Sinusitis
I recently gave a lecture to the physician assistant students at George Washington University on the topic of Sinusitis. If you will indulge me, I am going to review some of what I see are the highlights of a very common condition that is evaluated frequently in the medical office.
Sinusitis is an inflammation of the sinuses, which can come from infectious or non-infectious causes. It is actually formally known as Rhinosinusitis, since the nasal passages are always involved in the inflammatory process. Rhinosinusitis is subdivided pathophysiologically as being Acute (lasting up to 4 weeks) or Chronic (lasting greater than 12 weeks).
Acute Rhinosinusitis (ARS) is almost always viral in origin. When symptoms last for greater than 7-10 days, and there is sinus tenderness, a bacterial cause can be suspected. Overuse of antibiotics is very common with this condition. Interestingly, the most common bacterial pathogens in ARS are resistant to a frequently favored antibiotic that is used, Azithromycin, or Z-Pak.
Chronic Rhinosinusitis (CRS) is usually not infectious in origin, and is subdivided as being CRS with nasal polyps, and CRS without nasal polyps. The 2 types behave quite differently and have different treatment regimens. Nasal polyps are benign growths that block sinus drainage. They respond to nasal and oral steroid treatment, as well as the newer biologic therapies that are used to treat asthma. Patients can respond to removal of nasal polyps, although unfortunately they tend to grow back. CRS without nasal polyps do not respond to oral steroids, or biologic agents. It can be treated somewhat successfully with surgery to promote drainage.
Important Tips:
Do not treat ARS that has not been present for at least 1 week, and is not associated with facial or sinus pain.
Discolored mucus drainage is NOT a sign of a bacterial infection. It is a sign that certain types of white blood cells have been activated to treat any infection, viral or bacterial.
Although patients with allergic rhinitis do get ARS and CRS, the lack of an allergy diagnosis does not rule out the possibility of getting these conditions.
The sinuses are not sterile; they are full of bacteria normally as part of what is called a microbiome. CRS with nasal polyps and discolored mucus can respond to antibiotics. CRS without nasal polyps typically do not.
Both ARS and CRS are associated with ear problems and asthma. Asthma exacerbations most commonly occur in the setting of viral illnesses, many of which involve the sinuses.
You can treat ARS at home with nasal irrigation and use of nasal decongestants for a period of up to 3 days. Nasal steroids, which are mostly available over the counter, can also help.
Of course patients who have other illnesses, especially those that result in immune deficiencies, are more susceptible to getting more aggressive types of Rhinosinusitis, and may need to be treated differently.
Those of us who are exposed to small children (human petri dishes) in any capacity are susceptible to upper respiratory infections of all sorts. Such is life. And, not to raise an apparently sensitive topic nowadays, wearing masks in certain situations can help prevent infections.
*References are included in my presentation to the students, and if you are curious, let me know and I can send them.