Sinus Infection

Sinus infection, or sinusitis, is an inflammation of the sinuses and nasal passages. A sinus infection can cause a headache or pressure in the eyes, nose, cheek area, or on one side of the head. A person with a sinus infection may also have a cough, a fever, bad breath, and nasal congestion with thick nasal secretions. Sinusitis is categorized as acute (sudden onset) or chronic (long term, the most common type).

Anatomy of the sinuses (also called paranasal sinuses): The human skull contains 4 major pairs of hollow air-filled sacks called sinuses. These connect the space between the nostrils and the nasal passage. Sinuses help insulate the skull, reduce its weight, and allow the voice to resonate within it.

• Frontal sinuses (in the forehead)
  
  
• Maxillary sinuses (behind the cheek bones)
  
  
• Ethmoid sinuses (between the eyes)
  
  
• Sphenoid sinuses (behind the eyes)

The sinuses contain defenses against foreign bacteria (germs). If a disruption occurs that affects the normal host defenses inside the sinuses, those defenses may allow bacteria, which are normally present in the nasal passages, to enter any of the sinuses. Once there, the bacteria may stick to the lining cells and cause a sinus infection.

Acute sinusitis usually lasts less than 8 weeks or occurs no more than 3 times per year with each episode lasting no longer than 10 days. Medications are usually effective against acute sinusitis. Successful treatment counteracts damage done to the mucous lining of the sinuses and surrounding bone of the skull.

Chronic sinusitis lasts longer than 8 weeks or occurs more than 4 times per year with symptoms usually lasting more than 20 days.

These sinuses are covered with a mucus layer and cells that contain little hairs called cilia on their surface. These help trap and propel bacteria and pollutants outward. The ostiomeatal complex (OMC) connects the nasal passage to the paranasal sinuses.

Acute sinusitis usually follows a viral infection in the upper respiratory tract, but allergens (allergy-causing substances) or pollutants may also trigger acute sinusitis. A viral infection causes damage to the cells of the sinus lining. This damage leads to inflammation. The lining thickens with fluid that obstructs the nasal passage. This passage connects to the sinuses. The obstruction disrupts the process that removes bacteria normally present in the nasal passages, and the bacteria begin to multiply and invade the lining of the sinus. This causes sinus infection symptoms. Allergens and pollutants produce a similar effect.

Bacteria that normally cause acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. These microorganisms, along with Staphylococcus aureus and anaerobes (bacteria that live without oxygen), are involved in chronic sinusitis.

Fungi are also becoming an increasing cause of chronic sinusitis, especially in people with diseases that weaken the immune system, such as AIDS, leukemia, and diabetes.

Signs and symptoms of sinus infections depend upon which sinuses are affected and whether the sinus infection is acute or chronic.

Acute sinusitis:

• Ethmoid sinusitis (behind the eyes)
  
  
  • Nasal congestion with discharge or postnasal drip (mucus drips down the throat behind the nose)
    
    
  • Pain or pressure around the inner corner of the eye or down one side of the nose
    
    
  • Headache in the temple or surrounding the eye
    
    
  • Pain or pressure symptoms worse when coughing, straining, or lying on the back and better when the head is upright
  
  
• Maxillary sinusitis (behind the cheek bones)
  
  
  • Pain across the cheekbone, under or around the eye, or around the upper teeth
    
    
  • Pain or pressure on one side or both
    
    
  • Tender, red, or swollen cheekbone
    
    
  • Pain and pressure symptoms worse with the head upright and better by reclining
    
    
  • Nasal discharge or postnasal drip
    
    
  • Fever common
    
    
• Frontal sinusitis (behind forehead, one or both sides)
  
  
  • Severe headaches in the forehead
    
    
  • Fever common
    
    
  • Pain worse when reclining and better with the head upright
    
    
  • Nasal discharge or postnasal drip
    
    
• Sphenoid sinusitis (behind the eyes)
  
  
  • Deep headache with pain behind and on top of the head, across the forehead, and behind the eye
    
    
  • Fever common
    
    
  • Pain worse when lying on the back or bending forward
    
    
  • Double vision or vision disturbances if pressure extends into the brain
    
    
  • Nasal discharge or postnasal drip
  
  

Chronic sinusitis:

• Ethmoid sinusitis
  
  
  • Chronic nasal discharge, obstruction, and low-grade discomfort across the bridge of the nose
    
    
  • Pain worse in the late morning or when wearing glasses
    
    
  • Chronic sore throat and bad breath
    
    
  • Usually recurs in other sinuses
  
  
• Maxillary sinusitis
  
  
  • Discomfort or pressure below the eye
    
    
  • Chronic toothache
    
    
  • Pain possibly worse with colds, flu, or allergies
    
    
  • Increased discomfort throughout the day with increased cough at night
    
    
• Frontal sinusitis
  
  
  • Persistent, low-grade headache in the forehead
    
    
  • History of trauma or damage to the sinus area
    
    
• Sphenoid sinusitis
  
  
  • Low-grade general headache common

A person should call a doctor when experiencing pain or pressure in the upper face accompanied by nasal congestion or discharge, postnasal drip, or ongoing bad breath that is unrelated to dental problems.

Fever can be a symptom of a sinus infection or a cold. A person experiencing simple congestion with a low-grade fever probably has a cold and may not need special medications or antibiotics. Those also experiencing facial pain or headaches may have a sinus infection.

A doctor often can treat simple sinusitis. If left undiagnosed and untreated, though, complications of sinusitis can occur that may lead to severe medical problems and possibly death. The following complications are medical emergencies and require immediate treatment in a hospital's emergency department.

• Headache, fever, and soft tissue swelling over the frontal sinus may indicate an infection of the frontal bone, called Pott puffy tumor or osteomyelitis. Usually, this complication is limited to children.
  
  
• Infection of the eye socket may result from ethmoid sinusitis. The eyelid may swell and become droopy. Fever and severe illness are usually present. A person with this infection may lose the ability to move the eye, and permanently blindness may result.
  
  
• Ethmoid or frontal sinusitis may also cause the formation of a blood clot in the sinus area around the front and top of the face. Symptoms may be similar to those of eye socket infection with the addition of a fixed and dilated pupil. This condition usually affects both sides of the face.
  
  
• If a person experiences mild personality changes, headache, altered consciousness, visual problems, or seizures, infection may have spread to the brain. Coma and even death may follow.
• 
  
  

The diagnosis of a sinus infection is usually made based on a thorough medical history assessment and a physical examination. Adequately distinguishing sinusitis from a simple upper respiratory infection or a common cold is important.

Sinusitis is often bacterial and requires antibiotics for treatment. Sinusitis can also be viral (meaning antibiotics would not help). Upper respiratory infections and colds are viral. Proper diagnosis of these potentially similar conditions prevents confusion of which medications should be given. Overtreating viral infections with antibiotics can be dangerous.

• CT scan: In most cases, diagnosing acute sinusitis requires no tests. When testing is needed, the CT scan can clearly depict all of the paranasal sinuses, the nasal passages, and the surrounding structures.
  
  
  • A CT scan may indicate a sinus infection if any of these conditions is present:
    
    
    • Air-fluid levels in 1 or more sinuses
      
      
    • Total blockage in 1 or more sinuses
      
      
    • Thickening of the inner lining (mucosa) of the sinuses
    
    
  • Mucosal thickening can occur in people without symptoms of sinusitis. Therefore, CT scan findings must be correlated with a person’s symptoms and physical examination findings to diagnose a sinus infection.
    
    
  • In the past, doctors relied on x-ray films for diagnosis because the symptoms of acute sinusitis are very similar to those of an acute upper respiratory tract infection. In fact, most of the time, a viral infection is required to promote sinusitis. However, these films are not specific and depend on a good technique by the technician. According to one study, sinusitis is not visible on x-ray films about 55% of the time. If symptoms continue beyond 7-10 days and are associated with a simple cold, a diagnosis of sinusitis may be possible.
    
    
• Ultrasound: Another noninvasive diagnostic tool is ultrasound. The procedure is fast, reliable, and less expensive than a CT scan. However, the results are not as detailed as those from a CT scan are. Ultrasound has not been widely accepted for diagnosis of sinus infection by the medical community, especially among ear, nose, and throat physicians (ENTs, also known as otorhinolaryngologists). This is partly because a CT scan offers the ENT a more detailed image of the anatomy, which helps plan possible surgery.
  
  

If symptoms persist despite adequate therapy, a referral to an ENT may be made.

• In addition to specializing in sinusitis, the ENT can directly visualize the nasal passages and the OMC (passage into the sinuses) with a nasopharyngoscope. This is a fiberoptic, flexible tube that is insertable through the nose and enables the doctor to view the passageways and see if the OMC is open and draining right. Anatomical causes of breathing difficulties may also be found, such as a deviated nasal septum, nasal polyps, and enlarged adenoids and tonsils.
  
  
• An ENT may also drain the affected sinus to test for organisms. This is a more invasive test than those already mentioned. During this procedure, a doctor inserts a needle into the sinus through skin (or gum) and bone in an attempt to withdraw fluid, which can be sent to the lab for culture. Any present bacteria can be identified, usually in less than 2 days. Appropriate antibiotics can be given for treatment. This procedure is rarely used because it is uncomfortable, the CT scan is so clear, and because standard antibiotics are usually effective even though the exact bacterial cause is not known.

|Self-Care at Home|

Home care can help open the sinuses and alleviate their dryness.

• Promote drainage
  
  
  • Drink plenty of water and hydrating beverages. Hot tea is often recommended.
    
    
  • Inhale steam 2-4 times per day by leaning over a bowl of boiling hot water (not while the water is on the stove) or using a steam vaporizer with a towel over the head and bowl to prevent the escape of the steam. Inhale the steam for about 10 minutes. Taking a hot, steamy shower may also work. Mentholated preparations, such as Vicks Vapo-Rub, can be added to the water or vaporizer to aid in opening the passageways.
  
  

• Thin the mucus: Expectorants are drugs that help to expel mucus from the lungs and respiratory passages. They help to thin mucous secretions, enhancing drainage from the sinuses. The most common is guaifenesin (contained in Robitussin, for example). Over-the-counter (OTC) liquid cough medications or prescription tablets can also combine decongestants and cough suppressants to reduce symptoms as well as to eliminate the need for the use of many medications. Read label ingredients to find the right combination of ingredients or ask the pharmacist for help.
  
  
• Relieve pain: Pain medication such as ibuprofen (Motrin and Advil are examples), aspirin, and acetaminophen (Tylenol is in this category) can reduce pain and inflammation. These medications help to open the airways by reducing swelling.

|Medical Treatment|

The main goals in treating a sinus infection or sinusitis involve reducing the swelling or inflammation in the nasal passages and sinuses, eliminating the infection, promoting drainage from the sinuses, and maintaining open sinuses.

|Medications|

Reduce inflammation

Blood cells and lining cells of the mucosa in the sinuses can normally fight off foreign invaders. However, when overwhelmed by viruses and bacteria, coupled with a depressed immune system or over-reactivity to allergens, the result is the inflammation associated with sinusitis. With appropriate therapy, a short-lived infection can be treated effectively. Because foreign substances trigger numerous reactions, many treatments are available that can treat the symptoms of inflammation.

Decongestants help to reduce airway obstruction and are important in the initial treatment to alleviate symptoms.

• OTC nasal sprays (Afrin, Neo-Synephrine, Naphcon Forte, Otrivin, for example) work the fastest—within 1-3 minutes. However, these agents should not be used for more than 3 days because they become less effective and more frequent applications become necessary to attain the same clarity in breathing. This "rebound" phenomenon can be reduced by alternating between nostrils and using the medicine less frequently. Unfortunately, some people overtreat their nasal congestion with nasal spray and become dependent on it in order to breathe more easily. Overcoming the dependency requires a difficult withdrawal program that involves oral decongestants, saline, steroid nasal sprays, or a combination thereof.
  
  
• OTC oral decongestants (in tablet or liquid form) contain the active ingredients pseudoephedrine, phenylephrine, or phenylpropanolamine. (CAUTION: Phenylpropanolamine has recently been recalled from the market. Do not use products that contain this ingredient.) Most drug stores offer a wide variety of oral decongestants. All offer similar results, so price may be the deciding factor. The brand name medications are more expensive but release the drug slower, so they can be taken less frequently. Generics are less expensive and are to be taken every 4-6 hours or as needed. They work much slower than nasal sprays do. Usually, oral decongestants achieve their effect within 15-30 minutes. As with the nasal preparations, oral decongestants may become less effective with prolonged use. The rebound phenomenon exists but is not nearly as severe.
  
  
• Both nasal and oral decongestants have side effects, including general stimulation causing increased heart rate and blood pressure, insomnia, nervousness, anxiety, tremor, dry mouth, blurry vision, and headache. They may also cause an inability to urinate. Therefore, persons with a history of cardiac disease, high blood pressure, anxiety, or urinary problems should consult a physician before using decongestants. In addition, combining decongestants with other over-the-counter or prescribed medicines with similar side effects may cause dangerous complications.

Eliminate infection

The chief goal of treatment is wiping out bacteria from the sinus cavities with antibiotics. This helps to prevent complications, relieve symptoms, and reduce the risk of chronic sinusitis.

• For acute, uncomplicated cases, a synthetic penicillin is used—most commonly amoxicillin (such as Amoxil, Polymox, Trimox). This antibiotic has good effectiveness against the usual microorganisms and is relatively inexpensive. Amoxicillin’s main side effects include allergic reactions (throat swelling, hives) and stomach upset.
  
  
• People allergic to penicillin can take a sulfur-containing antibiotic called trimethoprim/sulfamethoxazole or TMP/SMX (such as Bactrim, Cotrim, Septra). This drug is not recommended for people who are allergic to sulfur.
  
  
• People who have several episodes of partially treated acute sinusitis or those who have chronic sinusitis may become resistant to amoxicillin and TMP/SMX. Newer synthetic penicillins such as Augmentin, Ceftin, and Lorabid can clear most of the resistant organisms that cause sinus infection.
  
  
• Overuse of these "broader-spectrum" antibiotics will eventually lead to organisms evolving that can resist even the most potent antibiotics currently available. Therefore, simpler antibiotics such as amoxicillin should be used first and taken for the entire duration (14-21 days). The basic rule of thumb is to take the antibiotic until the symptoms disappear, then continue to take the antibiotic for 1 more week.
  
  

Promote drainage

Home remedies that open and hydrate the sinuses may promote drainage. See Self-Care at Home for information on increasing daily fluid intake, inhaling steam, and taking expectorants and pain relievers.

If environmental allergies cause the sinusitis, the addition of an antihistamine may help reduce swelling of the mucous membranes. Allergens stimulate white blood cells in the blood and tissues to release histamine into the circulation. This causes fluid to leak from blood vessels into the tissues of the nasal passageways, leading to nasal congestion symptoms.

• OTC antihistamines are no longer recommended because they tend to dry out and thicken the mucus, making drainage more difficult.
  
  
• Prescription antihistamines such as fexofenadine (Allegra), loratadine (Claritin), or desloratadine (Clarinex) do not seem to dry out the mucosa. If nasal congestion is severe, a decongestant can be added (for example, Allegra-D or Claritin-D).
  
  

Maintain open sinuses

To treat acute sinusitis, 1 or more OTC or prescription therapies may be all that is necessary. However, for those with recurrent bouts of acute sinusitis or chronic sinusitis, the addition of an intranasal steroid may reduce symptoms. Commonly prescribed medications are Beconase, Flonase, Nasacort, Nasalide, and Vancenase.

• Steroids are potent inflammation inhibitors.
  
  
• Intranasal steroids (nasal sprays) work directly on the lining of the nasal passages and sinuses with little effect on the rest of the body when taken in prescribed dosages.
  
  
• As with the other classes of drugs, many intranasal steroids are available. Some are more tolerable than others. These are prescription medications, so a doctor usually chooses which one to give. These drugs do not relieve symptoms immediately like nasal and oral decongestants do, but once therapeutic drug levels are achieved, symptoms usually improve, and decongestants may be unnecessary.
  
  
• During months when environmental allergens are most widespread, the early administration of intranasal steroids may help to prevent sinusitis and keep the sinuses open and draining.
  
  

|Surgery|

• Some people experience chronic sinusitis despite adequate therapy with antibiotics and drugs for relief of symptoms. Those that have a CT scan indicative of sinus infection as well as those with any complications of sinusitis may benefit from sinus surgery.
  
  
  • The surgery is performed endoscopically using the same fiberoptic nasopharyngoscope used to make the diagnosis.
    
    
  • The goal is to remove obstructive mucosal disease, open the OMC or nasal passageway, and allow drainage of the sinuses.
    
    
  • During the surgery, nasal polyps can also be removed, and a crooked nasal septum can be straightened, leading to improved airflow.
    
    
  • Long-term nasal steroids and periodic antibiotics may still be necessary.
    
    
  • A continuing sinus infection may need further investigation. A culture obtained during a routine office visit or during endoscopic surgery may reveal anaerobes, which require treatment of broad-spectrum antibiotic drugs, or fungi, which require treatment of antifungal medications.

|Follow-up|

People whose symptoms of a sinus infection do not go away despite the use of antibiotics should follow up with their doctors or ear, nose, and throat specialists in 5-7 days.

|Prevention|

Prevention of a sinus infection depends on its cause.

• Avoid contracting upper respiratory tract infections.
  
  
  • Obtaining the influenza vaccination yearly will help to prevent the flu and subsequent infection of the upper respiratory tract. Other flu medicines, such as Relenza and Tamiflu, if taken at the onset of symptoms, may also help to prevent infection.
    
    
  • Maintain strict hand-washing habits and avoid people who are obviously suffering from a cold.
    
    
  • In some studies, zinc carbonate lozenges (Cold-Eeze and others) have been shown to reduce the duration of many cold symptoms.
    
    
  • Stress reduction and a diet rich in antioxidants, especially fresh, dark-colored fruits and vegetables, may help strengthen the immune system.
  
  
• Plan for seasonal allergy attacks.
  
  
  • If sinus infection is caused by seasonal or environmental allergies, avoiding allergens is very important. If avoidance is not an option, either OTC or prescription medication may be helpful. OTC antihistamines or decongestant nasal sprays can be used for an acute attack.
    
    
  • People who have seasonal allergies may benefit from nonsedating prescription antihistamines during those allergy-season months.
    
    
  • Avoid spending long periods outdoors during allergy season. Close the windows to the house and use air conditioning to filter out allergens when possible. Humidifiers may also be helpful.
    
    
• Stay hydrated
  
  
  • Maintain good sinus hygiene by drinking plenty of fluids to keep nasal secretions thin.
    
    
  • Avoid air travel. If air travel is necessary, use a nasal decongestant spray prior to departure to keep the sinus passages open.
    
    
  • Use of saline nasal sprays (available at drug stores) help keep the nasal passages moist, thus helping remove infectious agents. Inhaling steam from a bowl of boiling water or in a hot, steamy shower may also help.
    
    
• Avoid allergens in the environment
  
  
  • People who suffer from chronic sinusitis should avoid areas and activities that may aggravate the condition, such as cigarette smoke, secondhand smoke, and diving under water in chlorinated pools.

|Outlook|

Sinusitis or sinus infections usually clear up if treated early and appropriately. Aside from those who develop complications, the outlook for acute bacterial sinusitis is good. People who have allergic or structural causes for their sinusitis may have recurrent attacks of acute sinusitis or may develop chronic sinusitis.

|Web Links|

National Institute of Allergy and Infectious Diseases, Sinusitis

MedlinePlus, Sinusitis

American Academy of Allergy, Asthma, and Immunology, Tips to Remember: Sinusitis

MayoClinic.com, Chronic Sinusitis

sinus infection, sinusitis, acute sinusitis, chronic sinusitis, sinus headache, bronchitis, rhinosinusitis, ethmoiditis, sphenoiditis, antritis, hay fever, viral infection, bacterial infection, allergens, allergy, allergies, indoor allergy, indoor allergies, headache

Author: Barnett R Kantz, DO, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Henry Ford Wyandotte Hospital.

Coauthor(s): Linda Varon-Thomas, MD, Program Director, Department of Emergency Medicine, St John Oakland Hospital.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Thomas Rebbecchi, MD, FAAEM, Program Director, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey.