periods of emotional stress can result in swelling of the nasal lining. Many female patients develop nasal swelling during pregnancy. Certain medications used to treat high blood pressure can also cause swelling of the nasal lining. Or, if you have diabetes, high blood sugar can make you more prone to infections in general. Certain relatively rare disorders such as Lupus, Cystic fibrosis, Wegener's disease, Sarcoidosis, and others are associated with difficult sinus problems. Be sure to inform your physician if you have, or suspect, any medical problems.

If you have any underlying medical condition or illness, you should be under the care of an appropriate physician.

Question:: Any other general suggestions about treatment?
Answer: An important part of treatment of any of these various conditions is to avoid, whenever possible, the causative factor. If you smoke cigarettes, you should quit promptly. If you recognize a substance you are allergic to, you should avoid it as much as possible and consider treatment by a specialist. If you have any underlying medical condition or illness, you should be under the care of an appropriate physician.

Your general state of health and nutrition affects every part of your body, including your sinuses. For this reason, we advocate maintaining a healthy diet, including taking vitamin supplements, and getting regular exercise.

The Common Cold

Question: Is it true that the common cold can lead to a bacterial sinus infection?
Answer: A cold is a viral infection that typically goes away in a few days. Many episodes of acute sinusitis follow the common cold. When fluid taken from the sinuses of patients with acute bacterial sinusitis have been studied, cold viruses have invariably been found.

Viral infections destroy the cilia of the mucous membranes, and approximately six weeks are required for regeneration. Many doctors therefore believe that this is a predisposing factor for a bacterial sinusitis super-infection, since these patients have decreased mucus flow, thick abnormal mucus, and osteomeatal complex blockage.

In addition to problems such as the common cold, allergens and non-allergic pollutants are significant triggers to sinusitis. Irritants such as cigarette smoke, perfume, toxic chemicals, and other pollutants remain a problem for many patients.

Anatomic abnormalities can also predispose to acute sinusitis. These problems are typically easy to recognize and may be corrected surgically.

Question: Are some people more predisposed than others to colds, and also to sinusitis?
Answer: YES. If your nasal and sinus anatomy is particularly narrow, you are less able to tolerate the swelling of the nasal membrane lining that is caused by nasal irritants. Also, the nasal lining of some people is simply more sensitive than in others. For example, some people are very sensitive to cigarette smoke; their noses seem to "swell shut" almost immediately. Also, some people have severe allergies while others do not. These are two obvious examples, but the point is that the way each person's nose reacts to the world around them is unique, and based on genetic factors. Depending upon your anatomy, and depending upon how your nose reacts to the world around you, you may be more or less susceptible to sinusitis.

Allergies

Question: What is the difference between allergy and sinusitis?
Answer: Allergy is a specific way that your body reacts to certain foreign substances. For example, if you are allergic to dust mites, then when you breathe in "dustmite particles" they are recognized by specific allergy receptors in your nose. When they recognize the "intrusion" of dustmite particles, they cause the release of substances that are meant to fight the presence of these particles. These include the release of histamine and other substances that create an inflammatory response. These responses were designed as a defense against the "foreign intruder" - that is to say, the dustmite particles. However, this allergy response has the unfortunate consequence of causing unpleasant symptoms such as a scratchy throat, watery eyes, runny nose, sneezing (to expel the intruder) and so forth. Therefore, we often take anti-allergy medicines to tone down this response and relieve the symptoms of allergy and allergic response.

If you have allergies, your nose may react to allergy-inducing substances in the air, such as dust or mold. Allergic nasal and sinus swelling may in turn lead to sinusitis.

Sinusitis is a bit more generic, it is simply inflammation in your nose and sinus cavities from any cause. Allergy can be one cause of inflammation, hence the term allergic rhinosinusitis, or sinusitis with an allergic component. However, there are a number of other factors that can contribute to sinusitis such as sensitivity to pollution, cigarette smoke, infection, and so forth.

Question: Is allergy common?
Answer: An estimated 20% of the United States population suffers from allergies. The nose is most commonly affected in the allergic individual. Symptoms include sneezing, itching of the eyes, nose, and throat, watery eyes, rhinorrhea, congestion, cough, and post-nasal drainage. An estimated 40 million Americans are afflicted with allergic rhinitis which in turn predisposes to many cases of sinusitis.

Question: Is there a simple test to tell if I have allergies?
Answer: A simple screening test that any doctor can perform is a complete blood count with differential. Elevation of a particular type of blood cell called EOSINOPHILS is suggestive of allergy. Measurement of serum immunoglobulins can also be diagnostic. Specifically, measurement of serum immunoglobulin type E is useful; elevated levels are suggestive of allergy.

More complicated tests include specialized blood tests for allergies and also the "skin scratch tests" with which many of you are familiar. These tests are described in this section.

Question: What are the treatments of allergy?
Answer: Avoidance of the allergic substances if possible. Environmental changes can be helpful, such as covering furniture, cleaning the house duct work, electrostatic air filters, and so forth. Medical therapy includes anti-histamines, mast cell stabilizers (cromolyn sodium) and also more generic anti-inflammatory agents such as nasal steroid spray. Immunotherapy (allergy drops or allergy shots) can also be helpful in specific cases.

Question: Tell me about immunotherapy.
Answer: These are the "shots" that a patient receives on a weekly basis that gradually immunizes them to the things that they are sensitive to. As the patient becomes more resistant to allergens, symptoms may subside.

Question: What is the role of allergy testing?
Answer: During a visit to the doctor, underlying allergies may be suspected in a patient who describes itchy or watery eyes, itchy nose, frequent sneezing, copious nasal drainage with nasal congestion, and itchy throat. These patients are often treated with topical nasal corticosteroid spray or cromolyn spray (Nasalcrom) and oral antihistamines. When these treatments fail, patients often undergo allergy testing.

Oral antihistamines are generally reserved for sinus patients with underlying allergies, because the drying effects of antihistamines may thicken secretions and can be otherwise detrimental in treating sinusitis. Patients with seasonal allergies should avoid pollens. Patients with perennial allergies should avoid exposure to dust, mold, and pet dandruff.

Question: Name three avoidance measures.
Answer: Determination of what you need to avoid may be accomplished by allergy testing. If you are allergic to your pets, you need to keep them out of your bedroom if you are not willing to give your pets away. With regard to this, there is a saying: "When a doctor tells a patient to 'get rid of their pet,' more often, the patient gets rid of their doctor!"

If you are allergic to dust mites, there are a number of measures that you can take including removal of rugs. There are special filters that can be placed over the air conditioning vents that will capture microscopic allergic particles.

If you have an old house that has built-in air ducts, these ducts should be professionally cleaned.

Finally, vacuum cleaners should be equipped with special microphore vacuum bags. These special vacuum bags trap small particles that cause allergy but that are not trapped by normal vacuum bags.

Question: What is the difference between seasonal and perennial allergies?
Answer: Allergic rhinitis is a hypersensitivity of the sinus and nasal mucosal membranes to allergens mediated through IGE antibodies. Allergic rhinitis may be classified as seasonal or perennial. Allergic rhinitis is considered seasonal when the symptoms occur only during specific periods of the year depending upon exposure to pollens. Ragweed, trees, and grasses are the most common sources of seasonal allergens. Allergic rhinitis is considered perennial when the symptoms occur for more than two hours a day for more than nine months. Dust mites, mold, and animal dander represent the most common sources of perennial allergens.

Question: Tell me about allergy testing.
Answer: The two recommended allergy testing options are serial end point titration, or SET, and radioallergosorbent test or RAST. Both SET and RAST give qualitative and quantitative information about the patient's response to specific allergens. The RAST test can be ordered by any doctor, but a specialty-trained allergist usually performs the SET and administers immunotherapy.

Question: Tell me about in vitro testing (RAST or radioallergosorbent test).
Answer: The RAST test involves a blood sample taken from the patient. A predetermined panel of allergens (allergic substances) are studied. The patient's blood is placed on special paper discs which have allergens bound to them. If the patient's blood has antibodies to these allergic substances, then the antibiodies will attach to them.

The discs are then washed so only bound antibodies remain. The disks are then treated with radioactively-labelled "anti-antibody" which will bind to any of the patient's antibodies present on the disc. A radiation counter will detect the presence of this radio-labelled antibody to allergic particles.

More recently, enzyme markers have replaced the radioactive labels. Results from RAST are then used to determine which allergens are responsible and guide immunotherapy. The results are also used to help calculate treatment doses.

RAST has the advantage of greater comfort and ease of testing for the patients. The in vitro test presents no risk of reaction by the patient. Medications and skin conditions will not affect RAST results.

RAST is slightly less sensitive and more expensive than SET. Both SET and RAST give qualitative and quantitative information that may be used for immunotherapy. They can safely be applied in the office setting and are valuable in the treatment of allergic rhinosinusitis.

Question: Tell me about serial end point titration.
Answer: Serial end point titration requires serial skin application of several dilutions of the allergen being investigated. When the patient is sensitive to a specific allergen the wheel will increase by at least 2mm with each increase of the dilution. The first dilution that leads to a 2mm increase is the end point, which is considered the safe starting dose for immunotherapy for that specific antigen. Subsequently, during immunotherapy the clinical response determines changes in dose.

Many clinicians who favor SET find that it has the advantage of providing immediate results. This allows immunotherapy to begin without any delay. The SET method involves testing suspected allergens based on the patient's history, therefore avoiding the need to do a large in vitro test panel as in RAST.

SET is found to be quite sensitive. Unlike RAST, SET results can be affected by antihistamines, tranquilizers, and antidepressants. For example, antihistamines must be discontinued at least 48 hours before SET. Skin conditions may also alter results because this method relies on skin application of allergen dilutions.

Food Allergies

Question: Tell me about food allergy.
Answer: Food allergy is increasingly recognized as a culprit in allergic disease. Cow's milk is the most common food allergen. Symptoms are usually gastrointestinal but may be similar to those related to inhalent allergy. Cyclic and fixed food allergies may occur.

The Cyclic type is more common, representing approximately 95% of food allergies. Symptoms related to cyclic food allergy will occur several hours after ingesting the allergenic food.

Fixed food allergies involve an immediate type of hypersensitivity reaction.

Acid Reflux (GERD)

What is GERD?
Answer: The backflow of stomach juices, including acids and occasionally ingested foods, constitutes gastroesophageal reflux disease or GERD.

Question: What are the symptoms of GERD?
Answer: Common esophageal symptoms of GERD include repeated bouts of heartburn, difficulty swallowing, hoarseness, lump-in-the-throat sensation, chronic cough and throat clearing, and mucus build-up in the throat. People can suffer from one or more of these symptoms.

Question: What is the the relationship between GERD and sinusitis?
Answer: Sometimes, the symptoms of GERD can mimic some of the symptoms of sinusitis. The sensation of post-nasal draining and the need to clear your throat constantly may be due to post-nasal drainage -- but may also be due to GERD. The sinus specialist may therefore examine you in the office to see if there is physical evidence of GERD.

Acid reflux can sometimes actually contribute to sinusitis! That is to say, the acid can travel all the way up to your nose and sinuses (for instance, while you are lying down asleep), and this acid can inflame the nose and sinus linings. This problem is more common in children -- but it may also be seen in adults.

Question: What causes GERD?
Answer: There is a one-way valve near the top of the stomach. Stomach acid can escape through a weakened valve and travel up the esophagus -- even up to the voice box and throat -- and produce the symptoms listed above.

Question: How do you diagnose GERD?
Answer: Heartburn is easily recognized by the family doctor. However, some of the symptoms relating to the throat and voice box should be evaluated by a specialist. The specialist will then perform a complete examination including taking a look at the voice box with a small endoscope placed through the nose. If you have GERD, your sinus specialist may ask you to also see a gastroenterologist.

Question: Are there any diagnostic tests?
Answer: A gastroenterologist may decide to order some additional tests to evaluate your GERD. A Barium swallow is a series of x-ray films that monitor dye as it travels through the stomach. A PH monitoring test is a 24-hour test to record the back flow of acid from the stomach into the esophagus and even the throat. A small flexible tube is placed in the stomach through the nose and is connected to a small computer to record 24-hour acid reflux. Endoscopy is sometimes performed to evaluate the esophagus for damage from acid burns and to examine the stomach for irritation and ulceration.

Question: How is GERD managed?
Answer: With lifestyle and dietary changes, with medical treatment, and at times surgical treatment.

Question: Tell me about life style and dietary changes.
Answer: Don't drink alcohol, and don't smoke. Both nicotine and alcohol irritate the stomach and increase acid production. Also,

• Avoid clothing that is tight around the waist -- corsets, belts.
• Avoid bending over.
• Lose weight.
• Raise your head when lying down. This is best achieved NOT with pillows, but by raising the head of the bed by 6 to 8 inches. This can be done by sliding blocks under the legs at the head of the bed or a wedge under the head of the mattress.

Question: Tell me about dietary modifications regarding GERD.
Answer: You may wish to avoid coffee and tea, carbonated beverages, alcohol, fatty fried foods, spicy food, citrus fruits and juices, tomato juice, orange juice, and grapefruit juice, tomatoes, onions, peppermint, spearmint, chocolate, cheeses, and eggs.

Avoid large meals, especially in the evenings. Do not lie down right after eating. Allow three to four hours after supper and lying down. Make the mid day meal the heavier meal of the day and eat small, well-balanced meals.

Question: Tell me about medical treatment of GERD.
Answer: Medical treatment is based on neutralizing stomach acid, reducing or eliminating stomach acid and improving gastric emptying. Neutralizing stomach acid can be achieved by using over-the-counter antacids in liquid or tablet form such as Sucralfate suspension, Maalox, and Ryopan. Reducing or eliminating stomach acids can be achieved with H-2 blockers, which are drugs that depress acid production, such as Cimetadine (Tagamet), Ranitidine (Zantac), or Famotidine (Pepcid). These are also now available over-the-counter at lower dosage.

Antacids and H-2 blockers should be taken one hour apart as antacids may reduce the other drugs' effectiveness. New drugs like Omeprazole (Prilosec) and Nexium completely stop stomach acid production. These drugs are generally prescribed for short-term use.

Improving gastric emptying can be undertaken by Cisapride, Metoclopromide, Bethanachol, and other drugs. These drugs increase the squeezing action of the esophagus and tighten the esophageal sphincter, in addition to making the stomach empty faster.

Question: Tell me about surgical treatment of GERD.
Answer: Surgical treatment is undertaken as a last resort. If the dietary and medical treatments do not bring relief, or if the patient finds them hard to comply with, they may be candidates for surgery. One procedure is called "fundoplication." It involves wrapping the top of the stomach around the top of the esophagus in order to strengthen support and prevent reflux. If possible, it is preferable to control GERD with medical treatment!

Making The Diagnosis

Question: What are the sinuses?
Answer: The sinuses are chambers in the bones of the face and skull that are normally lined with a thin mucus-producing membrane (called mucosa). They communicate with the nasal cavity via narrow openings. Air and mucus enter and exit to and from the sinuses through these openings.

Question: What is sinusitis, and what causes it?
Answer: Sinusitis literally means "inflammation of the sinus cavities." This inflammation is what happens when your nose and sinuses are exposed to anything that might irritate the membranous linings. These irritants may include dust and pollution, cigarette smoke, and other irritants. Allergic reaction to mold, pollen and so forth may also irritate the nasal linings. Furthermore, infection with a virus or bacteria may irritate the nasal linings. All of these factors may cause the narrow openings in the nose and sinus cavities to narrow even further or even to shut entirely.

The "grand central station" of the sinuses is the osteomeatal complex -- the most important sinus opening. Any process that causes blockage in this sensitive area can occlude the other sinuses that drain into the osteomeatal complex. When obstruction occurs, the mucus is retained in the sinus cavity. These stagnant secretions thicken and provide a medium for bacterial growth. These changes lead to damage and dysfunction of the cilia (microhairs) that line the sinuses. The retained secretions and infection lead to further tissue inflammation, which in turn leads to further blockage. These events demonstrate a vicious cycle that leads to chronic sinusitis.

Question: What is the basic principle underlying treatments that restore normal sinus function?
Answer: We now know that sinus disease can often be resolved or controlled by controlling the sinus problems at the main sinus opening, or osteomeatal complex (OMC). This allows for restoration of normal sinus aeration and mucous clearance.

In general, the OMC can be blocked by mucosal congestion or anatomic obstruction. The causes are commonly reversible with appropriate medical and, at times, surgical management.

Question: What are the symptoms of sinusitis?
Answer: The symptoms of sinusitis include nasal blockage (the #1 symptom), facial pressure or pain, snoring, postnasal drainage, bad breath, fatigue, recurrent infections, tooth pain, loss of sense of smell, and others.

Question: Is there a relationship between sinusitis and asthma?
Answer: Sinusitis can actually exacerbate asthma. Many patients who have successful treatment of their sinuses find that their asthma also improves. The post-nasal drainage of diseased sinuses can irritate the reactive airways of asthmatics.

A significant number of asthma/sinusitis patients - nearly 2/3 - find they can decrease or, in some cases, come off of asthma medication after sinus surgery.

Question: What is the appropriate medical therapy for sinusitis?
Answer: Once the diagnosis of sinusitis is made, medical therapy is instituted. The exact therapy chosen by your doctor will depend upon the underlying cause. Therapy is aimed at relieving obstruction of the nose and sinuses, particularly at the osteomeatal complex. In addition, therapy is targeted in such a way as to treat any infection that may be present.

In general, medical management of sinusitis may include one or more of the following: Antibiotics, topical and systemic decongestants, topical nasal lavage, nasal saline sprays, humidification, mucolytics, decongestants, and steroids.

Medical therapy must be undertaken under a doctor's care. Some medications for sinusitis must not be taken if a patient has other medical conditions. For example, if a patient has high blood pressure, or if a patient is pregnant, certain medications must not be taken.

Most cases of chronic sinusitis treated by otolaryngologists are successfully treated with medical therapy. When medical therapy fails, the surgical alternative is a consideration.

Question: When is surgical intervention (FESS) considered?
Answer: Surgical intervention for chronic sinusitis is reserved for those patients in whom maximal medical therapy has failed. Functional endoscopic sinus surgery has become the most widely accepted approach for patients undergoing surgical intervention for chronic sinusitis. The goal is to return the sinuses to as near a normal anatomic state as possible. This surgery is intended to correct conditions that impede mucocilary clearance of the sinuses, especially through the osteomeatal complex. Respect of the normal drainage patterns of the sinuses and elimination or improvement of obstruction of these drainage pathways promotes the resolution of mucosal hypertrophy and infection and the return to a normal disease-free state.

Question: How many sinus surgical procedures are performed each year in the United States?
Answer: Some estimates suggest that more than 200,000 sinus surgical procedures are performed each year.

Question: When should I consider surgery?
Answer: When anatomic abnormalities exist and are contributing to your sinusitis, and when other therapies have failed, these abnormalities can be surgically corrected.

Endoscopic techniques allow otolaryngologists to diagnose and treat these problems more easily than in the past, allowing them to be more proactive in the management of anatomic nasal abnormalities.

Question: When is surgical management indicated?
Answer: Surgical management of sinusitis is considered when medical management fails to relieve the patient of the symptoms of sinusitis, when the patient's condition, unrelieved by medical therapy, is also associated with lower respiratory tract problems such as chronic bronchitis and asthma, and when complications of sinusitis are present or threatening.

In general, patients who fail maximum medical therapy are potential candidates for surgical management.

Question: What are the surgical options?
Answer: FESS (or functional endoscopic sinus surgery) has essentially replaced the traditional "old-fashioned" procedures for the conservative surgical management of sinus disease. Functional endoscopic sinus surgery (FESS) is aimed at restoring patency and normal mucociliary flow of the natural sinus openings.

With nasal endoscopes the narrow anatomical region of the sinus drainage pathways can be visualized and accurately approached surgically.

FESS has brought dramatic positive improvement in the surgical treatment of sinusitis.

Question: What is the key underlying concept behind minimally invasive, functional endoscopic sinus surgery (FESS)?
Answer: The osteomeatal complex, or OMC - the small compartment located in the region between the middle turbinate and the lateral nasal wall in the middle meatus - represents the key region for drainage of the anterior ethmoid, maxillary and frontal sinuses. Obstruction of the OMC causes a vicious cycle of events that lead to chronic sinusitis.

Functional endoscopic sinus surgery opens these natural sinus openings to restore normal sinus functioning.

Question: Tell me more about Functional Endoscopic Sinus Surgery.
Answer: In FESS, an endoscope is used in the nose to view the nasal and sinus cavities. This generally eliminates the need for an external incision. The endoscope allows for better visualization of diseased or problem areas. This endoscopic view, along with detailed X-ray studies, may reveal a problem that was not evident before.

FESS focuses on treating the underlying cause of the problem. The ethmoid area is usually opened, which allows for visualization of the maxillary, frontal and sphenoid sinuses. The sinuses can then be viewed directly and diseased or obstructive tissue removed if necessary. The surgery is commonly performed on an outpatient basis.

Careful postoperative care is essential to the success of this surgery. The patient will be provided postoperative care instructions. It is very important that the patient follow these instructions, as well as any other instructions given by the surgeon, to promote healing and decrease the chance of complications.

Question: Will endoscopic sinus surgery cure sinus problems?
Answer: Overall, the majority of patients have had significant improvement with the combination of surgery and continued medical management. FESS performed as a result of medical therapy failures in acute and chronic sinusitis is associated with a success rate of 75 to 95% according to sources in the literature.

Sinusitis is a chronic problem, and while your symptoms may improve or even disappear after surgery, the patients nose and sinuses still have the potential to be irritated by pollen, dust, pollution, etc It should be realized that some medical therapy is usually continued after surgery, especially if allergy or polyps play a role in the sinus disease. This is necessary to control or prevent recurrence of disease.

It is possible that the disease may not be cured by the operation, or that the disease may recur at a later time. If this should happen, subsequent surgical therapy may be required.

Medical Treatment

General Information

Question: What is the appropriate medical therapy for sinusitis?
Answer: Once the diagnosis of sinusitis is made, medical therapy is instituted. The exact therapy chosen by your doctor will depend upon the underlying cause. Therapy is aimed at relieving obstruction of the nose and sinuses, particularly at the osteomeatal complex. In addition, therapy is targeted in such a way as to treat any infection that may be present.

In general, medical management of sinusitis may include one or more of the following: Antibiotics, topical and systemic decongestants, topical nasal lavage, nasal saline sprays, humidification, mucolytics, decongestants, and steroids. Other treatment options are also possible and are discussed below.

Medical therapy must be undertaken under a doctor's care. Some medications for sinusitis must not be taken if a patient has other medical conditions. For example, if a patient has high blood pressure, or if a patient is pregnant, certain medications must not be taken.

Question: What is the goal of medical treatment?
Answer: Treatment is aimed at eliminating causative factors and controlling the inflammatory and infectious components. Ideal management includes preventative measures, including the use of specific medications in proper dose and duration.

Question: When I get a sinus infection, is there anything else that I should do besides taking an antibiotic?
Answer: Yes! Reversing the obstruction to the flow of sinus secretions is critical in reducing the incidence and severity of bacterial and fungal infections. Medications prescribed by your doctor to reduce sinus inflammation and blockage help your body's immune defenses fight back!

Therefore, the use of topical corticosteroids, the use of nasal decongestants and mucous thinners, the use of nasal salt water (saline) washes, the use of antihistamines in patients with allergic rhinitis, and other measures are important and effective when treating a sinus infection, and in preventing sinus infections in susceptible individuals, and moderating symptoms when they occur.

Of course, these treatments should only be undertaken under the direction of an experienced physician.

QUESTION: What should a patient do about her sinuses if she is pregnant?
Answer: Nasal congestion is a common complaint during pregnancy. Particularly for patients with a pre-existing sinus condition this can become a significant problem. Unfortunately, a number of the medications that are used to treat sinusitis are NOT safe during pregnancy.

We advise that all medications be approved by your obstetrician. The sinus specialist and the obstetrician, working together, should be able to help you manage your sinuses as you proceed through your pregnancy.

Antibiotics - General Information

Introduction: Antibiotics are medicines designed to treat bacterial infections. In many cases of sinus infections, your physician may prescribe an antibiotic for you based on what bacteria are most likely to be causing the infection. At times, your doctor's choice of antibiotic may be based on the bacteria that can be identified from a sample of pus taken from your nose or sinuses (i.e., a culture). Sometimes, more than one antibiotic will be prescribed to increase the likelihood of completely eliminating an infection.

Dosing: You should take your antibiotic exactly as prescribed. Unless you are having side-effects, you should complete the entire course of the antibiotic, even if you start feeling better before you are due to finish. By failing to complete the entire course of your treatment, you may be increasing the number of resistant bacteria. This could make further antibiotic therapy ineffective.

Most of the time, antibiotics are prescribed to be taken by mouth. Occasionally, for a more resistant or serious infection (such as when bone is infected, or if resistant bacteria are causing the infection), intravenous antibiotics may be needed.

Adverse effects: As with any medication, antibiotics can cause side-effects. Any antibiotic can cause an allergic reaction, ranging from a skin rash, with or without itching, to a swollen mouth or tongue, wheezing, and/or trouble breathing. In all cases of an allergic reaction, you should stop taking the drug immediately and call your physician. Most allergic skin reactions will resolve with little or no treatment. A drug reaction, somewhat different from an allergy, can develop from using antibiotics and cause fever and/or joint pain and swelling.

Perhaps the most common adverse effect of antibiotics is the gastrointestinal symptoms they produce. These can include stomach pain, nausea, vomiting, and diarrhea. If these symptoms are mild and tolerable they are probably not of concern, but if they are severe, you should stop the antibiotic and inform your physician. In rare cases, antibiotics can cause a severe diarrhea known as "pseudomembranous colitis." Patients with this disorder have severe watery diarrhea (not simply loose stools). In this case you should stop the antibiotic and notify your doctor or your family physician immediately. Do not try to treat yourself with an anti-diarrheal medication or hope that a severe diarrhea problem will subside.

Because antibiotics alter the normal bacteria in the body, as well as the disease-causing bacteria, they can cause other side-effects. A yeast infection, most commonly in the mouth or vagina, is one such complication.

To minimize the risk of both diarrhea and yeast from antibiotics, many doctors recommend daily ingestion of Lactobacillus acidophilus, popularly known as acidophilus. This can be important because with chronic sinusitis you may need to be on antibiotics for an extended period of time. Acidophilus can be found in two forms; yogurt with active cultures, and capsule preparations. We recommend eating 8 ounces of yogurt with active cultures daily while on antibiotics, and to continue doing so for another week or two following completion of your course of antibiotics. Some brands of yogurt do not contain active cultures, so read the container carefully. Although yogurt is the preferred source of acidophilus, acidophilus capsules are an acceptable alternative if you have a milk allergy or for some reason cannot eat yogurt. You can purchase acidophilus tablets at most health food stores.

Be sure to inform your doctor if any of the following apply to you: impaired kidney function, rash when previously given an antibiotic, ulcerative colitis, mononucleosis (mono), anemia, abnormal liver function, myasthenia gravis, pregnancy, breast feeding, other medications, mitral valve prolapse or prosthetic devices.

Antibiotics - Advanced Information (for doctors)

Question: What is the typical microbiology of a sinus infection?
Answer: Acute rhinosinusitis has causative organisms similar to acute otitis media. 75 percent of culture obtained from antral puncture in patients with acute maxillary sinusitis contain either Streptococcus pneumoniae or Hemophilus influenza (both beta lactamase + and -). Moraxella catarrhalis is also a common pathogen, especially in children, where it rivals Hemophilus influenzae.

Viruses are also prevalent. They mimic bacterial infection and often predispose to bacterial infections secondarily.

Staphylococcus aureus is frequently found in nasal cultures (even 30 percent of normal people) but rarely in antral puncture cultures, suggesting it is a contaminant. However, in hospitalized or immunosuppressed patients, the pathogenicity of Staphylococcus aureus is more likely. Anaerobic organisms on acute sinusitis suggest dental disease as the source.

Hemophilus influenza 38%
Streptococcus pneumonia 37%
Other hemophilus spp 8%
Streptococcus pyogenes 6%
Moraxella catarrhalis 5%
Alpha Streptococci 3%
Gram negative bacilli/mixed anaerobes 3%

Question: What is the best antibiotic for bacterial sinusitis?
Answer: A host of information has surfaced in the medical literature about appropriate antibiotic therapy for acute bacterial rhinosinusitis and chronic rhinosinusitis. While this is still a subject of ongoing debate, here is one proposed approach to antibiotic treatment:

Antibiotics are designed to kill bacterial pathogens or prevent their growth, and studies suggest that their use shortens the course of an infection and helps prevent complications. However, excessive and inappropriate use has led to the development of resistance. Pathogens are adept at mutation, transformation, conjugation and plasmid development. The end result is that Streptococcus pneumoniae and Hemophilus influenza are no longer readily eradicated by the usual course of therapy with antibiotics.

Guidelines promoted by the American Rhinologic Society and the Sinus & Allergy Health Partnership (Otolaryngol Head Neck Surg June 2000) established a new methodology for dealing with this problem. Proper use of the guidelines should improve patient care.

The guidelines recognize that patients who have been exposed to an antibiotic within 4 to 6 weeks of their current infection are likely to be infected with a resistant pathogen.

Thus, for patients who are evaluated for Acute Bacterial Rhinosinusitis (ABRS) who have NOT been exposed to antibiotics within the previous 4 to 6 weeks, first line therapy is limited to high-dose amoxicillin, amoxicillin-clavulanate, cefpodoxime, and cefuroxime axetil.

For adult patients with moderate infection and prior antibiotic use, the agents that are indicated are amoxicillin-clavulanate, or one of the fluoroquinolones (gatifloxacin, levofloxacin, or moxifloxacin) or combination therapy amoxicillin or clindamycin for gram positive coverage PLUS cefixime or cefpodoxime axetil for gram negative coverage.

Very similar first-line agents are recommended in the pediatric patient population with the exception of the fluoroquinolones, which still have no pediatric indication. Despite the recent reports of shorter course therapy, the guidelines still recommend 10-14 days of therapy.

Question: How long should a patient take antibiotics for acute sinusitis?
Answer: The usual recommendation is 10-14 days of antibiotic therapy. However, this is probably an empiricism. Patients who respond promptly rarely finish the full course. Several recent studies aimed at reducing antibiotic usage have shown that courses of 3,4,5, and 8 days yield similar cure rates as a 10-day course, at least in early disease in adults with mild symptoms. This should be expected, since uncomplicated sinusitis has a high probability of spontaneous resolution and nonbacterial (viral) cause.

Question: Tell me more about bacteria cultures in sinusitis.
Answer: The sinuses produce about one liter of mucus a day, most of which is swallowed without awareness. Nasal mucus has a bacterial concentration of 10,000 to 100,000 bacteria per ml. Compared to aerobes and facultative anaerobes, five times more anaerobes appear in this mucus.

In expert hands, rigid endoscopy with culture of the osteomeatal complex is a highly reliable test to identify acute bacterial maxillary sinusitis. When compared to material aspirated from a sinus puncture for the three most common bacterial causes of acute sinusitis (Hemophilus influenza, Streptococcus pneumonia, and Moraxella catarrhalis), endoscopy has a sensitivity and specificity of 80-85%. Transportation time of the specimen from patient to laboratory may influence the result.

Question: What antibiotics are approved by the FDA for treatment of acute sinusitis?
Answer: The FDA requires sinus puncture and aspiration to be done on a number of patients before a drug can be approved. Therefore, most studies have been done on maxillary sinus secretions.

As of April 2000 the FDA had approved a number of antibiotics for use in acute sinusitis. They are:

• Augmentin (Amoxicillin-Clavulanate)
• Ceftinere (Omnicef)
• Cefprozil (Cefzil)
• Cefuroxime Axetil (Ceftin)
• Ciprofloxacin (Cipro)
• Clarithromycin (Biaxin)
• Gatofloxicin (Tequin)
• Levofloxacin (Levaquin)
• Loracarbef (Lorabid)
• Moxifloxacin (Avalox).

Question: Which antibiotics are well-tolerated in general, and which ones aren't?
Answer: In general, all the agents used in treatment of bacterial sinusitis are well-tolerated. Of course, this varies from patient to patient. Clarithomycin often causes a fairly unpleasant metallic taste. Doxycycline may cause phototoxicity. Doxycycline and Moxifloxacin do not accumulate in the presence of decreased renal function, which is common in elderly patients.

Question: What if a patient is taking magnesium, iron, zinc, or other supplements?
Answer: The bioavailability or absorption of Ceftin, Doxycycline, and the Floroquinolones can be effected by divalent and trivalent cations such as Magnesium, Iron, Zinc, Aluminum, and so forth. Therefore, if these are taken within four to eight hours of Gadifloxacin, Levofloxacin, or Moxifloxacin administration, the antibacterial effect may be diminished by 50% or more for the entire 24 hours because these agents are given only once daily.

Question: Do Histamine II blockers affect the absorption of Quinolones?
Answer: No, Histamine II blockers do not affect the absorption of Quinolones.

Question: Which antibiotics may be used during pregnancy?
Answer: Many antibiotics are category B, that is to say no teratogenic effects were seen in non-human animals. However, there have been no adequate and well controlled studies in pregnant women. Therefore, no antibiotics should be prescribed unless prescribed by an obstetrician.

The following antibiotics are category B drugs. Amoxicillin, Zithromycin, Ceftin, Ceprozil, Cefuroxime Axetil, and Lorocarbef.

Question: Which antibiotics have a liquid form available?
Answer: Amoxicillin, Augmentin, Zithromycin, Ceftin, Ceprozil, Cefuroxime, Axetil, Ciprofloxacin, Clarithromycin, Doxycycline, and Lorocarbef.

Question: Which antibiotics have, in general, the least food/drug interactions?
Answer: Amoxicillin, Augmentin, Azithromycin, Ceftin, Ceprozile, Cefuroxime, Erthyromycin, Gadifloxacin, and Moxifloxacin.

Question: Which are least expensive?
Answer: Amoxicillin, Doxycycline, and Trimethoprim/Sulfamethoxazole (Bactrim).

Question: How do you distinguish between a bacterial infection and a viral infection?
Answer: It is extremely difficult to distinguish mild bacterial sinusitis from viral sinusitis (the common cold) during the first five days. Some patients are overtreated. If antimicrobial therapy is believed appropriate for this type of patient, the best initial agents are either Amoxicillin or Doxycycline, both of which are inexpensive. Duration of therapy is very controversial, but earlier studies have shown that bacteria persists in large amounts in the sinus after symptoms of acute bacterial sinusitis have resolved. In addition, sinus mucosal healing is variable. Therefore, for acute bacterial sinusitis, we favor 10-14 days of antibiotic therapy. Alternatively, Azithromycin is given for only five days because of its long half-life in tissues. For chronic sinusitis we recommend 21-28 days of antibiotic therapy. Long-term follow up studies with varying lengths of therapy are needed to settle the issue.

Question: What should the family doctor or internist do when a patient fails to respond to initial therapy?
Answer: Patients who fail to respond to initial antibiotic therapy for bacterial sinusitis should have a limited CT scan of the sinuses, and a consultation should be made with an otolaryngologist. This specialist will usually perform a nasal endoscopic evaluation and possibly obtain a specimen for culture and sensitivity. If the CT scan shows no fluid accumulation that would require surgical drainage, a change of antibiotic may be considered. Good second-line agents include Augmentin, Zithromycin, Ceftin, Cefuroxime, Gadifloxacin, and Moxifloxacin.

Question: Give me some important summary considerations or a recap.
Answer:

• Viral sinusitis is common and cannot be clinically distinguished from bacterial sinusitis for five to seven days.
• Viral sinusitis responds to placebo just as well as antibiotics; that is to say, it is self-limited.
• If a patient is still sick after one week of presumed viral rhinosinusitis, antimicrobial therapy plus a decongestant is beneficial. The appropriate length of antimicrobial therapy has not been established for acute bacterial sinusitis. 3-21 days of therapy have been used with many experts recommending 10-14 days for an initial episode and longer therapy of 21-28 days for patients with acute exacerbations of chronic sinusitis.
• The agents effective for acute bacterial sinusitis are also effective for acute bacterial exacerbations of chronic sinusitis; however, the prevalence of anaerobic bacteria in the latter is increased.
• For patients with mild acute bacterial sinusitis, initial therapy with Amoxicillin or Doxycyline is reasonable. For those patients who fail therapy or who have moderately severe disease all of the FDA-approved oral agents should be effective but Augmentin, Zithromycin, Ceftin, Gadifloxacin, or Moxyfloxacin are preferred.
• Patients who are ill enough to be hospitalized should receive IV antibiotics pending appropriate culture and sensitivities. These may include Vancomycin and Ceftriaxone or in the case of severe beta- lactam allergy, Vancomycin and Chloramphenicol plus Ciprofloxacin.
• Overall, the efficacy of the second-line oral agents listed do not differ significantly. Therefore, other factors such as previous therapy, cause, convenience, potential drug interactions, problems, safety, and antimicrobial resistance patterns are important as to which agent to use for empiric therapy for bacterial sinusitis.

OTHER MEDICAL THERAPY:

Nasal Saline Solutions

Question: Tell me about nasal lavage or nasal saline spray.
Answer: Daily frequent use of saline nasal spray or irrigation is recommended to cleanse thick secretions from the nose and sinuses. This simple economical treatment is effective but is unfortunately underused.

Saline nasal spray is available over-the-counter as sterile physiologic saline solution in spray bottles. Alternatively, saline solution may be prepared at home with 1/4 tsp of salt dissolved in 8oz of tap water. A pinch of baking soda may be added. The patient should place the solution in a spray bottle or ear bulb syringe for lavage. Two to four puffs of nasal saline spray should be administered at least three times a day. The alternative more aggressive method is lavage with a bulb syringe while leaning over the sink with the mouth open. Repeated full syringe wash and aspiration is recommended at least three times daily to wash out the secretions if they cannot be effectively removed with saline spray alone.

Not every patient wishes to perform nasal lavage, but some find it the most important treatment of all!

Question: Tell me more about NASAL IRRIGATIONS.
Answer: The nasal and sinus cavities are normally able to clear mucus on their own through "mucociliary transport." Up to one quart of mucus is produced daily and is swallowed. Sometimes swelling of the nose from either allergy, irritation, or infection can prevent this self-cleaning. In these cases, irrigations (nasal flushing or washing) are used until the lining of the nose and sinuses can recover and revert to normal.

Irrigations may be carried out with a spray bottle, a rubber bulb syringe (like the kind used for cleaning infants' noses) or a water-pik device (set on the lowest setting). Whichever device is used, it should be sterilized on a daily basis so that bacteria are not reintroduced into the nasal cavity with each irrigation. Sterilization may be performed with a weak solution of Betadine (available in pharmacies as a douche).

Irrigation solutions can be made from saline (salt water), baking soda, and/or antibiotics. When irrigating the nose, the irrigation solution will run out the front of your nose or down the back of your throat. Although a small amount of this is not harmful if swallowed, larger amounts may produce bloating or fullness in the abdomen. It is therefore best to perform the irrigations while leaning forward over a sink so that the solution may drip or be spit out. Occasionally, we recommend adding a prescription antibiotic (usually gentamicin) to the irrigation solution to inhibit bacterial growth. Patients on a salt-restricted diet should probably avoid using salt in the irrigation fluid (i.e., saline) and may use sterile water.

Homemade preparation of irrigation:

1 pint of boiled water
1/2 teaspoon salt
1/4 teaspoon baking soda
Let cool and irrigate nose with 1/4 to 1/2 cup on each side.

Question: What about steam inhalation?
Answer: In addition to irrigations, steam inhalation also has a beneficial effect on the nasal lining. Various steam-producing inhalation devices are commercially available. Room humidifiers may also provide some symptomatic improvement in some people. However, they can become a source of aerosolized mold and bacteria if they are not cleaned regularly.

Question: Tell me about humidification of air.
Answer: Humidification of inspired air and hydration are other methods recommended to clear thick secretions. In general, a cool mist humidifier, hot steamy showers, and drinking 8 full glasses of water per day are effective.

Question: Anything I should know about vaporizers?
Answer: Vaporizers must be cleaned thoroughly and frequently. While they can be helpful in conditioning air, they can harbor mold and other organisms if they are not cleaned thoroughly and frequently.

Question: What is a netty pot?
Answer: A netty pot is a device of Indian origin that delivers nasal irrigation to wash out a patient's nose. Some patients find netty pot irrigations to be very soothing.

Over-the-Counter Decongestant Sprays

Question: What about over-the-counter nasal sprays?
Answer: Topical nasal decongestants, in the form of drops or sprays, can be very effective in immediately shrinking the swelling of the lining of the nose. However, these sprays should be used no longer than 2 or 3 consecutive days, for prolonged usage may result in "rebound" swelling of the nose. Rebound swelling (known as "rhinitis medicamentosa") can be extremely difficult to treat.

For treatment of acute sinusitis, the topical decongestant Oxymetazoline (also known as Afrin decongestant spray) two puffs in each nostril twice a day for three days provides rapid and effective vasoconstriction. This decreases the obstruction of boggy turbinates and decreases the inflammation that blocks the osteomeatal complex. However, prolonged use of topical decongestant for greater than three days can lead to rebound congestion or rhinitis medicamentosa.

Pediatric strength Oxymetazoline frequently works well in adults and has less rebound congestion.

Over-the-counter topical nasal decongestant sprays are powerful nasal decongestants. For acute, urgent situations they are extremely helpful in opening the sinus and nasal passageways. However, patients with high blood pressure should avoid these sprays.

The nasal mucosa becomes "addicted" to these sprays if they are over-used. What is meant by this is that the decongestant spray loses its effectiveness and instead the patient experiences a "rebound effect" where the nasal blockage worsens unless the patient takes a "hit" or gets a "fix" of the nasal decongestant spray. Used chronically, nasal decongestant spray can also affect blood pressure.

For these reasons, most sinus specialists recommend that decongestant nasal sprays be used only sparingly.

Steroids - Topical Sprays and Oral

Question: Tell me about corticosteroids.
Answer: Steroids are anti-inflammatory medications that are used in the treatment of sinusitis in both a topical (nasal spray) and systemic (pill) form. Because topical steroids are quite effective for allergic rhinitis, systemic steroids are used less commonly than steroid sprays.

Steroids help prevent and decrease swelling of the lining of the nose and sinuses. They also help to decrease the size of polyps and may prevent them from recurring once they have been removed.

Because steroids can also decrease the immune response, there are certain risks associated with their use. The risks associated with topical nasal steroids are relatively limited because they do not have the same degree of widespread effect on the body that may occur with oral steroids. However, adverse reactions may still occur and are described below.

Question: Tell me about topical nasal steroids.
Answer: Topical nasal steroids, along with antibiotics, are considered primary therapy for chronic sinusitis. While antibiotics treat the infectious component, topical nasal steroids treat the inflammatory component, thereby reducing edema of the osteomeatal complex.

Several preparations are available. These agents are highly active topically. The small amounts that are absorbed systemically are rapidly metabolized by the liver and therefore significant systemic side-effects are not expected at the recommended doses.

These drugs include:

• Beclomethasone Diproprionate (brand name Vancenase or Beconase),
• Flunisolide (brand name Nasarel),
• Triamcinolone acetonide (brand name Nasocort),
• Budesonide (brand name Rhinocort),
• Fluticasone (brand name Flonase), and
• Mometazone furoate (brand name Nasonex).

Individuals should be advised to be patient, because the topical nasal steroids have a delayed onset of full action with clinical improvement expected after 7-10 days. There is some immediate effect, but full effect can take 7-10 days. Some recommend an oral steroid for an initial five days when a more rapid effect is desirable.

The patient must understand that nasal steroids are not as effective on a haphazard, as needed basis, and that these medications require regular daily administration. The maximum recommended dose should be used for at least the first four weeks to control symptoms. Otolaryngologists and Allergists often advise continued use at this dosage for two months or longer. The dosage may be weaned when symptoms are well-controlled.

Most of the topical nasal steroids are available as aerosol or aqueous preparations. Regardless of preparation, local side-effects may include burning, irritation, sneezing, drying, crusting, bleeding, and rarely septal perforation.

Question: Tell me more about topical nasal steroid sprays.
Answer: Nasal steroid sprays deliver a steroid dose to the lining of the nose. Because this dose affects the lining of the nose without being completely absorbed by the body, the adverse effects on the patient's body are reduced. For this reason, topical nasal steroids are relatively safe and effective medications for the treatment of nasal swelling and congestion in patients with and without allergies.

Question: Do nasal steroid sprays have any potential adverse effects?
Answer: Nasal steroids may have some local effects on the lining of the nose such as nasal drying, crusting, and bleeding. More extensive local effects such as nasal septal perforations are rare but may occur, especially if the preparations are used more frequently than recommended. Nasal steroids may also produce irritation of the throat.

Although steroid nasal sprays usually do not carry the same degree of risk that systemic (oral) steroids do, some of the same serious side-effects can occur (see section on oral steroids below).

Question: Tell me more about systemic (oral) steroids.
Answer: Systemic steroids are sometimes necessary for the treatment of nasal polyps or swelling of the nasal lining.

Steroids are normally produced by our bodies and are an essential part of our daily functioning. When oral steroids are taken, the body's natural production of steroids decreases. If oral steroids are discontinued suddenly, the body may not have sufficient time to respond and increase its natural steroid production back up to the normal rate. Therefore, the patient's steroid prescription is written so that you will slowly decrease your daily steroid dose (i.e. tapering) prior to stopping completely.

It is not infrequent to have some increased appetite or to retain some fluid when on oral steroid therapy. Patients should therefore watch their diet. An initial high dose may also make patients hyperactive, and they may feel somewhat down as the dose is decreased. However, with appropriate management of the steroid dosage, these effects can usually be minimized.

Individuals at risk for osteoporosis, especially women who have undergone menopause, should have a bone density study performed every 1-2 years if they are on long-term steroids. An annual ophthalmologic examination is also recommended. Systemic steroids should be avoided if the patient has a history of a bleeding abnormality, tuberculosis (TB), glaucoma, significant clinical depression, or an immune deficiency. If the patient has a history of a stomach or intestinal ulcer, he or she should inform the doctor. If steroids are required in these cases, the doctor will prescribe some medication to protect the stomach.

Question: Tell me some of the adverse effects of steroids.
Answer: The risk of cataracts, glaucoma, high blood pressure, high blood sugar (as with diabetes), mood changes, stomach irritation or ulcer disease, bone-thinning (osteoporosis) and menstrual irregularities may occur with oral steroid use. Thus, if a patient has a history of any of these problems, they should be sure to inform their doctor.

A serious but very rare adverse reaction to oral steroids (avascular necrosis) can result in permanent damage to an affected joint. Fortunately, this is very uncommon. However, patients should inform their physician if they develop significant joint pains while taking oral steroids. Patients should not stop their steroid medication suddenly without consulting their physician.

Question: Do you have anything else to say about steroids?
Answer: It would be worthwhile to summarize and repeat certain points about oral steroids. It is increasingly recognized that oral corticosteroids can provide significant temporary relief in patients whose rhinosinusitis responds incompletely to decongestants, antihistamines, topical nasal steroids or surgery.

Some of the more common side-effects that might be encountered include increased appetite or fluid retention with oral steroid therapy. Patients should therefore watch their diet. Patients may also experience mood swings. An initial high dose may make patients feel hyperactive or experience insomnia, and they may feel somewhat down or depressed as the dose is decreased.

Some of the less common side-effects include the risk of cataracts, glaucoma, high blood pressure, high blood sugar (as with diabetes), stomach irritation or ulcer disease, bone-thinning (osteoporosis), loss of potassium, and menstrual irregularities. The risk of these may increase with oral steroid use. If a patient has a history of any of these problems, they should be sure to inform their doctor.

Some of the rare side-effects must also be noted. A serious but very rare adverse reaction to oral steroids -- avascular necrosis -- can result in permanent damage to an affected joint, including chronic debilitating pain that may result in the need for joint surgery. Fortunately, this is very uncommon. However, patients should inform their physician if they develop significant pains while taking oral steroids.

With appropriate management of the steroid dosage, side-effects can usually be minimized. Below are instructions for taking this medicine to decrease side-effects and increase effectiveness:

• Take between 6AM and 8AM, when the body secretes a natural steroid named cortisol.
• Avoid excessive consumption of stimulating substances, such as decongestants or caffeine. They may add to the increased energy level causing irritability, restlessness, and insomnia.
• Avoid steroids during pregnancy, breast feeding or if there is a history of bleeding abnormality, tuberculosis (TB), significant clinical depression, or immune deficiency.
• If oral steroids are discontinued suddenly, the patient's body may not have sufficient time to respond and increase its natural steroid production back up to the normal rate. Therefore, steroid prescriptions are usually written so that patients will slowly decrease their daily steroid dose (tapering) prior to stopping completely.

The following are recommended to monitor for complications during long-term use of oral steroids:

Annual ophthalmologic examination
Bone density scan
TB test

The vast majority of patients we have treated with systemic corticosteroids do not suffer significant side-effects and tolerate the medication well. However, we believe it is best to inform patients of the potential risks.

Antihistamines

Question: Tell me about antihistamines.
Answer: Some chronic sinusitis sufferers have allergies that may contribute to swelling in the nose and sinuses. If a patient has a significant history of underlying allergies, antihistamines may be necessary to help control the allergic response.

Antihistamines are designed to oppose the effects of histamine, the main chemical released by the body in allergic reactions. Antihistamines do not truly alter allergic susceptibility but can lessen the uncomfortable symptoms of an allergic reaction. Antihistamines should be used to treat allergic sinusitis but should not be used to treat non-allergic sinusitis because they potentially thicken the secretions and lead to crust formation which can further obstruct the nasal and sinus passageways.

Antihistamines are most effective when taken before an anticipated allergic reaction (such as before visiting a friend with a cat if you have a cat allergy. If taken after an allergic reaction is already in progress, the helpful effects may be delayed. Therefore, in patients with significant allergies, the medication is typically taken on a regular basis.

Adverse effects: Many antihistamines have a sedating effect, and the drowsiness they produce is usually the most undesired side-effect. The more recently developed non-sedating antihistamines such as Claritin, Zyrtec and Allegra, are exceptions to this rule. Side-effects of antihistamines include dry mouth, blurry vision, and difficulty urinating.

Question: Tell me more about antihistamines.
Answer: Antihistamines are important in the treatment of inhalant allergies. Antihistamines work by competing with histamine for H-1 binding sites on the respiratory mucosa. Histamine is a mediator for immediate allergic reactions and anaphylactic reactions. Antihistamines work to prevent these reactions, and therefore are most effective when given before exposure to allergens.

Antihistamines are effective in relieving symptoms such as itching, sneezing, rhinorrhea, and post-nasal drip. The primary side-effect of the traditional antihistamine is sedation. They can also cause significant dryness and crusting within the nose. The second generation antihistamines are considered non-sedating and have less tendency to cause excessive dryness.

Traditional or "first generation" antihistamines include diphenhydramine (Benadryl, chlorpheniramine maleate (Chlor-Trimeton), meclizine (Antivert), hydroxyzine (Atarax), and promethazine (Phenergan). Meclizine is also useful for control of dizziness or vertigo. Hydroxyzine is used as a tranquilizer and Promethazine is useful for control of nausea.

Second generation antihistamines include loratidine (Claritin) and terfenadine (Seldane).

Third generation antihistamines include Cetirizine (Zyrtec) and fexofenadine (Allegra).

Topical antihistamines (nasal sprays) include azelastine (Astelin) and levocabastine (Livostin).

Question: Tell me about Astelin nasal spray.
Answer: Astelin is an antihistamine nasal spray. It can be used in patients with nasal allergy symptoms and can be used in addition to an oral antihistamine.

Question: Tell me about MAST CELL STABILIZERS.
Answer: Cromolyn sodium is a non-steroidal anti-inflammatory medication prescribed for patients with allergies. It acts to prevent the body's release of chemicals (mainly histamine) that produce allergic symptoms (such as nasal congestion, itchy eyes and nose, and wheezing). It does this by stabilizing the membrane walls of the cells that contain these chemicals. The mast cells are thus resistant to allergic reaction and less likely to release these chemicals when incited by an allergen.

These agents are used in the prevention of allergic reaction and, therefore, must be used before allergy symptoms occur. They should be taken on a regular basis in patients with extensive and unpredictable exposure to allergens (substances which induce an allergic reaction). In patients with more limited allergies, who can predict their exposure, cromolyn sodium can be used 30 to 45 minutes before the allergen is encountered (e.g., a person allergic to grass would spray his or her nose before mowing the lawn). Because there is currently no long-acting cromolyn preparation available, the medication must be administered at least four times per day. Adverse effects: The most frequent adverse reactions to cromolyn include nasal burning and sneezing, nasal bleeding, post-nasal drip, and rashes.

Decongestants

Question: Tell me about decongestants.
Answer: Because the treatment of chronic sinusitis requires a more prolonged course than acute sinusitis, topical decongestants are not recommended. When topical decongestants are used for more than three to five days, a "rebound effect" with worsened symptoms will typically result.

Instead, oral systemic decongestants such as Pseudoephedrine and Phenylpropenalanine are often used during the treatment, especially if significant congestion is detected on exam.

However, oral decongestants may raise blood pressure, and patients and their doctors should monitor blood pressure and may need to discontinue oral decongestants if blood pressure is affected.

Since higher concentrations are present in the bloodstream, systemic decongestants are more likely to produce side-effects. These include high blood pressure, anxiety and sleeplessness, and the "jitters." Decongestants can also cause blurry vision (in patients who suffer from glaucoma) and difficulty urinating in patients with prostrate problems.

Patients should let their doctor know if they are currently taking any medications for depression, since these medications can have serious adverse effects when they interact with either topical or systemic decongestants.

Mucolytics, Anti-Fungals and Macrolides, and Others

Question: Tell me about mucolytics.
Answer: Mucolytic agents are drugs that thin mucus and secretions so they can drain out of the sinuses more easily. They may be helpful for people suffering from thick post-nasal drip. Often, they are found in combination preparations with decongestants and/or antihistamines. Most are well-tolerated and have few side-effects. Some patients develop stomach upset when taking mucolytics.

A common mucolytic agent is Guaifenesin. This has long been used and is considered effective as a mucolytic and expectorant in bronchitis. Guaifenesin (brand name Humibid) is considered effective in liquifying the annoying thick secretions associated with chronic sinusitis.

Guaifenesin is the most common expectorant found in cough syrups. For chronic sinusitis, the recommended daily dose is up to 2400 mg. This is available in tablet or liquid form and may also be found in combination with oral decongestants. In higher doses Guaifenesin acts as an emetic and, occasionally, the dose used in chronic sinusitis must be limited because of GI discomfort. Other mucolytics, such as saturated solutions of Potassium Chloride or Ammonium Chloride, are occasionally used.

Question: Tell me about leukotriene esterase inhibitors.
Answer: Leukotriene esterase inhibitors include Zyleutin and Zyflo. These are medications that are used in pulmonary diseases such as asthma. Their exact biochemical effect is to interfere with a unique inflammatory pathway and thereby diminish inflammation and swelling. Because they do not work in the same way as steroids, they can have an additive effect when used in conjunction with steroids and other medications.

Question: Tell me about Singulair.
Answer: Singulair is a medication often used in asthma. It has specific anti-inflammatory effects. It works by blocking a specific inflammatory route that is not typically affected by other anti-inflammatory agents. Singulair is also sometimes useful in patients with sinusitis.

Question: Tell me about Sporonox.
Answer: Sporonox (generic name Itraconazole) is an antifungal medication. There is a current theory that some sinusitis is due to fungus. In these cases, it is thought that anti-fungal medication may be of benefit, just as antibiotics are of some benefit to many patients with chronic bacterial sinusitis.

Sporonox has some potentially serious side-effects, including the risk of damage to the liver. Therefore, it must be given only under the care of a physician. Liver function tests are obtained before, and periodically during, treatment. Treatment is terminated if the patient's blood tests are elevated by the medication, or if the patient develops any concerning symptoms such as abdominal pain.

Sporonox also has an effect of increasing the effectiveness of prednisone. So, if a patient on prednisone is given Sporonox and reports improvement, the improvement may not necessarily have been caused by an anti-fungal effect, but it may have been caused by the effect of improving the action of the prednisone.

There is anecdotal evidence that this treatment can be beneficial, but there is not yet strong evidence in the medical literature. Certainly, Sporonox is a medication that should not be used routinely.

Question: Tell me about Macrolides.
Answer: Macrolides are a class of antibiotics. An example is erythromycin. In Japan, these antibiotics are used commonly in patients with sinusitis -- not for their anti-bacterial effect but for their effect on the immune system. Research has indicated that macrolides up-regulate (improve) certain aspects of the immune system and can thereby help the body fight sinusitis. However, one criticism of this use of the Macrolide antibiotics is that there is a risk that bacteria could become resistant to these antibiotics if they are over-used, thereby potentially creating a difficult problem due to infection with resistant bacteria.

When Symptoms Persist Despite Medical Treatment

Question: Do guidelines exist that help in determining when surgery is warranted?
Answer: Yes. Doctors refer to these guidelines as the "indications" for surgery. Indications for surgery may be absolute, meaning that surgery is absolutely necessary, or they may be termed "relative indications," meaning that the patient and the doctor must weigh the potential risks and benefits, but that surgery may be considered a viable option given the patient's history and physical findings.

Question: What are some absolute indications for sinus surgery?
Answer: Absolute indications for sinus surgery include bilateral extensive and massive obstructive nasal polyposis with complications, complications of adult rhinosinusitis (such as subperiosteal or orbital abscess, meningitis, or brain abscess from progression of sinus disease), chronic rhinosinusitis with mucocele or mucopyocele formation, invasive or allergic fungal adult rhinosinusitis, cerebrospinal fluid rhinorrhea, and the diagnosis of a tumor of the nasal cavity or paranasal sinuses.

Question: What are some relative indications for FESS in chronic sinusitis?
Answer: Surgical intervention for chronic sinusitis is reserved for those patients in whom maximal medical therapy has failed. Functional endoscopic sinus surgery has become the most widely accepted approach for patients requiring surgical intervention for chronic sinusitis. The goal is to return the sinuses to as near a normal anatomic state as possible. This surgery is intended to correct conditions that impede mucocilary clearance of the sinuses, especially through the osteomeatal complex. Respect of the normal drainage patterns of the sinuses and elimination or improvement of obstruction of these drainage pathways promotes the resolution of mucosal hypertrophy and infection and the return to a normal disease-free state.

Most cases of chronic sinusitis treated by otolaryngologists are successfully treated with medical therapy. When medical therapy fails, the surgical alternative is a consideration.

Relative indications for sinus surgery include persistent chronic adult rhinosinusitis despite medical therapy. Associated factors exist that may alter the threshold for surgery; these include congenital variations in the anatomy of the nasal cavity and paranasal sinuses, mucociliary dysfunction, allergic fungal sinusitis, reactive airway disease, and others.

A relative indication for FESS exists in adults who have persistent troubling symptoms despite medical therapy and who have persisting endoscopic and/or CT scan evidence of sinusitis, anatomic obstruction, and persistent disease despite medical therapy. Endoscopic evidence of persisting sinusitis may include polyps, mucosal hypertrophy, edema, and pus from a sinus orifice.

Question: What are some relative indications in recurrent acute sinusitis?
Answer: Recurrent acute sinusitis refers to the situation where a patient has repeated acute sinus infections but is relatively symptom free between these infections. Relative indications for FESS in adults and in children over 12 who have recurrent acute sinusitis include:

1. Four or more episodes of infection during the past 12 months
2. A trial of immunotherapy for allergic rhinosinusitis or absence of allergy
3. Presence of an anatomic variant, especially one contributing to OMC obstruction
4. Prophylactic use of medical treatment without benefit.

Surgical Treatment

Question: Who is a candidate for sinus surgery?
Answer: Sinus surgery is a treatment of last resort. Most patient symptoms can be improved with a variety of medical and allergy treatments. For patients whose symptoms persist, and do not respond to medical interventions sinus surgery may be warranted. In particular, patients who have anatomical abnormalities that lead to persistent or recurrent obstruction of the sinus drainage pathways may benefit from a minimally invasive sinus procedure. In other patients with more severe anatomical abnormalities, more aggressive interventions may be required.

Question: What are the goals of sinus surgery?
Answer: In some patients with chronic sinusitis, anatomical abnormalities contribute to the persistent swelling, edema, and infections that may occur in the sinuses. Often this has to do with blockage of the small pathways through which the sinuses drain. By surgically opening and enlarging these pathways, the sinuses can drain more naturally and freely. Also, when the sinuses are "nasalized," or open to the nasal passage, topical nasal sprays can reach into the sinuses where they can further decrease inflammation without the systemic effect of oral medications. When patients do have sinus infections (and sinus surgery does NOT mean you will never get another sinus infection), the sinuses are now open so the infection can be cultured in clinic under endoscopic guidance. With results from a culture, the correct antibiotic can be chosen, so that patients decrease the incidence of unnecessary and ineffective treatments, as well as the development of resistant bacteria.

Question: If I have sinus surgery will I be done with sinus infections forever?
Answer: As noted above, having sinus surgery does NOT mean you will never have another sinus infection. The goals of surgery are to decrease the frequency of sinus infections, as well as to hasten the recovery time when you do get an infection.

Question: How is sinus surgery performed?
Answer: Most sinus surgery is performed through the nose using small (4 millimeter diameter) endoscopes. Using the endoscope, the surgeon finds the natural openings of the sinuses which have been blocked by swollen tissue. The blockages are removed and the natural openings are enlarged with small instruments also placed through the nose. In recent years there have been a variety of technological developments which have increased the range and variety of instruments available to open these blockages. Your surgeon will decide, based on your history and anatomy, which instruments and methods are most appropriate for your surgery.

Question: What is "functional endoscopic sinus surgery?
Answer: The nasal and sinus passages have a lining that clears mucous and foreign irritants in order to maintain a healthy environment. In "functional" surgery, care is taken to remove the offending portions of anatomy while sparing as much of the nasal and sinus lining as possible. This allows for maximal effect of the surgery in an attempt to regain a healthy, normal sinonasal environment. Most sinus surgery today is "functional endoscopic sinus surgery," or "FESS." As noted above, the surgery is usually performed through the nose (endonasal) and the areas are visualized with the use of a small (4mm) endoscope ("endoscopic sinus surgery").

Question: What is this balloon stuff I keep hearing about?
Answer: In the past several years there has been an application of heart catheter technology to the sinuses. In particular, 2 companies (Acclarent and Entellus) have devised tools to open and enlarge the sinus openings (ostia) with the placement of small balloons which are then inflated under steady pressure. These tools are appropriate for some, but not all patients who undergo sinus surgery. Your surgeon will discuss this with you if he/she feels that you would benefit from the use of balloon technology during your sinus procedure.

Question: What is image-guided sinus surgery?
Answer: When operating in the sinuses, surgeons strive to perform safe, efficient, and complete surgery. Image guidance systems are now routinely available at most surgery centers. These are, in essence, systems for the sinuses which track the location of the surgeon's instruments within several millimeters.

Question: If I have sinus surgery, will I need surgery again?
Answer: For the vast majority of patients who undergo sinus surgery, no further surgery will ever be required. In fact, many studies have demonstrated that the vast majority of patients who undergo endoscopic sinus surgery are ultimately very satisfied with their results. There are some patients; however, who will undergo revision procedures. This may be due to post-operative scarring after the initial surgery, progression of disease after the initial surgery, or other reasons. In most patients who do undergo revision procedures, the amount of surgery required is less than the initial procedure, since these cases tend to require "touch ups" at specific sites.

Question: What if I already have had sinus surgery and I am still suffering?
Answer: Patients who have had surgery and have persistent signs and symptoms of sinusitis should be seen by a trained otolaryngologist. Your otolaryngologist has a variety of tools to help pinpoint the source of your persistent problems. An in-office endoscopy can be performed in the matter of minutes and may reveal obvious anatomic causes of persistent symptoms, such as post-operative scarring. Sinus CT scans, allergy testing, and other diagnostics can also be performed to help find the source of persistent sinusitis after sinus surgery. In many cases, patients respond to a simple change of medication. Other cases may require a revision procedure.

Question: What can I expect the day of surgery?
Answer: Most sinus surgery is performed as an outpatient procedure, often at ambulatory surgery centers. Typically patients will be notified the day before surgery and told when to arrive at the surgery center. Arrival time is NOT the same as surgery time. You will be asked to arrive a few hours prior to your surgery time to review surgical logistics, and meet your anesthesia team. In most cases, patients will be told not drink or eat after midnight. If you are taking asthma inhalers, or other chronic medications, you will often be asked to bring these with you. In the private waiting areas, patients meet with their anesthesia team and discuss their medical history and prior anesthesia history. If the patient has a history of adverse reactions to anesthetics or other medications, it is essential to communicate this to the physicians and nurses. During this same time, nurses will review with the patient all pre-operative records, confirm the nature of the proposed surgery, and administer any required pre-operative medications. Patients should remember that they will not be able to drive themselves home after surgery center. A designated driver (usually a family member) is required for surgery to proceed.

Question: What can I expect the night after surgery?
Answer: The night after sinus surgery most patients try to relax at home (or in a hotel if they have traveled a long distance). Patients may have a sore throat for a day or two as a result of the endotracheal tube (breathing tube) used by anesthesia during the surgery. Patient s can expect mild to moderate pain after surgery. While pain is not typically a large complaint after sinus surgery, patients should take their prescribed pain medications (as they are prescribed) if they feel the need. Allowing pain to progress will increase patient blood pressure which in turn may increase post-operative bleeding. It is normal to have a small amount of by red (bloody) nasal drainage. For a few days after surgery, it may be useful to elevate the head of your bed. This will likely increase your comfort and decrease nasal bleeding. Most patients will experience some level of fatigue for the first 1-2 weeks after surgery. It is important to remember that just because you look the same (no big casts on your arm) and do not have much pain does not mean that you did not have surgery. You will need to give your body time to recover from the procedure.

Question: What are some tips for the immediate post-operative period?
Answer: Here are some important tips to remember during your immediate postoperative period:

• Cough and sneeze with your mouth open.
• Do not blow your nose.
• If you have nasal congestion, sniff and spit into a tissue.
• Keep the head of your bed elevated.
• Alert your doctor for any of the following - excessive bleeding, pain not controlled by pain medication, or vision problems

Question: How much pain should I expect after sinus surgery?
Answer: Sinus surgery is not typically associated with a high degree of post-operative pain. Patients are given narcotic pain medications (ie., Tylenol with codeine) to help manage any pain they may experience. Typically patients seen a few days after surgery will report that they take 1-2 pain pills a day. By 1 week most patients are doing well with over the counter pain medications like Tylenol.

Question: Is there a lot of bleeding during sinus surgery?
Answer: Most patients have minimal bleeding during sinus surgery (less than 50 ccs of blood loss). Patients with a history of bleeding disorders, easy bruising, bleeding when brushing teeth, heavy menses, etc should be evaluated closely prior to surgery. If you have a history of easy bleeding or bruising, make sure to bring this up to your doctor during your pre-operative discussions.

Question: How often do I have to come back to see my doctor after sinus surgery?
Answer: Your doctor will want to see you fairly often after surgery. Typically you will be seen several times in the first 6-8 weeks after surgery. This is to make sure that you heal well. During these visits your surgeon will use a small endoscope to inspect your surgical site and remove crusting that is present. This is an important aspect to having a successful outcome after your surgery.

Question: What can I expect in the days and weeks after sinus surgery? When can I resume my normal daily activities?
Answer: Most patients are advised to plan for 1 week off of work after nasal and/or sinus surgery. During this week patients should expect to have a small amount of pain which is typically well-controlled with prescribed medications. Ironically, many patients will have worsened nasal obstruction/congestion for the 7-10 days after surgery due to expected swelling after surgery. If this becomes bothersome, it can often be managed with an oral steroid pack. Patients should also expect to have fatigue during this first week or two after surgery. Most patients go back to work at the start of the second week after surgery. Patients typically feel well enough for work during this week, but do not feel "100 percent." After two weeks most patients are back to their baseline. At 1 month most patients typically feel the positive effects of their surgery. This should continue to improve over the months to come.

Question: Is there packing placed after surgery? Will I have "black and blue" marks?
Answer: In years past, packing was used routinely after septoplasty and sinus surgery and associated with significant post-operative pain and discomfort. In today's surgical environment, the use of non-absorbable packing is much less common. In many cases your doctor may use no packing at all. In some cases, your doctor may decide to leave small silastic splints in place for a few days. These splints typically have ports to allow air to pass in and out of the nose and are well-tolerated by patients. Splints are usually removed in the office a few days after the surgery. Splint removal typically takes under 60 seconds and is well-tolerated. In the case of significant bleeding your doctor may decide to use non-absorbable packing. With the easy availability of modern endoscopes and small surgical cautery devices for the management of nasal and sinus bleeding; however, this is uncommon. With traditional septoplasty there are no external incisions, and black and blue marks are for the most part a thing of the past.

Question: Do I need a septoplasty?
Answer: The nasal septum sits roughly in the midline of the nose and separates the right and left sides. If the septum is deviated, or tilted to one side it may decrease the nasal airflow on that side. Sometimes when the septum is deviated it may also push surrounding structures to the sides of the nose so that they obstruct the sinus drainage pathways. When septal deviation is found to contribute to symptoms of nasal obstruction, congestion, and � in some cases � sinusitis, surgical correction may be warranted.

Question: What is a septoplasty?
Answer: The nasal septum is like an "Oreo cookie": it has lining on each side with bone and cartilage "filling" in the middle. In a septoplasty, a small, hidden incision is made inside the nose, and the surgeon dissects underneath the lining. The deviated, obstructing portions of the bone and cartilage are removed, and the lining is then sewn back together so that it may heal. Sutures are dissolvable and do not require removal.

Question: What are the possible risks and complications of septal and sinus surgery?
Answer: Sinus surgery is considered safe, outpatient surgery and is performed on a routine basis in the United States. Complications do occur; however, and these should be reviewed during the informed consent process. A review of the national and international literature has revealed the following complications that have occurred in patients around the world. These include but are not limited to bleeding/hemorrhage, infection, anesthetic risk, persistence/ recurrence/ or even worsening of the problem (including the need for revision surgery), scarring, decreased or loss of smell and/or taste, changes to the voice, need for further surgery, temporary or permanent numbness of the upper lip/teeth/cheek and/or nose, atrophic rhinitis/empty nose syndrome, epiphora (persistent tearing), temporary or permanent numbness of the eyebrow and forehead (after frontal sinus trephination), septal hematoma, saddle nose deformity, and septal perforation. More severe risks to surgery include damage to surrounding structures, including the eyes with possible double vision and blindness and including the brain with possible cerebrospinal fluid leak, meningitis, abscess, seizures, stroke and death. These complications are reviewed in more detail in the Online Textbook (Chapter on Sinus Surgery).

Surgical Anatomy

Question: Why is the sinus anatomy important?
Answer: Each patient's sinus anatomy has a unique configuration, and it is vital that this is well delineated for surgery to be successful.

Question: Tell me a little about the general anatomy.
Answer: The four paired paranasal sinuses are the ethmoid, maxillary, frontal, and sphenoid sinuses. These are named after the cranial bones in which they are located. The sinuses normally contain air and are lined with ciliated pseudostratified columnar epithelium with interspersed mucus secreting cells.

Question: Tell me more details about the anatomy.
Answer: This detailed information is provided for those who are interested. This information is complex and may be best understood if you refer to the accompanying diagrams.

Question: Tell me about the ethmoid sinuses.
Answer: The ethmoid sinuses are the sinuses "between the eyes." They are typically fully developed by age 12. They are like a honeycomb, consisting of multiple small sinus cells that together form the ethmoid sinus. The ethmoid sinus lies near the brain and near the eyes. For this reason, untreated severe sinusitis can lead to brain and eye complications.

The ethmoid sinuses begin development at the third fetal month. They evaginate from the lateral nasal wall. At birth, usually three or four ethmoid cells are present. However, they are difficult to recognize on x-rays until the infant reaches about six months of age. Only the ethmoid and maxillary sinuses are significantly developed enough at birth to be clinically significant. (Significant growth of the sphenoid and frontal sinuses are rarely seen until three years of age.)

The ethmoid sinuses reach nearly adult size by age 12. They do not develop as single cavities but rather as multiple cells, usually 12-15 on each side that are separated by thin bony septa. The lateral or sidewall of the ethmoid sinus is called the "lamina papyracea," or "paper thin bone." The lamina papyracea also forms the medial (middle) wall of the orbit.

The upper border of the ethmoid sinus is called the fovea ethmoidalis, or "ethmoid roof." The fovea ethmoidalis is a part of the skull base and separates the ethmoid sinus from the brain. Medially along the roof of the ethmoid sinus is the thinner bone of the cribriform plate that separates the nasal cavity from the brain. The cribriform plate tends to lie 2-3mm lower than the fovea ethmoidalis. These anatomic relationships of the ethmoid sinuses to the eyes and the brain are the reasons that untreated severe sinusitis can lead to eye and brain complications.

The ethmoid sinus can be thought of as having two distinct groups of sinus cells. The anterior or front group drains into a space called the middle meatus, and the posterior group drains into a space called the superior meatus. The anterior and posterior ethmoid cells are divided by a plate of bone called the "basal lamella" or "ground lamella."

The anterior ethmoid cells can be further sub-divided into frontal recess cells, infundibular cells, agger nasi cells, bulla cells, and conchal cells. The frontal recess is the most anterior and superior (upper) area within the anterior ethmoid compartment - the frontal recess communicates with the frontal sinus. Agger nasi refers to a mound immediately in front (anterior) and above (superior) the insertion of the middle turbinates. When the agger nasi is aerated, its increased size may cause structural blockage. The ethmoid bulla is the largest and most constant air cell of the anterior ethmoid complex. Concha bullosa refers to pneumatization of the middle turbinate.

The ethmoid infundibulum represents a cleft or space through which a number of the sinuses (the frontal, maxillary, and anterior ethmoid) drain. Therefore, it is an important "major intersection." The boundaries of this space are formed in the front (anteriorly) by the uncinate process, on the side (laterally) by the lamina papyracea, and in the back (posteriorly) by the ethmoid bulla. The ethmoid infundibulum opens into a space in the middle, called the middle meatus, through an imaginary plane called the hiatus semilunaris.

Question: Tell me about the anatomy of the maxillary sinuses.
Answer: The maxillary sinuses are the first of the sinuses to begin in fetal development. While the maxillary sinus is pea sized and fluid filled at birth, it undergoes two rapid growth spurts. The first is between birth and age three years and the second is between age seven and 18. The sinus becomes adult size by adolescence.

The drainage pathway or ostium of the maxillary sinus is located in the upper and front part of the middle wall of the maxillary sinus. Through this ostium the maxillary sinus communicates with the nose. Specifically, mucus drains from the maxillary sinus into the infundibulum in the middle meatus and out into the nose.

If the main drainage pathway becomes closed by inflammation or infection, accessory or secondary openings can be formed. These are essentially holes in the thin bone making up the middle wall of the sinus that are caused when pressure buildup pushes through. If your doctor finds an accessory opening on examination of the inside of your nose, that may be "evidence" that you have had previous problems with sinus blockage.

The maxillary sinus is beneath the eye, so the roof of the maxillary sinus is also the floor of the orbit. The floor of the maxillary sinus is formed by the maxillary bone; specifically, a part called the "alveolar process." It is important to know that the roots of the first and second molar teeth and the second bicuspid teeth often project through the floor of the maxillary sinus, where they are covered only by the thin mucus membrane within the sinus. Infection around these tooth roots may cause inflammation of the sinus mucous membranes and sinus pain. At times, removal of these teeth can cause a fistula (opening between the mouth and sinus) which can lead to repeated sinus infections.

The anterior or front wall of the maxillary sinus separates the sinus from the cheek skin, while the posterior or back wall separates the sinus from a space filled with blood vessels and nerves. The upper part of this space is called the infratemporal fossa, and the lower part is called the pterygomaxillary space.

Question: Tell me a little about the frontal sinuses.
Answer: Although the frontal sinuses begin developing during the fourth month of gestation, they are not clinically perceptible at birth. The frontal sinuses can rarely be demonstrated on plain x-ray before two years of age. Growth of the frontal sinuses is typically complete by about age 20. About 5% of the population fails to develop one or both frontal sinuses.

The frontal sinus has a front (anterior) and and back (posterior) bony wall. The front wall separates the sinus from the forehead soft tissue and skin. The back wall separates the sinus from the brain. The front wall is approximately twice as thick as the back wall.

The frontal sinus is usually divided into two sides by a very thin bony divider. The mucus from the frontal sinus drains out a small channel called the frontal recess, into the infundibulum, then into the upper part of the middle meatus, and out into the nose. Sometimes, the frontal recess bypasses the infundibulum and drains directly into the middle meatus.

Question: Tell me about the sphenoid sinus.
Answer: The sphenoid sinus begins developing during the third month of gestation but is not perceptible at birth. Further significant growth does not begin until a child is three years of age. Pneumatization and growth usually becomes rapid after seven years and reaches adult size by 12-15 years.

The left and right sphenoid sinuses are separated by a thin bony partition. The sphenoid sinuses are usually asymmetric. The sphenoid sinus drains into the nose through the sphenoid ostium into a space called the sphenoethmoid recess, and out into the nose.

Several important structures occupy positions in relationship to the sphenoid sinus. Importantly, the optic nerve and pituitary gland are above the sphenoid, and a part of the brain called the pons is just behind the sphenoid. The internal carotid arteries are just to the side of the sphenoid sinus. A part of the brain called the cavernous sinus is also found to the side of the sphenoid sinus.

In half of the population, the internal carotid artery forms a visible indentation in the side wall of the sphenoid sinus. The bony wall is not always complete, so great care must be taken when performing sphenoid surgery.

Question: What are the turbinates?
Answer: The turbinates are scrolls of bones covered by mucous membrane that project from the side wall of the nose. The shape of the turbinates increases the surface area of the mucus lining within the nose, allowing greater filtration of particulate matter and greater efficiency in warming and humidifying inspired air.

The inferior turbinate usually is the most prominent and obvious projection from the sidewall of the nose on examination. There are usually three turbinates on each side the inferior, middle, and superior. However, at times a small fourth turbinate, the supreme turbinate, can be seen.

Question: What is the agger nasi?
Answer: Agger nasi refers to a small prominence seen in front of (anterior to) the middle turbinate. This is an aeration in the bone that overlies the lacrimal sac. At times this aerated agger nasi can be large and contribute to nasal and sinus blockage.

A number of doctors believe that the agger nasi represents the remnant of another turbinate found in animals.

Question: What are the meatuses?
Answer: The meatuses or meati are spaces created by the turbinate. The inferior meatus is a space between the inferior turbinate and the lateral nasal wall. The nasolacrimal duct drains into the inferior meatus, at the front.

The middle meatus is the space between the middle turbinate and the lateral nasal wall. A number of sinuses drain into the middle meatus.

Likewise, the superior meatus is located between the superior turbinate and the lateral nasal wall.

The frontal sinus, maxillary sinus, and anterior ethmoid sinus drain into a common channel called the infundibulum. This infundibulum then drains into the middle meatus and out into the nose.

Question: Delineate some more anatomic definitions.
Answer: The borders of the infundibulum are the uncinate process anteriorly, the ethmoid bulla posteriorly, the lamina propria laterally, and the hiatus semilunaris medially. The uncinate process is a thin bone attached anteriorly to the lacrimal bone and inferiorly to the superior aspect of the inferior turbinate.

The ethmoid bulla is the most anterior and most prominent ethmoid cell. The lamina papyracea is a paper-thin bone that separates the orbit from the ethmoid sinus. The hiatus semilunaris is the medial opening by which the secretions from the infundibulum are brought through the middle meatus into the nasal cavity.

The basal lamella or ground lamella is an important bony landmark that separates the anterior and posterior drainage systems. In the ethmoid sinus, the basal lamella separates the anterior ethmoid from the posterior ethmoid cavity. The anterior ethmoids, as mentioned, drain into the middle meatus while the posterior ethmoid sinus drains into the superior meatus. Finally, the sphenoid sinus drains posteriorly to the sphenoid ostium, from there into the sphenoethmoid recess into the back of the nasal cavity.

Question: What is the osteomeatal complex?
Answer: The osteomeatal complex is the key anatomic area addressed by endoscopic sinus surgeons. Most authorities agree that blockage of the osteomeatal complex prevents effective mucociliary clearance, thus leading to a stagnation of secretions and therefore leading to recurrent or chronic sinusitis.

The OMC is bounded medially by the middle turbinate, posteriorly and superiorly by the basal lamella, and laterally by the lamina papyracea. Inferiorly and anteriorly the OMC is open. This anatomic region therefore includes the anterior ethmoid sinus, ethmoid bulla, frontal recess, uncinate process, infundibulum, hiatus semilunaris, and middle meatus.

Question: Tell me about how sinusitis affects the quality of life.
Answer: If you have sinusitis, you already know sinusitis has a NEGATIVE impact on your quality of life. But did you know there is specific scientific proof?

To analyze quality of life, questionnaires have been developed to produce reliable Health Related Quality of Life (HRQL) data.

In an important study by Doctors Glicklick and Metson, patients with chronic sinusitis were found to have significant decreases in quality of life measures. The areas that were most affected were bodily pain, general health, vitality and social functioning. Such decrements in quality of life for chronic sinus patients were similar to those seen in other chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure, and chest pain or angina pectoris.

A subsequent study by Drs. Winston and Barnet, also in patients with chronic sinusitis, found that these patients had significant decrements in multiple areas of health-related quality of life. The most affected areas were physical bodily pain, social functioning and vitality.

Drs. Gliklick and Metson reported on the effect of sinus surgery on quality of life in 1997. In this study, 82% of patients who underwent surgery for chronic sinusitis demonstrated statistically significant clinical improvement in their sinusitis-specific measures of life quality. Patients who underwent surgery for chronic sinusitis demonstrated significant improvement in 6 of the 8 sub-scales of general health one year after surgery.

Question: Everyone is talking about the paper from the MAYO clinic. What is it all about?
Answer:The article published in the MAYO proceedings of September 1999 reported that using specialized techniques, fungal growth was found in 96% of patients with chronic sinusitis. Fungal growth was found in 100% of normal healthy volunteers, people without sinusitis. Why is this interesting? Well, the researchers have found evidence that the sinus patients appear to have an abnormal inflammatory reaction to the fungus, while normal subjects do not. These researchers speculate that treating fungus in these patients may improve their symptoms. The discovery that fungus is present in healthy people and in patients with chronic sinusitis was a surprise. The apparent difference in the way these two groups react to fungus provides some hope for new treatments.

There is little convincing published evidence that anti-fungal therapy routinely relieves sinus symptoms. Anecdotal reports do suggest that selected patients show improvement.

Question: What is itraconazole?
Answer: Itraconazole, or Sporonox, is a medication that is used by doctors to treat fungal infection. When doctors suspect fungal cause of sinusitis, they may discuss treatment with a course of Sporonox. The doctor will then order blood tests to check your liver function before treatment, and then several weeks into treatment, to be sure that it is not adversely affecting your liver. If it is, you may have to discontinue this therapy.

Question: Tell me about computer-assisted or image-guided endoscopic sinus surgery.
Answer: Computer-assisted surgery was initially developed for accurate localization during neurosurgical procedures. The application of this technique in endoscopic sinus surgery is available in many major centers. This system allows the surgeon to localize the tip of the surgical instrument in the paranasal sinuses, generally within 1-2 mm of accuracy on coronal, axial, and sagittal CT images. Computer-assisted endoscopic sinus surgery can potentially aid the surgeon, especially when working in or near difficult areas such as the frontal sinuses, sphenoid sinus, skull base and orbit.

These systems are not universally available. While they are helpful in specific cases, they are not always necessary for an experienced, skillful surgeon to perform difficult procedures. While they do provide potential advantage in specific situations. They are NOT, at this stage, associated with decreased surgical risk.

Question: Is image guidance surgery an important advance?
Answer: The first revolutionary change in the surgical treatment of the sinuses was the introduction and refinement of endoscopic techniques. The second important development in the modern history of rhinology was the introduction of powered instrumentation. Now we are seeing a third turning point, which is the use of intraoperative image guidance in endoscopic sinus surgery.

Question: What devices are used?
Answer: There are a number of companies making image-guidance systems, and the basic elements are the same in all of them. All of these devices have a tracking system, a head set, and a computer with hardware and software that interprets the information it receives from an instrument that is used inside the nose that has been registered with the system.

There are two types of image guidance surgery devices: optical and electomagnetic.

• In optical devices, a direct and uninterrupted line-of-sight between the patient and the image guidance system is necessary. The headset does not need to be present when the patient has a CT scan. Registration of fiducials, or positioning points, is required when the patient is in the operating room before the image guidance system may be used.
• The electromagnetic devices require that the patient wear a headset during the CT scan, and then this headset must be used at the time of surgery. The problems with line-of-site that are present in the optical systems is not an issue in the electromagnetic systems. Also the fiducials are on the headset, so markers or registration of fiducials is not required.

Question: Any summary thoughts about new technology in sinus surgery?
Answer: There have been a number of advances in rhinology in the 21st century. As we celebrate these advances and use them to the benefit of our patients, we must always remember the basic principles that always take priority over technology: anatomic knowledge, surgical ability, and clinical judgement.

Some patients who have elected to proceed with functional endoscopic sinus surgery (FESS) are also interested in changing the appearance of their nose. FESS does not change nasal appearance; however, sinus patients are often able to undergo cosmetic nasal surgery ("rhinoplasty") at the same time as their functional sinus surgery, if they wish. Please visit our website, www.TheRhinoplastyCenter.com, for more information on this subject:

If you have further questions regarding the latest technologies employed at The Becker Nose & Sinus Center, please call us at 856.589.NOSE (6673) or email your questions to Info@NoseAndSinus.com.