Friday, November 8, 2013

What is wrong with my sinuses, doc?

Let’s talk about sinuses—those pesky air chambers in your face that on a good day are completely forgotten, and on a bad day can’t be ignored no matter what. What are they? Why do we have them? What can go wrong, and how do we fix it?

What they are: the sinuses are 4 paired air chambers in the face and base of the skull as seen in fig. 1.

Fig. 1 Frontal, Ethmoid, and Maxillary sinuses (Sphenoids not seen)

Why we have them: I love teleological “why” questions, but they mostly belong in a philosophical discussion. The sinuses are air spaces in the facial and skull bones, and as such they may lighten the head (instead of the skull being solid bone), they may act as a shock absorber for the brain in a fall or blow to the head, and they may help sounds produced by the voice box to resonate more. The mucous membrane linings produce a blanket of continuously moving mucus that carries bacteria, viruses, fungus particles and foreign material (dust, smoke residue) out of the sinuses to be swallowed or expectorated (spat out). They may also exist solely to keep ENT doctors in business. Just sayin’.

What can go wrong: basically, as air chambers, the openings can become blocked, which starts a cascade of events that result in bacterial or fungal infection of the chamber linings. These mucous membranes swell, resulting in further blockage of the sinus openings. This is commonly known as a vicious cycle, and it can be vicious all right! A sinus infection usually begins with a viral head cold that swells the sinus openings, trapping normally harmless bacteria in an airless chamber where they go crazy. The usual symptoms of an acute sinus infection are pain in the face, forehead, and upper teeth, nasal drainage (out the front or down the throat which is call post-nasal drainage or PND), and nasal congestion.

If the infection remains for longer than a few weeks, it is considered a chronic sinus infection, and symptoms change slightly: post nasal drainage and congestion continue, but facial pain fades and is usually replaced by a chronic pesky cough. Other symptoms are usually related to the nasal congestion or drainage: ear plugging or fullness due to plugged Eustachian tubes, hoarseness from mucus drainage, and sore or dry throat from mouth breathing. Allergies can increase the nasal congestion, and a septal deviation ("broken nose") can obstruct the nose further, worsening an already bad situation.

How we fix them: Sometimes a mild case will clear itself up without specific treatment when the viral infection resolves. Lots of fluids, vitamin C, and natural immune boosters can speed up recovery. If a head cold lasts longer than 7 days or is getting worse after 5 days, it's probably time to check in with your family physician or ENT, as you may need an Rx, especially if you are prone to sinus infections. I usually recommend a 10 to 14 day course of a broad spectrum antibiotic like amox/clav, cefuroxime, or azithromycin; a nasal inhaler such as fluticasone, and a short course of tapering low dose prednisone (like a Medrol dose pack for 6 days). Sudafed can be helpful as well.

If this trio fails to clear the infection up, I might opt for an additional 3 weeks of another antibiotic, continue the nasal spray, and maybe repeat the medrol dosepack. If this additional treatment fails, I often recommend a CT scan at that point: sometimes I find the CT to be completely free of any sinus findings, indicating we've been barking up the wrong tree. Several conditions can mimic chronic sinusitis such as atypical migraines, fibromyalgia, vasomotor rhinitis, and severe allergic rhinitis. Usually though, I find severely blocked sinuses that don't open fully with the treatment, allowing the openings to block shut soon after the antibiotic is finished. These folks generally come to surgery, which is aimed at re-opening the blocked openings to restore airflow into the sinuses and mucus flow out of them. 

There are lots of urban legends and old wives' tales about sinus surgery, so let me assure you: I never leave 20 feet of gauze packing in your sinuses, and I rarely even have to put instruments into the sinuses once the openings are enlarged. Significant bleeding is rare, and post op pain is very manageable (unless a septoplasty is performed in addition to the sinus surgery; then you will be a hurtin' unit for a week). Time off work is usually 3-5 days for sinus surgery and a week or so if both sinus and septal surgery is done.

There is much more to be said, and I've only covered the basics. Every case is unique, and treatment needs to be tailored for each patient. You can find out more about sinusitis here and here. If you have specific questions, discuss your symptoms with your family doctor, or feel free to call your local ENT for an appointment.

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