Rhino-sinusitis: Causes and medical treatment

Mr James W Fairley BSc MBBS FRCS MS
Consultant ENT Surgeon


© 1987 - 2014   JW Fairley   Last updated 19 March 2013

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What is rhino-sinusitis?

Rhino-sinusitis is the combination of rhinitis and sinusitis.

  • Rhinitis (Rye-NIGHT-iss) is inflammation of the lining of the nose.
  • Sinusitis is inflammation of the sinuses.

As part of the same air passages, and lined by the same mucous membrane, the nose and sinuses tend to be affected by the same problems. Rhinitis is commoner than sinusitis, and causes similar symptoms. Most cases of sinusitis start off as rhinitis, so we usually get rhinosinusitis rather than pure sinusitis. Nearly all cases of sinusitis are in fact rhinosinusitis.

Where are the sinuses?

CT scan showing a thin vertical slice through the face at the level of the eyelids. Air is black, bone is white, soft tissues and fluids are shades of grey. The frontal sinuses are the black spaces above the eyes. The ethmoid sinuses are the black spaces between the eyes. Between the cheeks, the grey pear-shaped bumps in the side walls of the nose are the inferior turbinates. The nasal septum is the vertical structure in the midline. This slice lies in just front of the maxillary sinuses, so they don't show. The sphenoid sinuses are much further back.
CT scan showing a thin vertical slice through the face at the level of the eyelids. Air is black, bone is white, soft tissues and fluids are shades of grey. Healthy sinuses appear black, with a white outline. This is because they contain air, and the soft tissue lining is very thin. This slice lies in just front of the maxillary sinuses, so they don't show. The sphenoid sinuses are much further back.
Key:
f = frontal sinus
e = ethmoid sinus
s = nasal septum
it = inferior turbinate

CT scan showing a thin vertical slice behind the eyeballs, toward the back of the nose. The roof of the sinuses is the floor of the brain. The bone separating the sinuses from the eye sockets is paper thin - like an eggshell. The left posterior ethmoid (right on picture) is grey in its lower half. This could be thick sticky fluid - the horizonatal curve looks like a meniscus - or soft tissue swelling. The middle and inferior turbinates project into the nasal cavity. The inferior turbinates are much bigger. The maxillary sinuses are seen above the roots of the teeth, both have grey swollen linings indicating inflammation. The sphenoid sinuses are just a little further back. Key: b = brain; o = orbit (eye socket); pe = posterior ethmoid sinus; mt = middle turbinate; it = inferior turbinate; ma = maxillary antrum sinus
CT scan showing a thin vertical slice behind the eyeballs, toward the back of the nose. The roof of the sinuses is the floor of the brain. The bone separating the sinuses from the eye sockets is paper thin - like an eggshell. The left posterior ethmoid (right on picture) is abnormal. Its lower half is grey. It is half full of thick treacle-like fluid. The fluid level shows as horizontal curved meniscus, with black air above. The middle and inferior turbinates project into the nasal cavity. The inferior turbinates are bigger than normal, they are swollen due to chronic inflammation. The maxillary sinuses (antra) are seen above the roots of the teeth, both have grey swollen linings indicating inflammation. The sphenoid sinuses are just a little further back.
Key:
b = brain
o = orbit (eye socket)
pe = posterior ethmoid sinus
mt = middle turbinate
it = inferior turbinate
ma = maxillary antrum sinus


Normal opening into left maxillary sinus (the natural ostium) seen through a nasal endoscope. Key: mt = middle turbinate; mm = middle meatus; it = inferior turbinate.
Normal opening into left maxillary sinus (the natural ostium) seen through a nasal endoscope.
Key:
mt = middle turbinate
mm = middle meatus
it = inferior turbinate

The sinuses are air-filled spaces in the bones of the face and skull. There are five main pairs of sinuses:

  • Frontal - In the forehead, above the eyebrows
  • Ethmoid - Between the eye sockets. Divided into anterior at the front, and posterior further back
  • Maxillary - In the cheek bones. Also known as the Antrum, or Antra (plural).
  • Sphenoid - At the very back of the nose, above the throat, behind the eyes, at the base of the brain. In the middle of the head.
The sinuses open into the nose via narrow twisting channels. They can easily become blocked by swelling of the mucous membrane.

Air in the sinuses lightens the structure of the head, and provides resonance for the voice.

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What is the mucous membrane?

The nose is much more than an ornament on your face that you happen to breathe through. It is a very active organ, constantly working to provide clean, humidified air at the correct body temperature to the lungs. The normal adult nose is around four inches (10 cm) long, front to back. The side walls have projections, the turbinates. Like the fins on a radiator, they increase the surface area of mucous membrane in contact with the air. There are three pairs, the superior, middle and inferior turbinates. They lie horizontally, front to back, stacked one above the other along the side walls of the nose. They look a bit like the fingers of a glove. The largest is the inferior turbinate. It is about the size of your little finger. The superior turbinate is tiny in humans, it has a specialised membrane for the sense of smell. The nose, sinuses, trachea (windpipe) and bronchi (tubes carrying air to lungs) are all lined with the same soft tissue mucous membrane. Also known as respiratory mucosa, this lining is specialised for breathing in air. It constantly produces a surface coating of wet mucus, which moisturises and humidifies the air. The mucous membrane lining the nose and sinuses has some further modifications, to guard and protect the entrance to the lower airways and the lungs.

The lining of the nose is your personal air conditioner.

The mucous membrane of the nose

  • warms
  • humidifies
  • cleans & filters
the air you breathe.

Your lungs need fully humidified air at body temperature to work properly. Your nose can turn dry air fully humidified, and raise freezing cold air to body temperature, in under a second, before it reaches the throat. Heat comes from blood, flowing just under the surface mucosa. Much more blood flows through the nose than it needs for itself. It is like a radiator. A fast rate of bloodflow and a big surface area are needed, but not all the time. It depends on the temperature and humidity of the air you are breathing in, and the rate of airflow you need. The main area for control of blood flow is the turbinates. The turbinates are made of erectile tissue - like the sexual organs, they can swell up and shrink down considerably. Careful regulation of bloodflow and surface area allows us to survive in a variety of climates. But get it wrong, and you might end up with too much pooling of blood, swollen engorged turbinates, and a blocked nose which won't clear when you blow it.

Cleaning and filtering

The lining of the nose can trap and filter out microscopic impurities from the air. Here, fine smoke particles are seen in shafts of sunlight against the dark background of the trees

The lining of the nose can trap and filter out microscopic impurities from the air. Here, fine smoke particles are seen in shafts of sunlight against the dark background of the trees

Even fresh air contains microscopic impurities. The lining of your nose is designed to clean and filter it. The process is called muco-ciliary clearance.

The mucociliary clearance system

Diagram of mucociliary clearance. Microscopic particles in the air get trapped in the sticky gel layer. The cilia beat through the thin sol layer in coordinated waves, sweeping the surface gel layer along.
Diagram of mucociliary clearance. Microscopic particles in the air get trapped in the sticky gel layer. The cilia beat through the thin sol layer in coordinated waves, sweeping the surface gel layer along.

Under extremely high powered magnification, the surface of the mucous membrane looks hairy - tiny, short hairs, like a velvet lawn, or a carpet pile. Only this carpet doesn't need a Hoover. It cleans itself. And it beats as it sweeps as it cleans. The surface of the carpet is wet, and sticky. It oozes and seeps liquid. Tiny glands constantly pump out onto the surface a thin film of sticky mucus. This coating acts like flypaper. It traps airborne particles, including

  • dust
  • smoke
  • pollen
  • bacteria
  • viruses
  • fungi
  • anything else in the air

The mucus, and anything stuck in it, are swept to the back of the nose by the cilia (silly - ah). The cilia are microscopic hair-like projections that form the pile of the carpet. They beat like tiny oars in the film of mucus, constantly moving it along, a wet sticky conveyor belt. The mucus is in two layers. An upper gel layer is very sticky and thick, for trapping particles on the surface. A lower sol layer bathes the stalks of the cilia. This layer is thin and watery, to allow the cilia to swish easily through it. At the peak of their stroke, like an oar dipping into the water, the tips of the cilia catch onto the mucus layer and move it along. The cilia must work together, all beating in the same direction, otherwise they won't achieve much.

  • The cilia in the sinuses all beat toward the sinus openings and send mucus into the nose.
  • The cilia in the nose all beat backwards, toward the throat.
  • The cilia in the trachea and bronchi beat upwards, also toward the throat.

The contaminated mucus is either swallowed, spat, sneezed or coughed out, while fresh mucus is produced by the mucous membrane. It is normal to have mucus coming from the back of the nose and into the throat.

The type of mucus has to be just right. Too thin and it won't stick, it will just run like water. Too thick and the cilia won't be able to move it. It will build up in clumps. If it isn't kept moving, germs will breed in the mucus, like they do in a stagnant pond. They may form a biofilm, which is resistant to antibiotic treatment, and acts as a reservoir for recurrent infections.

Control of the heating, humidifying and cleaning functions of the nose

Mucus production and blood flow are controlled for you automatically. Sensitive organs and nerve endings in the mucous membrane trigger automatic reflex changes. Hormone levels in the blood also have an effect. Some work directly on the mucosa, others work through the nerve supply. There are many layers of control. A complicated set of responses is designed to keep the air conditioner working efficiently. The nose can adjust very rapidly to changes in the external environment, and to the body's requirements for airflow. Excessive or inappropriate triggering of normal reflexes is a cause of some nasal symptoms.

External factors affecting the nose include:

  • air temperature
  • humidity
  • airborne irritants
    • dust
    • smoke
    • pollution
  • drugs
    • alcohol
    • nicotine
    • caffeine
    • prescribed medicines
Internal factors include:
  • hormones
  • emotion
  • stress reactions
  • allergic tendency

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Sneezing

Sneezing is a normal healthy reflex. It is designed to stop you breathing in something that might harm you. The sensitive lining of the nose detects a hazardous irritant. It reacts by triggering an explosive sneeze. This physically blows away the irritant. The sneeze is often followed often by excessive watery running of the nose in an attempt to wash away any remaining irritant. The problem is when the nose mis-identifies harmless substances as irritant, and this triggers excessive and inappropriate sneezing. Sneezing is common in the early stages of a cold. Sometimes sneezing will persist for a long time afterwards. This is because infection can bring the body's defences to a high state of alert. The alarm is triggered for things that aren't really going to harm you - like airport security confiscating old ladies' nail scissors. The commonest cause of persistent excessive sneezing is allergy.

Chemical defences of the mucous membrane

As well as the physical mechanism of mucociliary clearance, there are chemical defences in the mucus. Natural antibacterial and antiviral substances are produced, together with white blood cells which can recognize and destroy foreign material. These chemical weapons are deployed when the body detects a threat. Sometimes, the side-effects of the chemical weapons on the body - pain, swelling, blockage, interference with normal function - are worse than the effects of the foreign material. This is especially the case in allergy, but excessive reactions against fungal material, and certain products of bacteria including biofilms, may well underly the development of nasal polyps and other chronic inflammatory diseases of the mucous membrane.

The mucous membrane - summary

  • The mucous membrane of the nose is your personal air conditioner.
  • It warms, humidifies, cleans & filters the air you breathe.
  • The mucous membrane is a front line defence mechanism.
  • It protects the body against physical, chemical and microbiological attack.
  • It is a very complex system that is not completely understood.
  • Complex systems tend to go wrong.
  • The causes of poor mucociliary function are not always clear.

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Inflammation

Inflammation is the active response of the body to injury. The injury could be from germs invading the body - an infection - or it could be from physical trauma, chemical irritation, burns or any other noxious agent. Sometimes the inflammatory response is triggered by mistake, for no good reason, by harmless substances. This is the basis of allergy and auto-immune inflammation. Inflammation does not mean the same as infection, though infection is one of the commoner causes of inflammation. Inflammation is divided into two stages: Acute and Chronic.

Acute inflammation

The acute inflammatory response happens immediately after injury. It normally lasts no more than a few days or weeks. After that, things will either resolve & go back to normal, or become Chronic. The classic signs of acute inflammation are:

  • pain
  • swelling
  • redness
  • raised temperature
Acute sinusitis is usually due to infection.

Chronic inflammation of the nose & sinuses

Chronic means long-term - months or years. Chronic rhino-sinusitis is less dramatic than the acute inflammation. It is less painful, or there may be no pain at all. Temperature is normal or only slightly raised. The main physical signs are

  • swelling
  • loss of function
  • scar tissue may be formed
Not all chronic sinusitis starts off as an acute infection. Some inflammations are low-grade and chronic from the start. Some of these are due to the formation of biofilms, persistent colonies of slow-growing bacteria and other micro-organisms which attach themselves to surfaces. Sometimes, chronic inflammation will flare up and become acute. This may happen repeatedly. Chronic rhinitis will often lead to repeated acute attacks of sinusitis. Persistent chronic rhino-sinusitis is often due to a combination of adverse factors.

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What are the causes of rhinosinusitis?

Acute rhinosinusitis

Acute rhinosinusitis seen through a nasal endoscope. The left middle turbinate is swollen and inflamed, blocking normal mucociliary clearance from the ethmoid and maxillary sinuses. Bacteria thrive in the retained mucus. Their toxic products cause more inflammation, more swelling and more blockage - a vicious circle.
Acute rhinosinusitis seen through a nasal endoscope. The left middle turbinate is swollen and inflamed, blocking normal mucociliary clearance from the ethmoid and maxillary sinuses. Bacteria thrive in the retained mucus. Their toxic products cause more inflammation, more swelling and more blockage - a vicious circle.
Key:
s = nasal septum
mt = middle turbinate
it = inferior turbinatge

Acute sinusitis. Plain X-Ray showing fluid level in left maxillary sinus. There is mucosal thickening in the right maxillary sinus.
Acute rhinosinusitis. Plain X-Ray showing fluid level in left maxillary sinus. Mucus can't drain from the sinus because the pathway is blocked by swelling of the middle turbinate (see endoscope view above). There is also mucosal thickening of the lining of the right maxillary sinus.

Anyone can get acute rhinosinusitis, but some are more prone to it.

The commonest cause of acute rhinosinusitis is a cold virus. This infection can paralyse or even destroy cilia. Impaired mucociliary clearance then opens the way for secondary infection by resident bacteria. Resident bacteria are germs are present in the normal nose. They live quiet, unassuming lives, hidden in the hair follicles and skin of the nostrils. Most of the time they cause no trouble. But they are loitering with intent, awaiting their opportunity. Any who stray deeper into the nose are picked up and swept away by the mucociliary clearance system. If a sinus opening or mucociliary clearance pathway gets blocked by swollen mucous membrane, stagnant mucus builds up. Mucus that is not kept moving, like a stagnant pond, provides a fertile breeding ground for bacteria. As soon as the mucociliary defence mechanism is down, the bacteria move in and replicate, producing toxins. The body's response is to pump extra blood and white cells to the area - the acute inflammatory response. Unfortunately this causes yet more swelling of the mucous membrane, resulting in more congestion and blockage - a vicious circle. The escalation of hostilities turns the nose and sinuses into a battleground. Chemical warfare ensues, with collateral damage inevitable.

Recurrent acute and chronic rhinosinusitis

Anything which interferes with the normal functions of the mucous membrane predisposes to rhinosinusitis. Some people are born with poor quality mucous membrane. Rare causes of severely impaired mucociliary function from birth are:

  • Cystic fibrosis. All mucus secretions throughout the body are abnormally thick and sticky. Cystic fibrosis patients suffer chronic rhinosinusitis as well as chronic lung disease and poor absorption of food through the gut.
  • Kartagener's syndrome. The cilia, instead of being lined up in proper patterns to sweep the nose, sinuses and bronchial tree, are arranged at random. They don't succeed in moving the mucus along, they just stir it around. Sufferers get chronic lung disease as well as sinus problems. Half of them have their heart and other organs the wrong way round - the mechanism that causes things to line up correctly in the body is generally defective.
It is much commoner for the mucous membrane to be damaged during the course of life, rather than being born with a defect. The mucous membrane can be damaged, usually temporarily but sometimes permanently, by:
  • Infection
  • Polluted air
  • Smoking (including passive smoking)
  • Poor diet
  • Over-use of decongestant nasal sprays
Broken nose with sharp spur of deviated nasal septum pressing on root of left inferior turbinate. No inflammation at time of photograph, but patient had a history of recurrent episodes of sinusitis, always on the left side. Picture taken with rigid nasal endoscope under local anaesthetic in out-patient clinic.
Broken nose with sharp spur of deviated nasal septum pressing on root of left inferior turbinate. No inflammation at time of photograph, but patient had a history of recurrent episodes of sinusitis, always on the left side. Picture taken with rigid nasal endoscope under local anaesthetic in out-patient clinic.
Key:
s = nasal septum
mt = middle turbinate
it = inferior turbinate

Physical narrowing of the sinus openings and mucociliary clearance pathways can also predispose to recurrent sinusitis.

  • Abnormally narrow sinus openings are more easily blocked by minor swelling of the mucosa.
  • A broken nose can result in one side being blocked with sinusitis more likely.
Patients with
  • nasal allergy
  • polyps
  • non allergic rhinitis (previously called vasomotor rhinitis)
are likely to get sinusitis because of excessive mucosal swelling.

Non-allergic rhinitis used to be called vasomotor rhinitis. It results in excessive swelling and /or mucus secretion by the mucosa. There is defective control of the nasal reflexes. Another descriptive term is hyper-reactive rhinopathy. The cause is unknown.

Rare causes of chronic sinusitis are

  • immune deficiency
  • nasal foreign bodies
  • tumours

Sinusitis from dental infection

Occasionally the maxillary sinus is infected from the root of a diseased upper tooth.

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What are nasal polyps?

Patient with severe nasal polyps and asthma for 35 years. The polyps have gradually pushed the nasal bones outwards, resulting in a broad bridge.
Patient with severe nasal polyps and asthma for 35 years. The polyps have gradually pushed the nasal bones outwards, resulting in a broad bridge.

Same patient's large polyps seen by simple examination with a Thudichum speculum in the nostril. Very large polyps can hang down from the nostril.
Same patient's large polyps seen by simple examination with a Thudichum speculum in the nostril. Very large polyps can hang down from the nostril.

Same patient's CT scan showing nasal bones pushed apart by mass of polyps filling and blocking the nose
Same patient's CT scan showing nasal bones pushed apart by mass of polyps filling and blocking the nose.
Very large nasal polyps can sometimes be seen with the naked eye
Very large nasal polyps can sometimes be seen with the naked eye.

Nasal polyp seen through an endoscope in the right side of the nose. The polyp is the paler, softer looking, more gelatinous structure hanging below the middle turbinate. Polyps and turbinates can look quite similar to the non-specialist. Smaller polyps may not be seen without specialist endoscopy.
Nasal polyp seen through an endoscope in the right side of the nose. The polyp is the paler, softer looking, more gelatinous structure hanging below the middle turbinate. Polyps and turbinates can look quite similar to the non-specialist. Smaller polyps may not be seen without specialist endoscopy.
Key:
mt = middle turbinate
it = inferior turbinate
s = nasal septum
p = polyp

Polyps are benign soft swellings of the mucosal lining of the nose and sinuses. They can be the size of your thumb, though most are smaller. Often described as being like grapes, they are more like raw oysters, slippery and squashy. You can have half a dozen, or a dozen, packed up each side. Some polyps have a stalk, others arise from a broad base. They contain a lot of water and irritant chemicals with some cells from the immune system. To the pathologist, under the microscope, a polyp looks like a local allergic reaction. Polyps can arise from any part of the nose or sinus lining. The ethmoid sinuses and middle turbinates are most commonly affected. Polyps have no nerve endings, and are not painful, unlike the turbinates which are very sensitive. Polyps often occur in asthmatics. They tend to come back after they have been removed. Not all polyps are benign. You can get a malignant (cancerous) polyp. These are rare. They look different to the trained eye. Histological examination by a qualified pathologist will tell us what kind of polyps you have.

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What are the symptoms of sinusitis?

The symptoms of sinusitis are usually mixed with symptoms of rhinitis. Rhinitis alone can cause:

  • blocked nose
  • runny nose
  • post nasal drip (a feeling of something coming down from the back of the nose into the throat)
  • bouts of sneezing
  • pain over the bridge of the nose, face or eye
  • headache
  • loss of sense of smell

Acute sinusitis is usually painful, chronic sinusitis usually isn't. The site of pain depends on which sinuses are involved, but often more than one set of sinuses is involved at the same time.

  • Ethmoiditis causes pain between or behind the eyes and pressure over the bridge of the nose.
  • Maxillary sinusitis is felt in the face, upper teeth or eye.
  • Frontal sinusitis causes headache or pain over the eyebrow.
  • Infection in the posterior ethmoids and sphenoidal sinusitis go together. Sphenoidal sinusitis can cause pain anywhere in the head, in the ears or even in the neck.
Chronic polypoidal sinusitis. The left middle meatus is blocked by a polyp. A stream of pale green mucopus is discharging toward the back of the nose
Chronic polypoidal sinusitis. The left middle meatus is blocked by a polyp. A stream of pale green mucopus is discharging toward the back of the nose.
s = nasal septum
mt = middle turbinate
p = polyp in left middle meatus
it = inferior turbinate

If the mucus from an infected sinus is able to drain, rather than being blocked up, thick green or yellow mucus appears. This can discharge via the nose or as a "post nasal drip".

Secondary symptoms of sinusitis and its complications

Sometimes chronic sinusitis causes no direct symptoms, but secondary problems occur.
  • Earache, discharge and deafness results from middle ear disease, caused by interference with the Eustachian tube.
  • Eustachian tube inflammation due to chronic rhinosinusits. Thick sticky discharge streaming from the back of the nose over the left Eustachian tube, causing secondary glue ear. Unaware he had a sinus problem, this 46 year old man presented with difficulty hearing.
    Eustachian tube Inflammation due to chronic rhinosinusits. Thick sticky discharge streaming from the back of the nose over the left Eustachian tube, causing secondary glue ear. Unaware he had a sinus problem, this 46 year old man presented with difficulty hearing. Out-patient rigid nasal sinus endoscopy carried out under local anaesthetic at the same consultation revealed the cause.

  • Sore throat and hoarseness are symptoms of laryngitis, caused by the infected post nasal drip.
  • Laryngitis associated with rhinosinusits. The V-shaped vocal folds are red and inflamed. A blob of sticky mucus is sitting between the vocal folds at the bottom of the picture. Patient came with sore throat and hoarseness, unaware of any nose or sinus problem.
    Laryngitis associated with rhinosinusits, seen with flexible fibreoptic nasolaryngoscopy. The V-shaped vocal folds are red and inflamed. A blob of sticky mucus is sitting between the vocal folds at the bottom of the picture. Patient came with sore throat and hoarseness, unaware of any nose or sinus problem.
If complications set in, due to spread of infection into neighbouring structures, there may be
  • Swelling of the eye with disturbance of vision.
  • Orbital cellulitis due to spread of infection from the right ethmoid sinus into the soft tissues around the eye in a four year old child. Urgent hospital treatment with intravenous antibiotics, and surgical drainage prevented blindness in this case
    Orbital cellulitis due to spread of infection from the right ethmoid sinus into the soft tissues around the eye in a four year old child. Urgent hospital treatment with intravenous antibiotics, and surgical drainage prevented blindness in this case.
  • Severe headache with vomiting - indicates the possibility of meningitis or spread of infection into the brain.
  • Swelling of the cheek is hardly ever caused by sinusitis, dental infection is much more likely.

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Can sinusitis be serious?

Although most cases resolve completely, sinusitis can, rarely, have serious complications, especially in children.

  • Spread of infection to the eye can result in blindness.
  • Spread of infection into the brain or its coverings can result in meningitis, brain abscess and death.
  • The bone structure of the sinus can itself become infected. This osteomyelitis will require months of antibiotic treatment.
Prior to the discovery of antibiotics, sinusitis was a killer disease, and major surgery was often necessary to treat it. However, with modern antibiotic treatment, serious complicatons are rare. Early treatment reduces the risk of developing complications.

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Water mist spray

Mists, sprays, steam inhalations and mineral rinses are traditional remedies for sinus problems. They can thin down thick sticky mucus, helping your natural mucociliary clearance system to work better.

Extracts of mint produce menthol, a traditional herbal remedy for sinus problems

Herbal extracts such as menthol and eucalyptus stimulate the sensation of nasal airflow, making your nose feel clearer.

What can I do to help myself?

Sinusitis can get better on its own. Simple treatment with
  • rest
  • plenty of fluids
  • decongestant nasal sprays
  • painkillers such as paracetamol
may be sufficient. One traditional treatment which we still recommended today is steam inhalations.

Steam Inhalations

Towel over the head to form a steam tent over bowl of boiling hot water
Steam inhalation
  • Put a large container e.g. a washing up bowl on the table
  • Pour 3 pints of boiling water into it (take sensible precautions against splashing/accidents)
  • Add a small amount of Karvol or Menthol & Eucalyptus (from the pharmacist)
  • Sit down in front of the bowl with a towel over your head to form a "tent" over the bowl
  • Breathe the steam in through your nose, out through your mouth for five minutes
  • If decongestant nose drops are also being used, take them before the inhalations
  • The effect of steam is to cause a reflex shrinking of the mucous membrane. It also encourages ciliary activity.

Nasal Rinses / Washes / Douches

Traditional washing of the nasal lining with salt water, alkaline nasal douches (sodium bicarbonate and salt) and various mineral extracts is useful when the mucus is abnormally thick, and in dry arid environments. Rinsing can

  • thin down thick sticky mucus
  • wash away crusts or scabs following surgery
Modern convenenient and sterile forms include

To prevent attacks of sinusitis

  • Ensure a healthy balanced diet and regular exercise with plenty of fresh air
  • Avoid dusty, dirty or smokey atmospheres
  • Do not smoke and do not expose children to passive smoking
  • Go to bed at a sensible time - lack of sleep can depress the immune system

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What medical treatment is available?

For acute sinusitis caused by bacterial infection

  • Antibiotics are the mainstay of medical treatment.
  • Antibiotics can be taken by mouth, intravenously for severe acute cases, or topical creams & sprays as a preventive measure.
  • Decongestants - either nose drops, tablets or medicine - will help to reduce the swelling of the mucosa and speed resolution of acute sinusitis.
  • Decongestant nose drops and sprays such as Otrivine and Vicks Sinex should only be used for short periods - a week at most.
  • They are very effective at shrinking the swollen lining of the nose, which improves breathing and helps open the sinuses.
  • But prolonged use causes a "rebound" effect - the mucosa swells more than ever when you stop using them. They can also damage the cilia.
  • Damage to the lining of the nose caused by prolonged use of decongestants is known as rhinitis medicamentosa.

For chronic rhinosinusitis

  • Short courses of antibiotics - a week or two - are of little benefit in most cases, though sometimes they can can help.
  • Much longer courses of a particular type of antibiotic - up to three months of macrolides such as clarithromycin - have been found to help some patients and are recommended in the European Position Paper on Rhinosinusits and Nasal Polyps (EPOS guidelines, 2012)
  • Antibiotic / antiseptic creams and ointments such as Naseptin® and Bactroban® are sometimes used to reduce colonization of the nostrils with bacteria.
  • Decongestants are not suitable for prolonged use as they will cause rhinitis medicamentosa.
The treatment of any underlying allergy is very important. Any known allergens should be avoided if possible.
  • Anitihistamines - either tablets or local sprays - can be helpful especially if sneezing and running of the nose are prominent symptoms.
  • Where blockage of the nose is a prominent symptom, steroid nose drops or sprays are the most useful medical treatment for chronic rhinosinusitis.

Steroids for rhinosinusitis and polyps

Steroid nasal drops and sprays work by reducing the body's inflammatory response. They are slow to act - you may not notice much benefit for several days or even weeks - and need to be taken regularly, not just for an acute attack. They will gradually reduce swollen mucosa, and can even shrink polyps.

Modern nasal steroids such as Beconase™, Rhinocort®, Flixonase™ and Nasonex® are proven safe for long term treatment. They should not be confused with dangerous anabolic steroids abused by some athletes - you will be perfectly eligible for the Olympics on these treatments. Potential side-effects of being “on steroids” are minimal because the total dose is small, and very little of the small dose taken is absorbed into the body. However, you might get local side-effects, such as nosebleeds. Occasionally, nosebleeds can be bad enough to stop you taking nasal steroids.

Sometimes a short, sharp course of steroid tablets such as Prednisolone ec is used to shrink polyps. The risks of steroid side-effects from short courses of treatment are fairly small, but long term steroid tablets are likely to give rise to serious side-effects. No one should take steroid tablets longer than necessary.

The general principle of steroid treatment is to use the minimum amount which will keep things under control. Everyone is different, some need large doses, some small. We don't really know until we've tried, and assessed the the response to treatment. You will know yourself if you are feeling better. We can tell by nasal sinus endoscopy whether the polyps are shrinking.

We treat nasal polyps with steroids in the same way we treat asthma. The conditions are very similar. Many patients have both nasal polyps and asthma. In both cases, we want to control the disease using the least amount of steroid. A fairly high dose may be needed for initial control. After this kick start, the dose is gradually stepped down. If and when we reach a dose where symptoms begin to come back, the dose is increased to the previous level. We may need to adjust the dose and type of steroid over several months. This way, treatment is tailored to suit the individual patient.

However, steroids do not help everyone. If there is a bony narrowing, or polyps which are too large and established to be shrunk by steroids, surgical treatment may be needed.

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How to use nose drops

Head down and forward position for steroid nose drops
Lying on your stomach, head over the side of the bed, produces the correct position for nose drops. Keep your head down for a full sixty seconds after putting in the drops.

You may be advised to use steroid drops such as Flixonase Nasules™ in the head down and forward position. This is because most cases of sinusitis start with swollen mucosa high up in the nose and ethmoid sinuses, between the eyes. This is where the maxillary and frontal sinuses open, and where most polyps start.

To make sure the drops get to the affected area, you can either:

  • Lie on your stomach, with your head hanging over the side of the bed, or
  • Lean forward over a the corner of a table, or
  • Kneel down and put your head on the floor, or
  • Bend down and put your head between your knees

After putting in the drops, keep your head down for at least one minute to allow them to percolate into the narrow spaces.

  • There is no need to sniff or snort.
  • Don't worry if some run out when you come back up.
  • So long as you kept your head down for sixty seconds, enough will go in.

Lying on your back, and tipping your head backwards over the edge of the bed, is another option. It is not quite as good as the head down and forward methods.

Just sniffing up the drops where you stand is not really much use. Half will go straight down your throat, and half will run out. The drops won't reach high up, between the eyes, where they are needed.

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Rigid Nasal Sinus Endoscopy under local anaesthetic
Rigid Nasal Sinus Endoscopy under local anaesthetic

What is sinus endoscopy?

Sinus endoscopy (sometimes called FESS) is the modern way to diagnose rhino-sinusitis and plan treatment. It is normally done as an out-patient.

  • First, your nose will be sprayed with a local anaesthetic and decongestant.
  • After waiting a few minutes for this to work, you will lie back on a couch.
  • A small instrument, like a silver pencil with a light on the end of it, is passed gently along the nose.

The rigid nasal sinus endoscope has an angled lens which lets the surgeon see into all the nooks and crannies of the nose, showing the exact location of any narrowings, bony deformities, polyps and the source of any pus drainage.

Further information on rigid nasal sinus endoscopy

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Further reading

European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2012)

Disclaimer

All information and advice on this website is of a general nature and may not apply to you. There is no substitute for an individual consultation. We recommend that you see your General Practitioner if you would like to be referred.

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