Sinusitis

Signs and Symptoms

The symptoms of acute and chronic sinusitis are similar. Chronic sinusitis usually does not cause fever and its symptoms last longer. Chronic sinusitis is most common in people who have allergies.

• Pain or pressure in your forehead, temples, cheeks, nose, and behind your eyes
• Nasal congestion
• Nasal discharge (yellow or green)
• Postnasal drip (a sensation of fluid dripping down the back of your throat, particularly at night or when lying down)
• Toothache
• Cough, often worse at night
• Sore throat
• Fever
• Bad breath
• Loss of sense of smell
• Fatigue
• General sense of not feeling well (malaise)
• Headache

Causes

Sinusitis usually follows an upper respiratory infection (such as a cold) or an allergic reaction (such as hay fever or allergic rhinitis). These can cause inflammation and swelling that prevent the sinuses from draining properly. When sinuses become blocked, they provide a place for bacteria, viruses, and fungus to live and grow rapidly. Although a cold is most often the culprit, anything that prevents the sinuses from draining can cause sinusitis.

Other common causes of sinusitis include:

• Allergies (such as hay fever, cigarette smoke, dry air, and pollutants)
• Changes in air pressure (for example, from swimming or climbing high altitudes)
• Infections from dental problems
• Obstructions in the nasal or sinus cavities (such as nasal polyps, deviated septum, or nasal bone spur)
• Physical injury to the sinuses
• Bacteria, viruses, and fungi

Risk Factors

Risk factors for sinusitis include:

• Having asthma
• Overuse of nasal decongestants
• Frequent swimming or diving
• Climbing or flying to high altitudes
• Nasal polyps (swellings in the nasal passage), nasal bone spurs, or other abnormalities such as a deviated septum or cleft palate
• Dental infection
• Exposure to air pollution and cigarette smoke
• Pregnancy
• Gastroesophageal reflux disease (GERD), in which stomach acid backs up into the esophagus
• Being in the hospital, especially if the reason you are in the hospital is related to a head injury or you needed a tube inserted into your nose (for example, a nasogastric tube from your nose to your stomach)

Diagnosis

Although chronic sinusitis can be hard to diagnose because symptoms are similar to cold symptoms, your health care provider can generally diagnose sinusitis from your medical history and by examining you. If your provider suspects chronic sinusitis, they may order imaging tests, including an x-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI).

If your provider suspects allergies may be causing your sinusitis, they may suggest an allergy test. Sometimes, a referral to a specialist, known as an ear, nose, and throat (ENT) doctor or an otolaryngologist, is necessary. This specialist may perform a nasal endoscopy using a fiber optic scope to look at your sinuses.

Preventive Care

The best way to prevent sinusitis is by:

• Getting an annual flu shot
• Washing your hands often, particularly after shaking hands with others
• Eating plenty of fruits and vegetables to keep your immune system strong
• Reducing stress
• Exercise regularly
• Getting plenty of sleep

Treatment Approach

Treatment of sinusitis aims to reduce inflammation and clear your sinuses. Your doctor may prescribe antibiotics or corticosteroids. Lifestyle changes, such as using a humidifier or irrigating your nasal passages with salt water, may also help. Several dietary supplements and herbs may help prevent colds and flu, shorten their duration, or work together with antibiotics to treat your infection and support your immune system.

Lifestyle

These measures can help reduce congestion in your sinuses:

• Using a humidifier
• Using a saline nasal spray
• Inhaling steam 2 to 4 times per day (for example, sitting in the bathroom with the shower running)
• Quickly treating allergic and asthma attacks

Medications

Antibiotics. Your health care provider may prescribe antibiotics if your symptoms suggest you have a bacterial infection. However, antibiotics should not be prescribed for mild-to-moderate sinusitis within the first week of the illness. To treat acute sinusitis, you may take from 10 to 14 days of antibiotics. Treating chronic sinusitis may take longer, usually 3 to 4 weeks.

Nasal corticosteroids. These prescription sprays reduce inflammation of the nose and help relieve sneezing, itching, and runny nose. They are most effective at reducing symptoms, although it can take from a few days to a week after you start using them to see improvement.

• Beclomethasone (Beconase)
• Fluticasone (Flonase)
• Mometasone (Nasonex)
• Triacinolone (Nasacort)

Antihistamines. Antihistamines are available in both oral and nasal spray forms, and as prescription drugs and over-the-counter (OTC) remedies. OTC antihistamines are short acting and can relieve mild-to-moderate symptoms. All work by blocking the release of histamine in your body.

• OTC antihistamines. Include diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton), and clemastine (Tavist). These older antihistamines can cause sleepiness. Loratadine (Claritin), a newer antihistamine, does not cause drowsiness. All OTC antihistimines are short acting and can relieve mild-to-moderate symptoms.
• Prescription antihistamines. Include fexofenadine (Allegra) and cetrizine (Zyrtec). These medications are longer acting than over-the-counter antihistamines and are usually taken once a day.

Decongestants. Many OTC and prescription decongestants are available in tablet or nasal spray form. They are often used with antihistamines. Oral and nasal decongestants include Sudafed, Actifed, Afrin, Neo-Synephrine. Some decongestants may contain pseudoephedrine, which can raise blood pressure. People with high blood pressure or an enlarged prostate should not take drugs containing pseudoephedrine. Nasal decongestants can cause "rebound congestion," where the nasal passages swell. Avoid using nasal decongestants for more than 3 days in a row, unless instructed by your health care provider, and do not use them if you have emphysema or chronic bronchitis.

Surgery and Other Procedures

For chronic sinusitis that does not respond to medication, your doctor may recommend endoscopic sinus surgery, which may be done to remove polyps or bone spurs. Enlarging the sinus opening is also sometimes recommended. A newer procedure called balloon rhinoplasty involves inserting a balloon inside the sinus cavity and then inflating it. Your health care provider may suggest other alternatives.

Nutrition and Dietary Supplements

Because supplements may have side effects, or interact with medications, you should take them only under the supervision of a knowledgeable health care provider.

• Bromelain. Several studies suggest that bromelain, an enzyme derived from pineapples, may help reduce inflammation and swelling and relieve symptoms of sinusitis. However, not all studies show a benefit. Bromelain is often combined with the flavonoid quercetin, which may act as an antihistamine. Bromelain may increase the risk of bleeding, so people who take anticoagulants (blood thinners) should not take bromelain without talking to their doctor first. Taking bromelain with ACE inhibitors may cause a drop in blood pressure (hypotension).
• Quercetin. Quercetin is a flavonoid. In test tubes, it inhibits the production and release of histamine, which causes allergy symptoms such as a runny nose and watery eyes. However, there is not much evidence that quercetin works the same way in humans. More studies are needed. Some people report that water-soluble quercetin, such as quercietin methyl chalcone, may work best. Quercetin can potentially interact with some prescription medicaions, including antibiotics.
• Probiotics (Lactobacillus). Probiotics, or "friendly" bacteria, may be helpful if you are taking antibiotics for sinusitis. They may also reduce your chances of developing allergies. Probiotics may not be appropriate for people who are extremely immunocompromised or who take immunosuppresent drugs. Talk to your provider.
• N-acetylcysteine (NAC). NAC is a modified form of a dietary amino acid that works as an antioxidant in the body. It also helps thin mucus. NAC may interact with nitroglycerin, use to treat chest pain (angina). NAC may not be appropriate for certain people with asthma and/or bleeding disorders.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider.

• Sinupret. A proprietary formulation containing Sambucus nigra (European elder), Rumex acetosa (common sorrel), Primula veris (cowslip), Verbena officinalis (European vervain), Gentiana lutea (gentian). Several studies suggest that Sinupret may be effective in relieving symptoms of sinusitis. The herbs it contains may work by thinning mucus and helping the sinuses drain. They may also help strengthen the immune system. Ask your doctor if sinupret is right for you.

Acupuncture

Although studies are few and have found conflicting results, some people may find that acupuncture helps relieve symptoms of sinusitis. Acupuncturists usually describe sinusitis as "dampness," which creates inflammation and congestion in the mucus membranes. This dampness is cleared by strengthening the spleen meridian, and by working with the stomach meridian. Practitioners often perform needling therapy or moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) for this condition.

A 2009 double-blind, randomized, controlled study found that acupuncture significantly improved nasal air flow and decreased congestion in participants with chronic sinusisits. These benefits also increased 30 minutes after treatment.

Chiropractic

Some practitioners suggest chiropractic care may decrease pain and improve sinus drainage for some people.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. In one study of homeopathy for sinusitis, more than 80% of the 119 participants had significant improvement in their symptoms after taking the homeopathic remedy for 2 weeks without antibiotics or other medications. Professional homeopaths may recommend one or more of the following treatments for sinus congestion based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. In homeopathic terms, a person's constitution is their physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Hepar sulphuricum. For the later stages of sinus inflammation when the pain is concentrated between the eyes and is worsened by cold or motion; nasal discharge tends to be thick and the individual may experience sensitivity of the scalp.
• Kali bichromicum. This remedy is considered the first choice homeopathic treatment for sinusitis; it is most appropriate for individuals who have pain between the eyes or in the forehead above one eye; nasal discharge is generally stringy; scalp and facial bones are tender to touch and the person may feel dizzy or nauseated; pain is worse around noon and with cold and motion, but improves with warmth and pressure.
• Mercurius. For sinusitis with thick, green, foul-smelling nasal discharge, which may be blood tinged; there may also be a gripping pain around the head extending to the teeth; persons for whom Mercurius is appropriate have symptoms that worsen with open air, sleeping, eating, drinking, and extreme hot or cold; they may also have difficulty regulating their temperature (the individual often fluctuates from feeling cold and chilled to hot and sweaty).
• Pulsatilla. For individuals who have a thick, bland, yellow or greenish discharge that is often accompanied by nausea and indigestion; symptoms tend to improve with cool air, pressure, and cool compresses; symptoms worsen when the individual is lying down, especially in a warm room; this remedy is appropriate for individuals who are distinctly not thirsty and require tremendous comforting.
• Silicea. For individuals with chronic congestion accompanied by head pain that tends to be worse in the right eye; this pain is worsened by cold, movement, light, noise, and mental concentration (such as when studying), but relieved by heat and pressure.
• Spigelia. For sinusitis with sharp pains on the left side of the face, generally coming on after exposure to cold, wet weather; symptoms are aggravated by warmth, light, noise, and movement, but are relieved by cold compresses or cool water on the face and when the individual is lying down with the head propped up.

Other Considerations

If you are not better in a few weeks, your doctor may refer you to an ENT specialist for tests to find the cause of your sinus infection.

Pregnancy

Sinusitis often acts up during pregnancy. There are many herbs and medications that pregnant and breastfeeding women should not use. Always ask your doctor before taking any medication, whether prescription, over the counter, or alternative.

Warnings and Precautions

Some serious diseases have similar symptoms to sinusitis. Be sure to see your health care provider if you are not feeling better or have new symptoms. Tell your health care provider if you may be pregnant.

Prognosis and Complications

Acute sinusitis is usually curable. If you have recurrent attacks, you should be evaluated for underlying causes (such as nasal polyps or another structural problem). Although very rare, complications may include:

• Osteomyelitis, an infection that spreads to the bones in the face
• Meningitis, an infection that spreads to the brain
• Orbital cellulites, an infection that spreads to the area surrounding the eye
• Abscess
• Blood clot

Supporting Research

Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams JW, Makela M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;2:CD00243.

Asher BF, Seidman M, Snyderman C. Complementary and alternative medicine in otolaryngology. Laryngoscope. 2001;111(8):1383-9.

Audera C, Patulny RV, Sander BH, Douglas RM. Mega-dose vitamin C in treatment of the common cold: a randomised controlled trial. Med J Aust. 2001;175(7):359-62.

Bellavite P, Marzotto M, Chirumbolo S, Conforti A. Advances in homeopathy and immunology: a review of clinical research. [Review]. Front Biosci (Schol Ed). 2011;3:1363-89

Belongia EA, Berg R, Liu K. A randomized trial of zinc nasal spray for the treatment of upper respiratory illness in adults. Am J Med. 2001;111(2):103-8.

Bhattacharyya N. Air quality influences the prevalence of hay fever and sinusitis. Laryngoscope. 2009;119(3):429-33.

Blumenthal M, Goldberg A, Brinckmann J. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000:33-35, 88-102, 111-7, 118-23.

Cohen S, Hamrick N, Rodriquez MS, Feldman PJ, Rabin BS, Manuck SB. Reactivity and vulnerability to stress-associated risk for upper respiratory illness. Psychosom Med. 2002;64(2):302-10.

Di Baise JK, Olusola BF, Huerter JV, Quigley EM. Role of GERD in chronic resistant sinusitis: a prospective, open label, pilot trial. Am J Gastroenterol. 2002;97(4):843-50.

Dixon AE. Rhinosinusitis and asthma: the missing link. Curr Opin Pulm Med. 2009;15(1):19-24.

Douglas RM, Chalker EB, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2000;(2):CD000980.

Ernst E. The risk-benefit profile of commonly used herbal therapies: Ginkgo, St. John's Wort, Ginseng, Echinacea, Saw Palmetto, and Kava. [Review]. Ann Intern Med. 2002;136(1):42-53.

Falagas M, Giannopoulou K, Vardakas K, Dimopoulos G, Karageorgopoulos D. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. The Lancet Infectious Diseases. 2008;8(9).

Ferguson BJ, Otto BA, Pant H. When surgery, antibiotics, and steroids fail to resolve chronic rhinosinusitis. [Review]. Immunol Allergy Clin North Am. 2009;29(4):719-32.

Ferri: Ferri's Clinical Advisor 2016. Philadelphia, PA: Elsevier; 2016.

Frank LG. The efficacy of Echinacea compound herbal tea preparation on the severity and duration of upper respiratory and flu symptoms: a randomized, double blind, placebo-controlled study. J Comp Alt Med. 2000;6(4):327-34.

Guo R, Canter PH, Ernst E. Herbal medicines for the treatment of rhinosinusitis: a systematic review. Otolaryngol Head Neck Surg. 2006 Oct;135(4):496-506. Review.

Hirt M, Nobel Sion, Barron E. Zinc nasal gel for the treatment of common cold symptoms: A double-blind, placebo-controlled trial. ENT J. 2000;79(10):778-80, 782.

Huang SW, Small PA. Rapid diagnosis of bacterial sinusitis in patients using a simple test of nasal secretions. Allergy Asthma Proc. 2008;29(6):640-3.

Ivker RS, Silvers WS, Anderson RA. Clinical observations and seven-and-one-half-year follow-up of patients using an integrative holistic approach for treating chronic sinusitis. Altern Ther Health Med. 2009;15(1):36-43.

Jaber R. Respiratory and allergic diseases: from upper respiratory tract infections to asthma. Prim Care. 29(2):231-61.

Kalliomaki M, Salminen S, Arvilommi H, Kero P, Koskinen P, Isolauri E. Probiotics in primary prevention of atopic disease: a randomized placebo controlled trial. Lancet. 2001;357(9262):1076-9.

Karkos PD, Leong SC, Arya AK, Papouliakos SM, Apostolidou MT, Issing WJ. 'Complementary ENT': a systematic review of commonly used supplements. J Laryngol Otol. 2007 Aug;121(8):779-82. Review.

Kliegman: Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Elsevier Saunders; 2007;377.

Leung R, Katial R. The diagnosis and management of acute and chronic sinusitis. Primary Care: Clinics in Office Practice. 2008;25(1).

Lindenmuth GF, Lindenmuth EB. The efficacy of echinacea compound herbal tea preparation on the severity and duration of upper respiratory and flu symptoms: a randomized, double-blind placebo-controlled study. J Altern Complement Med. 2000;6(4):327-34.

Mahady GB. Echinacea: recommendations for its use in prophylaxis and treatment of upper respiratory tract infections. Nutr Clin Care. 2001;4(4):199-208.

Maurer HR. Bromelain: biochemistry, pharmacology and medical use. Cell Mol Life Sci. 2001;58(9):1234-45.

Melchart D, Linde K, Fischer P, Kaesmayr J. Echinacea for preventing and treating the common cold. [Review]. Cochrane Database Syst Rev. 2000;(2):CD000530.

Min YD, Choi CH, Bark H, Son HY, Park HH, Lee S, et al. Quercetin inhibits expression of inflammatory cytokines through attenuation of NF-kappaB and p38 MAPK in HMC-1 human mast cell line. Inflamm Res. 2007 May;56(5):210-5.

Moore BM, Blumberg K, Laguna TA, Liu M, Zielinksi EE, Kuracheck SC. Incidental sinusitis in a pediatric intensive care unit. Pediatr Crit Care Med. 2012;13(2):e64-8.

Prasad AS, Fitzgerald JT, Bao B, Beck FW, Chandrasekar PH. Duration of symptoms and plasma cytokine levels in patients with the common cold treated with zinc acetate. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2000;133(4):245-52.

Pynnonen MA, Mukerji SS, Kim HM, Adams ME, Terrell JE. Nasal saline for chronic sinonasal symptoms: a randomized controlled trial. Arch Otolaryngol Head Neck Surg. 2007 Nov;133(11):1115-20.

Rössberg E, Larsson PG, Birkeflet O, Söholt LE, Stavem K. Comparison of traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis. Complement Ther Med. 2005 Mar;13(1):4-10.

Rotblatt M, Ziment I. Evidence-Based Herbal Medicine. Philadelphia, PA: Hanley & Belfus, Inc; 2002:221-5.

Russell PT, Bekeny JR. Oral antibiotics and the management of chronic sinusitis: what do we know? Curr Opin Otolaryngol Head Neck Surg. 2014;22(1):22-6.

Sarber KM, Dion GR, Weitzel EK, McMains KC. Approaching chronic sinusitis. South Med J. 2013;106(11):642-8.

Sertel S, Bergmann Z, Ratzlaff K, Baumann I, Greten HJ, Plinkert PK. Acupuncture for nasal congestion: a prospective, randomized, double-blind, placebo-controlled clinical pilot study. Am J Rhinol Allergy. 2009;23(6):e23-8.

Smith SR, Montgomery LG, Williams JW. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012;172(6):510-3.

Takkouche B, Regueira-Mendez C, Garcia-Closas R, Figueiras A, Gestal-Otero JJ. Intake of vitamin C and zinc and risk of common cold: a cohort study. Epidemiology. 2002;13(1):38-44.

Taw M, Nguyen C, Wang M. Complementary and Integrative Treatments. Otolaryngologic Clinics of North America. Philadelphia, PA: W.B. Saunders Company. 2013;46(3).

Ullman D, Frass M. A review of homeopathic research in the treatment of respiratory allergies. [Review]. Altern Med Rev. 2010;15(1):48-58.

Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2014;3:CD008115.