Fact sheet: Chronic sinusitis

Having a stuffy nose is normal for most people and is usually not much of a problem. It becomes more unpleasant if you find it difficult to breathe properly through your nose over a longer period of time and you have pain or pressure in your face. This can be a real problem and lower your quality of life quite a lot. It is often caused by an ongoing inflammation of the paranasal sinuses – chronic sinusitis, in other words. This fact sheet discusses the causes and symptoms of chronic sinusitis and lets you know what treatment options are available.

What is sinusitis?

Sinusitis is an inflammation of the paranasal sinuses. The medical term is "rhinosinusitis" ("rhino-" meaning "nose"), because it affects the mucous membranes lining the nose and the sinuses.

The paranasal sinuses are part of the upper airways, and are connected to the nasal cavity. They are made up of several cavities in the skull found from the forehead down to the teeth of the upper jaw. Depending on where they are, these cavities are known as the frontal sinuses, the sphenoid sinus, the ethmoid cells and the maxillary sinuses. Chronic sinusitis mostly affects the maxillary sinuses. The paranasal sinuses are lined with mucous membranes that have tiny hairs on them (ciliated epithelium). These mucous membranes produce a secretion that runs down through the nose and throat. 
 

 

Sinusitis can be acute or chronic: The acute form may appear several times a year, but it always goes away within several weeks at the latest. Acute sinusitis is often caused by a common cold.

Chronic sinusitis means that the mucous membranes in the nose are inflamed and swollen for a longer period of time: The paranasal sinuses and the nose are stuffed up and it is not possible for any fluid to drain. Sinusitis is commonly considered to be chronic if symptoms continue for more than three months.

There are basically two types of bilateral chronic sinusitis (“bilateral” means affecting both sides of the face):

• Chronic sinusitis without polyps: The mucous membranes are swollen, but no polyps have formed. Polyps are benign (non-cancerous) growths in the mucous membranes of the nose and sinuses.
• Chronic sinusitis with polyps: The mucous membranes are swollen and polyps have formed.

This fact sheet deals with these two main forms. Rarer types of chronic sinusitis which are, for example, due to a weak immune system or a fungal infection, require special treatment and will not be included here.

What things can make chronic sinusitis more likely?

Often it is not known what exactly has caused chronic sinusitis. Sometimes it develops from acute sinusitis that has not healed properly. But there are other factors that can make chronic sinusitis more likely or make it worse:

• immune system disorders, for example hay fever and other allergies
• a deviated nasal septum (when the wall between the two nostrils is bent to one side) or other abnormalities in the nose area 
• intolerance of acetylsalicylic acid (ASA, or ASS in German – the drug in Aspirin)

Environmental factors like chemicals or cigarette smoke are also thought to play a role.

Enlarged polyps constrict the nasal cavities, preventing proper ventilation. This makes it easier for germs to grow.

ASA intolerance can increase the likelihood of both sinusitis as well as the formation of polyps in the sinuses in some people. ASA is an active ingredient in many painkillers and anticoagulants.

This fact sheet is about treating normal chronic sinusitis in adults. Other types of chronic sinusitis are not discussed. You can find information on acute sinusitis in the fact sheet (URL: http://www.informedhealthonline.org/fact-sheet.494.en.html) of the same name.

What are the symptoms?

People with chronic sinusitis often have

• a runny nose with watery or purulent (pus) discharge,
• trouble breathing through their nose,
• pain or pressure in their face, mostly when tilting their head forward, and
• an impaired sense of smell and taste.

In sinusitis, the mucous membranes swell up and nasal secretion collects. This causes the nasal passages to become blocked and you get a stuffy nose. That is why it is difficult to breathe through your nose.

Sinusitis often causes pain in the forehead, the jaw and around the eyes and – less commonly – toothache. And it usually gets worse when you lean forward – for example when getting up out of bed. The sense of smell and taste is often impaired. Many people with chronic sinusitis also feel pressure in their face.

Nasal polyps often develop as a result of chronic sinusitis. Nasal polyps are mucous membrane growths that can develop from chronic inflammation. They impair nasal breathing and sense of smell.

What effects and complications can sinusitis have?

The effects of sinusitis are usually limited to the symptoms described above, which may be more or less severe. But when symptoms persist for several months, they may start to be a real problem. Sleep is often affected, and then on the following day you may feel worn out and weak.

Serious complications occur in only very rare cases where inflammation spreads to neighboring parts of the body, for example to the eyes or the brain. Signs of a complication include

• high fever,
• swelling around the eyes,
• skin redness,
• severe facial pain,
• sensitivity to light,
• general feeling of weakness and apathy, and
• neck stiffness.

If you have these symptoms, it is important to seek medical assistance immediately.

How is chronic sinusitis diagnosed?

The first thing a doctor will do is ask about symptoms such as pain, fever and your general wellbeing, as well as coughing, coughed-up phlegm and loss of smell and asthma. Then a tube-shaped instrument with a small light at the end (endoscope) is used to check the inside of the nose. This is done to find out whether the mucous membrane is swollen and whether polyps have formed, for example. Computed tomography (CT) or ultrasound may be used if the diagnosis is still not clear after the first check, or if complications are suspected.

An allergy test may also be of use if it is thought that you have an allergy in addition to sinusitis. It is common to have both at the same time. You can read more about treating allergies in our feature (URL: http://www.informedhealthonline.org/allergies.474.56.en.html)  of the same name.

What kinds of drug treatments are available?

Steroids

Nasal steroid sprays cause the swelling in the mucous membranes of the sinuses to go back down. This can relieve the symptoms. The full effect of steroid sprays is usually not felt for several days. Relieving the symptoms on a permanent basis often requires taking medication for months or years.

There may be adverse effects, but they are usually not very severe. The nasal mucous membranes may become irritated or dry out, which may lead to nosebleeds or temporary headaches. You can find out more about steroid sprays in the package insert.

Some people are reluctant to take any medication containing steroids. And with good reason: steroids can – when taken at a high dose and over a longer period of time – have side effects. However, steroids are often highly effective and the benefits outweigh the possible harms.

The advantage of nasal sprays: They have far fewer side effects than medication taken as tablets or delivered by infusion (a drip). This is because steroids in tablets or in a solution are carried through the entire body – but topical agents like nasal sprays or skin creams mostly only have an effect where they have been applied. So before you decide not to take steroids because you are scared of the side effects, it might help to discuss the advantages and disadvantages of the treatment together with your doctor.

Antibiotics

There is not enough high-quality research to say how effective taking antibiotics is for chronic sinusitis. Sinusitis is not usually caused by bacteria. Yet antibiotics are only effective against bacteria. What is more, the inflammation that occurs in chronic sinusitis is often also influenced by other factors, for example allergies.

The complications described here may occur in bacterial sinusitis, but this is rare. If that is the case, however, antibiotics must be used quickly because they can prevent serious complications such as meningitis.

Decongestant nose drops

Decongestant nose drops or nasal sprays aim to soothe the mucous membranes and reduce swelling. This makes it easier to breathe through the nose, which may also help you to sleep better at night. But decongestant drugs can also trigger the opposite effect as well: even after a few hours, the mucous membrane of the nose will start to swell up again. The longer the medication is used, the greater this effect will be. For this reason, it is not a good idea to use this medication continuously for more than a few days. Rinsing your sinuses using a nasal wash to free up your nasal passages is also an option in chronic sinusitis (see below).

Nasal irrigation and inhalation

In addition to medication, you can use saline solutions to reduce swelling in the mucous membranes and to help drain your sinuses. Saline solutions are available as pre-packaged nasal sprays. It is possible to rinse your nose with salt water as well. This approach, known as nasal irrigation, can make it easier to breathe through your nose and relieve the symptoms. You can also heat water and inhale the steam. Some people add things like chamomile or peppermint to the water. But there is not enough scientific research on steam inhalation to say for sure how effective it is.

Painkillers

Some medications may not be able to make you healthy faster, but they can relieve the pain caused by the condition. These include painkillers and anti-inflammatory agents like acetylsalicylic acid (ASA), ibuprofen or acetaminophen (paracetamol). It is important to note, however, that some people do not tolerate ASA. This drug may then make their sinusitis worse, or even trigger asthma attacks. Other painkillers, for example acetaminophen, are better suited for these people.

What other treatments are there?

Surgery

Especially if the symptoms are very severe and they do not improve enough or consistently just by taking medication, some people will decide to have surgery. One common type is a procedure for expanding restricted passageways in the paranasal sinuses. Mucous membrane growths (polyps) and inflamed parts of the mucous membrane are also removed. This operation is called “functional endoscopic sinus surgery (FESS)”. It aims to improve ventilation of the nose and the sense of smell, as well as to enable better drainage of nasal secretion. During FESS, a tube (endoscope) is inserted into the sinuses and the narrowed passageways are then expanded using smaller instruments.

Unfortunately, only few conclusive trials have looked into what long-term effect FESS has on the symptoms. Surgery is an option if steroid sprays and other treatments have not provided enough relief. The procedure also aims to help medications or saline solutions work better by allowing more of them to reach the nasal cavities. But even after surgery, you will need to continue to use a steroid spray or other medication to relieve the symptoms.

Severe complications following FESS are very rare. Complications that are more common include bleeding, inflammation, bruising or an altered sense of smell: according to various estimates, about 5 to 15 out of 100 people can expect these kinds of temporary side effects following surgery. The nose is often still stuffed up for several days after the procedure and scabs may form. This will also improve after a few days, but it may take several weeks until the wounds in the sinuses have completely healed. It is important to have regular check-ups over several weeks. These will involve the doctor removing wound secretions from the nose at several different appointments. The nose will also be rinsed with a saline (salt) solution.

One newer surgical procedure is balloon dilatation of the sinuses. Here a catheter is placed in the nose so that a balloon resting at the sinus opening can slowly be inflated. This procedure aims to expand the constricted passageways at the sinus openings, but it is not suitable for all forms of chronic sinusitis. Unfortunately, not enough conclusive research is available on the benefits and possible side effects of balloon dilation.

Other treatments

Many different types of medications and treatments are available for chronic sinusitis. Examples include herbal products, acupuncture, infrared light therapy or zinc products. There is no scientific evidence that these treatments will help to treat chronic sinusitis.

What can I expect from treating chronic sinusitis?

Chronic sinusitis can be burdensome and have a negative effect on your quality of life. Unfortunately, there is no treatment that can consistently get rid of chronic sinusitis quickly. But there are things that have been proven to be effective at relieving the symptoms. Nasal steroid sprays are the most helpful. Rinsing your nose with saline solutions can also sometimes provide relief. Surgery is an option if medications do not provide enough relief, or if the symptoms are very severe.

Author: Institute for Quality and Efficiency in Health Care (IQWIG)

Next planned update: March 2015. You can find out more about how our health information is updated in our text "Informed Health Online: How our information is produced" (URL: http://www.informedhealthonline.org/our-methods.643.en.html?bab[subpage_id]=0-8&sidgi=) .