Sinus Problems

Sinus problems are a common and troublesome issue for many people. The sinuses can become inflamed as a consequence of any common cold and the symptoms may resolve quickly. In some people symptoms become more severe or more prolonged and can be a source of significant discomfort over months to years. Read this overview of sinus problems to gain a better understanding of “sinus”.

The symptoms of a sinus problem may include:

breathing problems through the nose
a runny nose
a drip down the back of the nose (post-nasal drip)
a loss or reduction in the sense of smell
facial pains or pressures
headaches
a chronic cough

Some patients with sinus problems simply develop colds and flu’s much more frequently than the average person or are unwell for much longer than the average person when they do become unwell. Treatments are available.

Why do I have sinus problems or “sinus”?

The nasal sinuses can become diseased from a range of causes. Generally these all cause swelling of the lining of the nose and sinuses which blocks normal airflow into the sinuses and prevents drainage of mucus. When the sinuses become “blocked” bacterial or fungal infections may follow and establish colonies that can be difficult for the body to clear. These colonies have been termed a “biofilm” and possess sophisticated defence mechanisms that allow the chronic infections to evade the body’s normal immune mechanisms.

The specific causes for sinus problems include the following:

Acute sinusitis / rhinosinusitis (an infection lasting less than 3 months)
Allergic rhinitis (hay fever)
Anatomical problems such as a deviated nasal septum, enlarged turbinates, adenoid tissue
Autoimmune or other immune system problems
Chronic rhinosinusitis (sinus inflammation lasting more than 3 months)
Non-allergic rhinitis
Foreign bodies in the nose
Tumours (rare)

What is chronic rhinosinusitis?

Chronic rhinosinusitis is an inflammatory condition of the sinuses lasting 3 or more months. It is really an umbrella term for a range of clinical conditions from different causes that eventually present with similar symptoms.

The diagnosis is considered when two of the following are present:

Nasal obstruction/blockage
A runny nose or posterior drainage
Facial pain or pressure or headaches
Loss or reduction in the sense of smell

What causes chronic rhinosinusitis?

Chronic rhinosinusitis has a large number of possible causes and more than one factor may be present in an individual.

Anatomical problems – a deviated nasal septum, enlarged turbinates, extra sinus air cells or additional drainage pathways
Allergic (hay fever) or non-allergic rhinitis
Chronic bacterial or fungal infection
Immune problem – autoimmune or immunodeficiency
Nasal polyps
Systemic diseases – these include Cystic fibrosis, Sarcoidosis and Wegener’s granulomatosis

How do I find out what is causing my sinus problems?

The first step is to visit your GP and discuss the problems you have been having. GP’s treat patients with sinus problems every day and in the majority of cases will be able to address things adequately. Your GP may look inside your nose to see if any nasal polyps or obvious issues are visible. They may take a swab of any infected material in the nose.

If things reach the point where your GP cannot completely cure your sinus problems they may then refer you to an ENT (otolaryngology) specialist.

Are there investigations / tests that can help diagnose the cause of my sinus problems?

Your GP can order a blood test or organise skin prick testing to look for any allergic rhinitis. Skin prick testing is generally more accurate than a blood test but the blood test can be easier to organise. A CT scan of your sinuses can look for inflamed sinus lining, cysts, polyps and other anatomical issues such as a deviated nasal septum.

What treatments are available for my sinus problems?

Your GP can prescribe a range of treatments that may be helpful. These include:

Nasal steroid sprays – These are well tolerate by children and adults and are very safe. They settle down swelling and inflammation in the nose and sinuses from a large number of causes. They take 2-3 weeks to reach their peak effect so it is important to be patient while using them. Remember to aim the spray outwards towards your ear and do not “sniff” the spray in excessively otherwise it will distribute down into your mouth.
Antibiotics – If a bacterial infection is suspected these are indicated. Some antibiotics are better than others for sinus problems. Different antibiotics are typically used for acute rhinosinusitis versus chronic rhinosinusitis.
Anti-histamine tablets and sprays – These are most useful for treating allergic problems (hay fever). They are not as useful for treating infections.
Nasal saline sprays and rinses – These can be very helpful when sinus issues have been present for many weeks to months. They essentially assist with cleaning debris out of the inside of the nose. In the early stages of a sinus infection (first 2 weeks) there is a theoretical risk of spreading the infection further into the nose and sinuses (and ears) with sinus rinsing.
Oral corticosteroid medications – These are very strong medications with a range of potential side effects. They need to be taken with care and only for specific causes. They are sometimes used to assist with severe pain/pressure in acute rhinosinusitis or to shrink polyps in chronic rhinosinusitis.

My GP has tried everything for my sinus problems, what is the next step?

The next step is to ask for a referral to an ear, nose and throat specialist (otolaryngologist). Sydney is fortunate to have a number of otolaryngologists with extensive international subspecialty training in nose and sinus problems. There are surgeons in Sydney’s Eastern suburbs, Sydney CBD, Western suburbs, North Shore and Northern Beaches who specialise in nose and sinus problems.

What will an ENT specialist do to work out the cause of my problems?

An ENT specialist will begin by going over the history of your sinus symptoms and trying to organise them to diagnose possible contributing factors. They will then use a tiny fiberoptic telescope to carefully examine the lining of your nose and the sinus drainage pathways. Any anatomical problems and chronic infections can usually be seen.

The ENT specialist may then go on to organise additional blood tests or a CT scan of your sinuses. Occasionally an MRI scan may be ordered as well.

Often certain treatments will be trialled that may assist with making the diagnosis as well. If you respond well to these it suggests one diagnosis, if there a poor response it suggests another.

How are sinus problems treated?

Some sinus problems can be treated with medicines other problems require surgery. Surgery is generally avoided if the problem can be treated with medicines.

Specific problems that can be treated with surgery include:

A deviated nasal septum. This is treated with a septoplasty operation.
Narrow sinus openings, additional drainage pathways, extra air cells blocking the sinuses. These problems are treated with functional endoscopic sinus surgery.
Enlarged inferior turbinates. The inferior turbinates can be resized through a turbinoplasty procedure.
Nasal polyps. These can also be treated medically in some patients.

Treatments that do not involve surgery include:

Nasal sprays and rinses. Some steroid preparations can be placed in the saline rinse bottle for better distribution. See this page on nasal irrigation solutions.
Allergy treatment. Immunotherapy can reduce the symptoms of allergies without requiring ongoing treatment.
Antibiotics. These work best in patients in whom there is a degree of infection.
Antihistamine tablets. These work best in patients with allergies.
Oral corticosteroids. These can be used for short periods but are not recommended for long term use. There are potential side effects of which patients need to be aware.

Generally your GP will try you on some of these non-surgical treatments before you see an ENT specialist. Your ENT specialist will discuss the surgical and non-surgical treatment options available to you. Some patients feel they have tried many medications over a long period of time and are quite keen for an operation to treat things definitively. Other patients feel very apprehensive about surgery. Both approaches are understandable and your ENT specialist will be able to work with your particular preferences and your particular variant of sinus disease.

Are there risks with sinus surgery?

Sinus surgery is generally very safe but like all surgery there are risks that need to be considered. Although already a very safe operation, safety in endoscopic sinus surgery has been improved in recent years with the advent of high definition endoscopes, cameras and image guidance. Patients frequently experience some nose bleeding after surgery for a few days. Occasionally additional courses of antibiotics are needed to settle infections. There are other rare risks of sinus surgery that your ENT specialist will explain to you during your consultation.

I have already seen an ENT specialist or even had sinus surgery but I am still having problems, what do I do next?

Sinus problems can be complicated and sometimes the solution is not straightforward. There are a small group of ENT specialists in Sydney who specialise in complicated sinus problems. They can usually offer further treatments to improve things even after you have been treated by another ENT specialist. This may involve further medical management or further surgery.

Generally we recommend returning to your original surgeon to discuss your ongoing issues. You can ask them or your GP for a referral to see Dr Roth or another specialist nose and sinus surgeon.

Further information

Dr Roth is one of a very small number of Australian surgeons to have undertaken an accredited United States sinus surgery fellowship. Dr Roth spent twelve months working at RUSH University Medical Centre in Chicago with the Midwest Sinus Centre. He has a special interest in all disorders of the nose and sinus. He attends regular international meetings regarding the latest techniques for managing nose and sinus problems. He hopes to share these with his patients to improve the quality of their care.

Please click through these links for further information on problems with the sinuses and the treatments available.