HOW many can miss that sniffing, throat clearing or palatal sound of people with “sinuses”? It can be very
uncomfortable at times sitting next to someone who wants to get some nasal relief. What exactly are sinuses?
Do these people need medication? What happens if they don’t get treated?
Sinus comes from the Latin word which means hollow, bend, curve or cavity. In the bones of our skull and
face, sinuses are cavities lined with the same tissue that covers the inside of our nostrils (nasal mucosa).
These sinuses are present in every person and open into the nose. In children, some sinuses develop at
different ages and are only fully formed by adolescence. Some believe that sinuses are necessary
to make our skulls lighter, absorb blows to the face to limit damage to underlying structures, humidify
or moisten the air we breathe or enhance our voices.
There you have it. Next time you want to report a problem with your sinuses, try saying “I have sinusitis”
rather than “I have sinuses”. Sinusitis describes inflammation (swelling) of the nasal mucosa found in sinuses.
We all have four groups of sinuses generally occurring in pairs. Just above the nose, by the forehead area
above the eyebrows, we have frontal sinuses. Ethmoid and Sphenoid sinuses are deep in our face between
our eyes and just behind the nose respectively.
Inside our cheek bones, we have the Maxillary sinuses, largest of the sinuses. Normally, sinuses produce
mucus and are usually empty. With sinusitis, the nasal mucosa gets inflamed and there is nasal
congestion leading to an increased secretion of mucus, clogging these cavities.
Because the same mucosal lining found in sinuses is also found in the nose (nasal cavity), sinusitis
usually doesn’t occur in isolation. The inflammatory condition which involves both the nose and the
sinuses is called rhinosinusitis.
Acute rhinosinusitis is diagnosed if nasal and sinus cavities are inflamed presenting with the
following symptoms within 12 weeks:
-Purulent nasal discharge (thick mucus)
– Nasal obstruction/blockage (blocked nose)
– Facial congestion/fullness
– Facial pain/pressure/fullness
– Hyposmia/anosmia (decreased or no sense of smell)
– Ear pain/pressure/fullness
– Halitosis (bad breath)
– Dental pain (pain from teeth or jaw)
– Nasal and sinus mucosal inflammation can be caused by viral or bacterial infections. Other irritants (strong chemicals) or allergens (pollen or dust) can also cause inflammation. Viral infections like common cold or flu virus
(influenza) may predispose to nasal bacterial infection.
It is believed that the infection may be worsened by blowing one’s nose as this spreads the virus and bacteria found in the nasal or sinus mucus. The above symptoms are usually related to mucosal lining swelling, increased mucus secretion, increased blood flow to the inflamed mucosa and temporarily impaired ability of the mucosal cells to clear mucus from the nose or sinuses.
The subsequent complication in the sinuses is blockage of sinus openings into the nose (ostia) leading to more
problems and secondary bacterial infection. The normally occurring bacteria in our nose and sinuses will
then proliferate and will need to be treated.
Acute viral rhinosinusitis
The diagnosis of rhinosinusitis is made if there are at least two major symptoms; or one major symptom with two or more minor symptoms according to the Rhinosinusitis Initiative (RI) guidelines.
Viral rhinosinusitis is more common and usually presents as a common cold (which most people may refer to as
flu). The symptoms usually last for three to five days. Please note that a common cold is not flu! Flu is usually
severe and symptoms come on quickly.
Treatment with antibiotics is not recommended.
The following can be used:
– Pain killers (Panado® or Brufen®)
– Nose irrigation with saline containing nasal sprays (Salex® or Iliadin®)
– Topical nasal steroid sprays containing mometasone furoate (Nasonex®) twice a day
– Topical decongestants containing oxymetazoline (Vicks Sinex Decongestant Nasal Spray® or Otrivin®) for 3 days maximum
– Mucolytics/Expectorant/Mucus thinning syrups (containing guaifenesin)
– Antihistamines (Allergex if you want to be sleepy or Cetirizine if you don’t)
Other preparations like oral decongestants (Sinutab®) and ipratropium bromide can be used with caution or if recommended by health professionals.
Oral decongestants can raise blood pressure, stimulate the heart or affect diabetes control and are therefore to
be used in caution in patients with Hypertension, Hyperthyroidism, Angina (Coronary Heart Disease) and
Acute bacterial rhinosinusitis
In viral rhinosinusitis, symptoms are usually self-limiting and expected to improve and resolve within 10 days, latest, without complications.
Worsening of symptoms after five days with severe headache or pain, temperature > 38⁰c or persistence
of symptoms beyond 10 days are usually indicative of bacterial rhinosinusitis and antibiotics are indicated.
Some patients may improve without antibiotics (40-60%), but complications may arise in others if not treated.
-Infection spreading to the brain lining or brain itself (meningitis, intracerebral/epidural abscesses) presenting as high fever, altered mental status or unconsciousness Eye surrounding or eye infection (osteitis, peri-orbital abscess or orbital cellulitis) leading to eye “popping out” or protrusion (proptosis), double vision or
blindness if severe Chronic rhinosinusitis Some people get recurrences of acute rhinosinusitis.
If one gets about four episodes per year, they have acute recurrent rhinosinusitis. For those who get persistence of some major or minor symptoms over three months (12 weeks), they have chronic rhinosinusitis.
The following factors are associated with acute recurrences or chronic rhinosinusitis:
– Aspirin sensitivity
– Nasal polyposis
– Allergic rhinitis (hay fever)
– Immunodeficiency syndromes
– Hormonal factors (hypothyroidism or menopause)
– Structural abnormalities like congenital ciliary impairment disorders (inability of mucosal cells
to clear mucus), middle turbinate or ethmoid sinuses malformation or deviated nasal septum.
These can only be diagnosed or confirmed by a doctor People with chronic rhinosinusitis usually complain of blocked nostrils, nasal discharge (mucus from the nose) or post-nasal drip. When the mucus comes down at the back of
the throat and sometimes gives one a metallic taste; that is post-nasal drip.
Recurrent dry cough can result from post-nasal drip. Facial pain or pressure, headache or decreased smell are other common symptoms.
Management principles of chronic rhinosinusitis
Avoid self-diagnosis as you might miss reversible or surgicallycorrectible causes of your chronic rhinosinusitis.
Your doctor will need to ask specific questions related to your symptoms and risk factors.
On review, the doctor will look into your nostrils to assess your nasal turbinates, sinus openings
and exclude polyps.
Turbinates are structural projections inside the nose, on the side walls. They help warm and moisturise the air we breathe. They are covered by nasal mucosa as well and may become swollen and block the nose.
Nasal polyps are soft tissue growths covered by nasal mucosal lining that usually arise from ethmoid
sinuses. They too can swell and worsen sinusitis symptoms. Polyps can sometimes be missed by general
practitioners (GPs) as they may need special scopes for visualisation.
ENT (Ear, Nose and Throat) specialists should be consulted.
Removal of polyps by ENT specialists can result in good longterm results and prevent recurrence
of symptoms. The ENT specialist will also exclude structural abnormalities and treat accordingly.
Specific treatment for chronic rhinosinusitis
Treatment is usually tailored for specific risk factors and conditions.
Topical nasal steroids are effective in chronic rhinosinusitis.
Examples are fluticasone propionate (Flixonase®), triamcinolone acetonide (Nasacor T®), budesonide
(Rhinocort®), beclomethasone diproprionate (Beclate Aquanase®) Allergic rhinitis patients usually
present with sneezing, itching of the nose, red and watery eyes as well.
These patients may benefit from antihistamines and seven to 10 days of topical decongestants in addition
to topical nasal steroids used in other forms of chronic rhinosinusitis.
Treating associated conditions like asthma and aspirin sensitivity; and considering immunotherapy may be
effective in allergic rhinitis. Nasal saline sprays or drops are usually safe and effective for symptomatic relief in most patients.
Long term oral antibiotic therapy (over 12 weeks) with macrolide antibiotics (erythromycin) have been proven effective in patients with chronic sinusitis without nasal polyps. Please discuss this treatment option with your doctor as erythromycin might interact with other medications (including
contraceptives) rendering them ineffective.
For patients with nasal polyps, surgery (operation) may be recommended by your doctor or ENT specialist. If an operation cannot be done, oral corticosteroids can be used for about 10 days, at a time, to reduce polyp swelling. If polyps cannot be cured by surgery or oral corticosteroids, long term antibiotic trial can be effective in these specific
Dr Tendani Matoro is a medical doctor and social commentator