John R. Bennett, MD
1255 East 3900 South #301, Millcreek, Utah 84124
756 East 12200 South, Draper, Utah 84020 22 South 900 East, Salt Lake City, Utah 84102
Symptoms of sinusitis are sinus pressure, nasal congestion, thick discolored drainage anteriorly, and thick post-nasal drip. There is often a cough at night when the post-nasal drip is worse as you lay flat. Fevers typically are low, if any. Sinusitis generally isn’t very painful, but it may trigger a painful headache. Sinusitis feels a lot like a viral cold, but lasts longer. Our immune systems can usually get rid of a cold in a week or so, but the viral cold may trigger a bacterial infection. Any “cold” that lasts more than 7-10 days is probably a bacterial sinus infection. Anything that causes swelling in the nose may pinch off the sinus openings, causing the sinuses to fill with fluid and leading to infection. Viral colds, allergies, air irritants, and smoking are common irritants that trigger sinusitis. Our sinuses constantly secrete mucus, which drips down the back of our noses, cleaning our nasal passages and lubricating our throats. When this mucus gets stuck in our sinuses it quickly becomes a great place for bacteria to grow. Sinusitis is treated by first facilitating drainage, and second, sterilization with antibiotics if improved drainage isn’t enough to return the sinuses to good health.
When the nose becomes congested and the sinuses become blocked, conservative measures can often get the sinuses draining, and sinusitis can be avoided. Two things have clearly been shown to get the sinuses draining again- nasal steroid sprays and salt water irrigations (flushes). Nasal steroid sprays such as Flonase (fluticasone), Nasacort (triamcinolone), and Rhinocort (budesonide) are available over-the-counter. These should be used daily, but they take several days to build up and become effective. They may be used for weeks, months, and possibly years, but will ultimately dry out the nose, cause nosebleeds, and may even contribute to cataract formation in the eyes over many years. Although fluticasone (Flonase) is the most popular and widely advertised of the three steroid sprays, it is the only one that is alcohol based, and it tends to dry out the nose more than the other two (especially here in Utah with our high dry desert air). Nasal flushes like Neti pot and Neil-med saline nasal rinses decongest the nose while physically removing debris from the nose, and do a great job getting the sinuses to drain. They should be used twice a day when the sinuses are symptomatic. They are squirted up each side of the nose, and they drain out the opposite side of the nose and also out of the mouth. Nasal rinses usually take several tries before you get used to them!
The following medications have not been clearly shown to help sinusitis despite many studies, so at best these are all optional. Over-the-counter nasal decongestants like Afrin and Neosynephrine work immediately and can be used several times a day but must be stopped after three days as they diminish blood flow in the nasal lining, damage the nasal lining after 3-5 days of use, cause rebound congestion when stopped, and can even cause a hole to form in the septum. Nasal saline mist spray every several hours (while awake) naturally decongests the nose, keeps the nose healthy and moist, and allows debris to drain out. Mucinex (guaifenesin) is an over-the-counter pill that thins mucus, allowing the sinuses to drain easier. Mucinex-D has Sudafed to also decongest, but as this keeps most people awake at night, consider using Mucinex-D in the morning, and plain Mucinex at night. Sudafed should be avoided by those with high blood pressure, heart rhythm irregularities, enlarged prostates, and people who don’t tolerate the feeling of anxiety that Sudafed can cause. Antihistamines should be avoided as they dry out and thicken the nasal mucus, which make it harder for our sinuses to drain. If allergies are suspected, an allergy test and treatment can be very helpful.
The first goal in helping our sinuses is to get them to drain, which is what the conservative measures do. If symptoms persist beyond 7-10 days, then you may need antibiotics. If you haven’t had any antibiotics for 6 months, you may do well with just high-dose Amoxicillin (for adults, 2000 mg twice a day for 5-10 days), but often more aggressive antibiotics are needed, such as high-dose Augmentin (Amoxicillin plus Clavulanic acid, 875 mg, PLUS another 1000mg of Amoxicillin twice a day) or Levaquin. A number of other antibiotics are often employed. A five-ten day course of antibiotics may be inadequate for curing sinusitis, so refills may be necessary. If no improvement is noticed, it may be wise to get a sinus CT. Some apparent sinusitis can actually be something else, such as a migraine or tension headache, allergic rhinitis, or even a deviated nasal septum pushing into the lateral nasal wall causing constant congestion, irritation, and drainage.
Chronic sinusitis is sinusitis that lasts more than three months. A sinus infection resistant to multiple antibiotics, or someone who has recurrent sinusitis (such as three bad episodes a year for three years, five episodes a year for two years) may need to consider sinus surgery. Endoscopic sinus surgery is performed through the nostrils. The natural sinus openings are enlarged to facilitate nasal drainage, making it harder for the sinuses to block off and get infected, and easier for nasal medications to penetrate into the sinuses. Someone who has had sinus surgery can use medicated rinses to put antibiotics and steroids directly into the sinuses, avoiding antibiotic and steroid pills, and their side effects. Sinus openings may scar down after surgery, requiring a revision surgery. Image guided sinus surgery allows the surgeon to see exactly where the instruments are during surgery, making the surgery safer, as sinus surgery is performed between the eyes and below the brain. Balloon sinuplasty uses catheters with balloons to safely enlarge sinus openings in certain situations, either in the clinic or in the OR.
The conservative measures described earlier will often stop sinusitis from getting started or from worsening, and should be regularly used by those with chronic and recurrent sinusitis.
Please call Dr. Bennett at 801-328-2522 if you have any questions, problems, or concerns.