This letter originally appeared in Dr. Hoffman's column on allHealth.com. |
Q: I have had recurring sinus infections for the past year. I have been treated with antibiotics each time. However, whenever I stop taking them, the infection comes back. My ENT put a tube in my right ear in the hope that it would allow the fluid to drain. No luck. I have also had a CAT scan, which shows mucosal thickening. I am currently using Flonase and taking various decongestants and sinus remedies but nothing seems to relieve the headaches and sinus pain. Last week I even had a prednisone shot. It helped a little, but only for a day or so. Is there any treatment that works or at least relieves some of the pain?
A: One reason that chronic sinusitis is chronic is that there is often little rhyme or reason to the treatment plan. But let’s not get ahead of ourselves.
Sinuses are "air pockets" within the facial bones. Each sinus is lined with a tissue known as mucosa. Mucosa produces mucus, and mucus is a good thing. A thin blanket of mucus lines the mucosa of the sinuses, nasal cavities and throat. It is analagous to the sticky stuff on a No Pest Strip, trapping dirt, dust, microbes, pollen, and anything else that doesn’t belong inside the body. Microscopic "hairs" on the mucosal surface (cilia) sweep the mucus up and out of the sinuses, out of the nose, and into the back of the throat... and you swallow it!
Sinusitis is a generic term for any sinus inflammation. In order to devise a rational treatment plan for sinusitis, your doctor must attempt to answer a number of important questions regarding the nature of this inflammation. The answers to these questions will determine which medications would be helpful, and whether or not an operation might be helpful.
1. Is the inflammation due to infection? Viruses, bacteria and fungi can all cause infection. Viral infection of the nose (the common cold, in other words) can cause mucosal swelling (a stuffy nose), impeding the natural drainage pathways of the sinuses. The self-cleaning ability of each obstructed sinus is hindered, and bacterial infection (acute sinusitis) may result. Undertreatment of acute sinusitis may lead to a smoldering infection known as subacute sinusitis, later followed by chronic sinusitis.
Finally, we all have a small number of fungal spores in our nasal cavity at all times– they are in the air we breathe. Fungal overgrowth within the sinuses may occur; only rarely do these fungi actually invade tissues, causing a much more serious disease (invasive fungal sinusitis). Invasive disease occurs in individuals with poor immune systems, such as diabetics and cancer chemotherapy patients. In people with normal immune systems, fungal overgrowth merely tends to promote mucosal inflammation and contribute to obstructed sinus drainage.
Simultaneous infection by all three types of microorganisms is possible. It is also possible to have sinusitis in the absence of any infection (see next paragraph).
2. Is the mucosa intrinsically diseased? Allergy can cause a remarkable degree of mucosal inflammation in the nasal cavity and sinuses. Cigarette smoke and other toxic fumes can damage the cilia, impairing the mucosa’s ability to self-clean. There are particular diseases in which the mucosa is intrinsically diseased; cystic fibrosis is an excellent example of this.
3. Are any anatomic problems promoting sinusitis? One example of this is severe septal deviation. The nasal septum is a bony/cartilaginous structure that divides the nose into two cavities. "Septal deviation" is present if the septum is "pushed over" to one side or another. (This is usually due to trauma, but sometimes the septum becomes deviated as a result of facial growth in childhood and adolescence.) If the septum is severely deviated, this will certainly cause chronic nasal airway obstruction (at least on one side) and may contribute to sinusitis.
Many other anatomical abnormalities can predispose towards sinusitis. These bits of aberrant anatomy may be obvious on physical examination, but sometimes a sinus CT scan (CAT scan) is needed to find these problems. Nasal endoscopy (examination of your nose with a flexible fiberoptic camera) can also be extremely helpful for finding such problems.
SO.... I hope you can now appreciate that there is no "cook book approach" for the treatment of sinusitis; every patient must be evaluated individually, and the treatment plan must be tailored to the patient’s specific problems. Uninspired treatment plans are doomed to failure and may even worsen the situation.
Ear, nose, and throat doctors are typically a bit better at this than nonspecialists, but unfortunately not all ENTs are created equally, so you may have to shop around. Ask your physician for a referral. Ask friends, relatives and co-workers for their recommendations. Their recommendations may be based more on bedside manner than clinical acumen; on the other hand, a doctor’s reputation ultimately depends on whether his/her patients’ problems are solved!