Sinus Infection

Picture of the anatomy of the sinuses

Picture of the detail of the sinuses

Sinus Infection Overview

Sinus infection, or sinusitis, is an inflammation of the sinuses and nasal passages. A sinus infection can cause aheadache or pressure in the eyes, nose, cheek area, or on one side of the head. A person with a sinus infection may also have a cough, sore throat, fever, bad breath, and nasal congestion with thick nasal secretions. Sinusitis is categorized as acute (sudden onset) or chronic (long term, the most common type).

Sinusitis is very common. In 2010 there were 29.8 million adults diagnosed with sinusitis in the United States. In 2007 there were 12.5 million visits to health practitioners for chronic sinusitis alone.

Here is an overview of the anatomy of the sinuses (also called paranasal sinuses). The human skull contains four major pairs of hollow air-filled cavities called sinuses. These are connected to the space between the nostrils and the nasal passage (behind your nose). Sinuses help insulate the skull, reduce its weight, and allow the voice to resonate within it. The four major pairs of sinuses are the:

1. frontal sinuses (in the forehead),
2. maxillary sinuses (behind the cheek bones),
3. ethmoid sinuses (between the eyes), and
4. sphenoid sinuses (behind the eyes).

The sinuses contain defenses against viruses and bacteria (germs). The sinuses are covered with a mucous layer and cells that contain tiny hairs on their surfaces (cilia). These help trap and propel bacteria and pollutants outward.

Acute sinusitis typically lasts less than eight weeks or occurs no more than three times per year with each episode lasting no longer than 10 days. Medications are generally effective against acute sinusitis. Successful treatment counteracts damage done to the mucous lining of the sinuses and surrounding bone of the skull.

Chronic or recurring sinusitis lasts longer than eight weeks or occurs more than four times per year, with symptoms usually lasting more than 20 days.

Sinus Infection Causes

Acute sinusitis usually follows a viral infection in the upper respiratory tract, but allergy-causing substances (allergens) or pollutants may also trigger acute sinusitis. Viral infection damages the cells of the sinus lining, leading to inflammation. The lining thickens, obstructing the nasal passage. This passage connects to the sinuses. The obstruction disrupts the process that removes bacteria normally present in the nasal passages, and the bacteria begin to multiply and invade the lining of the sinus. This causes the symptoms of sinus infection. Allergens and pollutants produce a similar effect.

Bacteria that normally cause acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. These microorganisms, along with Staphylococcus aureus and some anaerobes (bacteria that live without oxygen), are involved in chronic sinusitis.

Fungi are also an increasing cause of chronic sinusitis, especially in people with diseases that weaken the immune system, such asAIDS, leukemia, and diabetes.

Sinus Infection Symptoms

Signs and symptoms of sinus infections depend upon which sinuses are affected and whether the sinus infection is acute or chronic.

Acute sinusitis:

• Ethmoid sinusitis (behind the eyes)
  • Nasal congestion with discharge
  • Postnasal drip (mucus drips down the throat behind the nose) often accompanied by a sore throat
  • Pain or pressure around the inner corner of the eye or down one side of the nose
  • Headache in the temple, or surrounding or behind the eye
  • Pain or pressure symptoms are worse when coughing, straining, or lying on the back and better when the head is upright
  • Fever is common
• Maxillary sinusitis (behind the cheek bones)
  • Pain across the cheekbone, under or around the eye, or around the upper teeth
  • Pain or pressure on one or both sides of the face
  • Tender, red, or swollen cheekbone (maxilla)
  • Pain and pressure symptoms are worse with the head upright and bending forward and better when reclining
  • Nasal discharge or postnasal drip
  • Fever is common
• Frontal sinusitis (behind forehead, one or both sides)
  • Severe headaches in the forehead
  • Fever is common
  • Pain is worse when reclining and better with the head upright
  • Nasal discharge or postnasal drip
• Sphenoid sinusitis (behind the eyes)
  • Deep headache with pain behind and on top of the head, across the forehead, and behind the eye
  • Fever is common
  • Pain is worse when lying on the back or bending forward
  • Double vision or vision disturbances if pressure extends into the brain
  • Nasal discharge or postnasal drip

Chronic sinusitis:

• Ethmoid sinusitis
  • Chronic nasal discharge, obstruction, and low-grade discomfort across the bridge of the nose
  • Pain is worse in the late morning or when wearing glasses
  • Chronic sore throat and bad breath
• Maxillary sinusitis
  • Discomfort or pressure below the eye
  • Chronic toothache or increased tooth sensitivity
  • Pain possibly worse with colds, flu, or allergies
  • Increased discomfort throughout the day with increased cough at night
• Frontal sinusitis
  • Persistent, low-grade headache in the forehead
  • History of trauma or damage to the sinus area
  • Chronic postnasal drip
• Sphenoid sinusitis
• Low-grade general headache is common
• Chronic postnasal drip

When to Seek Medical Care

Call a doctor when experiencing pain or pressure in the upper face accompanied by nasal congestion or discharge, postnasal drip, fever for several days, or ongoing bad breath unrelated to dental problems.

Fever can be a symptom of a sinus infection or a cold. Simple nasal congestion with a low-grade fever and a runny nose probably indicates a cold and may not call for medications orantibiotics and may be contagious. Those also experiencing facial pain, headaches, and fever for several days may have a sinus infection.

If left undiagnosed and untreated complications of sinusitis can occur that may lead to severe medical problems and possibly death. If you have the following symptoms, you may have a medical emergency and should seek immediate evaluation in a hospital's emergency department.

• Headache, fever, and soft tissue swelling over the frontal sinus may indicate an infection of the frontal bone, called Pott's puffy tumor or osteomyelitis. Usually, this complication is limited to children.
• Ethmoid sinusitis can cause infection of the eye socket. The eyelid may swell and become droopy. Vision changes are rare but are signs of serious complications. Fever and severe illness are usually present. A person with this infection may lose the ability to move the eye, and permanent blindness may result. Symptoms of sinusitis associated with pain when moving the eye or swelling around the eye are an emergency and should be evaluated immediately.
• Ethmoid or frontal sinusitis can cause the formation of a blood clot in the sinus area around the front and top of the face. Symptoms may be similar to those of eye socket infection with the addition of a dilated pupil (the pupil is larger than usual). This condition usually affects both sides of the face.
• If a person experiences personality changes, headache, neck stiffness, high fever, altered consciousness, visual problems, seizures, or rash on the body, infection may have spread to the brain or the lining tissues of the brain (meningitis). This is a severe illness and a medical emergency. Coma and death may follow.

Sinus Infection Diagnosis

The diagnosis of a sinus infection is made based on a medical history assessment and a physical examination. Adequately distinguishing sinusitis from a simple upper respiratory infection or a common cold is important.

Sinusitis caused by bacteria usually requires antibiotics for treatment. Sinusitis can also be caused by viruses (meaning antibiotics would not help). Upper respiratory infections andcolds are viral illnesses. Over-treating viral infections with antibiotics can be dangerous and can cause antibiotic resistance to occur.

CT scan: In most cases, diagnosing acute sinusitis requires no tests. When testing is needed a CT scan can clearly depict all of the paranasal sinuses, the nasal passages, and the surrounding structures. A CT scan may indicate a sinus infection if any of these conditions is present:

• Air-fluid levels in one or more sinuses
• Total blockage in one or more sinuses
• Thickening of the inner lining (mucosa) of the sinuses
• Mucosal thickening can occur in people without symptoms of sinusitis. CT scan findings must be correlated with a person's symptoms and physical examination findings to diagnose a sinus infection.

Ultrasound: Another noninvasive diagnostic tool is ultrasound. The procedure is fast, reliable, and less expensive than a CT scan although the results are not as detailed. Ultrasound has not been widely accepted for diagnosis of sinus infection by the medical community, especially among ear, nose, and throat physicians (ENTs, also known as otorhinolaryngologists). This is partly because a CT scan offers the ENT physician a more detailed image of the anatomy of the sinuses, which helps plan possible surgery.

If symptoms persist despite adequate therapy, a referral to an ENT physician may be made.

• The ENT physician can directly visualize the nasal passages and the connection to the sinuses with a nasopharyngoscope, or sino-nasal endoscope. This is a fiberoptic, flexible or rigid tube that is inserted through the nose and enables the doctor to view the passageways and see if the sinuses are open and draining correctly. Anatomical causes of breathing difficulties may also be found, such as a deviated nasal septum, nasal polyps, and enlarged adenoid and tonsils.
• An ENT specialist may also drain the affected sinus to test for organisms. This is a more invasive test. During this procedure, a doctor inserts a needle into the sinus through skin (or gum) and bone in an attempt to withdraw fluid, which can be sent to the lab for culture. Any present bacteria can be identified, often in less than two days. Antibiotics may be given for treatment. If necessary, discomfort is alleviated by local anesthesia. The draining procedure is seldom used, because the CT scan may suffice for the diagnosis of sinusitis, and standard antibiotics are usually effective even when the exact bacterial cause is not known.

Sinus Infection Treatment

Sinus Infection Home Remedies

Home care can help open the sinuses and alleviate their dryness.

Promote drainage:

• Drink plenty of water and hydrating beverages such as hot tea.
• Inhale steam two to four times per day by leaning over a bowl of hot water (not while the water is on the stove) or using a steam vaporizer. Inhale the steam for about 10 minutes. Taking a hot, steamy shower may also work. Mentholated preparations, such as Vicks Vapo-Rub, can be added to the water or vaporizer to aid in opening the passageways.

Thin the mucus: Expectorants are drugs that help expel mucus from the lungs and respiratory passages. They help thin mucous secretions, enhancing drainage from the sinuses. The most common is guaifenesin(contained in Robitussin and Mucinex). Over-the-counter (OTC) sinus medications can also combine decongestants and cough suppressants to reduce symptoms and eliminate the need for the use of many prescription medications. Read label ingredients to find the right combination of ingredients or ask the pharmacist.

Relieve pain: Pain medication such asibuprofen (Motrin and Advil), aspirin, andnaproxen (Aleve) can reduce pain and inflammation. These medications help to open the airways by reducing swelling.Acetaminophen (Tylenol) can be used for pain and fever but does not help with the inflammation.

Nasal saline irrigation: There are several methods of nasal irrigation, and a popular remedy is the Neti-pot - a ceramic pot that looks like a cross between a small teapot and Aladdin's magic lamp.

• Some ENT physicians recommend nasal irrigation with a Neti-pot to help clear crusting in the nasal passages. Many people with chronic sinus symptoms use the Neti-pot to alleviate congestion, facial pain and pressure, and reduce the need for antibiotics and nasal sprays.
• Before using nasal saline irrigation, discuss it with your physician.

Sinus Infection Medical Treatment

The main goals in treating a sinus infection or sinusitis involve reducing the swelling or inflammation in the nasal passages and sinuses, curing the infection, promoting drainage from the sinuses, and maintaining open sinuses.

Sinus Infection Medications

Medications to Reduce Inflammation and Promote Drainage

Reduce inflammation

Blood cells and lining cells of the mucosa in the sinuses can normally fight off foreign invaders. However, when overwhelmed by viruses or bacteria, coupled with a depressed immune system or over-reactivity to allergens, the result is the inflammation associated with sinusitis. With appropriate therapy, a short-lived infection can be treated effectively. Because foreign substances trigger numerous reactions, many treatments are available that can treat the symptoms of inflammation.

Decongestants help reduce airway obstruction and are important in the initial treatment to alleviate symptoms.

• OTC nasal sprays: oxymetazoline (Afrin),phenylephrine (Neo-Synephrine), naphazoline (Naphcon), and chlorzoxazone(Forte) work the fastest, within one to three minutes. These agents should not be used for more than three days because they become less effective and more frequent applications become necessary to attain the same clarity in breathing. This "rebound" phenomenon can be reduced by alternating between nostrils and using the medicine less frequently. Some people over-treat their nasal congestion with nasal spray and become dependent upon it in order to breathe more easily (a disorder called rhinitis medicamentosum). Overcoming the dependency requires a difficult withdrawal program involving oral decongestants, saline, steroid nasal sprays, systemic steroids, or a combination thereof.
• OTC oral decongestants: OTC oral decongestants (in tablet or liquid form) contain the active ingredientspseudoephedrine or phenylephrine. They work much slower than nasal sprays do, and achieve their effect within 30-60 minutes. As with the nasal preparations, oral decongestants may become less effective with prolonged use. The rebound phenomenon exists but is not as severe as with spray preparations. Preparations containing pseudoephedrine are now kept behind the counter at the pharmacy but are still available without a prescription.

Both nasal and oral decongestants have side effects, including increased heart rate and blood pressure, insomnia, nervousness, anxiety, tremor, dry mouth, blurry vision, and headache. They may also cause an inability to urinate. Persons with a history of cardiac disease, high blood pressure, anxiety, or urinary problems (especially prostate disorders) should consult a physician before using decongestants. Combining decongestants with other over-the-counter or prescribed medicines with similar side effects may cause dangerous complications.

Promote drainage

Home remedies that open and hydrate the sinuses may promote drainage. See Sinus Infection Home Remedies for information on increasing daily fluid intake, inhaling steam, taking expectorants and pain relievers, and nasal saline irrigation.

If environmental allergies cause the sinusitis, an antihistamine may help reduce swelling of the mucous membranes. Allergens stimulate white blood cells in the blood and tissues to release histamine into the circulation. This causes fluid to leak from blood vessels into the tissues of the nasal passageways, leading to nasal congestion symptoms.

• Some of the older sedating OTC antihistamines (diphenhydramine [Benadryl]) are no longer recommended because they tend to dry out and thicken the mucus, making drainage more difficult.
• Non-sedating antihistamines such as fexofenadine (Allegra), cetrizine (Zyrtec),loratadine (Claritin), or desloratadine (Clarinex) do not seem to dry out the mucosa. If nasal congestion is severe, a decongestant can be added (for example, Allegra-D or Claritin-D).

Medications to Cure Sinus Infection and Open Sinuses

Cure sinus infection

The chief goal of treatment is eliminating bacteria from the sinus cavities with antibiotics. This helps to prevent complications, relieve symptoms, and reduce the risk of chronic sinusitis.

• For acute, uncomplicated cases, a synthetic penicillin like amoxicillin (Amoxil, Polymox, or Trimox) is used most commonly. This antibiotic is effective against the usual causative microorganisms and is relatively inexpensive. Amoxicillin's main side effects include allergic reactions (throat swelling,hives) and stomach upset.
• People allergic to penicillin can take a sulfur-containing antibiotic calledtrimethoprim/sulfamethoxazole or TMP/SMX (Bactrim, Cotrim, or Septra). Sulfa drugs ares not recommended for people who are allergic to sulfur.
• People who have several episodes of partially treated acute sinusitis or those who have chronic sinusitis may become resistant to amoxicillin and TMP/SMX. Newer synthetic penicillins and cephalosporins such asamoxicillin/clavulanate (Augmentin),cefuroxime (Ceftin), and loracarbef (Lorabid) can clear most of the resistant organisms that cause sinus infection.
• Overuse of these "broad-spectrum" antibiotics may eventually lead to organisms evolving that can resist even the most potent antibiotics currently available. Simpler antibiotics such as amoxicillinshould be used first and taken for the entire duration (14-21 days). The basic rule of thumb is to take the antibiotic until the symptoms disappear, and then continue to take the antibiotic for one more week.

Maintain open sinuses

To treat acute sinusitis, one or more OTC or prescription therapies may be all that is necessary. For those with recurrent bouts of acute sinusitis or chronic sinusitis, the addition of intranasal or oral steroids (prednisone) may reduce symptoms. Commonly prescribed medications are beclomethasone (Beconase, Vancenase),fluticasone (Flonase), triamcinolone (Nasacort), and flunisolide (Nasalide).

• Steroids are potent inhibitors of inflammation.
• Nasal sprays (intranasal steroids) work directly on the lining of the nasal passages and sinuses with little effect on the rest of the body when taken in prescribed dosages.
• As with the other classes of drugs, many intranasal steroids are available. Some are more tolerable than others. These are prescription medications. These drugs do not relieve symptoms immediately like nasal and oral decongestants do, but once therapeutic drug levels are achieved, symptoms usually improve, and decongestants may be unnecessary.
• During months when environmental allergens are most widespread, the early administration of intranasal steroids may help keep the sinuses open and draining, and prevent sinusitis.

Sinus Surgery

Some people experience chronic sinusitis despite adequate therapy with antibiotics and drugs for relief of symptoms. Those that have a CT scan indicative of sinus infection as well as those with any complications of sinusitis may benefit from sinus surgery.

• The surgery is performed endoscopically using a fiberoptic nasopharyngoscope.
• The goal is to remove obstructive mucosal tissue, open the sinus-nasal passageway, and allow drainage of the sinuses.
• During the surgery, nasal polyps can also be removed, and a crooked nasal septum can be straightened, leading to improved airflow.
• Long-term nasal steroids and periodic antibiotics may still be necessary.

A continuing sinus infection may need further investigation. A culture obtained during a routine office visit or during endoscopic surgery may reveal anaerobes, a type of bacteria that grow in the absence of oxygen, which require treatment with broad-spectrum antibiotic drugs, or fungi, which require treatment with antifungal medications.

Sinus Infection Follow-up

People whose symptoms of a sinus infection do not go away despite the use of decongestants and antibiotics should follow-up with their primary care doctor or ENT specialist as soon as possible.

Sinus Infection Prevention

Prevention of a sinus infection depends upon its cause.

• Avoid contracting upper respiratory tract infections. Maintain strict hand washing habits and avoid people who are obviously suffering from a cold or the flu.
• Obtaining the influenza vaccination yearly will help to prevent the flu and subsequent infection of the upper respiratory tract.
• Antiviral medicines to treat the flu, such aszanamivir (Relenza) oseltamivir (Tamiflu),rimantadine (Flumadine), and amantadine(Symmetrel), if taken at the onset of symptoms, may also help to prevent infection.
• In some studies, zinc carbonate lozenges have been shown to reduce the duration of many cold symptoms.
• Stress reduction and a diet rich in antioxidants, especially fresh, dark-colored fruits and vegetables, may help strengthen the immune system.
• Plan for seasonal allergy attacks.
  • If sinus infection is caused by seasonal or environmental allergies, avoiding allergens is very important. If avoidance is not an option, either OTC or prescription medication may be helpful. OTC antihistamines or decongestant nasal sprays can be used for an acute attack.
  • People who have seasonal allergies may benefit from nonsedating prescription antihistamines during allergy-season months.
  • Avoid spending long periods outdoors during allergy season. Close the windows to the house and use air conditioning to filter out allergens when possible. Humidifiers may also be helpful.
  • Allergy shots, also called "immunotherapy," may be effective in reducing or eliminating sinusitis due to allergies. Shots are administered by an allergist regularly for 3 to 5 years, but they often offer a reduction to complete remission of allergy symptoms for years.
• Stay hydrated
  • Maintain good sinus hygiene by drinking plenty of fluids to keep nasal secretions thin.
  • Saline nasal sprays (available at drug stores) help keep the nasal passages moist, helping remove infectious agents. Inhaling steam from a bowl of boiling water or in a hot, steamy shower may also help.
  • Avoid air travel. If air travel is necessary, use a nasal decongestant spray prior to departure to keep the sinus passages open and frequently instill saline nasal spray during the flight.
• Avoid allergens in the environment
• People who suffer from chronic sinusitis should avoid areas and activities that may aggravate the condition, such as cigarette smoke, secondhand smoke, and diving under water in chlorinated pools.

Sinus Infection Prognosis

Sinusitis or sinus infections usually clear up if treated early and appropriately. Aside from those who develop complications, the outlook for acute bacterial sinusitis is good. People may develop chronic sinusitis or have recurrent attacks of acute sinusitis if they have allergic or structural causes for their sinusitis.

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