Sinus Problems
Anatomy

The human sinus cavities consist of 4 paired air filled spaces in the middle and upper face.

The maxillary and ethmoid sinuses
are present at birth.

The sphenoid sinus
, located far back under and between the eyes, develops around age 6.

The frontal sinus begins developing about the same time and is usually present around age 12.

The nasal septum separates the nose into right and left sides. Inside the nose there are 3 turbinate bones which project into the nose; these function to direct air through the nose as well as heat and moisten it. There are sensory nerves in the nose, but few, if any, in the sinuses themselves!
 
Physiology

The sinus cavities are normally filled with air. The sinuses are lined with a very thin lining similar to the inside of your mouth, known as mucosa. This lining secretes mucous which normally is very watery and is sterile. The mucosa has cilia, fine finger like projections, which rhythmically beat the mucous ‘blanket’ to the back of the nose. The sinuses and nose help to heat the air we breathe and most importantly, to humidify the air so our lungs stay moist. Some filtration of particles in the air occurs in the nose, as they are trapped in the mucous. There is a normal slow movement of this mucous blanket through the nasal cavity to the back of the throat where it is swallowed. The nose and sinuses secrete approximately 2 liters of mucous every day!
Disease

When the normal flow of mucous is changed, or stops, problems arise. This can be due to numerous factors:
  • Anatomic abnormalities such as: crooked (deviated) septum, abnormal development of normal sinus anatomy and drainage system, large adenoids or tonsils, foreign bodies, hypertrophic or enlarged turbinate bones, or rarely – tumors or polyps.

  • The most likely cause is a viral infection. The lining of the nose and sinuses becomes damaged, the mucous is altered or becomes thick, and stops moving. Once the lining is damaged by a virus it takes up to 3 weeks and sometimes longer to return to normal! The lining of the nose, like blood, is red. When the red heme molecule breaks down it normally turns YELLOW or GREEN. This does not mean bacterial infection! If the body cannot clear the secretions (see treatment) it can become secondarily infected. This usually occurs after about 7-10 days. It is estimated that 90% of BACTERIAL sinus infections resolve without antibiotic treatment!
How does a patient or Doctor know when it is viral, bacterial, or Allergy?

This is not always clear cut. Viruses last 7-14 days. There can be fever. Drainage is usually clear, then becomes thicker and yellow-green near the end. The nose is congested, and the person usually cannot breathe out of the nose. Pain is dull, like a pressure, and can be in the upper canine teeth. Bacterial infection can result from this and cause persistence of the dull pressure, fever, and nasal discharge. The person usually feels ill; if the symptoms last over 10 days with simple treatment- you may want to see a doctor.

Allergy symptoms are usually, not always, seasonal - meaning certain times of the year. Itchy eyes and palate, thin watery nasal secretion, and congestion, with sneezing. Rarely is there pain.


Diagnosis.
As mentioned above, diagnosing a bacterial sinus infection is sometimes difficult. A proper examination after listening to the patient’s history, is very important. The examination consists of looking in the nose with a nasal speculum, to examine the anatomy. A proper headlight is necessary for this. The ENT physician will usually also spray topical decongestant in the nose to see all the normal anatomy. In chronic conditions, sometimes a magnifying endoscope is used as well. The Gold standard to make a diagnosis is History, Physical exam, and a CT Screen (limited 6-8 views of the sinuses). CT, however, can misinterpret a ‘cold’ as an infection, especially if done within 14 days of onset of symptoms.
Treatment

Moisture.
Treatment of nasal congestion starts with trying to re-establish airflow and normal sinus drainage. Moisture is very important: humidifiers, vaporizers, nasal saline irrigation, nasal saline gels (Ayr saline gel, Ocean saline gel, Ponaris ,etc.). Taking a nice steamy shower or inhaling steam with a towel over your head!!!

Decongestants.
Use a topical nasal spray decongestant such as Afrin, or Neosynephrine. Read the label: use only for 3 days. This can be repeated again a week later. ANTIHISTAMINES are not decongestants!!! Oral decongestants such as Sudafed, Tylenol-sinus, Robitussin PE. Again avoid antihistamines as they can dry and thicken secretions.

If symptoms persist: an antibiotic MAY be necessary. Recent articles have shown 90% of bacterial infection will clear without antibiotic use. Chronic sinusitis studies have shown little to no benefit from long term antibiotic treatment.

Topical steroid sprays are effective to help reduce swelling and return the lining to normal. These are also effective for Allergy. Allergy treatment also includes antihistamine use.
Surgery

Treatment of sinus or nasal problems is dependent on the individual patients problems. Pediatric and young adult patients may require adenoidectomy and/or tonsillectomy to relieve the nasal obstruction. This re-establishes normal mucous flow.

The surgical treatment of sinus problems is to promote drainage and open the nasal airway. This may include straightening the septum, removing polyps (benign fluid filled sacs which grow out of the mucosa) , or removing or opening the normal sinus drainage pathways. Functional endoscopic sinus surgery. Using small telescopes the ENT surgeon can open and promote drainage of the sinuses.

Balloon Sinuplasty™ (in Office)
New technology allows the placement of a small balloon in the sinus cavity which opens the normal ostia or opening. This promotes drainage and decreases time of operation and scarring. [Read More] [Take the Quiz]

A microdebrider is sometimes used to exactly remove diseased tissue in some instances. This decreases operating time as well as scarring. Rarely is old fashioned gauze packing used. If bleeding does occur, newer hemostatic gels can be used. This greatly reduces discomfort post-operatively. Septoplasty patients (straightening the nasal septum) will require thin plastic splints which are removed 1 week later. If you are concerned about sinus problems discuss it with your ENT specialist.
 

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