WHAT IS SINUSITIS?

The skull contains a number of air-filled spaces called sinuses. They reduce the weight of the skull and provide insulation for the skull and resonance for the voice. Four pairs of sinuses, known as the paranasal air sinuses, connect to the space running from the nostrils and up through the nose known as the nasal passage. They are located in the forehead (frontal sinuses), behind the cheekbones (maxillary sinuses), between the eyes (ethmoid sinuses), and behind the eyes (sphenoid sinuses). A membrane lining the sinuses secretes mucus, which drains into the nasal passage from a small channel in each sinus. Healthy sinuses are sterile and contain no bacteria. (The nasal passage, on the other hand, normally contains many bacteria that enter through the nostrils.)

The Maintaining of sinus health depends on a cycle that involves a number of important factors and processes. The mucus must be fluid but sticky in order to flow freely yet absorb pollutants and entrap bacteria. It must also contain sufficient amounts of bacteria-fighting substances, including antibodies. Small, hair-like projections called cilia must beat in unison to propel mucus outward, expelling bacteria and other particles. The mucous membranes themselves must be intact, and the sinus passages must be open to allow drainage and the circulation of air through the nasal passage.

If one or more of these processes or factors are amiss, an infection can occur called sinusitis. For example, a number of conditions may impede the flow of air through the nasal passage, directly obstruct the sinuses, or cause mucus to thicken and stagnate. In such cases, drainage of secretions and the flow of air are blocked. Secretions build up, encouraging the growth of certain bacteria. The resulting infection, swelling, and inflammation create further blockage, which may cause the sinuses to close up completely.

Sinusitis is usually defined as acute, recurrent acute, or chronic. Acute sinusitis lasts no longer than eight weeks or occurs less than four times a year with each attack lasting no longer than ten days. Acute sinusitis can be successfully treated with medications, leaving no residual damage to the mucous linings. Recurrent acute sinusitis involves more frequent episodes but leaves no significant damage. Chronic sinusitis lasts for 8 weeks or longer (twelve or longer in children) or occurs more than four times a year (6 in children) with symptoms persisting for more than 20 days. In cases of chronic sinusitis, imaging techniques show mucous tissue damage.

WHAT CAUSES SINUSITIS?

Obstruction of the sinus passages may lead to the development of the bacterial infections that cause acute sinusitis, which in certain circumstances may progress into chronic sinusitis. Among the causes of obstruction or congestion are the common cold, allergies, certain medical conditions, abnormalities in the nasal passage, and change in atmosphere. [ See Who Gets Sinusitis? in this report. ]

Causes of Acute Sinusitis

The most common trigger for sinusitis is a viral cold or flu that infects the upper respiratory tract and causes obstruction. Obstruction creates a hospitable environment for bacteria, the primary causes of acute sinusitis. In fact, one study suggested that nose blowing during a cold may transmit bacteria or viruses back into the sinuses, increasing the risk for sinusitis.
Bacterial Sinusitis. The organisms most commonly found in acute sinusitis are Streptococcus pneumoniae (also called pneumococcal pneumonia or pneumococci), H. influenzae (a common bacteria associated with many upper respiratory infections), and Moraxella (or Branhamella) catarrhalis. Less common bacterial culprits include other streptococcal strains (8% of adult cases), Staphylococcus aureus (6% of adult cases), and others. Fungal Sinusitis. Fungi are uncommon causes of sinusitis, but the incidence of these infections is increasing. There are four categories of fungal sinusitis: acute or fulminant invasive fungal sinusitis, chronic or indolent invasive fungal sinusitis, fungus ball (mycetoma), and allergic fungal sinusitis. Acute, invasive fungal sinusitis is most likely to affect people with diabetes and compromised immune systems. Chronic fungal sinusitis occur mainly in people with normal immune systems but is generally found outside the US, most commonly in the Sudan and northern India. Both chronic and acute fungal sinusitis require immediate treatment. Fungus ball (mycetoma) is noninvasive and occurs usually in one sinus, most often the maxillary sinus. One form of a highly recurrent Aspergillus sinusitis results from an allergic reaction to the fungus. In such cases, a peanut butter-like fungal growth occurs in the sinus cavities that may cause nasal passage obstruction and the erosion of the bones. The fungus Aspergillus is the common cause of all forms of fungal sinusitis. Others include Curvularia, Bipolaris, Exserohilum, and Mucormycosis. Fungal infections can be very serious and should be suspected in people with sinusitis who also have diabetes, leukemia, AIDS, or other conditions that impair the immune systems. Fungal infections can also occur in patients with healthy immune systems. There have been a few reports of fungal sinusitis caused by Metarrhizium anisopliae , which is used in biological insect control.

Viruses. Viruses are detected in only about 10% of sinusitis cases.

Causes of Chronic or Recurrent Acute Sinusitis

Chronic or recurrent acute sinusitis can be a lifelong condition and may result from untreated acute sinusitis that causes damage to the mucous membranes, medical disorders that cause chronic thickened stagnant mucus, or structural abnormalities. The same organisms that cause acute sinusitis are often present in chronic sinusitis. In addition, about 20% of chronic sinusitis cases are caused by Staphylococcus aureus (commonly called Staph infection), which may be present in cases of acute sinusitis but does not appear to cause it. Along with these bacteria, certain anaerobic bacteria, particularly the species Peptostreptococcus, Fusobacterium, and Prevotella, are found in 88% of cultures in chronic sinusitis cases; anaerobic bacteria exist without air and are the primary organisms found in brain abscesses. Fungi are the cause of about 6% to 8% of chronic sinusitis cases. It should be noted, however, that one study reported that in patients with chronic sinusitis who had not responded to antibiotics, 30% had no evidence of bacteria in their passageways and 20% had bacteria unrelated to infection, indicating that some cases chronic sinusitis may be a persistent inflammatory condition triggered by acute sinusitis rather than a bacterial disease.

WHO GETS SINUSITIS?

Sinusitis is one of the most common diseases in the United States, affecting an estimated 15% of the population. Women appear to be at higher risk than men are. Rates in the US are higher in the Midwest and South than in the Northeast and West. The number of office visits for the problem has increased from 9 million in 1989 to more than 30 million today. Some experts believe that factors accounting for this rise include increased air pollution and exposure to colds and flu from day care centers. Other experts claim that the actual incidence of sinusitis has not increased significantly. They argue that the apparent rise is due to better imaging techniques that are sensitive to sinus abnormalities, which may not actually be causing sinusitis. Asthma, however, which is often associated with sinusitis and has many of the same causes, has also increased dramatically over the past 10 years, a rate which is not attributable to better diagnostic techniques. Still, some studies indicate that sinusitis tends to be overdiagnosed and that only about half of patients who see a doctor for symptoms of sinusitis actually have the condition.

Colds and Flu

Everyone gets viral colds and flu, and most people develop symptoms in the upper respiratory tract (air passages in the head and neck) at some point. Over 85% of people with colds have inflamed sinuses, with the maxillary sinuses (behind the cheek bones) being the most common site, followed by the ethmoid sinuses (between the eyes). About a third of patients with colds have inflamed frontal and sphenoid sinuses. These inflammations are typically brief and mild. Although upper respiratory tract infections are the primary trigger for sinusitis, only between 0.5% and 5% of people with colds develop true sinusitis.

Co-Infections in Children

The same bacteria that cause sinusitis are also usually responsible for ear and adenoid infections in children. Studies report that nearly half of children with otitis media with effusion (inflammation in the middle year), or OME, have maxillary sinusitis, and nearly a quarter of children with sinusitis have OME. In one study, 38% of children with ear infections and 26% of those with adenoid infections without ear infections also had sinusitis. Sinusitis occurs in nearly half of HIV-positive children.

Abnormalities of the Nasal Passage

Abnormalities in the nasal passage can cause blockage and thereby increase the risk for chronic sinusitis. Polyps (small benign growths) in the nasal passage impede mucus drainage and restrict airflow. Polyps may themselves be a consequence of previous sinus infections that caused overgrowth of the nasal membrane. Other abnormalities that can cause obstruction are enlarged adenoids, cleft palate, tumors, or a deviated septum (a common condition in which the septum, the center section of the nose, is shifted to one side, usually the left).

Asthma

Between 53% and 75% of children with asthma caused by allergies have sinus abnormalities, and various studies have shown that between 17% and 30% of asthmatic patients develop true sinusitis. The risk for sinusitis in asthmatic children is increased with exposure to second hand smoke. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter's or ASA triad) are at very high risk for chronic or recurrent acute sinusitis. Conversely, people with chronic sinusitis are sometimes at increased risk for developing asthma. In such cases, after the sinusitis is treated, the accompanying asthma is often reduced or cured. A number of theories have been proposed for a causal association between sinusitis and a worsening of asthma. At a 2000 meeting, some experts suggested that stimulation of nerve pathways in the nasal passage eventually affects those in the lungs. Others noted that when the nose is blocked, a person has to breathe through the mouth. In such cases the air breathed in has large particles that would other wise be filtered by the nasal defense system. In addition, air breathed through the mouth is colder than air warmed in the nasal passages. Cold air is a known trigger of asthma.

Allergic Rhinitis

Those with allergic rhinitis (so-called hay fever and rose fever) often have symptoms of sinusitis, and true sinusitis can develop as a result of the mucus blockage it causes. A causal association, however, has not been proved, and many experts believe it rarely triggers sinusitis.

Gastroesophageal Acid Reflux

Gastroesophageal acid reflux (GERD), a disorder in which acid backs up from the stomach to the esophagus, has been noted as a risk factor for a number of upper respiratory conditions. It has been associated with sinusitis in children in a number of studies and there is some suggestion that it may play a role in some adults cases of chronic sinusitis.

Medical Conditions Affecting the Sinuses

People with certain rare genetic or other medical conditions are at risk for chronic sinusitis. One such genetic disorder is cystic fibrosis, in which the mucus is very thick, and another is Kartagener's syndrome, in which the major organs in the body are reversed, and the body's cilia (hair-like projections on many body tissues that help to move mucus and other fluids) are motionless. In both disorders, mucus build-up produces an environment favorable to infection-causing organisms. Wegener's granulomatosis, a serious but very rare illness that causes long-term swelling and tumor-like masses in air passages, increases the risk for sinusitis. Diabetes, AIDS, and other disorders of the immune system also predispose the patient to sinusitis, with fungal infections being a particular risk. Pregnancy and hypothyroidism are sometimes associated with congestion and symptoms of sinusitis, although the condition clears up after delivery or treatment, respectively. Hospitalized patients with head injuries, conditions requiring insertion of tubes through the nose, and those taking antibiotics or steroids are also at risk for sinus infection.

Reduced Antioxidant Defense

Antioxidants are important agents in opposing oxygen-free radicals, natural particles produced by the body's chemical processes that are harmful in high amounts. A recent, small study reported that patients with chronic sinusitis have lower levels of two important, natural antioxidants: glutathione and uric acid.

Miscellaneous Risk Factors

Anaerobic bacteria are associated with infections from dental problems or procedures, which precipitate about 10% of cases of sinusitis. People who experience changes in atmospheric pressure, such as while flying, climbing to high altitudes, or swimming, risk sinus blockage and therefore an increased chance of developing sinusitis. Swimming increases the risk for sinusitis for other reasons, as well. Air pollution and smoking damage the cilia responsible for moving mucus through the sinuses, leading to increased risk. People whose breathing is aided by mechanical ventilators may have a significantly higher risk for maxillary sinusitis. In fact, treating sinusitis in such patients may significantly reduce the risk for ventilator-associated pneumonia.

WHAT ARE THE SYMPTOMS OF SINUSITIS?

General Symptoms

In acute sinusitis, nasal congestion and discharge are almost always present. The discharge is typically thick and contains pus that is yellowish to yellow-green. Severe headache occurs and there is pain or pressure in the face. A persistent cough (particularly during the day), other upper respiratory symptoms, fever, and fatigue may be present. Sneezing, sore throat, and muscle aches are rarely caused by sinusitis itself, but may result from muscle aches caused by fever, sore throat caused by post-nasal drip, and sneezing resulting from allergies. Infections around the eyes can cause bulging, redness, and pain. In some cases, patient may also have double vision and even temporary vision loss.

The symptoms of recurrent acute and chronic sinusitis tend to be vague and generalized, last longer than eight weeks, and occur throughout the year, even during nonallergy seasons. Nasal congestion and obstruction are common. Yellowish discharge, chronic cough, bad breath, and postnasal drip (which can cause sore throat) may occur. Sufferers do not usually experience facial pain unless the infection is in the frontal sinuses, which usually results in a dull, constant ache. Facial tenderness or pressure, however, may be present.

Site-Specific Symptoms

Specific symptoms depend on the location of the infection. Frontal sinusitis causes pain across the lower forehead. The pain in maxillary sinusitis occurs over the cheeks and may travel to the teeth, and the hard palate in the mouth sometimes becomes swollen. Ethmoid sinusitis causes pain behind the eyes and sometimes redness and tenderness in the area across the top of the nose. Sphenoid sinusitis rarely occurs by itself; when it does, the pain may be experienced behind the eyes, across the forehead, or in the face. [ See Table, Symptoms of Sinusitis by Specific Site, below.] Rare complications of sinusitis can produce additional symptoms, which may be severe or even life threatening. [ See How Serious Is Sinusitis? in this report. ]

HOW SERIOUS IS SINUSITIS?

Severity of Bacterial Sinusitis

Bacterial sinusitis is nearly always harmless (if uncomfortable and sometimes even very painful), and if an episode becomes severe, antibiotics generally eliminate further problems. In rare cases, however, sinusitis can be very serious.

Osteomyelitis. Adolescent males with acute frontal sinusitis are at particular risk for severe problems. An infection of the bones (osteomyelitis) of the forehead can result from frontal sinusitis, particularly in children. In such cases, the patient usually experiences headache, fever, and a soft swelling over the bone known as Pott's puffy tumor.

Infection of Eye Socket. Infection of the eye socket, or orbital infection, which causes swelling and subsequent drooping of the eyelid is a rare but serious complication of ethmoid sinusitis. In these cases, the patient loses movement in the eye, and pressure on the optic nerve can lead to vision loss, which is sometimes permanent. Fever and severe illness are usually present.

Blood Clot. Another danger from ethmoid or frontal sinusitis is the formation of a blood clot in the sinus area around the front and top of the face. Symptoms are similar to orbital infection, but in addition, the pupil may be fixed and dilated. Although symptoms usually begin on one side of the head, the process usually spreads to both sides.

Widespread Infection. The most dangerous complication of sinusitis, particularly frontal and sphenoid sinusitis, is the spread of infection by anaerobic bacteria to the brain, either through the bones or blood vessels. Abscesses, meningitis, and other life-threatening conditions may result. In such cases, the patient may experience mild personality changes, headache, altered consciousness, visual problems, and, finally, seizures, coma, and death.

Severity of Fungal Sinusitis

Chronic and acute fungal sinusitis caused by the fungi Aspergillus and mucormycosis is difficult to treat and potentially lethal, particularly in people with diabetes and compromised immune systems. Mucormycosis is particularly dangerous if it is not treated quickly. Fungal ball is not invasive and is nearly always treatable. Recurrence is rare.

HOW IS SINUSITIS DIAGNOSED?

A patient who has symptoms of sinusitis that do not clear up within a few days or are accompanied by high fever or acute illness should see a physician, but it should be noted that only one-half to two-thirds of patients with such symptoms actually have sinusitis. Diagnostic goals are to rule out other possible causes of symptoms, and then to determine whether the condition is acute or chronic, what organism is causing the infection (if possible), and to locate the site where blockage has occurred. True bacterial sinusitis can usually only be definitively diagnosed using expensive procedures and imaging techniques. Fortunately, such procedures are rarely needed, since most cases of sinusitis are mild. Some experts complain that too many patients are diagnosed with true sinusitis and given unnecessary antibiotics when their symptoms would actually resolve within days if treated with over-the-counter medications or no drugs at all. Others believe that true sinusitis is often mistakenly diagnosed as allergies and can lead to serious illness without treatment.

Diagnosing Acute Sinusitis

Assessing Symptoms. The signs and symptoms suggestive of true acute sinusitis include the following: a return of congestion and discomfort after initial improvement in a cold (called double sickening), purulent (pus-filled) nasal secretion, fatigue from lack of good rest, lack of response to decongestants or antihistamines, pain in the upper teeth, pain on one side of the head, and facial pain above or below both eyes when leaning forward. [ See also Table, Symptoms of Sinusitis by Specific Site, above.] Symptoms in children may be less specific, but may include a high fever or prolonged upper respiratory symptoms (eg, a daytime cough that does not improve for 11 to 14 days). Children are less likely to experience facial pain and headache. When the diagnosis is unclear or complications are suspected, certain imaging techniques may be required.

Medical History. An important first step in diagnosing sinusitis is the thorough consideration of the patient's medical history by a physician. Patients should report any history of allergies or headaches, recent upper respiratory infection, recurrent or on-going sinusitis, exposure to cigarette smoke or other environmental pollutants, recent travel or dental procedures, medications being taken (particularly decongestants), and any abnormalities of the upper respiratory system. The patient should also describe symptoms such as nasal discharge and specific pain in the face and head, including eye and tooth pain. Parents or other caregivers of children with sinusitis should also report recent viral illness, whether the child attends a day care center, injury to the head or face, and any family history of allergies, immune disorders, cystic fibrosis, or immotile cilia syndrome.

Physical Examination. The physician will press the forehead and cheekbones to check for tenderness and check for other signs of sinusitis, including yellow to yellow-green nasal discharge, a lack of response to decongestants, and toothache toward the back of the mouth. Taking a culture of nasal discharge to identify the bacterial agents causing sinusitis is not useful because other unrelated bacteria are often present that can confuse the results. If a culture reveals fungi, however, fungus infection should be strongly suspected, particularly if sinusitis is not resolved by the use of antibiotics and if nasal discharge is brown and thick.

Transillumination. To perform transillumination, the physician shines a bright light against the cheek or forehead in a dark room. If the light does not pass through the maxillary or frontal sinus areas, then disease in these sites is likely. Transillumination is fast, safe, inexpensive, and a good first diagnostic step, but it is not very accurate. It can, however, be very useful when used in combination with x-rays.

X-Rays and Other Imaging Techniques. If the physician strongly suspects the presence of true acute sinusitis but the results of the physical examination are ambiguous, x-rays may be taken. Some experts argue that one x-ray is adequate for diagnosis of maxillary sinusitis. Single x-rays are not useful, however, in diagnosing frontal and sphenoid sinusitis. Additionally, single x-rays, particularly in cases involving children, cannot differentiate between inflammation caused by bacteria from that caused by viruses, so a series of four views is usually taken. X-rays do not detect ethmoid sinusitis, which is often the primary site of an infection that has spread to the maxillary or frontal sinuses. Computed tomography (CT) scans are not very useful in diagnosing acute sinusitis, but may be employed in some cases. Some experts believe they should be used when sinusitis is strongly suspected in a patient who has headache and pressure as the only symptoms, since headache severity is not always a true indicator of the extent of sinusitis.

Sinus Puncture and Endoscopy. Sinus puncture involves using a needle to withdraw a small amount of fluid from the sinuses. The fluid is then cultured to determine what type of bacteria is causing sinusitis. This procedure requires a local anesthetic and is performed by a specialist. It is performed only if a reasonable diagnosis cannot be made using noninvasive techniques. Endoscopy may also be used to diagnose acute sinusitis [ see Nasal Endoscopy, below].

Diagnosing Chronic Sinusitis

If the patient has a history of sinusitis episodes that are unresponsive to antibiotic treatment, the physician will usually diagnose chronic or recurrent acute sinusitis. Although a series of x-rays taken over time may be useful for diagnosing recurrent acute sinusitis, experts recommend more sophisticated procedures, such as endoscopy and imaging techniques, for evaluation, diagnosis of complications and potential emergencies, and as a guide during surgery. An ear, nose, and throat specialist (an otolaryngologist) usually performs these procedures.

Nasal Endoscopy. Nasal endoscopy is now used for diagnosing chronic and recurrent acute sinusitis and for differentiating between allergies and true sinusitis. It involves the insertion of a flexible tube into the nasal passage and the use of a fiberoptic light that enables the physician to see inside the sinuses. Endoscopy allows detection of even very small abnormalities in the sinuses. It can determine whether surgery is necessary and if medications are having any effect. Unfortunately, nasal endoscopy requires expertise not available everywhere.

Imaging Techniques. Sophisticated imaging techniques, particularly computed tomography (CT) scans and magnetic resonance imaging (MRI), provide extremely useful images for diagnosing chronic or recurrent acute sinusitis and difficult cases. CT scans are also used by surgeons as a guide during surgery. They show inflammation and swelling and the extent of the infection, including that in deep hidden air chambers missed by x-rays and nasal endoscopy. Often, they can detect the presence of fungal infections. MRI is more expensive than CT and so it is usually not performed unless the physician is concerned about tumors, fungal infections, or complications within the skull.

Laboratory Test s. Laboratory tests may be required to determine the organism causing the sinusitis so that the correct therapies can be administered.

Ruling Out Other Causes of Sinusitis Symptoms

Ruling out Colds. Symptoms of sinusitis and the common cold are very similar. Those of a common cold, though, including muscle aches, fatigue, and fever, are mild. Coughing, sneezing, and sore throat may occur. Usually nasal discharge resulting from a cold is clear at first and then becomes purulent; it almost always clears up within 10 days. Studies have found that between 40% and 85% of patients with the common cold show signs of sinusitis on x-rays or CT scans. A cold, however, unlike sinusitis, clears up without treatment within a couple of weeks.

Ruling out Influenza. The symptoms of influenza are headache, severe muscle aches and fatigue, and a high fever. There is usually a cough, which can be severe, and sometimes a runny nose. Symptoms such as sneezing, sore throat, and itchy eyes, nose, or throat are rare.

Ruling out Allergies. Symptoms of both sinusitis and allergic rhinitis include nasal obstruction and congestion. The conditions often occur together. People with allergies and no sinus infection are apt to have thin, clear, and runny nasal discharge, itchy nose, eyes, or throat (which never occur with sinusitis), and recurrent sneezing. Symptoms of allergies appear only during exposure to allergens. [ For more information, see Well-Connected Report #77 , Allergic and Nonallergic Nasal Congestion (Rhinitis). ]

Ruling out Headache from Other Causes. Many primary headaches, particularly migraine or cluster, may closely resemble sinus headache. Sinus headaches are usually more generalized than migraines, but it is often difficult to tell them apart, particularly if headache is the only symptom of sinusitis; they even coexist in many cases. Often, the visual changes associated with migraine can rule out sinusitis, but such visual changes do not occur with all migraines and not at all in cluster headaches. In some cases, headache that persists after successful treatment of chronic sinusitis may be due to neuralgia (nerve-related pain) in the face. This condition may possibly have been initiated by sinusitis but now requires specific drugs, such as carbamazepine, that are used for neuralgia.

Ruling out Other Conditions. A number of other conditions can mimic sinusitis. They include dental problems, a foreign object in the nasal passage, temporal arteritis, persistent upper respiratory tract infections, and temporomandibular disorders (problems in the joints and muscles of the jaw hinges). Vasomotor rhinitis, a condition in which the nasal passages become congested in response to irritants or stress, also resembles sinusitis; it often appears in pregnant women. Diseases of the immune system, including AIDS, and rare disorders such as cystic fibrosis, Kartagener's syndrome, and Wegener's granulomatosis are uncommon conditions that should be ruled out before a diagnosis chronic sinusitis is reached.

HOW CAN SINUSITIS BE PREVENTED?

The best way to prevent sinusitis is to avoid and, if unavoidable, effectively treat colds and influenza. [For detailed information see the Well-Connected Report Upper Respiratory Tract Infections (Colds, Flu, Sore Throat, and Acute Bronchitis ).]

Lifestyle Changes

Hygiene. The best way to prevent pneumonia is to take measures to avoid the organisms that cause the respiratory infections, including colds and flus. Everyone should always wash their hands before eating and after going outside. Ordinary soap is sufficient; antibacterial soaps add little protection, particularly against viruses. In fact, a recent study suggests that common liquid dish washing soaps are up to 100 times more effective than antibacterial soaps in killing respiratory syncytial virus (RSV), which is known to cause pneumonia. Nasal secretions containing RSV can remain infectious for several hours. Flus and colds are not spread by touching inanimate objects, such as subway poles or toilet seats; bacteria do not thrive on such objects and of the organisms that do survive on inanimate objects, most are harmless.

Daily Habits. Daily diets should include foods such as fresh, dark-colored fruits and vegetables, which are rich in antioxidants and other important food chemicals that help boost the immune system. Supplements of vitamin C and E may be helpful, but there is no evidence to prove their benefits, and high amounts of vitamin C may cause diarrhea. Interestingly, maintaining an active social lifestyle could help prevent colds. One study found that the more social interaction a person has the less likely they are to have a cold, possibly because stress hormones, which suppress the immune system, are reduced.

Supplements

Zinc. There is much evidence on the importance of zinc for maintenance of the immune system, and adequate zinc levels are critical, especially in patients at high risk for serious infections, such as those with HIV or children with sickle-cell disease. In such people, supplements may be important. The use of zinc supplements for otherwise healthy people with colds, however, is uncertain. Some research indicates that zinc may help prevent the rhinovirus from attaching to nasal passage membranes. One analysis of studies on the use of zinc supplements, however, found no significant effect on colds. In 1999, the FDA charged the manufacturer of the zinc carbonate lozenges Cold-Eeze and Kids-Eeze Bubble-Gum with making unsubstantiated claims about their benefits against colds, allergies, and pneumonia. Of some interest, however, is Zicam, a nasal gel that contains zinc ions as the active ingredient. A 1999 study found that in patients who used the zinc gel common cold symptoms resolved six and one half to eight days sooner than those taking placebo (an inactive gel). The zinc gel may be more effective than zinc lozenges or sprays because the zinc resides within the nasal cavity long enough to interact with the virus. More studies are underway. It should be noted, however, that no one with an adequate diet and a healthy immune system should take zinc for prevention. Some research has suggested that taking zinc for long periods, even in moderate recommended doses, may actually weaken immunity, reduce HDL (the so-called good cholesterol), and interfere with copper metabolism. In any case, zinc does not seem to reduce fever or soothe muscle aches or scratchy throats. Side effects include nausea and a bad taste, and the mineral may be toxic in large doses. More studies are needed.

Vitamins. A number of studies have found that large doses of vitamin C reduce the duration of the cold by 5% to 50%, depending on the study. In one study, taking megadoses of vitamin C (1000 mg) every hour reduced cold symptoms by 85%. Such high doses, however, may cause headaches and intestinal and urinary problems, and even kidney stones. Because ascorbic acid increases iron absorption, people with certain blood disorders, such as hemochromatosis, thalassemia, or sideroblastic anemia, should particularly avoid high doses. Large doses can also interfere with anticoagulant medications, blood tests used in diabetes, and stool tests for diagnosing colon cancer. It should further be noted that vitamin C has limited protective properties. In an examination of 60 studies, the six largest ones reported no preventive effects of vitamin C in well-nourished individuals. (It may be useful for prevention of respiratory infections in people in poor health or under heavy physical stress, however.)

Echinacea. The herbal remedy echinacea is now commonly taken to prevent onset of cold or flu and to ease symptoms. There are three species: Echinacea (E.) purpurea , E. pallida , and E. augustifolio . In some studies, people who took extracts of either E. purpurea or E. augustifolio experienced no protection against colds. Others have found benefits with various Echinacea forms, such as Echinaforce (a purpurea preparation). At this time there are no standards or quality controls available for echinacea (including what part of the plant to use) or any other herbal remedies. People with autoimmune diseases or who are allergic to plants in the daisy family should not take it. No one should take untested so-called natural remedies without a doctor's approval. No studies have confirmed the benefits of these medications and many can cause toxic side effects in large doses.

Experimental Therapies for Colds

A nasal spray, tremacamra, is under investigation for treating colds. It contains a genetically engineered compound that resembles a natural molecule called ICAM-1, which is located in human cells and attaches to rhinoviruses that are present in the nasal passages. The similar tremacamra tricks the virus into attaching to it rather than to the ICAM-1 receptor, thereby preventing the virus from affecting human cells. An early study reported that it reduced cold symptoms by 45% and actual colds by 23%, although it is not yet clear how beneficial it actually will be. Several other drugs are being studies for prevention and treatment of colds. One, pleconaril, inhibits viral attachment and is also showing promise.

Vaccines

Haemophilus Influenzae. All children under five should be vaccinated against Haemophilus influenzae. Studies suggest that it is also beneficial for people with illnesses that put them at risk for pneumonia, including sickle cell disease, leukemia, HIV infection, and splenectomies.

Viral Influenza Vaccines. The two major influenza viruses are called A and B. Unfortunately, influenza A viruses undergo changes (antigenic drift) over time, so a vaccine that works one year may not work the next. Vaccines are then redesigned annually to match the current strain. Influenza B viruses tend to be more stable than influenza A viruses, but they too vary. The vaccines use inactivated, not live, viruses. Flu shots are given in the fall, usually between October and December. Amantadine (Symmetrel) and rimantadine (Flumadine) are drugs that offer some protection against influenza A, and may also shorten the duration and lessen the severity of the flu if given within 48 hours of onset of symptoms. They are not effective, however, against influenza B.

An intranasal vaccine (FluMist) is made from weakened influenza viruses that are engineered to grow only in cooler temperatures found in the nasal passages, not in the warmer temperatures of the lungs and lower airways. The vaccine boosts the specific immune factors in the mucous membranes of the nose that fight off the actual viral infections. It is employed using a nasal spray and in one study provided protection against the flu in up to 93% of children.

Any child with a condition that requires regular medical care or who has been hospitalized for a serious illness should be vaccinated against influenza. Children who are receiving long-term aspirin therapy should also be immunized against the flu because they are at higher risk for Reye's syndrome, a life-threatening disease, if they get the flu.

The vaccines may be slightly less effective in the elderly, the very young, and patients with certain chronic diseases than in healthy young adults. Even in people with a weaker response, however, the vaccine is usually protective against serious flu complications, particularly pneumonia, although patients may still experience symptoms in the upper respiratory tract (the nose and throat). All adults 50 years and older, particularly those in nursing homes, and anyone at risk for serious complications from the flu should have an annual vaccination. Those at high risk include people with heart disease, lung problems, immune deficiencies, diabetes, kidney disease, or chronic blood disease, such as sickle cell disease. Certain other younger adults who should be vaccinated include health care workers and others who may expose high-risk people to the flu. Current studies suggest that influenza vaccinations are very effective for people with HIV. People at risk for complications of influenza and who are traveling to the tropics at any time or to the Southern Hemisphere between April and September should consider vaccination. Pregnant women who are at risk for complications of influenza should be vaccinated, usually after the first trimester unless they are in their first trimester during flu season and their risk for complications of the flu is higher than any theoretical risk to the baby from the vaccine.

Newer vaccines contain very little egg protein, but an allergic reaction still may occur in people with strong allergies to eggs. Almost a third of people who receive the influenza vaccine develop redness or soreness at the injection site for one or two days afterward. Other side effects include mild fatigue and muscle aches and pains; they tend to occur between six and 12 hours after the vaccination and last up to two days. It should be noted that these symptoms are not influenza itself but an immune response to the virus proteins in the vaccine. Anyone with a fever, however, should not be vaccinated until the ailment has subsided.

Pneumococcal Vaccines. Experts are now recommending that more people, including healthy elderly people, be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria. People who should especially be vaccinated are adults and children who are receiving treatments to suppress the immune system or who have immune deficiencies (eg, HIV), kidney disease or kidney transplants, problems in the spleen, alcoholism (especially with cirrhosis), or any condition that places them at high risk for pneumonia. Protection lasts for over six years in most people, although the protective value may be lost at a faster rate in elderly people than in younger adults. A recently approved pneumococcal vaccine (Prevenar) is very effective in children and, some experts believe that universal vaccinations for infants would prevent a million cases of ear infections as well as serious infections. Those at high risk for serious pneumonia should be revaccinated six years after the first dose. Older people who have had transplant operations or those with kidney disease may also require a revaccination. Side effects include pain and redness at the injection site, fever, and joint aches. Rarely, such local reactions can be severe. Even if a person is mistakenly revaccinated before the effects of the first vaccination have worn off, the risk for severe side effects is very low. Allergic reactions are very rare. Because the vaccine is inactive, it is safe for pregnant women and people with immune deficiencies.

Antiviral Agents

Although they are no substitutes for vaccines, the antiviral agents amantadine, rimantadine, zanamivir, and oseltamivir have some protective properties. Amantadine and rimantadine has some effect against influenza A. Early studies are reporting that a single daily dose of zanamivir or one or two doses of oral oseltamivir may be effective and safe for reducing the risk of influenza A and B during the flu season. Such agents are also proving to be effective for treating influenza.

HOW IS ACUTE SINUSITIS TREATED?

The primary objectives for treatment of sinusitis are reduction of swelling, eradication of infection, draining of the sinuses, and ensuring that the sinuses remain open. Less than half of patients reporting symptoms of sinusitis need aggressive treatment and can be cured using home remedies and decongestants alone.

Hydration

Home remedies that open and hydrate sinuses may, indeed, be the only treatment necessary for mild sinusitis that is not accompanied by signs of acute infection. Drinking plenty of liquids is essential. Inhaling steam two to four times a day is also very helpful, costs nothing, and requires no expensive equipment. The patient should sit comfortably and lean over a bowl of boiling hot water (no one should ever inhale steam from water as it boils) while covering the head and the bowl with a towel so the steam remains under the cloth. The steam should be inhaled continuously for ten minutes. A mentholated or other aromatic preparation may be added to the water. Long, steamy showers, vaporizers, and facial saunas are alternatives.

Nasal Washes

For common colds and mild allergic rhinitis, a nasal wash can be helpful for removing mucus from the nose. A saline solution can be purchased at a drug store or made at home. One study reported that neither a home-made solution (using one teaspoon of salt and one pinch of baking soda in a pint of warm water) nor a commercial hypertonic saline nasal wash had any effect on sinusitis. Some physicians, however, argue for the effectiveness of a traditional nasal wash, used for centuries, that uses no baking soda and more fluid for each dose and less salt than the saline washes in the study. The patient leans over the sink head down, pours some solution into the palm of the hand, and inhales it through the nose one nostril at a time. The patient spits the remaining solution out and blows the nose gently. The solution may also be inserted into the nose using a large rubber ear syringe, available at a pharmacy. Leaning over the sink head down, the patient inserts only the tip of the syringe into one nostril. He or she gently squeezes the bulb several times to wash the nasal passage and then presses the bulb firmly enough so that the solution passes into the mouth. The process should be repeated in the other nostril. A nasal wash should be performed several times a day.

Over-the-Counter Medications

Nasal Decongestants. Decongestants to reduce obstruction are very important for initial treatment of the symptoms of sinusitis. They work by shrinking blood vessels in the nose and reducing blockage, decreasing the risk for true sinusitis caused by viruses or bacteria. Many over-the-counter decongestants are available, either in oral form or as sprays, drops, or vapors, which bring the medication into direct contact with nasal tissue. Devices are being developed such as the RinoFlow Nasal Wash and Sinus System that may prove to deliver nasal decongestants more efficiently than standard spray devices and so reduce the need for more aggressive treatments. The benefits of oral decongestants in treating sinusitis have not been confirmed by any studies.

Active ingredients in nasal decongestants include oxymetazoline (Sinex Long-Lasting, Afrin, Sinarest, Dristan 12-Hour, Neo-Synephrine 12-Hour, Nostrilla, NTZ, Vicks), xylometazoline (Otrivan), phenylephrine (Neo-Synephrine, Nostril Nasal Decongestant, Sinex), naphazoline (Naphcon Forte, Privine), and tetrahydrozoline (Tyzine). Oxymetazoline and xylometazoline are long-acting decongestants; they are effective in a few minutes and remain so for six to eight hours. When using a nasal spray, the patient should spray each nostril once, wait a minute to allow absorption into the mucosal tissues, and then spray again. This procedure is repeated again in four hours with drugs containing pseudoephedrine and every 12 hours with those containing oxymetazoline. All forms of nasal decongestants may dry out the affected areas and damage tissues. Keeping the area moist is very important to prevent this. Any sprayers, inhalators, or devices used to deliver the decongestants become reservoirs for bacteria over time, so should be discarded when the medication is no longer needed. If the medicine becomes cloudy or unclear, it, too, should be discarded. Droppers and inhalators should not be shared with other people, and they should not be inserted into the nostril. Nasal decongestants are generally recommended for no more than one to three days because of the risk of nasal irritation, rebound effect, and dependency. With prolonged use, nasal decongestants become ineffective; some people then increase the frequency of their doses to as often as every hour. Withdrawal from the drug after three to five days then causes a rebound effect; that is, symptoms of sinusitis and nasal congestion return. Short-acting nasal decongestants may have a rebound effect after only eight hours. Nasal forms work faster than oral decongestants and have fewer side effects but often require frequent administration.

Inhaled decongestants contain propylhexedrine or levmetamfetamine, also called desoxyephedrine.

Oral decongestants also come in many brands and contain pseudoephedrine (eg, Sudafed, Vicks NyQuil Multi-Symptom Cold/Flu Relief Liquid, and Robitussin PE) or phenylpropanolamine (eg, Contact 12-Hour Cold Capsules, Dimetapp 12-Hour Extentabs, and Robitussin CF). Sudafed, which contains pseudoephedrine, is the only over-the-counter single ingredient oral decongestant.

The most common side effects of most decongestants are agitation and nervousness. All nasal and oral decongestants can cause changes in heart rate and blood pressure, with oral decongestants having a greater effect. The FDA warns that anyone with heart disease, high blood pressure, thyroid disease, diabetes, or prostate enlargement problems that cause urinary difficulties should not use either oral or nasal decongestants without a doctor's guidance. Inhalers that contain propylhexedrine or levmetamfetamine do not pose these risks. Oral medications with pseudoephedrine have less of an effect on blood pressure than those containing phenylpropanolamine, but both should be avoided by anyone with high blood pressure. Of some concern is a study indicating that phenylpropanolamine may even increase the risk for stroke in certain individuals. Although a very rare occurrence, some experts advise against anyone taking phenylpropanolamine.

Children appear to metabolize decongestants differently than adults. Decongestants should not be used at all in infants and small children, who are at particular risk for side effects that depress the central nervous system, which can result in changes in blood pressure, drowsiness, deep sleep, and, rarely, coma. Those at risk are people whose blood vessels are highly susceptible to contraction, including those with migraines and Raynaud's phenomenon, in which people are highly sensitive to cold. p> Analgesics. Over-the-counter analgesics, including aspirin, ibuprofen, and acetaminophen (eg, Tylenol), are effective against pain and inflammation. Aspirin and products containing aspirin can, although rarely, precipitate asthma attacks in susceptible individuals, however, and children should not take them. Acetaminophen is an alternative in such cases.

Expectorants. Expectorants, which are drugs that cause mucus to be coughed up from the lungs and may help promote draining and reduce tissue swelling, are sometimes recommended for treatment of sinusitis. Expectorants generally contain ingredients that thin mucus secretions called mucolytics. The most common mucolytic used is guaifenesin (Breonesin, Glycotuss, Glytuss, Hytuss, Naldecon Senior EX, Robitussin), which may cause drowsiness or nausea.

Antibiotics

If decongestants or home remedies fail to improve sinusitis or if signs of infection (such as yellowish nasal discharge) or other complications are present, antibiotics are prescribed. They are very effective in relieving symptoms and eliminating bacteria. They also may be important in patients with chronic sinusitis who have serious medical conditions when blood tests suggest evidence of potential widespread infection. There is much evidence, however, that antibiotics are inappropriately prescribed for about half of sinusitis cases, and although they may prevent complications and reduce the risk of chronic sinusitis, proof is lacking to confirm these effects. Overuse is a particular concern in light of the increase in antibiotic-resistant Haemophilus influenzae and Streptococcus pneumoniae , organisms most commonly implicated in acute sinusitis.

Until recently, the antibiotic most widely prescribed for acute sinusitis was amoxicillin, a form of penicillin that is both inexpensive and effective. Ampicillin, also a form of penicillin, is an equally inexpensive alternative to amoxicillin but requires more doses, should not be taken with meals, and may have a higher risk for diarrhea than amoxicillin. Physicians now commonly first prescribe trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra), unless the infection occurred after dental work or the patient is allergic to sulfa drugs. It is less expensive than amoxicillin and particularly useful for people allergic to penicillin, but it is not effective against certain streptococcal strains. Many physicians recommend more potent but very expensive antibiotics that work against a wide spectrum of bacteria. These include augmented penicillins, such as amoxicillin-clavulanate (Augmentin); cephalosporins, often classed as first generation (cephalexin, cefadroxil), second generation (cefuroxime axetil, cefaclor, cefprozil), or third generation (cefixime); macrolides (erythromycin, azithromycin, clarithromycin, roxithromycin); clindamycin; tetracycline; and fluoroquinolones (eg, ciprofloxacin, levofloxacin, sparfloxacin, gemifloxacin, moxifloxacin). They are all effective, although side effects may vary and some may have more convenient dosage schedules. Antibiotics that have anti-inflammatory actions, such as clarithromycin (Biaxin), might be useful for certain patients with chronic sinusitis. A new once-a-day formulation (Biaxin XL) is now available. .

The most common side effect for nearly all antibiotics is gastrointestinal distress. Antibiotics also double the risk for vaginal infections in women. Certain drugs, including some over-the-counter medications, interact with antibiotics, and all antibiotics carry the risk for allergic reactions, which can be serious in some cases. Patients should inform the physician of all medications they are taking and of any drug allergies.

Patients must be sure to take all of the tablets prescribed; failure to do so may increase the risk for reinfection and also for development of antibiotic-resistant bacteria. Most standard oral antibiotics require a seven to 10-day course with a tablet taken three or four times a day, although people often fail to complete such regimens. Such behavior increases the risks for resistant bacteria, the incomplete eradication of the infection, or both. Various studies are finding that certain antibiotics are just as effective in shorter courses or in fewer doses as their originally prescribed longer courses. Gatifloxacin (Tequin) and moxifloxacin (Avelox) are new drugs that only need to be taken once a day.

It should be noted, however, that even after antibiotic treatments, between 10% and 25% of patients still complain of symptoms. If there is no improvement after two weeks of treatment, x-rays should be taken and a stronger antibiotic used.

Antibiotic-Resistant Bacteria. Of major concern for physicians and the public is the emergence of strains of common bacteria that are resistant to specific antibiotics and even those that are now resistant to a wide spectrum of antibiotics. The prevalence of such bacteria has dramatically increased worldwide, and, although resistance is highest to penicillin, it is also increasing rapidly to other antibiotics. It should be noted that such resistance has not yet had any significant affect on antibiotic treatments outside the hospital setting. In one 1999 US report of 34 medical centers, overall nearly 30% of bacterial strains showed resistance to penicillin, with 12% being complete resistant. In some of these centers, the penicillin resistance rate has increased from 2.9% to 30.2% in three years. In a 1998 study, among the cephalosporins, 92% of pneumococcal strains were resistant to a first-generation, 38% to a second-generation, and 4% to a third-generation cephalosporin. Resistance to the macrolides ranged from 4% to 14% and nearly 20% of the strains were resistant to trimethoprim-sulfamethoxazole.

Major efforts are underway to combat the problem. Continually creating new antibiotics is one approach, although repeated exposure to even these antibiotics can eventually result in bacterial resistance. One approach involves creating antibiotics that have the capacity to either self-destruct or regenerate themselves. The theory behind these antibiotics is that they will spend less time in the environment and therefore reduce exposure to the forces that lead to development of resistance. Such agents have yet to be tested in either animals or humans.

A third approach involves physician and patient education. A plan presented by a panel of international disease specialists in 1999 calls for improved communications between physicians and patients regarding the use of antibiotics and encourages a conservative approach to prescribing and using antibiotics. A program in Finland, for example, has nearly halved the incidence of erythromycin-resistant bacteria by limiting the use of penicillin and similar antibiotics only to serious infections.

In general, if a patient with acute sinusitis lives in a region where resistance to standard antibiotics is still low, it is probably safe to start with a less expensive antibiotic and switch over to a more powerful drug if the infection does not clear up. In areas where outbreaks of resistant strains have occurred or for patients with recurrent or more severe conditions, physicians might recommend amoxicillin-clavulanate (Augmentin) or other so-called second line drugs, such as cefuroxime axetil (Ceftin), azithromycin (Zithromax), or clarithromycin (Biaxin).

Treating Sinusitis in Asthmatic and Allergic Patients

Patients often have various combinations of allergies, sinusitis, and asthma, and treating every condition is important for improving them all. Successful treatment of both allergic rhinitis and sinusitis in children who also have asthma may reduce symptoms of asthma. It is particularly important to treat any coexisting bacterial sinusitis in people with asthma, who might not respond to asthma treatments unless the infection is cleared up first.

Patients with sinusitis who also have allergies, including those to pollen, mold, dust mites, and animal dander, appear to benefit from immunotherapy (allergy shots). In one year-long study using immunotherapy, over half of young patients participating experienced improvement in overall sinusitis symptoms, and nearly all felt better in general. In addition, subjects experienced 72% fewer school absences and required half the antibiotics. Dozens of over-the-counter cold or allergy remedies are available that contain one or more drugs, including antihistamines, decongestants, and pain relievers (usually acetaminophen). Small children should not be given combination cold or allergy remedies; in fact, everyone should try to select a product with a single drug that targets specific symptoms. People with bacterial sinus infections should not use antihistamines, even during allergy season; antihistamines thicken mucus secretions and may actually worsen sinusitis. Corticosteroid and cromolyn (Nasalcrom) nasal sprays are sometimes prescribed or recommended for patients with asthma or hay fever but, like antihistamines, they are not effective in treating and may even worsen existing bacterial infection.

Emergency Treatment

Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull require emergency care. [For emergency symptoms , see How Serious is Sinusitis? above.] High dose antibiotics are administered intravenously, and emergency surgery is almost always necessary in such cases.

Severe Fungal Sinusitis. Sinusitis caused by severe fungal infections is a medical emergency. Treatment is aggressive surgery, and high-dose antifungal chemotherapy with a drug such as amphotericin B can be life saving. The use of oxygen administered at high pressure (hyperbaric oxygen) is showing promise as additional therapy for potentially deadly fungal infections.

HOW IS CHRONIC OR RECURRENT ACUTE SINUSITIS TREATED?

If a primary trigger for chronic sinusitis can be identified, it should be treated or controlled if possible. For treating chronic sinusitis itself, some physicians recommend a corticosteroid nasal spray, the expectorant guaifenesin combined with an oral (not spray or droplet) decongestant, and a 3-week course of antibiotics. Even with the use of this aggressive treatment, surgery is often required. A staging system for chronic sinusitis has been developed to help guide treatment. In stage I, the disease is located in one site. In stage II, the disease is located in a number of separate sites in the ethmoid sinuses. In stage III, the disease is diffuse but responds to therapy. In stage IV, the disease is diffuse and either poorly responsive or unresponsive to medication. In the early stages, damage to the mucous lining is usually reversible with medical treatment. Surgery is often needed for later stages. For many people with chronic sinusitis, the condition is not curable, and the goal of treatment is to improve the quality of life.

Medications

Antibiotics. Chronic sinusitis is often the result of damage to the mucous membrane from a past, untreated acute sinus infection. The aerobic and anaerobic bacteria present in chronic sinusitis are often different from those that cause the acute form, and more potent and expensive antibiotics are usually needed to oppose these organisms. Treatment may continue for several weeks.

Corticosteroids. Corticosteroid, or steroid, nasal sprays are sometimes prescribed to reduce inflammation that occurs in chronic sinusitis. Steroids commonly used include beclomethasone (Beconase, Vancenase), triamcinolone (Nasacort), and flunisolide (Nasalide). Oral or injection forms of steroids should never be used for sinusitis. Corticosteroids are rarely used for acute sinusitis; they are not infection fighters and can actually prolong infections. They may be effective, however, in certain cases, such as treating allergic fungal sinusitis after surgery. Corticosteroids are also useful in shrinking polyps that are obstructing sinuses, although polyps often enlarge again after treatment has ended. Corticosteroid nasal spray is the primary treatment for people with Samter's or ASA triad (the combination of polyps in the nose, asthma, and sensitivity to aspirin). This condition, which develops from a sensitivity to aspirin followed by the development of polyps and then by asthma, is life long. Steroid sprays control it but are not cures. Experimental drugs called cytokine or leukotriene receptor antagonists block substances that cause inflammation and are showing promise in treating this condition.

Sinus Surgery

Surgery is used to unblock the sinuses when drug therapy is not effective or if there are other complications, such as structural abnormalities or fungal sinusitis.

Insertion of a Drainage Tube. The simplest surgical approach is the insertion of a drainage tube into the sinuses followed by an infusion of sterile water to flush them out.

Functional Endoscopic Sinus Surgery. In the past few years there has been a major advance in the surgical treatment called functional endoscopic sinus surgery (FESS). The procedure allows correction of obstructions, including any polyp and ventilation and drainage to aid healing. Adults require only a local anesthetic for the procedure, though a general anesthetic is needed for children. Before the procedure, a computed tomography (CT) scan is taken for use by the surgeon in planning the procedure and as a guide to the sinuses during surgery. A flexible tube, a miniature camera, and a fiberoptic light source are inserted through a single small opening. An instrument called a microdebrider, which uses a blade on a tiny rotor, may be used to remove the polyps without harming the sinus area. Some physicians are now using a device called a depth of field image (DOFI) video enhancement screen that displays a holographic 3-D image. It allows the surgeon an excellent view of the sinus cavities and may prove to significantly reduce complications.

Serious complications of endoscopy are very rare, but may include meningitis, hemorrhage, infection, or vision loss. Cerebrospinal fluid leak is the most common major complication, but it occurs in only 0.2% of cases and is usually easily repaired during surgery. Following surgery, the patient should flush the sinuses twice daily with a saline or alkaline solution. Antibiotics may be prescribed for several weeks until postnasal drip has stopped, and corticosteroid sprays and antihistamines may be needed. Children may require a second procedure two to three weeks after the first surgery to remove crusty matter. For those whose symptoms do not clear, a high-pressure water jet (HPWJ) treatment which flushes diseased mucus that remains after FESS surgery is being investigated. One 2000 study found the procedure an effective therapy that may even be safe for children.

It may take several months for the mucous membranes to completely recover, but between 85% and 90% of patients experience good to excellent symptomatic relief after surgery. Most patients who undergo FESS can expect improvements of up to 90% after the procedure. Endoscopy is well suited for people with chronic sinusitis associated with structural abnormalities. Several studies are finding it to be safe and effective in children with chronic sinusitis or whose sinuses have not developed, causing no adverse effect on facial growth. In one study, the best results of endoscopy were seen in people with polyps not associated with ASA triad (the combination of polyps in the nose, asthma, and sensitivity to aspirin). Others are reporting that surgery may help HIV patients with chronic or recurrent sinusitis and also patients with sinusitis and asthma. In the latter patients, it may even improve lung function. Surgery may not be as effective for patients with the ASA triad, fungus infections, or severe chronic sinusitis, although endoscopy is proving to be beneficial even for these conditions with the use of more powerful instruments.

Invasive Conventional Surgery. Endoscopy is now used in most cases of chronic sinusitis, but in severe cases, invasive surgery using conventional scalpel techniques to remove infected areas may be required. This may be the case with acute ethmoid sinusitis in which pus breaks through the sinus and threatens the eye, with very severe frontal sinusitis, with invasive fungal sinusitis, or when cancer is present in the sinuses.

WHERE ELSE CAN HELP BE FOUND FOR SINUSITIS?

American College of Allergy, Asthma & Immunology, 85 West Algonquin Road, Suite 550, Arlington Heights, IL 60005. Call (847-427-1200) or fax (847-427-1294) or on the Internet (http://allergy.mcg.edu/)
This organization publishes information sheets on specific allergies and offers a number for referrals to allergists in local areas. Its web site is excellent.

American Academy of Otolaryngology, Head and Neck Surgery, One Prince Street, Alexandria, VA 22314-3357. Call (703-836-4444) or on the Internet (http://www.entnet.org/)

American Rhinologic Society, c/o Frederick J. Stucker, MD, Dept. of Otolaryngology/Head and Neck Surgery, LSU School of Medicine in Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71103-4228. Call (318-675-6262) or toll-free (1-888-520-9585)

Both companies below not only offer products for people with allergies and asthma, but their customer support is friendly, very well-informed, and offers detailed information on their products.

National Allergy Supply, Inc., 4400 Abbott's Bridge Road, Duluth, GA 30097. Call (800-522-1448) or fax (770-623-5568) or on the Internet (http://www.natallergy.com)

Allergy Control Products, Inc., 96 Danbury Road, Ridgefield, CT 06877. Call (800-422-DUST or 3878) or fax (203-431-8963) or on the Internet (www.allergycontrol.com)

National Immunization Information Hotline (from the Centers for Disease Control) Call (800-232-2522)

The Website of the Alliance for the Prudent Use of Antibiotics. Professional Development (www.apua.org)

ABOUT WELL-CONNECTED

Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information, and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition.

This report may not be copied, displayed on Internet web sites, or otherwise distributed without the express permission of the publisher.

Board of Editors

Harvey Simon, MD, Editor-in-Chief, Massachusetts Institute of Technology; Physician, Massachusetts General Hospital

Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center

Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital

John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital

Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital

Carol Peckham, Editorial Director

Cynthia Chevins, Publisher

Lea Kling, Update Editor

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