Acute and Chronic Sinusitis

Everybody knows what sinusitis is, right? Well, sometimes it is not so straightforward. This article will try to explain what sinusitis is in a common sense way, especially the different forms of it. We will also touch on what endoscopic sinus surgery and balloon sinuplasty attempts to accomplish.

Humans are not actually born with sinus cavities which appear as mere identations into the facial bone in newborns. It is not until around age 7 years do they become significant in size. By adolescence, they have become fully developed.

Once sinus cavities have formed, simply put, sinusitis is an infection of the sinus cavities creating pus. Symptoms include facial pain/pressure, purulent drainage from the nose, fevers, etc. When the sinuses are functioning well, the infection gets cleared rapidly with antibiotics and the pus gets cleared easily through the nose. In this scenario, the openings of the sinus cavities into the nose are not blocked so things flow easily. No difficult concepts in this particular scenario.

peds_sinus_eyeHowever, let’s look at other sinusitis scenarios which are a bit more unclear.
What about the situation where one experiences pain/pressure in the face and head, but little or no drainage? In this case, infection as the cause of the discomfort may or may not be true.
Sinusitis IS Due to Infection: It is possible that the sinus openings into the nose are blocked preventing pus from coming out. In this scenario, the typical history is mulitple courses of antibiotics that help temporarily before the pain/pressure returns. When given this history, a long (3-6 weeks) course of antibiotics +/- steroids may be prescribed. The rationale for the much longer course of antibiotics is due to the belief that infection is trapped inside the sinus cavities and like a water balloon filled with pus, the antibiotics can only reach where the pus touches the sinus wall cavity, but not in the center. Steroids are used to decrease the swelling and inflammation that may have led to sinus obstruction. By relieving the obstruction, accumulated pus should be able to drain out into the nose properly. What led to sinus obstruction in the first place? Most commonly, it is due to allergies. That’s why people with seasonal allergies also tend to get sinus infections when the allergies act up. Treatment of the underlying cause of the sinus obstruction will prevent sinus infection! Treating the infection alone will work temporarily at best.

Pain/Pressure NOT Due to Infection: No bacterial infection is present and the pain/pressure is due to something else. Those somethings could be trigeminal migraines, trigeminal neuralgia, sluder’s neuralgia, tension headaches, allergies, cold, etc. Assuming it is not neurologic, allergies are a common culprit. Allergies cause inflammation and swelling of the sino-nasal lining. Unfortunately, the nose does not get bigger to accomodate all the swelling going on inside and as such, the lining starts to press against each other. That’s where the facial pressure comes from. Treatment is with steroid nasal sprays, antihistamines, and nasal saline flushes. NO antibiotics are needed. Viral upper respiratory infections can cause similar symptoms and is treated symptommatically. Of note, CT scans, if obtained, generally are normal in these situations. Sluder’s neuralgia (pain/pressure over the face due to a pressure point in the nose) is usually caused by a deviated septum which when corrected, completely alleviates all symptoms (and you can breath better)! Large adenoids is another common problem, especially in children.

Tumors: Unfortunately, the pain/pressure is due to a tumor growth that has been ignored for too long due to the erroneous assumption that their symptoms were due to “sinusitis” or “allergies”. Danger signs include nasal obstruction, difficulty smelling/tasting foods, numbness on the face, loose teeth, nosebleeds, etc.

Nasal Polyps: Click here for more information on this situation.

So what is a person to do if they truly have bona fide sinus infections that keep persisting or recurring despite optimal use of antibiotics, steroids, saline sinus washes (Neilmed Sinus Rinseamazon recommended; sinus irrigation devices also exist for greater ease), and other medications? That’s when sinus surgery is considered.

The goal of sinus surgery whether it is performed endoscopically or via balloon sinuplasty is to make the small drainage openings of the sinuses into the nose larger. That’s it! By making the sinus openings big enough, the sinuses can’t get obstructed as easily and therefore allow for good sinus drainage no matter how much swelling or inflammation may be present. Good sinus drainage prevents/minimizes sinus infections. Paradoxically however, sinus surgery may make your allergy symptoms worse (easier for allergens to gain access into your nose and sinuses since things are opened up), so it’s very important to get your allergies under good control before sinus surgery is performed. For those with asthma, having sinus surgery has been shown to markedly improve lung function resulting in decreased number of asthma attacks and use of inhalers overall.

When investigating what may be causing a given person’s sinus pressure/pain, a CT scan of the sinus is often ordered. The reason for the CT scan is to first of all, see if the symptoms are indeed truly coming from an infection as well as to see if there are any anatomic causes of sinus obstruction including a deviated septum or large adenoids that makes a person more prone to sinus infections.

Other diseases to be aware of.
It should also be mentioned that some patients’ chronic sinus infections are actually not due to anatomic factors, but some type of immune deficiency, most commonly a lower than normal amount of antibodies (IgM, IgA, or IgG). More info here. More rarely, the chronic sinus infections may be due to an underlying genetic abnormality (cystic fibrosis, immotile ciliary dyskinesia, etc).


Normal CT Sinus: Note the air within the sinus cavities denoted by black (just like the black surrounding the head). White is bone. Grey is soft tissue.


Abnormal CT Sinus: Note the grey coloration within the sinus cavity, especially the right side. This person has right greater than left maxillary sinusitis along with severe bilateral ethmoid sinusitis. Entirely possible that nasal polyps are present in these same locations as well. This person also has a deviated septum.