Chronic Sinusitis

Chronic sinusitis is a long-lasting inflammation of the sinuses that persists for 12 weeks or longer, affecting millions of people worldwide and significantly impacting quality of life through persistent facial pain, nasal congestion, and thick mucus drainage.

Table of contents

• What Is Chronic Sinusitis?
• Understanding the Sinuses
• Signs and Symptoms
• Causes and Risk Factors
• How Is It Diagnosed?
• Treatment Options
• Potential Complications
• Self-Care and Prevention

What Is Chronic Sinusitis?

Chronic sinusitis, also called chronic rhinosinusitis (a term that recognizes that nasal airway inflammation usually accompanies the condition), is a long-term inflammatory disease of the spaces inside your nose and head called sinuses^[1]. The condition lasts 12 weeks or longer, even with treatment^[1].

chronic rhinosinusitis

This common condition keeps mucus from draining properly, making your nose stuffy and making it hard to breathe through your nose^[1]. In the United States, chronic rhinosinusitis has an estimated prevalence of 1% to 5% of the population^[4]. Chronic rhinosinusitis is one of the most common chronic conditions, prevalent among all age groups and the fifth most common reason for an antibiotic prescription^[3].

Unlike acute sinusitis (a short-lived infection that typically goes away within 10 days and is often linked to a cold), chronic sinusitis involves persistent inflammation that may last months or years^[2]. While acute and chronic sinusitis have similar symptoms, chronic sinusitis is more complex in its causes and requires different management approaches^[1].

Understanding the Sinuses

• frontal sinuses (forehead)
• maxillary sinuses (cheekbones)
• ethmoid sinuses (between the eyes)
• sphenoid sinuses (behind the eyes)
• nasal passages

There are four paired sinus cavities: the ethmoid, sphenoid, frontal, and maxillary sinuses^[3]. These hollow spaces behind your cheekbones and forehead connect to the inside of the nose^[2]. The sinuses are lined with ciliated, pseudostratified columnar epithelium, a type of tissue that helps move mucus^[5].

Normally, the sinuses drain through small openings into the inside of the nose^[8]. Air that comes in through your nose moves through your sinuses on its way to your lungs. Your sinuses are lined with tissue and make mucus that keeps the inside of your nose moist and takes care of debris that air might move into your nose, like bacteria, viruses, and dust-carrying allergens^[2].

For the sinuses to work properly and filter out antigens, they need to drain effectively^[3]. Chronic inflammation can cause obstruction to the nasal passage, hinder drainage, and lead to lower oxygen tension. This creates an environment where bacteria can build up. Problems with the tiny hairs called cilia (structures that move mucus) or structural abnormalities can further worsen this process^[3].

Signs and Symptoms

Common symptoms of chronic sinusitis include thick, discolored mucus from the nose, known as a runny nose, and mucus down the back of the throat, known as postnasal drip (mucus that builds up and drips down the back of your throat)^[1]. You may also experience a blocked or stuffy nose, known as congestion, which makes it hard to breathe through the nose^[1].

Pain, tenderness, and swelling around the eyes, cheeks, nose, or forehead are characteristic features^[1]. Many people notice a reduced sense of smell and taste^[1]. The thick mucus is often yellow or green in color^[2].

Other symptoms can include ear pain, headache, aching in the teeth (particularly upper teeth), cough, sore throat, bad breath (called halitosis), and tiredness^[1][2]. The pain can feel like a toothache, and often the pain is more severe in acute sinusitis than chronic sinusitis^[9].

Chronic sinusitis and acute sinusitis have similar symptoms, but acute sinusitis is a short-lived infection of the sinuses often linked to a cold^[1]. The key difference is that symptoms of chronic sinusitis persist for 12 weeks or longer^[1].

Causes and Risk Factors

There is increasing evidence that chronic rhinosinusitis is an inflammatory disease and not simply an infectious process^[4]. The etiology of chronic sinusitis is multifactorial in nature and can include infectious, inflammatory, or structural factors^[3].

In chronic sinusitis, your sinus tissues swell, sometimes trapping mucus so it can’t flow from your nose as it should^[2]. When the mucous membranes that line the sinuses get inflamed, they swell and make more mucus. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat^[1].

Chronic sinusitis may happen because you have conditions that block your airways, like asthma, allergies, or cystic fibrosis (a genetic disease affecting mucus production)^[2]. Allergic rhinitis caused by dust mites, molds, or pollen can trigger inflammation^[3]. In adults, chronic sinusitis most often is linked to nasal swelling caused by allergies, especially allergies to inhaled dust, mold, pollen, or the spores of fungi^[8].

Other possible causes include tooth infections, a weak immune system (which makes you more vulnerable to infections), and polyps (growths) in your nose^[2]. Structural causes such as nasal polyps and a deviated nasal septum (a crook in the partition that separates the right from left nasal cavities) can contribute^[3][8].

Exposures to airborne irritants, cigarette smoke, or other toxins can play a role^[3]. Problems with cilia function, immune deficiencies, and fungal infections should also be considered^[3]. Other medical conditions that can be associated with chronic rhinosinusitis include otitis media, asthma, AIDS, and cystic fibrosis^[3].

If you have asthma or allergies, you’re more likely to develop chronic sinusitis because your airways are more likely to become inflamed or irritated, making your sinus tissue swell^[2]. Chronic sinusitis is also associated with other inflammatory diseases^[4].

How Is It Diagnosed?

Chronic rhinosinusitis is defined by the presence of at least two out of four cardinal symptoms (facial pain or pressure, reduced sense of smell, nasal drainage, and nasal obstruction) for at least 12 consecutive weeks, in addition to objective evidence^[4].

A health care provider might ask about symptoms and do an exam^[10]. The exam might include feeling for tenderness in the nose and face and looking inside the nose^[10]. If sinus infection symptoms last 12 weeks or more, healthcare providers may determine that you have chronic sinusitis^[2].

Other ways to diagnose chronic sinusitis and rule out other conditions include nasal endoscopy, where a health care provider inserts a thin, flexible tube, known as an endoscope (a viewing instrument), into the nose^[10]. A light on the tube allows a care provider to see inside the sinuses. They may also remove tissue that medical pathologists examine under a microscope^[2].

Non–contrast-enhanced computed tomography (CT scan) is the imaging study of choice to confirm the diagnosis of chronic rhinosinusitis^[4]. CT or MRI scans can show details of the sinuses and nasal area and might pinpoint the cause of chronic sinusitis^[10]. These scans may be done to look for polyps or see if you have a deviated septum^[2].

If allergies might be causing chronic sinusitis, an allergy skin test might show the cause^[10]. Lab tests aren’t often used to diagnose chronic sinusitis, but if the condition doesn’t get better with treatment or gets worse, tissue samples from the nose or sinuses might help find the cause^[10]. Providers rarely do biopsies to diagnose chronic sinusitis^[2].

Treatment Options

Treatment is directed at enhancing mucociliary clearance (the natural cleaning process of the airways), improving sinus drainage and outflow, eradicating local infection and inflammation, and improving access for topical medications^[4]. Chronic sinusitis treatment focuses on controlling or easing inflammation, because most chronic sinusitis happens when something irritates your sinuses^[2]. Treatments may vary depending on your situation^[2].

First-line treatment is nasal saline irrigation and intranasal corticosteroid sprays^[4]. Nasal saline irrigations improve sinonasal symptoms in patients with chronic rhinosinusitis^[4]. Your provider may prescribe nasal saline irrigation to help flush out mucus and allergens^[2].

Nasal corticosteroids are nasal sprays that help prevent and treat swelling^[10]. Some are available without a prescription. Examples include fluticasone, budesonide, mometasone, and beclomethasone^[10]. Intranasal corticosteroid sprays improve sinonasal symptoms in patients with chronic rhinosinusitis^[4]. Nasal steroid sprays may be prescribed by your provider^[2].

Saline nasal rinses using a specially designed squeeze bottle or neti pot can help clear sinuses^[10]. Saline nasal sprays also are available^[10]. Short courses (up to three weeks) of oral corticosteroids, alone or as an adjunct to standard maintenance therapy, improve sinonasal symptoms in the short term in patients with chronic rhinosinusitis and polyps^[4]. However, these shots and pills can cause serious side effects when used long term, so they’re used only to treat severe symptoms^[10].

Oral antibiotics, given for up to three weeks, may be considered as a treatment option for acute exacerbations of chronic rhinosinusitis^[4]. There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection^[4]. However, antibiotics are not routinely prescribed for chronic sinusitis without evidence of active infection^[4].

If medical management fails, endoscopic sinus surgery may be effective^[4]. Surgery may be needed to fix a deviated septum, remove nasal polyps, open up your sinuses, or remove fungal balls (clumps of fungal infection that block sinuses)^[2]. Balloon sinuplasty is a procedure that opens your sinus cavities^[2].

Patients not responding to first-line medical therapy should be referred to an otolaryngologist (an ear, nose, and throat specialist), and selected patients with a history suggestive of other comorbidities may also benefit from referral to an allergist or pulmonologist^[4].

Potential Complications

Untreated chronic sinusitis may cause infections that spread from your sinuses into your eyes, bones, brain, or spine^[2]. Orbital and intracranial complications are the most serious sequelae of chronic rhinosinusitis but are extremely rare, usually arising in patients with superimposed acute sinusitis^[4]. Orbital complications include periorbital cellulitis, orbital cellulitis, and orbital abscess. Intracranial complications include cavernous sinus thrombosis, meningitis, and epidural abscess^[4].

Chronic rhinosinusitis may also exacerbate comorbid pulmonary diseases^[4]. Bacterial flora from the paranasal sinuses of patients with cystic fibrosis, who almost always develop chronic rhinosinusitis, can serve as a reservoir for seeding pulmonary infections^[4]. In persons with asthma, comorbid chronic rhinosinusitis is associated with poor asthma control, as well as more asthma-related emergency department visits and systemic corticosteroid use^[4].

The greatest impact of chronic rhinosinusitis is decreased quality of life through burdensome chronic sinonasal symptoms and acute exacerbations^[4]. Several years ago, researchers found that sinusitis sufferers reported significant problems with work, energy, and mental health similar to those experienced by people with other chronic conditions^[1].

Self-Care and Prevention

You can usually treat mild sinusitis yourself by getting plenty of rest, drinking plenty of fluids, taking painkillers such as paracetamol or ibuprofen (do not give aspirin to children under 16), avoiding things that trigger your allergies, not smoking, and cleaning your nose with a salt water solution^[16].

One of the simplest, cheapest, and most effective ways to prevent and treat sinus problems is nasal irrigation^[21]. Using a homemade solution, you can often relieve sinusitis symptoms, reduce reliance on nasal sprays and antibiotics, and improve your quality of life^[21].

Breathe warm, moist air using a steamy shower, a hot bath, or a sink filled with hot water^[1]. Avoid cold, dry air. Using a humidifier in your home may help^[1]. Keep your nasal passages moist by running a humidifier in your bedroom or living space, using saline nasal sprays, or inhaling steam^[1].

Stay hydrated by drinking plenty of water throughout the day to help thin the mucus in your sinuses, making it easier to drain^[1]. Warm liquids like herbal teas, broths, or soups can provide added comfort by loosening mucus and reducing congestion^[1].

Avoid irritants by minimizing exposure to environmental factors that can aggravate your sinusitis^[1]. Watch out for allergens like dust, pollen, and pet dander, which are common allergens that can irritate your sinuses^[1]. Do not smoke or breathe second-hand smoke, as smoking can make sinusitis worse^[1].

If you have a high temperature or you do not feel well enough to do your normal activities, try to stay at home and avoid contact with other people until you feel better^[16].