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National Institute of Allergy and Infectious Diseases | health information

Sinusitis Your nose is stuffy. You have thick, yellowish mucus. You’re coughing, and you feel tired and achy. You think that you have a cold. You take medicines to relieve your symptoms, but they don’t help. When you also get a terrible headache, you finally drag yourself to the doctor. After listening to your history of symptoms and examining your face and forehead, the doctor says you have sinusitis.

What Is Sinusitis? “Sinusitis” simply means your sinuses are inflamed—red and swollen— because of an infection or another problem. Your sinuses—specifically, paranasal sinuses—are four pairs of cavities (air­ filled spaces) located within the skull or bones of your head surrounding the nose. When people say, “My sinuses are killing me,” they usually are refer­ ring to symptoms of congestion and achiness in their sinuses. There are several types of sinusitis. Health experts usually identify them as follows:

Sinus pressure can really weigh you down.

• Acute, which lasts up to 4 weeks • Subacute, which lasts 4 to 12 weeks • Chronic, which lasts more than 12 weeks and can continue for months or even years • Recurrent, with several attacks within a year In 2009, the Centers for Disease Control and Prevention reported that nearly 31 million adults were diagnosed with sinusitis. Women were almost twice as likely as men to receive the diagnosis, and there were more cases in the southern United States than elsewhere in the country.

What Are the Symptoms of Sinusitis? One of the most common symptoms of any type of sinusitis is pain, and the location depends on which sinus is affected. The sinuses are named for the bones that contain them.

U.S. department of HealtH and HUman SerViceS national institutes of Health national institute of allergy and infectious diseases

• If you have pain in your forehead, the problem lies in your frontal sinuses (over the eyes in the brow area). • Experiencing pain between your eyes, sometimes with swelling of the eyelids and tissues around your eyes, and tenderness when you touch the sides of your nose may mean sinusitis has devel­ oped in your ethmoid sinuses (just behind the bridge of the nose, between the eyes). • Pain in your upper jaw and teeth, with tender cheeks, may mean your maxillary sinuses (inside each cheekbone) are involved. • Pain in your neck, with earaches, and deep achiness at the top of your head could be a sign that your sphenoid sinuses (behind the ethmoids in the upper region of the nose and behind the eyes) are involved (though these sinuses are affected less often). Most people with sinusitis have pain or tenderness in several places, and their symptoms usually do not clearly indicate which sinuses are inflamed. Pain is not as common in chronic sinusitis as it is in acute sinusitis. In addition to the pain, people who have sinusitis (acute or chronic) often have thick nasal secretions that can be white, yellowish, green­ ish, or blood-tinged. Sometimes these secretions drain in the back of the throat and are difficult to clear. This is referred to as “post-nasal drip.” Also, cases of acute and chronic sinusitis are usually accompanied by a stuffy nose, as well as by a general feeling of fullness over the entire face. Less common symptoms of sinusitis (acute or chronic) can include tiredness, decreased sense of smell, cough that may be worse at night, sore throat, bad breath, and fever. On very rare occasions, acute sinusitis can result in brain infection and other serious complications.

What Causes the Symptoms of Sinusitis? The paranasal sinuses, like the inside of your nose, are lined with a thin layer of tissue called the mucous membrane, which produces mucus. This mucus flows out through openings of the paranasal sinuses and into the nose. When these openings become blocked, your sinuses are affected. 2

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Because your nose can get stuffy or congested when you have a condition like the common cold, you may confuse simple nasal congestion with sinusitis. A cold usually lasts about 7 to 14 days and goes away without treatment. Acute sinusitis often lasts longer and typically causes more symptoms than a cold.

Anything that causes swelling in the nose—including a cold; an allergic condition, such as hay fever; or a reaction to some chemical to which you’ve been exposed—can block the openings between your paranasal sinuses and your nose. The blockage causes air and mucus to become trapped within the sinuses. This may cause pain and thickened mucus. • The pain of a sinus attack arises because the trapped air and mucus put pressure on the mucous membrane of the sinuses and the bony wall behind it. Also, when a swollen membrane at the opening of a paranasal sinus prevents air from entering into the sinuses, it can create a vacuum that causes pain. • Mucus thickens because it loses its water content as it stays trapped inside the sinuses for a long time. In addition, inflammation leads to extra materials being secreted into the mucus, causing thickening.

What Are the Differences Between Acute and Chronic Sinusitis? Acute Sinusitis Acute sinusitis can be caused by the common cold, allergies and other chronic conditions, or pre­ existing health conditions. Common cold Most cases of acute sinusitis start with a common cold, which is caused by a virus. Colds can inflame your sinuses and cause symptoms of sinusitis. Both the cold and the sinus inflammation usually go away without treatment within two weeks. If the inflammation produced by the cold leads to infec­ tion caused by bacteria, then this infection becomes acute sinusitis. The inflammation caused by the cold results in swelling of the mucous membranes of your sinuses, trapping air and mucus behind the narrowed sinus openings. When mucus stays inside your sinuses and is unable to drain into your nose, it can become the source of nutrients for bacteria, which can then multiply. Most healthy people have bacteria, such as Streptococcus pneumoniae and Haemophilus influenzae, in their noses and throats. Usually, these bacteria cause no problems, but when you sniff or blow your nose when you have a cold, these actions create pressure changes that can send typically harm­ less bacteria into the sinuses. If your sinuses stop draining properly, the bacteria can begin to multi­ ply in your sinuses, causing acute sinusitis.

People who have allergies or other chronic problems that affect the nose also are prone to episodes of acute sinusitis. Chronic nasal problems cause the mucous membranes to swell and the sinus passages to become blocked. The normally harmless bacteria in your nose and throat again lead to acute sinusitis.

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Allergies and other chronic conditions

Pre-existing health conditions In general, people who have reduced immune function, such as those with primary immune deficien­ cy disease (a defect in the way the immune system responds to infection) or HIV infection, are more likely to suffer from sinusitis. People who have abnormal mucus secretion or mucus movement, such as those with cystic fibrosis (an inherited disease in which thick and sticky mucus clogs the lungs, causing breathing problems and making it easier for bacteria to grow), also are more likely to suffer from sinusitis. Infections caused by fungi very rarely cause acute sinusitis because the human body has a natural resistance to fungi. However, in people whose immune systems are not functioning properly, fungi can cause acute sinusitis.

Chronic Sinusitis In chronic sinusitis, the membranes of both the paranasal sinuses and the nose thicken because they are constantly inflamed. Most health experts now use the term “chronic rhinosinusitis” to describe this condition. They also recommend that the condition be distinguished as either rhinosinusitis with or rhinosinusitis without nasal polyps. Nasal polyps are grape-like growths of the mucous membrane that protrude into the sinuses or nasal passages, making it even more difficult for the sinuses to drain and for air to pass through the nose. The causes of chronic rhinosinusitis are largely unknown, but there are some conditions that may put you at higher risk for developing it, including asthma and allergies, recurrent acute sinusitis, and pre­ existing health conditions. Asthma and allergies Chronic rhinosinusitis often occurs in people who have asthma, many of whom also have allergies. It is possible that constant exposure to airborne allergens (substances that causes an allergic reaction) from house dust mites, pets, mold, and cockroaches causes chronic inflammation of the lining of the nose and the sinuses. An allergic reaction to certain fungi causes some cases of chronic rhinosinusitis: this condition is called allergic fungal sinusitis. However, at least half of all people who have chronic rhinosinusitis do not have allergies. Recurrent acute sinusitis

Pre-existing health conditions As with acute sinusitis, other causes of chronic rhinosinusitis may be an immune deficiency disorder or cystic fibrosis.

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Although most health experts believe that chronic rhinosinusitis is not an infectious disease like acute sinusitis, if you suffer from frequent episodes of acute sinusitis, you may be prone to developing chronic rhinosinusitis. Some experts believe that chronic rhinosinusitis is caused by an exaggerated immune response to fungi that normally are found in the sinuses or to the bacterium Staphylococcus aureus, which commonly lives inside the nose.

Some people are born with a physical structure inside the nose that makes mucus flow out of the sinuses difficult. Others may develop a structural problem after experiencing an injury to the nose. These people are at higher risk for developing chronic rhinosinusitis.

How Is Sinusitis Diagnosed? Your healthcare professional usually can diagnose acute sinusitis by noting your symptoms and examining your nose and face. If your symptoms do not clearly indicate that you have sinusitis or if they persist for a long time and do not get better with treatment, your healthcare professional may order a CT (computerized tomography) scan (a form of X-ray that shows some soft-tissue and other structures that cannot be seen in conventional X-rays) to confirm that you have sinusitis. Other laboratory tests your healthcare professional may use to check for possible causes of chronic rhinosinusitis include the following: • Blood tests to rule out conditions, such as an immune deficiency disorder, that are associated with sinusitis • A sweat test or a blood test to rule out cystic fibrosis • Tests on the material inside your sinuses to detect bacterial or fungal infection

How Is Sinusitis Treated? After diagnosing sinusitis and identifying a possible cause, your healthcare professional can suggest various treatments.

Acute sinusitis If you have acute sinusitis, your healthcare professional may recommend the following: • Antibiotics to control a bacterial infection, if present • Pain relievers to reduce any pain • Decongestants (medicines that shrink the swollen membranes in the nose and make it easier

to breathe)

Follow your healthcare professional’s instruction on how to use over-the-counter or prescription decongestant nose drops and sprays. You should use these medicines for only a few days, as longer term use can lead to even more congestion and swelling of your nasal passages.

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Even if you have acute sinusitis, your healthcare professional may choose not to use an antibiotic because many cases of acute sinusitis will end on their own. However, if you do not feel better after a few days, you should contact your healthcare professional again.

If you suffer from sinusitis and nasal allergies, such as hay fever, your healthcare professional may recommend medicine to control your allergies. This may include a nasal steroid spray that reduces the swelling around the sinus passages and allows the sinuses to drain. If you have asthma and then get sinusitis, your asthma may worsen. You should contact your health­ care professional, who may change your asthma treatment.

Chronic rhinosinusitis Healthcare professionals often find it difficult to treat chronic rhinosinusitis successfully. They have two options to offer patients: medicine and surgery. Medicine • Nasal steroid sprays are helpful for many people, but most people still do not get full relief of

symptoms with these medicines.

• A long course of antibiotics is occasionally recommended by physicians, but results from clinical research do not support this kind of antibiotic use. • Saline (saltwater) washes or saline nasal sprays can be helpful in chronic rhinosinusitis because they remove thick secretions and allow the sinuses to drain. • Oral steroids, such as prednisone, may be prescribed for severe chronic rhinosinusitis. However, oral steroids are powerful medicines with significant side effects, and these medicines typically are prescribed when other medicines have failed. Research is needed to develop new, more effective treatments. Surgery When medicine fails, surgery may be the only alternative for treating chronic rhinosinusitis. The goal of surgery is to improve sinus drainage and reduce blockage of the nasal passages. Nasal surgery usu­ ally is performed to accomplish the following: • Enlarge the natural openings of the sinuses • Remove nasal polyps • Correct significant structural problems inside the nose and the sinuses if they contribute to sinus obstruction

In children, problems can sometimes be eliminated by removing the adenoids. These gland-like tissues, located high in the throat behind and above the roof of the mouth, can obstruct the nasal passages.

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Although most people have fewer symptoms and a better quality of life after surgery, problems can reoccur, sometimes even after a short period of time.

Can Sinusitis Be Prevented?

There are no methods that have been scientifically proven to prevent acute or chronic sinusitis. Your healthcare professional may recommend the following measures that can help: • Keep your nose as moist as possible with frequent use of saline sprays or washes. • Avoid very dry indoor environments and use a humidifier, if necessary. Be aware, however, that a humid environment also may increase the amount of mold, dust mite, or cockroach allergens in your home; this is important only if you are allergic to any of those organisms. • Avoid exposure to irritants, such as cigarette and cigar smoke or strong odors from chemicals. • Avoid exposure to substances to which you are allergic.

Air travel may pose a problem if you suffer from acute or chron­ ic sinusitis. When air pressure in a plane is reduced, pres­ sure can build up in your head, blocking your sinuses or the eustachian tubes (the airways between the middle ear and the back of the throat that equalize air pressure on either side of the eardrum). As a result, you might feel discomfort in your sinuses or middle ear during the plane’s ascent or descent. Some health experts recom­ mend using decongestant nose drops or sprays before a flight to avoid this problem.

• If you haven’t been tested for allergies and you are getting frequent sinus infections, ask your healthcare professional to give you an allergy evalua­ tion or refer you to an allergy specialist. • Avoid long periods of swimming in pools treated with chlorine, which can irritate the lining of the nose and sinuses. • Avoid water diving, which forces water into the sinuses from the nasal passages.

Are Researchers Studying Sinusitis?

• Most people who have moderate to severe asthma also have chronic rhinosinusitis, suggesting that these two diseases may be the same disease occurring in the lower and upper parts of the respiratory system, respectively. NIAID supports research to understand the causes of chronic airway inflammation in asthma that could help scientists understand chronic rhinosinusitis and develop more effective treatment and prevention strategies. • At least two-thirds of acute sinusitis cases are caused by two bacteria: Streptococcus pneumoniae and Haemophilus influenzae. NIAID supports studies to better understand how these bacteria cause infection and to identify potential targets for future vaccination strategies that could pre­ vent these infections.

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NIAID supports research to better understand the immune system in health and disease and to devel­ op new treatments. Examples of NIAID-supported research to improve our understanding of the causes of sinusitis and to develop treatments for the condition include the following:

• NIAID funds research that examines the causes of thickening and inflammation of the lining of the sinuses and nasal passages. These projects also focus on the cells that produce mucus and line the sinuses and nasal passages. • In many people who have chronic rhinosinusitis, especially those with nasal polyps, a large num­ ber of eosinophils (white blood cells that have strong inflammatory properties) are found in the tissues that line the sinuses and nasal passages. NIAID funds several projects that examine the role of eosinophils and the messenger molecules they produce in causing chronic sinus inflamma­ tion and chronic rhinosinusitis with polyps. • NIAID supports research to test the theory that chronic rhinosinusitis is caused by an exagger­ ated immune response to fungi. One study has shown that when blood cells from people who have chronic rhinosinusitis are exposed to fungal material, these cells make messenger molecules that cause inflammation. • NIAID supports projects to identify human genes and proteins that are different in patients who have chronic rhinosinusitis from those whose sinuses are healthy. The results will help us under­ stand the causes of chronic rhinosinusitis and develop promising new treatments. For example, research has found that some people who have chronic rhinosinusitis also have certain alterations in the gene that causes cystic fibrosis.

Where Can I Get More Information? Visit www.niaid.nih.gov/topics/sinusitis for a list of Web resources on sinusitis, or contact NIAID for more information:

8 U.S. department of HealtH and HUman SerViceS national institutes of Health

national institute of allergy and infectious diseases www.niaid.nih.gov

January 2012

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National Institute of Allergy and Infectious Diseases National Institutes of Health 6610 Rockledge Drive, MSC 6612 Bethesda, MD 20892–6612 866–284–0147 or 301–496–5717 E-mail: [email protected] www.niaid.nih.gov