Signs of Sinusitis: Prevention and Treatment -- Gailen D. Marshall, MD. -- 01/30/03

WebMD Live Events Transcript

If your latest winter cold seems to be hanging on for a long time, you might be suffering from sinusitis. How can you tell the difference, and what should you do if your sinus problems become a chronic condition? You'll breathe easier after reading what Gailen D. Marshall, MD, had to say on WebMD Live.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Hello Dr. Marshall. Welcome to WebMD Live. Let's start by defining sinusitis.

Marshall: That's a very important question. It really means different things to different people. For most people, if their nose is stopped up and they have any sort of drainage, either from their nose or down their throat, they assume they have a "sinus infection," and that they need antibiotics.

The true definition of sinusitis is an inflammation of one or more sinuses. We have eight sets of sinuses normally from which any can be infected. That infection will typically clear up by itself over a matter of five to seven days, even if no treatment is given. Antibiotics for a bacterial sinus infection will shorten the illness to three to five days. Unfortunately, most sinus infections at least start out as VIRAL, for which there is no antibiotic that works.

Member: I have been on Levaquin for the past 45 days for a sinus infection that isn't clearing up. Why does it take so long for a sinus infection to clear up and why does it kick off my asthma?

Marshall: Those are two very good questions. Let's address each separately. First a long course of antibiotics is commonly necessary for chronic sinusitis. Chronic sinusitis typically occurs for one of several reasons. The most common reason is for persons who have chronic nasal congestion often due to underlying allergic rhinitis, also known as hay fever. Other reasons include structural abnormalities within the nose such as a septal deviation, air cells in a structure inside the nose called a turbinate. Turbinates are nature's air conditioning -- they warm, moisten, and purify the air we breathe. Unfortunately, they are also very much a target for allergic rhinitis, which causes them to swell and causes chronic nasal congestion that so often precedes sinusitis.

Another, much less common, reason for chronic sinusitis is an underlying immune deficiency. The deficient part of the immune system that causes chronic sinusitis is almost always related to low antibody levels. In someone who has been on antibiotics as long as you have, and who is apparently not responding to those antibiotics, a thorough evaluation of the structures in the nose (this could be done by examination and or X-ray procedures such as a CT Scan), a thorough evaluation for allergic sensitivity, and a screen to determine whether your immune system might have a specific defect. All of this can be done by specialists such as board-certified allergist-immunologists.

Your second question regarding why sinusitis affects asthma is less clear. It is certainly a known association that people with asthma that's difficult to control often have chronic sinus disease as well. A particular type of sinus disease known as nasal polyposis (the presence of nasal polyps) is often associated with this as well. Again, this can be evaluated quite readily with intranasal exams and or X-ray procedures.

Member: Does sinusitis cause post nasal drip, or is that caused by colds and allergies only?

Marshall: Again this is an interesting question. Typically postnasal drainage is due to either allergic rhinitis where the individual is congested nasally but also makes what would cause a runny nose (mucous). With the congestion, the mucous runs down the back of the throat rather than the nose causing post nasal drainage instead of runny nose. In older individuals, there is a phenomenon known as vasomotor rhinitis, which is not allergic. In this, the individual often is NOT congested but has terrible postnasal drainage. Sinusitis can certainly result in postnasal drainage but is not a prominent feature of this condition.

Member: Can people develop sinus problems as they age?

Marshall: Certainly the development of sinus problems with age is well recognized. Again the reasons can be from several different causes. As we age growth hormone levels go up, particularly after age 65. The result of this is an increase in the size of our feet, our hands, our ears, and ... our nose. As these structures increase inside the nose, the potential for obstruction (blocking) of the sinus openings in the nose goes up. A basic principle is that a blocked sinus WILL get infected. The only question is how long it will take for the infection to occur. Thus a basic principle in treatment of sinus disease from very young babies to very senior citizens is to KEEP THE NOSE OPEN.

Member: Will you always run a fever with sinusitis?

Marshall: Good question. No. Fever is often subjective not objective. What I mean is that the results of fever are feeling hot, body aches, and lethargy (slowing down everything you do). Fever is defined as an increase in your basal temperature. 98.6 is what most think of as a normal temperature. For some, 98.6 means they have one to two degrees of "fever" as their normal body temp is closer to 96. However, even with that knowledge, not everyone who has a sinus infection will have a fever. And likewise, not everyone with a fever and congestion will always have sinusitis.

Member: Dr. Marshall, is it natural to have a lot of sinus drainage in the mornings or is it a cold causing this?

Marshall: In most individuals, morning sinus drainage is a sign of increased mucous production at night primarily from the nose, not sinuses. Typically this is a result of perennial allergic rhinitis due to such things as dust mites, or mold spores, or animal danders often found in high concentrations in bedrooms of susceptible individuals.

Member: My son sniffs rather than blow his nose when he gets a cold. He claims his doctor told him that blowing his nose would lead to infection. However, he gets sinus infections, complete with bad bloody noses. The infections are accompanied by sinus headaches, which wipe him out. I say the infections are caused by sniffing rather than blowing. What do you think?

Marshall: I suspect the infection likely has little to do with sniffing versus blowing his nose. Individuals typically blow their noses much harder than is necessary to clear them of mucous. Even in individuals with large noses, the distance from the tip of the nose to the beginning of the throat is less than four inches. It does not take a huge amount of effort (and certainly no noise) to clear those four inches even if it were completely full of mucous.

What many people do not realize is that when we blow our nose hard we get a reflex nasal congestion, that is our nose will stop up right after. This is related to what happens when someone sneezes. A sneeze is the body's main defense to expel something considered noxious or even dangerous. The body does not want to breathe that noxious stimulus into the nose with the next breath. Thus, the congestion protects the nose against the immediate re-introduction of that noxious stimulus. When the nose is blown very hard, it mimics a sneeze and congestion can result. Remember, a congested nose will ultimately cause a sinus infection. Sniffing seems to not really cause an increase in sinus infections that I am aware of.

Member: Is there any reason why my symptoms seem limited to one side of my face? I am constantly swallowing, and NEVER have a runny nose.

Marshall: When patients report symptoms related to one side of the face, we most often think of some structural abnormality. In small children we look for foreign bodies (green bean up the nose). In older children and adults, we look for deviated septum, polyps, or hypertrophied (enlarged) turbinates. Thus, I would suggest a careful evaluation of the structures of both sides of your nose is in order.

Member: Can a sinus blockage cause you to feel lightheaded or get sort of hot flashes in your face?

Marshall: The lightheadedness, if speaking of dizziness, is not rare. The likely cause is chronic nasal congestion that ultimately in many patients will block the tube connecting the nose to the middle ear. This tube (called the eustation tube) keeps the pressure in the middle and inner ear normal. Among its other functions, the inner ear is responsible for balance. Thus, if the inner ear is disturbed, such as an infection, which is usually viral, an affected patient will often complain of lightheadedness or dizziness. Hot flashes in the face may be related to the discomfort that is so commonly associated with inflamed sinus and nasal tissue.

Member: I have a 5-year-old daughter. She was diagnosed with chronic sinusitis by MRI at 3 ½; she was treated with antibiotics; repeat CT showed clear sinuses. One year later repeat CT showed severe pansinusitis, which she had surgery for. Doctor removed small polpys, adenoids, and scraped sinuses to the bone. During this time she also had mycoplasma pneumonia. Her Igg and Igm were very elevated for eight months, and she was chronically infected with this. Numbers came down to Igg normal 0-200 hers Igg 600, Igm 0-770 her Igm 1500. Her Igm was as high as 3000.

My daughter has had symptoms of a sinus infection again, cold symptoms on and off for months, she complains of severe pain behind her nose in between eyes, pain under her eyes, and a sore throat. The ENT told me it is very unlikely that she would get a sinus infection again, and he is not concerned about Igg and Igm.. She has had 10 chest X-rays, two CT scans, and an MRI, so I am hesitant to have another CT done for the amount of radiation she has had is concerning. 1. Do you know any doctor that could help? 2. Do you think mycoplasma Igg and Igm should still be of concern? 3. Are there any other ways to detect a sinus infection other than a CT? Allergy testing is negative. No asthma.

Marshall: The major issue in this child in my mind relates to the underlying immune mechanisms you described. It does not sound at least initially like she has an immune deficiency to explain her symptoms and recurrent clinical episodes. What I strongly recommend to you is for your child to be evaluated by a pediatric immunologist. You could likely find one near you by searching the web site of the American Academy of Allergy, Asthma and Immunology at www.aaaai.org

Member: While I have a sinus infection, am I contagious to other people as with a cold?

Marshall: Good question. There is no evidence bacterial sinusitis is contagious. The reason for the infection is the blockage of the sinus openings. The major organisms that cause sinus infections can readily be found in people who have no infection. Don't forget however that many sinus infections occur as a result of congestion that comes from a cold. So basic avoidance issues (not drinking after someone, not exchanging oral secretions) while someone with a cold is sick or has a fever will minimize the likelihood of the second person getting ill.

Member: Do the "breathe easy strips" help sinus problems?

Marshall: Great question. The breathe easy strips do not directly help sinuses. What they do is ease certain types of nasal congestion. While to my knowledge there are no studies that demonstrate that breathing strips will reduce the incidence, severity or duration of sinus infection, it seems sensible to try this (unless sensitive to adhesive on back of the strip) since it's a harmless procedure.

Member: What about using a salt and water solution to irrigate your sinuses. Does that help much?

Marshall: The use of a saline irrigation for sinus disease and rhinitis in general can be very useful. As a rule of thumb, it will only work if the nose is decongested. What we recommend for salt water solution is one fourth teaspoon salt with one fourth teaspoon baking soda (not powder) in eight ounces of warm (NOT HOT) water. Then the individual leans over the sink and either using ear bulb or syringe can expel solution in each nostril sucking the solution back into the syringe until the solution is clear, indicating all mucous has been removed.

What I do for myself and recommend for other patients who do not like to use the bulb syringes is to merely cup one's hand, pour the saline into the cupped hand, place the nostril in the saline, and sniff. Then take a tissue and gently clear the nose. Either method can be highly effective in keeping the nose clean. All other things being equal, a clean nose will be less congested than one that is full of mucous.

Member: Are there any holistic (natural herbs/fruits/veggies/tea) ways to help chronic sinusitis?

Marshall: There are many methods that you have mentioned that have been reported or claimed to be useful in chronic sinusitis. To date, none of these procedures or agents has been PROVEN to be helpful in the treatment of sinusitis. Having said that, I commonly hear from my patients that they use a variety of different agents successfully for the treatment of THEIR sinus disease. The major caution I provide to my patients is the potential for adverse reactions to the agent or an interaction between the agent and that drug or drugs prescribed by one's physician.

Thus, my recommendation is to express your intent or desire to utilize a specific holistic agent to treat your sinus disease in addition to that prescribed by your physician so he or she can counsel you about any potential adverse effects.

Member: How effective is surgery in opening nasal blockage?

Marshall: The surgical intervention for sinus disease has several different thoughts behind it. Early on, it was thought that when the major sinuses under your eyes (maxillary) were opened to the side (called sinus windows) that this would allow them to drain and decrease the incidence of sinus infection. It was determined ineffective in reducing sinus infections in individuals with chronic recurrent episodes, thus this procedure is not done much anymore.

What is more commonly done is the straightening of the nose (septoplasty) and or a reduction of the size of the turbinates. These can be effective particularly if an individual has problems with sinus infections on one side only (the side where the nasal septum is deviated toward). Turbinate surgery is temporarily effective because it reduces the obstruction. However, if the individual has underlying chronic rhinitis (hay fever) the turbinates will often grow back to their pre-surgical size within one to two years after surgery. Therefore, it's critical that such surgery be accompanied by chronic medical treatment of the nasal disease.

Member: What's good for postnasal drip? So far, no one seems to know how to stop this. Could stress trigger a postnasal drip?

Marshall: Postnasal drainage typically occurs either due to inflammation or what's called cholinergic stimulation. That is an abnormal stimulation of certain nerves found in the nose. The inflammatory cause will typically respond to anti-inflammatory medications (intranasal steroids). The second cause is very unresponsive to intranasal corticosteroids. There are several drugs that are referred to as anticholinergic drugs. Some are sprays that have very few side effects and can be useful to dry the nose. These are prescription drugs and would be available from your physician.

Stress does cause worsening of postnasal drainage in many patients. Interestingly the mechanisms may be multiple. In the allergic patient, stress can make allergy worse, which will increase PND. In the cholanergic patient, stress can stimulate that arm of the system that can make the PND worse. The practical value of these statements means that stress management can for many patients help control (in combination with medications) their chronic post nasal drainage (PND).

Member: How do you know when its sinus and not allergy?

Marshall: That's one of the best questions of the day. There are commonalities and uniqueness to sinusitis versus allergic rhinitis. While both conditions can have nasal congestion, sneezing and itching are much more common in allergic rhinitis compared to sinusitis. Headache is more common in sinusitis than allergic rhinitis. The same can be true for facial pressure, loss of or difficulty in smelling, and fever.

Remember, hay fever is actually a misnomer -- that is, there is no fever associated with allergic rhinitis. If a person has fever, there is likely some infection going on somewhere.

Finally, don't forget that allergic rhinitis and sinusitis can go hand in hand in many patients. However the order is almost always allergic rhinitis symptoms first causing congestion followed by sinus infection.

Member: I have allergies all year long and get a sinus infection at least once a year. Is there any way to prevent this?

Marshall: The basic principle is that the sinus infection is tied to congestion. If you have allergies all year long, you likely do not even think about the fact that you stay congested most of the time. When the congestion moves to total congestion (now breathing through your mouth, which might be snoring while asleep) that total blockage can lead to sinus infection. Thus, managing your year round allergies by whatever means necessary (such as environmental exposure control), use of appropriate medications, and possibly allergy injections) will treat the underlying congestion, which should minimize or eliminate your episodes of sinusitis.

Member: Are yellow and/or green mucus still considered a good indication of an infection?

Marshall: By itself, it's not the definitive sign. However, if it's accompanied by facial pain, congestion, foul breath (a particular important sign), and/or fever, it certainly supports the likelihood that you have a sinus infection.

Moderator: Dr. Marshall, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Marshall: The most important thing I can relate to you is to resist the temptation to believe that any nasal problem is automatically sinusitis and thus automatically needful of antibiotic. The reason I say this:

  1. If it's rhinitis or viral infection (much more common) you will not feel better from the antibiotic.
  2. Second, and perhaps most important, is that the inappropriate use of antibiotic causes the development of bacteria resistant to that antibiotic necessitating the development of new, more expensive and potentially more toxic antibiotics to treat these bacterial infections.

Thus, if you think you are beginning to develop a sinus infection, there are several important things you can do.

  1. Lots and lots of water (six to eight glasses per day for a normal size individual).
  2. Long acting decongestants that are topical used twice daily for up to 10 days. There are many OTC brands that will work effectively.
  3. Follow this with nasal lavage using saline as we described earlier.
  4. Finally, particularly with a history of allergic rhinitis, the use of prescription intranasal corticosteroids can reduce inflammation and congestion that lead to sinusitis.

Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Our thanks to Gailen D. Marshall, MD. For more information, please visit the AAAAI web site at www.aaaai.org. Also check out the information at the Cold and Flu Center and the Allergy and Asthma Center on WebMD.


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