How is sinusitis diagnosed?

Symptoms of sinusitis can be quite variable, both in whether or not they are present and how severe they are. They can mimic many other conditions, including the common cold, allergies, migraines, and other types of headaches and jaw problems. Patients with sinusitis typically have at least one of the following symptoms:

  • Discolored nasal discharge, often yellow or green
  • Facial fullness, heaviness, or congestion
  • Facial pain or pressure
  • Decrease in or loss of the sense of smell (the sense of taste may also be affected)
  • Decrease in the ability to breathe through the nose

Other symptoms that patients may have in association with the ones above are the following:

  • Fever, often low grade and variable
  • Fatigue or malaise (flu-like symptoms)
  • Pain in the upper teeth
  • Pressure or fullness in the ears
  • Chronic cough
  • Bad breath
  • Nasal dryness and crusting of secretions

Clearly, these symptoms are not specific and could be from a number of conditions. It is for this reason that sinusitis can be difficult to diagnose. Fortunately, recent diagnostic advances have improved our ability to accurately identify patients with sinusitis so that they can be appropriately treated.

Because the symptoms of sinusitis can mimic other diseases, a careful history of the problem is important. While facial pain and discolored nasal discharge or mucus is most often associated with sinusitis, other more subtle symptoms like cough, malaise, or fatigue should also be sought out. Questions about each specific symptom, including its duration and severity, and about the success or failure of past interventions can help to shed light on the nature of the problem. In order to be thorough and complete, we use a questionnaire to gather information about a patient's symptoms. The patient's responses then form a basis for a more thorough discussion of the history of the illness. An equally thorough physical examination is then conducted.

Because symptoms within the nose and sinuses can be associated with findings within the ears, throat, and neck, a complete otolaryngological (ENT) examination is done. Often a more thorough examination of the nose, called a diagnostic nasal endoscopy is performed. This procedure involves passing a fiber-optic telescope, or endoscope, into the nose and examining the interior of the nasal cavity. In this manner, the condition of the mucosal lining surrounding the sinus openings can be examined. Nasal endoscopy has greatly advanced the diagnosis and treatment of sinusitis. By providing superb illumination and magnification, it gives physicians the ability to closely examine conditions deep within the nose. It allows precise identification and targeting of problem areas and gives physicians an increased ability to monitor a patient's response to therapy.

Despite the great advances brought about by nasal endoscopy, this procedure can only give information about the openings of the sinuses. Unless a patient has had previous sinus surgery, the examiner cannot see the interior of the sinuses. Even in patients who have had sinus surgery, scarring can obscure the view into the previously opened sinuses. For this reason, another tool is used to visualize the sinus interior: computerized tomography, also known as a CT scan.

The CT scan provides information about swelling within the sinuses and also provides a road map of sinus anatomy should surgery be necessary. CT scanning can be a powerful tool in diagnosing sinusitis but must be performed under the right conditions. In patients with chronic sinusitis, the procedure should be performed when the patient’s symptoms are relatively quiescent. Patients should have received appropriate medical therapy and the scan should be performed no sooner than four weeks after the last flare-up. Otherwise, residual acute (short-term) inflammation will show up on the CT scan and give a false impression about the severity of the disease. If a patient undergoes a scan during an acute flare of sinusitis—or even during an episode of the common cold—the scan may show inflammation that may completely resolve. Such inflammation does not necessitate long-term medications and especially does not require surgery.

CT imaging must therefore be interpreted in the context of the each patient’s overall condition. All components of each patient's assessment—history, general otolaryngological examination, nasal endoscopy, and CT scanning—must be considered before choosing a course of treatment. Trying to use just one without the others can lead to errors in diagnosis and delays in instituting the correct therapy.

What is the difference between acute and chronic sinusitis?

  • Acute Sinusitis - When symptoms of sinusitis are present for less than four weeks, it is defined as acute sinusitis. Acute simply refers to the time course, not the severity of the symptoms. Typical acute sinusitis is caused by bacteria and will often follow a viral upper respiratory infection (common cold). The inflammation and swelling in acute sinusitis usually resolved completely or nearly completely following effective treatment. Patients who have multiple episodes of acute sinusitis with resolution of symptoms in between are said to have “recurrent acute sinusitis” and may benefit from interventions aimed more at prevention of the repeating episodes.
  • Chronic Sinusitis - Some patients have continued symptoms that wax and wane but never completely go away. When these symptoms are present for over three months, these patients are said to suffer from chronic sinusitis. While acute sinusitis is primarily a relatively short-lived bacterial infection, chronic sinusitis is different in many ways. Inflammation, rather than infection with bacteria, appears to play a larger role in causing chronic sinusitis and the treatment of chronic sinusitis therefore differs from the treatment of acute sinusitis.

What causes sinusitis?

This answer to this question differs for acute and chronic sinus problems.

Acute Sinusitis - In acute sinusitis, an inflammation typically occurs in the nasal cavity, which then spreads to the sinuses. When we have inflammation in the nose and sinuses (from colds, allergens, bacteria, irritants, and others) a few changes occur. First, as we all know, we produce more mucus and it often gets thicker. These changes overcome the mucosa cilia’s ability to transport the mucus and it starts to accumulate in the sinus rooms or in the nasal cavity hallway. The mucus may begin to accumulate cells and proteins from the immune system, which can begin to change the color of the mucus. For this reason, a change in the color of the mucus doesn’t always mean there is a bacterial infection.

Inflammation in the nose and sinuses also causes the mucosa/wallpaper lining to swell. Because the openings between the sinuses/rooms and the nasal cavity/hallway are so small, this swelling can block off the openings. When this happens, the air in the sinuses can’t exchange and the mucus becomes trapped. Bacteria that normally exist in the nose and throat can get into the sinuses and infect the mucus there, causing acute bacterial sinusitis. Air circulation into and out of the sinuses is also impaired.

With further inflammation, the movement of mucus out of the sinuses by the microscopic hairs called cilia slows and the secretions become stagnant. These conditions favor growth of bacteria and an infection sets in. Once the bacterial infection begins, it causes more inflammation and swelling and leading to increased mucus production. More swelling only worsens the mucus transport and air exchange, favoring more bacterial growth and the cycle continues.

Chronic Sinusitis - Formerly we thought chronic sinusitis was a longer version of acute sinusitis, but recently this has changed. Instead, it appears that chronic sinusitis is more of an inflammatory disorder that from time to time has bacterial flare-ups. The bacteria, however, may not always be driving the inflammation. They may be the effect of impaired transport of the mucus, taking advantage of the mucus that accumulates because of the inflammation, rather than originally causing it.

The next question then is what is causing the inflammation in the first place? The answer to this question is not clear and there may actually be multiple answers. Chronic sinusitis may have one cause in some patients and another cause in others. Some patients may have multiple causes present. Researchers have found an association between chronic sinusitis and a number of conditions, including fungus, bacterial proteins called superantigens, allergies, viruses, and acid reflux. It isn’t always clear in patients which of these factors is present and whether they are the cause or effect of the sinus inflammation. Many researchers feel that finding the answers to these questions is the key to unlock the effective treatment of chronic sinusitis, since we can’t fully treat or prevent a disease when we don’t know the cause or causes.

What are polyps?

A polyp by definition is an outgrowth from a tissue, shaped like a little bit like a teardrop. Depending on the tissue, however, they can have significantly different implications. Polyps in the intestines are often removed because there is a concern they may develop into cancer. This is almost never the case in sinus polyps. Sinus and nasal polyps indicate a more severe form of chronic sinusitis. The polyps typically start in the sinuses and may grow out into the nose (from the rooms into the hallway). When severe, they can completely block the airflow through the nose. Patients with nasal polyps frequently have asthma as well and may be sensitive to aspirin and similar anti-inflammatory products. Like other forms of chronic sinusitis, it’s not entirely clear why some patients get polyps, hampering our ability to completely rid patients of them.

Do I have allergies?

Allergies affect 16 percent of Americans and are seen much more commonly in patients with chronic sinusitis. Allergy symptoms are caused by the body’s reaction to allergens, which are proteins produced by insects, animals, plants, and molds. These allergens can be divided into two large classes based on when they are present. Perennial allergens are present year round. They include mold, animal dander, and dust (actually we’re allergic to the microscopic insect called the dust mite). Seasonal allergies are present for shorter periods of time, often repeating each year at the same time. Pollens from trees, grasses, and weeds are the best example of these seasonal allergens.

Patients with allergies can have classic symptoms including itchy nose or eyes, sneezing, watery eyes, and nasal congestion. These symptoms typically occur within a few minutes after exposure to the allergen in sensitive individuals. When patients are more or less constantly exposed to allergens, they react in a different way. They may not experience the typical itching and sneezing symptoms, but may have chronic congestion, runny nose, and fatigue. Often the allergic response to an irritant results in sufficient inflammation within the nose to precipitate or worsen the sinus condition.

Identifying and treating allergies is important in reducing inflammation that can affect the nose and sinuses, which can predispose individuals to sinusitis. By identifying the allergens a patient is sensitive to through allergy testing, patients may be able to avoid or limit their exposure to them. Medications to block the allergic reaction can be helpful, as can allergy shots, which have the potential to permanently blunt the body’s allergic reaction to the allergens in the shots.

How is sinusitis treated?

The goal in treating sinusitis is to re-open the narrow areas between the sinuses and the nasal cavity (to keep the doorway from the rooms into the hallway open) and to reestablish the normal movement of secretions along the nasal and sinus lining (the special wallpaper lining the rooms. This in turn promotes movement of mucus out of the sinus and re-establishes normal oxygen levels within the sinuses. The principal way to accomplish these goals remains medications. In some patients, medical therapy fails to provide relief of their symptoms and these patients may be considered for surgery. Often the treatment of chronic sinusitis involves combining a number of medications. Each type of treatment is summarized below.

  • Steroid nasal sprays - This class of medications works to diminish the nasal lining's inflammatory response, resulting in less swelling and better mucus transport. These sprays form the first in the treatment of chronic sinusitis as well as a number of other inflammatory conditions within the nose. They are typically sprayed into both sides of the nose and work directly on the lining they come into contact with. Their onset of action is relatively slow and patients may not feel their effect for days or weeks. For this reason, some patients give up on this method of treatment too soon.
    Steroid nasal sprays are generally well tolerated. Side effects from these medications include irritation within the nose and nasal bleeding. This bleeding can be avoided by pointing the spray bottle away from the nasal septum (the bone and cartilage that runs down the middle of the nasal cavity). Because the sprays are minimally absorbed throughout the rest of the body, side effects seen with taking steroid pills (see below) are extremely rare.
  • Antibiotics - The vast majority of cases of acute sinusitis are due to bacteria. For this reason, antibiotics are a mainstay of treatment for the acute form of sinusitis. Acute flare-ups of symptoms in chronic sinusitis are also likely to be caused by bacteria, while their role in the long-term symptoms of chronic sinusitis is more speculative.
    For acute sinusitis, a seven to ten day course of antibiotics is usually effective, although more recently a number of shorter duration antibiotic regimens have been developed. For patients with the underlying inflammation of chronic sinusitis, however, the nose and sinuses may take longer to respond. In these patients, three to four weeks of antibiotics, or even longer, may be necessary to treat an acute exacerbation of their chronic sinusitis.
    Most patients with chronic sinusitis have previously been on many short courses of antibiotics, usually not enough to stamp out the bacteria in a chronically inflamed sinus. In patients who do not respond well to antibiotics, a culture can be quite helpful. In this circumstance a sample of the bacteria is sent to the laboratory for identification and other testing. Because the openings of the sinuses cannot be seen without an endoscope, blind sampling of the nasal cavity using conventional equipment is nearly useless. Nevertheless, endoscopically directed cultures have proven very useful.
    Antibiotics have a number of side effects, many of which are specific to each different type of drug. Nevertheless, some are common including rash and diarrhea. If these occur, the drug should be discontinued and the symptoms immediately reported to your physician. While most reactions are mild, some can be serious and may require additional medical attention. Some antibiotics have been shown to have positive side effects, at least in the test tube. This class of antibiotics, called macrolides, includes erythromycin, clarithromycin, and azithromycin and is suspected to decrease inflammation in the nasal cavity and sinuses, independent of its antibacterial effect. For this reason, many physicians chose to treat patients with one of these drugs, especially in chronic sinus exacerbations.
  • Saline irrigations - Some physicians advocate rinsing the nose with saline or other solutions. Research done here at the University of Utah and at other institutions have demonstrated that irrigation is one of the most effective methods of reaching the sinuses, probably more effective than sprays or nebulizer machines. Saline or other solutions are most effectively delivered with a squirt bottle that can be regularly cleaned. Machines like pulsatile dental irrigators adapted for use in the sinuses are difficult to keep clean and are suspected to introduce bacteria into the sinuses.
    Many experts recommend using distilled water for irrigations or tap water that has been boiled. Irrigations can assist in removing thick or dried mucus and can help keep the nose and sinuses cleaned out when the normal mucus transport system is not working well. In cases of frequent or persistent infections, antibiotics can be added to the solution.
  • Saline nasal spray - Like saline irrigation, nasal saline (salt water) has been theorized to improve mucus transport. While there are few studies to support this claim, saline sprays are relatively innocuous and inexpensive. They appear to be helpful in some patients, especially those with dryness or crusting as a major symptom. Other sprays, which have various glycerin and herbal additives, are particularly helpful in relieving nasal dryness. Frequent use of saline nasal sprays is useful after sinus surgery to keep the secretions within the nose moist and prevent crusting.
  • Antihistamines - Antihistamines combat the allergic response within the nose. Blocking this allergic response can improve sinus function and reduce symptoms of sinusitis. One problem with many older antihistamines is the fact that they can cause sedation as well as drying and thickening of nasal secretions. Many new antihistamines have little or no sedative side effects and don't cause problems with secretions. Some are also combined with a decongestant to further reduce swelling within the nose and sinuses. While most antihistamines come in the form of pills taken once or twice a day, others can be sprayed into the nose or come as eye drops to control specific symptoms.
  • Decongestants - Decongestants act specifically to decrease swelling within the nose. They work directly on the blood vessels within the nose that control the thickness of the lining. They may also affect blood vessels throughout the body and should be used with caution (if at all) in individuals with certain disorders that are particularly difficult to control, such as hypertension (high blood pressure). Most decongestants are available over the counter and they are often combined with antihistamines. They can cause jitteriness or difficulty sleeping for some patients and should not be used in men with prostate problems.
    You should be careful with decongestant nasal sprays. They are particularly useful in diminishing swelling within the nose for a short period of time. If used for more than three days in a row, they can lead to a rebound effect and actually worsen nasal swelling. Often patients will then increase the dosage or the frequency with which they use the sprays in order to diminish the rebound swelling. This leads to a cycle of decongestion followed by rebound swelling, a condition known as rhinitis medicamentosa.
  • Mucolytics - These drugs, also known as expectorants, are common ingredients in cough syrups and cold remedies because of their ability to loosen and thin mucus. Because mucus often becomes thick and stagnant in sinusitis many physicians believe these medications may be helpful in this condition as well. The mucolytics are usually well tolerated with almost no side effects. In higher doses they can cause nausea, and, because these drugs act to thin mucus, they can increase fertility in women.
  • Leukotriene antagonists - These drugs are a newer class of drugs approved to treat asthma and allergies. They inhibit the leukotriene pathway, a series of chemical reactions in the body involved in inflammation. These drugs have proven successful in diminishing sinus inflammation in some patients but these effects can take some time to develop and don’t occur in all patients. Rarely they can cause problems with liver function and, depending on which drug in the class is chosen, it may be necessary to monitor the liver with periodic blood tests.
  • Oral steroids - In severe cases of chronic sinusitis, oral steroids (steroid pills taken by mouth) may be used. By increasing the delivery of the steroid drug to the nasal and sinus tissues, these drugs augment the action of the nasal steroid sprays in decreasing the inflammatory response. While they are quite effective, because these drugs are taken in pill form the medication spreads throughout the body and may have significant side effects. These include osteoporosis, liver abnormalities, cataracts, glaucoma, weight gain, emotional changes, and joint problems. With the exception of emotional changes and weight gain, most of the side effects are rarely seen unless the drug is used for a prolonged period of time. Rare idiosyncratic reactions severely affecting the hip and shoulder joints have been reported.
    Oral steroids are often given to patients with nasal polyps or asthma in preparation for surgery. They may be continued for a few weeks following the procedure to diminish the inflammatory response during healing.

What about other nasal and sinus conditions?

A number of other conditions can affect the nose and either mimic or contribute to sinusitis (such as allergies). Patients who have facial pain as a primary component of their symptoms may not have sinus problems at all. Numerous headache and facial pain problems mimic sinus disease and can be nearly impossible to differentiate based on symptoms alone. Only a thorough evaluation, sometimes including nasal endoscopy and/or sinus imaging can rule in or rule out a particular diagnosis.

Nasal airway obstruction - When patients find it difficult to breathe through their noses, physicians label this condition nasal airway obstruction. Because of the nose’s ability to warm, humidify, and remove particles from the air before it goes into the lungs, we are naturally nose breathers. Nasal airway obstruction can cause discomfort due to the need to breathe through the mouth, leading to a dry mouth and throat irritation. It may also contribute to snoring or its more serious cousin, obstructive sleep apnea. Nasal airway obstruction can also result from swelling of the lining within the nose (the mucosa), from structural narrowing within the nose, or both. Medications to control the mucosal swelling are often effective in relieving the sense of obstruction.

When the problem is a structural one, often surgery is necessary to resolve the problem. The first step in resolving a structural narrowing is defining the location of the obstruction. Earlier we referred to the nose as a hallway through which air passes from the outside environment on its way in and out of the lungs. This hallway has shelves that hang off of the walls, called turbinates and also has a narrowing at its beginning, called a nasal valve. Narrowing or collapse of this valve or enlargement of the shelf-like turbinates can impede the movement of air through the nasal hallway. Moreover, there is a wall that runs the length of the hallway and divides it into more or less equal halves. If the wall, the septum, is crooked, the air will not pass down the hallway properly, also giving the sensation of nasal obstruction. This condition is called a deviated septum. Straightening of the septum can often lead to improvements in nasal airflow through the nose. This is called a septoplasty.

Occasionally removal of some of the turbinate tissue may also be advantageous. Called an inferior turbinate reduction, this can typically be performed in the office under local anesthesia with return to normal activities the same day.

Rhinitis medicamentosa - Nasal decongestant sprays are effective ways of diminishing swelling within the nose. Nevertheless, when used for more than three days in a row, they can lead to worsening of the swelling. This occurs because of a rebound effect that occurs as the spray wears off. Increasing the frequency of use only worsens the condition, and may lead to more serious consequences. Treatment is relatively simple: complete discontinuation of the nasal decongestant sprays. Because this course of action often results in severe rebound swelling, other medications to diminish swelling can be prescribed by your physician to assist in getting through this short-term recovery phase.