Sinusitis

WHAT IS SINUSITIS?

The Paranasal Sinuses

The skull contains a number of air-filled spaces called sinuses. They perform the following functions:

They reduce the weight of the skull.
Provide insulation for the skull.
Provide resonance for the voice.

Four pairs of sinuses, known as the paranasal air sinuses , connect to the nasal passages (the two airways running through the nose) and are those that are involved in sinusitis. These sinuses are the following:

Frontal sinuses (behind the forehead).
Maxillary sinuses (behind the cheekbones).
Ethmoid sinuses (between the eyes).
Sphenoid sinuses (behind the eyes).

Defense System in the Sinuses

Healthy sinuses are sterile and contain no bacteria. (The nasal passage, on the other hand, normally contains many bacteria that enter through the nostrils.) Maintaining sinus health depends on a cycle that involves a number of important factors and processes:

The sinuses are lined with a membrane that secretes mucus, which drains down into the nasal passage from a small channel in each sinus. The mucous membranes must be intact and free of injury.
The mucus must be fluid in order to flow freely while being sticky enough to absorb pollutants and entrap bacteria.
The mucus must also contain sufficient amounts of bacteria-fighting substances, including immune factors called antibodies.
Small, hair-like projections called cilia must beat in unison to propel mucus outward, expelling bacteria and other particles.
The sinus passages must be open to allow mucus drainage and the circulation of air through the nasal passage.

Sinusitis

The Disease Process. Sinusitis is an infection that occurs if one or more of the defense processes or factors are amiss, causing obstruction, and bacterial growth occurs in the paranasal sinuses. Among the many causes of such obstruction or congestion are the common cold, allergies, certain medical conditions, abnormalities in the nasal passage, and change in atmosphere. In any of these cases, sinusitis can develop as follows:

Mucus drainage and airflow 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.

Forms of Sinusitis. Sinusitis is usually defined as acute, recurrent acute, or chronic.

Acute sinusitis is the most common form. Nearly everyone experiences it at one time or another. It lasts no longer than eight weeks or occurs less than four times a year with each attack lasting no longer than 10 days. Acute sinusitis can be successfully treated with medications, leaving no residual damage to the mucous linings.
Recurrent acute sinusitis occurs more frequently but leaves no significant damage.
Chronic sinusitis lasts for eight weeks or longer (12 or longer in children) or occurs more than four times a year (six times in children) with symptoms persisting for more than 20 days. In cases of chronic sinusitis, imaging techniques show mucous tissue damage.

Chronic and recurrent acute sinusitis can be lifelong conditions.

WHAT CAUSES SINUSITIS?

Bacteria are the most common direct cause of acute sinusitis. (Other organisms might be the infecting agents in less common cases.) The ability of bacteria or other agents to infect the sinuses, however, must first be set up by conditions that create a favorable environment in the sinus cavities. Sinusitis is most often an acute condition, which is self-limiting and treatable. In some cases, however, the inflammation in the sinuses persists or is chronic do begin with. The causes for such chronic sinusitis cases are sometimes unclear.

Conditions that Predispose The Sinus Passages to Acute Bacterial Infection

The typical process leading to acute sinusitis starts with a flu or cold virus. Viruses themselves do not usually cause sinusitis directly. Instead, they set the stage by causing inflammation and congestion in the nasal passages (called rhinitis) that leads to obstruction in the sinuses. This creates a hospitable environment for bacterial growth, which is the direct cause of sinus infection. In fact, rhinitis is the precursor to sinusitis in so many cases that expert groups now refer to most cases of sinusitis as rhinosinusitis.

Rhinosinusitis tends to involve the following sinuses:

The maxillary sinuses (behind the cheekbones) are the most common sites.
The ethmoid sinuses (between the eyes) are the second most common sites affected by colds.
The frontal (behind the forehead) and sphenoid (behind the eyes) sinuses are involved in the balance of cold-related cases (about a third).

It should be noted that nearly everyone with colds have inflamed sinuses. These inflammations are typically brief and mild, however, and less than 5% of people with colds develop true sinusitis.

Conditions Leading to Chronic or Recurrent Sinusitis

Chronic or recurrent acute sinusitis typically results from one of the following conditions:

Untreated acute sinusitis that results in damage to the mucous membranes.
Chronic medical disorders that cause inflammation in the airways or persistent thickened stagnant mucus. Some of these include diabetes, AIDS or other disorders of the immune system, hypothyroidism, cystic fibrosis, Kartagener's syndrome, and Wegener's granulomatosis.
Structural abnormalities.

Chronic or recurrent acute sinusitis can be a lifelong condition.

The Role of Bacteria. The role of bacteria or other infectious agents is complicated in chronic sinusitis. They may play a direct, an indirect, or, in some patients, infectious agents may not play any role at all. For example, one study reported the following for 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.

The absence of bacterial agents as a causal factor in many cases suggests that some instances of chronic sinusitis may be due to a continuing inflammatory condition. Such on-going inflammation may have been triggered originally by acute sinusitis and became persistent because of immune problems.

Abnormalities of the Nasal Passage. Abnormalities in the nasal passage can cause blockage and thereby increase the risk for chronic sinusitis. Some include the following:

Polyps (small benign growths) in the nasal passage. Polyps impede mucus drainage and restrict airflow. Polyps themselves may be consequences of previous sinus infections that caused overgrowth of the nasal membrane.
Enlarged adenoids.
Cleft palate.
Tumors.
Deviated septum (a common structural abnormality in which the septum, the center section of the nose, is shifted to one side, usually the left).

Gastroesophageal Reflux Disease. 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 adult cases of chronic sinusitis. In a 2001 study over 4% of children with GERD had sinusitis, and in a surprising 2000 study 63% of children with chronic sinus problems had GERD. GERD, however, is very normal in children, and some experts believe this association has no significance for sinusitis or any other airway problems.

Asthma and Allergies . Allergies, asthma, and sinusitis often overlap. 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 allergies themselves rarely predispose to sinusitis

Severe asthma (which is often associated with allergies) and chronic sinusitis often overlap, although the relationship is unclear. 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. In fact, chronic sinusitis may actually be the cause of asthma in some cases. [See How Serious is Sinusitis?]

Infectious Agents that Cause Sinusitis

Bacterial Sinusitis. Bacteria are the most common infectious agents in sinusitis. The bacteria most commonly implicated in sinusitis are the following:

Streptococcus pneumoniae (also called pneumococcal pneumonia or pneumococci). This bacterium is found in between 20% and 43% of adults and children with sinusitis.
H. influenzae (a common bacteria associated with many upper respiratory infections). This bacterium colonizes nearly half of all children by age two, and it causes about 25% of sinusitis cases in this group. Studies have reported the presence of this bacteria in 22% to 35% of adult sinusitis patients.
Moraxella catarrhalis . Over three-quarters of all children harbor this bacterium and it causes about 25% of sinusitis cases.

Less bacterial culprits include:

Other streptococcal strains (8% of adult cases).
Staphylococcus aureus (6% of adult cases).

Fungal Sinusitis. Fungi are uncommon causes of sinusitis, but the incidence of these infections is increasing. Funguses involved in sinusitis are the following:

The fungus Aspergillus is the most common cause of all forms of fungal sinusitis.
Others include Curvularia, Bipolaris, Exserohilum, and Mucormycosis.
There have been a few reports of fungal sinusitis caused by Metarrhizium anisopliae , which is used in biological insect control.

There are four categories of fungal sinusitis:

Acute or invasive fungal sinusitis. This infection is most likely to affect people with diabetes and compromised immune systems.
Chronic or indolent fungal sinusitis. This form is generally found outside the US, most commonly in the Sudan and northern India.
Fungus ball (mycetoma). This fungal sinusitis is noninvasive and occurs usually in one sinus, most often the maxillary sinus.
Allergic fungal sinusitis. This form typically occurs because of an allergy to the fungus Aspergillus (rather than being caused by the fungus itself). 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.

Fungal infections can be very serious, and both chronic and acute fungal sinusitis require immediate treatment. Fungal ball is not invasive and is nearly always treatable.

Fungal infections should be suspected in people with sinusitis who also have diabetes, leukemia, AIDS, or other conditions that impair the immune system. Fungal infections can also occur in patients with healthy immune systems but they are far less common.

Viral Sinusitis. Viruses are directly implicated in only about 10% of sinusitis cases.

Infectious Agents in Chronic Sinusitis. The same organisms that cause acute sinusitis are often present in chronic sinusitis, but other agents are often detected in chronic cases that are not present in the original acute condition:

About 20% of chronic sinusitis cases are caused by Staphylococcus aureus (commonly called Staph infection). This bacteria may be present but is not usually the infecting agent in acute sinusitis.
Along with other 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.)
Fungi are the cause of about 6% to 8% of chronic sinusitis cases.

It should also be noted that sometimes bacteria or other organisms do not appear to be directly involved with chronic sinusitis.

WHO GETS SINUSITIS?

Sinusitis is one of the most common diseases in the United States, affecting an estimated 15% of the population as a whole. Along with asthma, allergies, and other upper respiratory tract infections, sinusitis has increased dramatically. According to a 2000 study, 66 million American adults reported having some sinus problems during the year. The causes for the increases in upper respiratory problems are under intense debate.

General Risk Factors for Sinusitis after a Cold

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. These inflammations are typically brief and mild, however, and only between 0.5% and 10% of people with colds develop true sinusitis. (One study suggested that nose blowing during a cold may transmit bacteria back into the sinuses and increase the risk for sinusitis.) Studies suggest that the following population groups have higher risks for sinusitis:

The very young and the very old are at higher risk for more serious upper respiratory tract infections and for complications from them.
Women appear to be at higher risk than men are.
People living in the Midwest and South have a higher incidence of sinusitis than those in the Northeast and West.
People in higher income and educational groups appear to have a greater risk than those in lower groups.
Caucasian and African Americans have a higher rate than Hispanic Americans.

Young Children and Sinusitis

Before the immune system matures, all infants are susceptible to respiratory infections, with a possible frequency of one cold every one or two months. Young children are prone to colds and may have eight to 12 bouts every year. Smaller nasal and sinus passages also make children more vulnerable to upper respiratory tract infections than older children and adults. Nevertheless, true sinusitis is very rare in children under eight or nine. Some experts believe it is greatly overdiagnosed in this population.

The Elderly and Sinusitis

The elderly are at specific risk for sinusitis. Their nasal passages tend to dry out with age. In addition, the cartilage supporting the nasal passages weakens causing airflow changes. They also have diminished cough and gag reflexes and faltering immune systems and are at greater risk for serious respiratory infections than are young and middle-aged adults.

People with Asthma, Allergies, or Both

People with asthma, allergies or both are at higher risk for non-infectious inflammation in the sinuses. The risk for sinusitis is higher in patients with severe asthma. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter's or ASA triad) are specifically at very high risk for chronic or recurrent acute sinusitis.

Hospitalization

Hospitalized patients are at higher risk for sinusitis, particularly the following:

Patients with head injuries.
Patients with conditions requiring insertion of tubes through the nose.
Patients taking antibiotics or steroids.
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.

People with High-Risk Medical Conditions Affecting the Sinuses

A number of medical conditions put people at risk for chronic sinusitis. They include the following:

Diabetes.
AIDS and other disorders of the immune system predispose the patient to sinusitis, with fungal infections being a particular risk.
Pregnancy is sometimes associated with congestion and symptoms of sinusitis, although the condition is temporary.
Hypothyroidism is associated with congestion that clears up when the condition is treated.
Cystic fibrosis, a genetic disorder in which the mucus is very thick and builds up.
Kartagener's syndrome, a very rare genetic disorder 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.
Wegener's granulomatosis, a serious but very rare illness that causes long-term swelling and tumor-like masses in air passages.

Miscellaneous Risk Factors

Dental Problems. Anaerobic bacteria are associated with infections from dental problems or procedures, which precipitate about 10% of cases of sinusitis.

Changes in Atmospheric Pressure. 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.)

Cigarette Smoke and Other Air Pollutants. Air pollution from industrial chemicals, cigarette smoke, or other pollutants can damage the cilia responsible for moving mucus through the sinuses. Whether air pollution is an important cause of sinusitis and, if so, which pollutants are critical factors is still not clear. Cigarette smoke, for example, poses a small but increased risk for sinusitis in adults. Second-hand smoke does not appear to have any significant effect on adult sinuses, although it does seem to pose a risk for sinusitis in children.

WHAT ARE THE SYMPTOMS OF SINUSITIS?

General Symptoms of Acute Sinusitis

Sinus symptoms are very common during a cold or flu, but in most of these cases they are due to the effects of the infecting virus and resolve when the infection does. It is important to differentiate between inflamed sinuses associated with cold or flu virus and sinusitis caused by a bacteria. With true acute bacterial sinusitis, the signs and symptoms typically have the following course:

They continue for 10 days or more after the start of a cold or flu, or
They worsen after five to seven days, or
They return after initial improvement in a cold (called double sickening).

General Symptoms in Adults. Symptoms of acute sinusitis include the following:

Nasal congestion and discharge. The discharge is typically thick and contains pus that is yellowish to yellow-green.
Severe headache and pain or pressure in specific areas in the face. For example, eyes may be red, bulging or painful eyes if the sinus infection occurs around the eyes. In some cases, patients may also have double vision and even temporary vision loss. [ See Table, Symptoms of Sinusitis by Specific Site.]
A persistent cough (particularly during the day).
Fever (may be present).
Fatigue (from lack of good rest).
Lack of response to decongestants or antihistamines.

Sneezing, sore throat, and muscle aches may be present, but they are rarely caused by sinusitis itself. Muscle aches may be caused by fever, sore throat by post-nasal drip, and sneezing from cold or allergies.

Rare complications of sinusitis can produce additional symptoms, which may be severe or even life threatening. [ See How Serious Is Sinusitis?]

Symptoms in Children. Children are most likely to develop infection in the ethmoid sinuses, located between the eyes. Children with sinusitis are also less likely to experience facial pain over the affected sinus and headache, which are the primary signs in adults. Symptoms of bacterial sinusitis may be less specific than in adults and include the following:

Persistent nasal discharge (of any type) and day time cough for more than 10 days, or
Severe symptoms that last for at least three or four days in a row and include thick, greenish nasal discharge plus a fever of at least 102 degrees.

General Symptoms of Recurrent Acute and Chronic Sinusitis

Recurrent acute and chronic sinusitis tend to take the following course:

Symptoms are more vague and generalized than acute sinusitis.
They last longer than four weeks. (Subacute sinusitis lasts longer than four weeks but less than three months. Chronic sinusitis lasts three months or more.)
They occur throughout the year, even during nonallergy seasons.

Specifically symptoms may include:

Nasal congestion and obstruction.
Chronic cough (day and night).
Bad breath.
Postnasal drip (which can cause repeated throat clearing).
Facial tenderness or pressure may be present. Sufferers do not usually experience facial pain unless the infection is in the frontal sinuses, which usually results in a dull, constant ache.

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. [ SeeTable, Symptoms of Sinusitis by Specific Site, below.]

Symptoms of Sinusitis by Specific Site
Site	Acute Symptoms	Chronic Symptoms
ETHMOID SINUSITIS (Ethmoid sinuses are located between the eyes. They resemble a honeycomb and are vulnerable to obstruction. This is a common location for sinusitis in children.)	Nasal congestion. Nasal discharge or postnasal drip. Pain or pressure around the inner corner of the eye or down one side of the nose. Headache in the temple or surrounding the eye. Symptoms worse when coughing, straining, or lying on the back and better when the head is upright. Fever. Symptoms of maxillary sinusitis ( see below ) often occur. Symptoms indicating medical emergency: Increasing severity of symptoms. Fever, swelling and drooping eyelid, loss of eye movement (possible orbital infection, which is in the eye socket). Fever, vision changes, Pupil fixed or dilated. Symptoms spreading to both sides of face (may indicate blood clot).	Chronic nasal discharge, obstruction, and low-grade discomfort usually across the bridge of the nose. Symptoms worse in the late morning or when wearing glasses. Chronic sore throat and bad breath. Sinusitis recurs also in other sites.
ACUTE MAXILLARY SINUSITIS ( Maxillary sinuses are located behind the cheek bones. They are present at birth and continue to develop as long as teeth erupt. Tooth roots, in some cases, can penetrate the floor of these sinuses.)	Pain across the cheekbone, under or around the eye, or around the upper teeth; may occur on one or both sides of the face. Area over the cheekbone is tender and may be red or swollen. Possibly tooth pain. Symptoms are worse when the head is upright; improved when patient reclines. Nasal discharge or postnasal drip. Fever.	Discomfort or pressure below the eye. Chronic toothache. Symptoms become worse with colds, flu, or allergies. Discomfort increases during the day. Coughing increases at night.
FRONTAL SINUSITIS (Sinuses are located on both sides of the forehead. These sinuses are late in developing, so infection here is uncommon in children.)	Severe headache in the forehead. Fever (common but not always present). Symptoms are worse when lying on the back and when pressing against the area over the eye on the side closest to the nose. Symptoms are better when the head is upright. Nasal discharge or postnasal drip. Symptoms indicating medical emergency: Increasing severity of symptoms, particularly severe headache, altered vision, mild personality or mental changes (may indicate spread of infection to brain). Fever, vision changes, fixed or dilated pupil. Symptoms spreading to both sides of face (may indicate blood clot). Headache, fever, along with a soft swelling over the bone (may indicate bone infection).	Persistent, low-grade headache in the forehead. History of physical injury or other damage to the sinus area.
SPHENOID SINUSITIS (Sinuses are located behind the eyes. The are generally present by age 3 and are fully developed by age 12.)	Deep headache with pain in many places, including the back and top of the head, across the forehead, and behind the eye. Fever. Symptoms are worse when lying on the back or bending forward. Nasal discharge or postnasal drip. Symptoms indicating medical emergency: Increasing severity of symptoms, particularly severe headache, altered vision, mild personality or mental changes (may indicate spread of infection to brain).	Low grade, general headache (although not always present). (Adapted from: Sinus Disease: Guide to First-line Management. D. Kennedy, ed. B© 1994 Health Communications, Inc. Adrian, CT.)

HOW SERIOUS IS SINUSITIS?

Complications of Bacterial Infection in the Sinuses

Bacterial sinusitis is nearly always harmless (although 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. One important complication is infection of the bones (osteomyelitis) of the forehead. In such cases, the patient usually experiences headache, fever, and a soft swelling over the bone known as Pott's puffy tumor.

Infection of the 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, although rare, from ethmoid or frontal sinusitis are blood clots. If a blood clot forms in the sinus area around the front and top of the face, symptoms are similar to orbital infection. 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.

Ischemic Stroke. One small and preliminary study found a link between ischemic stroke and sinusitis. More research is needed to determine if this possibility is valid.

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.

Complications of Fungal Infection in the Sinuses

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.

Asthma

The relationship between sinusitis is unclear. A number of theories have been proposed for a causal or shared association between sinusitis and asthma. Some include the following:

Stimulation of nerve pathways, inflammation, and overproduction of mucus in the nasal passages and sinus cavities may eventually affect the airways in the lung, causing them to hyperreact.
Breathing through the mouth when the sinuses are blocked allows in large particles that would other wise be filtered by the nasal defense system. Such particles could trigger allergic responses in the lungs that can trigger asthma in susceptible people.
Air breathed through the mouth is colder than air warmed in the nasal passages. Cold air is a known trigger of asthma.
Both may share similar immune abnormalities that cause inflammation in the airways in the lungs and sinuses.

Successful treatment of both allergic rhinitis and chronic 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. They might not respond to asthma treatments unless the infection is cleared up first. [For more information, see Well-Connected Report #04 Asthma in Adults , Report #05 A sthma in Children , or Report #77, Allergic Rhinitis (Hay Fever and Rose Fever) and Chronic Nasal Congestion .]

HOW IS SINUSITIS DIAGNOSED?

A patient who has sinusitis symptoms that do not clear up within a few days, are severe, or are accompanied by high fever or acute illness should see a physician. It should be noted, however, that only one-half to two-thirds of patients with such symptoms actually have sinusitis. Some experts complain that too many patients are diagnosed with true sinusitis and given unnecessary antibiotics when their symptoms would actually resolve easily in days with over-the-counter medications or no drugs at all. Others believe that true sinusitis is often mistakenly diagnosed as an allergy and not treated, which could lead to serious illness.

The first goal in diagnosing sinusitis is to rule out other possible causes of symptoms, and then determine the following:

The site where the infection has occurred [ See Table Symptoms Of Sinusitis by Specific Site],
Whether the condition is acute or chronic, and
The organism causing the infection (if possible).

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.

Ruling Out Other Causes of Sinusitis Symptoms

Ruling out Sinus Symptoms due to Cold or Flu Viruses. It is often difficult to tell when a viral infection converts to a bacterial infection. Studies have found that between 40% and 85% of patients with the common cold show signs of inflamed sinuses on x-rays or CT scans. A cold, however, unlike sinusitis, typically clears up without treatment within a week. (Only about 0.5% to 2% of adults with viral colds or flus actually develop bacterial infections.) In general, the physician should suspect a bacterial infection under the following circumstances:

If sinus symptoms persist for 10 days or longer after a cold or flu, or
If symptoms become worse after five to seven days.

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 the following:

Thin, clear, and runny nasal discharge.
Itchy nose, eyes, or throat (which never occur with bacterial sinusitis).
Recurrent sneezing.
Symptoms of allergies appear only during exposure to allergens. [ For more information, see Well-ConnectedReport #77 , Allergic and Nonallergic Nasal Congestion (Rhinitis). ]

Ruling out Migraine and Other Headaches. Many primary headaches, particularly migraine or cluster, may closely resemble sinus headache. Migraine and sinus headaches may even coexist in many cases. 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. The following symptoms suggest a migraine rather than a sinus headache:

The headache is recurrent.
It has a significant impact on daily activities.
The headache does not get worse over time.

Ruling Out Neuralgia. 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 requires specific drugs, such as tricyclic antidepressants or carbamazepine. Trials using such agents may identify patients with neurolgia and help avoid unnecessary invasive treatments for chronic sinusitis.

Ruling out Other Conditions. A number of other conditions can mimic sinusitis. They include the following:

Dental problems.
A foreign object in the nasal passage.
Temporal arteritis.
Persistent upper respiratory tract infections.
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. It often occurs in pregnant women.

Diagnostic Approach to Acute Sinusitis

Medical History. The patient should describe all symptoms such as nasal discharge and specific pain in the face and head, including eye and tooth pain.

After assessing symptoms, the physician should take a thorough medical history of the patient, including the following:

Any history of allergies or headaches.
Recent upper respiratory infection (colds, flus, infection) and any lack of response to decongestants.
History of sinusitis episodes that are unresponsive to antibiotic treatment. (In such cases, the physician will usually diagnose chronic or recurrent acute sinusitis and refer the patient to a specialist for more advanced testing.)
Exposure to cigarette smoke or other environmental pollutants.
Recent travel.
Recent dental procedures, particularly if there is pain toward the back of the mouth.
Medications being taken (particularly decongestants).
Any known structural abnormalities in the nose and face.
Injury to the head or face.
Any family history of allergies, immune disorders, cystic fibrosis, or immotile cilia syndrome.
In small children with sinusitis, whether they attend a day care center or nursery school.

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. The doctor will also check the inside of the nasal passages using a device with a bright light to check the mucus and look for any structural abnormalities.

Transillumination

Transillumination is a procedure aimed at visualizing the sinuses. It is fast, safe, inexpensive, and a good first diagnostic step in some patients, such as those older than 10 years old who may have infection in the frontal or maxillary sinuses. It is not very useful in younger children. To perform it, the physician does the following:

First he or she shines a bright light against the patient's cheek or forehead in a completely darkened room.
If the sinuses are clear, the physician will observe a glow on the hard palate of the open mouth or in the areas of the cheek where the sinus passages are located.

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.

X-Rays. If the physician strongly suspects any complications, x-rays may be taken. A single x-ray is adequate for diagnosis in adults of maxillary sinusitis, the most common sinusitis. More than one, however, is needed for diagnosing frontal and sphenoid sinusitis. X-rays do not detect ethmoid sinusitis at all, which can be the primary site of an infection that has spread to the maxillary or frontal sinuses.

Computer Tomography. Computed tomography (CT) scanning is the best method for viewing the paranasal sinuses. They are recommended for acute sinusitis only if there is a severe infection, complications, or a high risk for complications. CT scans are useful for diagnosing chronic or recurrent acute sinusitis and for 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.

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) is not as effective as CT in defining the paranasal sinus anatomy. MRI is also 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.

Ultrasound. Although ultrasound has not been thought to be very useful, a 2000 study reported that it was more accurate than MRI or x-rays in diagnosing maxillary sinusitis. And, when used in combination with an x-ray, ultrasound can identify 86% of infections.

Sinus Puncture and Bacterial Culture

The gold standard for diagnosing a bacterial sinus infection is sinus puncture and bacterial culture. It is performed only if a reasonable diagnosis cannot be made using noninvasive techniques.

Sinus puncture involves using a needle to withdraw a small amount of fluid from the sinuses. It requires a local anesthetic and is performed by a specialist. The fluid is then cultured to determine what type of bacteria is causing sinusitis.

Taking a culture of nasal discharge to identify the bacterial agents causing sinusitis is not generally useful because other unrelated bacteria are often present that can confuse the results. If sinusitis is not resolved by the use of antibiotics and if nasal discharge is brown and thick, a fungus should be suspected and a culture taken for its presence.

Nasal Endoscopy (Rhinoscopy)

Nasal endoscopy, or rhinoscopy, is now used for diagnosing chronic and recurrent acute sinusitis and for differentiating between allergies and true acute 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. This procedure is less invasive than sinus puncture, and a 2001 study reported that it was just as accurate in identifying organisms associated with sinusitis.

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 Habits for Preventing Colds

Good Hygiene. A very common method for transmitting a cold is by shaking hands. Everyone should always wash his or her hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleaners that contain an alcohol-based gel are also effective for every day use and may even kill cold viruses. (They are less effective, however, if extreme hygiene is required, In such cases, alcohol-based rinses are needed.) Antibacterial soaps add little protection, particularly against viruses. In fact, one 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.

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.

Researchers are also studying the possible protective value of certain strains of lactobacilli, bacteria found in the intestines. Some of these strains, particularly acidophilus, are used to make yogurt. According to one Finnish study, children attending day care who ate milk containing the strain lactobacilli GG could reduce respiratory infections in these children by 10% to 20%. More research is warranted. (The strain used was not the kind found in most commercial yogurt products,)

Breastfeeding. Some evidence suggests that women who breastfeed reduce the risk of respiratory infections in their children.

Low Stress and Active Social Life. More than one study has reported that people with low stress who also have an active social life have fewer colds than people who have high stress levels or those who have low stress and few social connections.

Zinc

Zinc appears to have certain important effects on the immune system and it may have a direct effect on viruses. How it works is not entirely clear, however. Zinc preparations in lozenge or nasal gel form are now available as cold treatments. Studies are very mixed on the effects of zinc on colds. The variance may be due to different zinc preparations. Studies are underway to determine advantages, if any. Some examples include the following:

A nasal gel (Zicam), which contains zinc gluconate, has shown some early success, possibly because the gel sticks to the nasal passages long enough for the zinc to interact with the virus. In one 2000 study, patients with colds who used it achieved full recovery in an average of 2.3 days compared to nine days in patients using a "dummy" nasal preparation. More studies are underway.
Zinc lozenges are showing mixed results. One 2000 study suggested that the use of zinc acetate lozenges (e.g., Fast-Dry, Galzin) may be more effective and have a better taste than other formulations, such as zinc gluconate (Cold-Eeze, Orazinc). In the study, this preparation reduced both duration and severity of symptoms compared to a dummy pill. The two zinc lozenge preparations were directly compared in another 2000 study, however, and neither was effective.
A small 2001 study on a nasal spray preparation found no benefits. The spray preparation had less zinc than the nasal gel.

In any case, no one with an adequate diet and a healthy immune system should take zinc for prolonged periods for preventing colds.

Side Effects. Side effects include the following:

Dry mouth.
Constipation.
Nausea.
Bad taste (possibly only with zinc gluconate lozenges).
Overdose may cause severe vomiting, dehydration, and restlessness. Call a physician if any of these symptoms occur.
In rare cases, an allergic response may occur.

Food and Drug Interactions. Zinc may also interact with drugs or other elements.

It may reduce absorption of certain antibiotics.
Foods high in calcium or phosphorus may reduce zinc absorption.
high doses and for long periods of time zinc can cause copper deficiencies.

Vitamins

Different studies have found that large doses of vitamin C reduce the duration of a cold by a range of 5% to 50%. Large doses of vitamin C, however, do not appear to protect against getting a cold in the first place, even after exposure to a cold virus. (It may help protect specific people, however, such as in poor health or who endure regular heavy physical stress.)

Some precautions against taking high doses of vitamin C include the following:

High doses of vitamin C 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.

There is no evidence that other vitamins, such vitamin E, are helpful. In fact, one small study conducted by military doctors suggested that that older individuals who regularly took a multivitamin had less protection from the flu vaccine. (The supplement contained only vitamins and no trace elements, such as zinc.)

Echinacea

The herbal remedy echinacea is now commonly taken to prevent onset and ease symptoms of cold or flu. There are three species:

Echinacea (E.) purpurea.
E. pallida.
E. augustifolia .

In some studies, people who took extracts of either E. purpurea or E. augustifolia experienced no protection against colds. Preparations themselves vary, however, and effectiveness may depend on whether the root, herb, or whole plant is used. For example, in a 1999 study, a root and herb preparation of E. purpurea (Echinoforce) reduced cold symptoms while another E. purpurea root preparation did not. Preparations made with 50% alcohol and from fresh root or fresh root and cone are preferred. The drying process also effects the active chemicals in the herb. (Freeze-drying may be best.) 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.

Precautions. Some precautions are as follows:
Allergic reactions have been reported. People with autoimmune diseases or who have plant allergies should particularly avoid it.
There have been some reports of a reaction called erythema nodosum associated with echinacea. This involves a rash, sometimes accompanied by fever, headache, muscle and joint aches, and sore throat.

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. [See Warnings on Alternative and So-Called Natural Remedies.]

Warnings on Alternative and So-Called Natural Remedies

It should be strongly noted that alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public. There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication.

The following are special concerns for people taking natural remedies for colds:

Grapeseed extract is sometimes touted as a natural antihistamine. A 2002 study, however, reported no benefits from it.
Aller Relief Chinese herbal cold and allergy contains trace amounts of aristolochic acid, a chemical that is toxic to the kidneys and a carcinogen. Products containing aristolochic acid have been associated with several reports of kidney failure in Europe. Of specific concern are studies suggesting that up to 30% of herbal patent remedies imported from China having been laced with potent pharmaceuticals such as phenacetin and steroids. Most problems reported occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

The following website is building a database of natural remedy brands that it tests and rates. Not all are available yet. http://www.ConsumerLab.com/ The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (call 800-332-1088).

Viral Influenza Vaccines

Effectiveness and Benefits. Vaccinations now protect against influenza in between 70% and 100% of healthy adults when the virus and the vaccine are well matched. In the absence of a match and among the elderly and children, they are fully protective in 30% to 60% of people. Even in people with a weaker response, the vaccine is usually protective against serious flu complications, particularly pneumonia, if such people get the flu. Additionally, studies are finding that the more people that are vaccinated, the healthier the community at large.

Description of Vaccines. Vaccines are designed to recognize foreign agents (called antigens) in the body and to attack them. Vaccines against influenza currently employ inactivated (not live) viruses to produce an immune response that will then attack the active virus. Vaccines are now given by injection in the fall, usually between October and December.

A live but weakened intranasal vaccine (Flumist) known as a cold-adapted, live, attenuated, trivalent, intranasal influenza vaccine (CAIV-T) has been investigated for some time. Because it doesn't need to be injected, it may increase the number of children being vaccinated if it proves to be safe. It is engineered to grow only in the cooler temperatures of the nasal passages, not in the warmer 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 studies are showing it to be highly effective. A CAIV-T vaccine has been used for 10 years to immunize children in Russia, where it has reduced hospitalization and respiratory infection rates by 30% to 50%.

Annual Redesign. At this time, vaccines must be redesigned each year to match the current strain. The influenza virus contains two primary molecules (hemagglutinin and neuraminidase) that serve as antigens, targets of the vaccines that used to prevent influenza. Unfortunately, the antigens in these influenza viruses undergo genetic alterations (called antigenic drift ) over time, so they are likely to become resistant to a vaccine that worked in the previous year. Vaccines are then redesigned annually to match the current strain. The two major influenza viruses are called A and B depending on their stability:

Influenza A is a particular problem because it can infect other species, such as pigs or chickens, and undergo major genetic reassortments.
Influenza B viruses tend to be more stable than influenza A viruses, but they too vary. Although influenza B has been far less common than A, a vaccine for type B is important because experts are concerned that small children will not have developed any immunity to the virus and will experience severe flu if they are exposed to type B.

The current flu vaccines may be slightly less effective in the elderly, the very young, and patients with certain chronic diseases than in healthy young adults. (Even vaccinated patients may still experience some flu symptoms, such as nasal congestion or sore throat.) Even in people with a weaker response, however, the vaccine is usually protective against serious flu complications, particularly pneumonia.

Influenza Vaccines in Older Children and Adults. The following in order of priority, are the population groups who should be vaccinated each year. The first two groups have the highest need for influenza vaccinations and are given top priority:

All adults 65 years and older. According to a national survey, about two thirds of older people received the influenza vaccine in 1998. Older African American and Hispanic adults, however, are far less likely to be vaccinated that older Caucasian people. Vaccinated older adults have lower hospitalization rates and death from any cause than unvaccinated peers. One small, preliminary study found a lower risk for stroke in vaccinated adults over the age of 60. Of further note, studies in 2000 suggested that benefits of influenza vaccinations for older people may also extend to their hearts. One reported a lower risk for cardiac arrest in vaccinated subjects and the other a lower risk for recurrent heart attack in vaccinated patients with heart disease.
People of any age at high risk for serious complications from influenza. Such people include those with heart disease, lung problems, immune deficiencies, diabetes, kidney disease, or chronic blood disease. (There have been concerns about the safety of the vaccinations in certain high-risk patients such as those with HIV or asthma. Studies now suggest that the vaccine is generally safe in these patient groups. Furthermore, their risk for serious complications from influenza outweighs any potential adverse effects from the vaccines.)
Adults between the ages of 50 and 64 who have chronic medical conditions. (The US Advisory Committee on Immunization Practices (ACIP) suggests that all adults over age 50 should be vaccinated, although this is not recommendation of the CDC.)
People (such as household members or healthcare workers) in contact with individuals who are at high-risk for complications from influenza.

Other adults who should consider influenza vaccinations include the following:

People at risk for complications for influenza and who are traveling to the tropics at any time or to the Southern Hemisphere between April and September.
Pregnant women who are at risk for complications of influenza and who will be in their second or third trimester during flu season. (Vaccinations should usually be given after the first trimester. Exceptions may be women who are in their first trimester during flu season and their risk from complications of the flu is higher than any theoretical risk to the baby from the vaccine.)
People such as firemen or policemen who are critical for public safety.
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.

The vaccines may be slightly less effective in the elderly, the very young, and patients with certain chronic diseases than in healthy young adults.

Influenza Vaccine in Children. The following children over six months should be vaccinated against influenza:

Any child with a condition that requires regular medical care. In fact, in 2002 the American Academy of Pediatrics (AAP) and the CDC recommended the vaccination for all healthy children under two years of age. This recommendation may vary from year to year depending on the supply of the vaccine.
Any child who has been hospitalized for a serious illness (particularly lung, kidney, diabetes, sickle-cell, or immune deficiencies). The effects of the influenza vaccine on children with asthma are not entirely clear. Some studies have reported more severe asthma symptoms in children with the lung condition. A 2000 study of asthmatic children, however, reported no increased risk. In fact, there was some indication that the vaccination helped reduce asthma attacks over time. More research is needed to confirm or refute these results.
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.

Although such high-risk children have considerable risk for hospitalization from influenza, most of these children are not being vaccinated. One interesting study in Japan found that vaccinating children actually helps protect the elderly.

Negative Effects. Possible negative responses include the following:

Allergic Reaction. Newer vaccines contain very little egg protein, but an allergic reaction still may occur in people with strong allergies to eggs.
Soreness at the Injection Site. Almost a third of people who receive the influenza vaccine develop redness or soreness at the injection site for one or two days afterward.
Symptoms. 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

The pneumococcal vaccine protects against S. pneumoniae (also called pneumococcal) bacteria, the most common cause of respiratory infections. It does not prevent influenza, but it may help prevent pneumonia in people who are susceptible to severe influenza. 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. This has created a great sense of urgency in the medical community to find effective measures for preventing infection.

Pneumococcal Vaccine in Young Children. The pneumococcal vaccine (Prevnar or PCV7) 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, such as pneumonia. In one study, a similar vaccine under investigation protected not only children in day care from serious respiratory infections, but their younger unvaccinated siblings had fewer infections as well.

The pneumococcal vaccine is now recommended by many experts for the following groups:
All children up to age two. The pneumococcal vaccine (Prevnar or PCV7) has now been added to the Recommended Childhood Immunization Schedule. The pneumococcal vaccine (Prevnar or PCV7) is very effective in children. Studies are suggesting that it prevents common ear infections as well as serious infections, such as pneumonia. In one study, a similar vaccine under investigation protected not only children in day care from serious respiratory infections, but their younger unvaccinated siblings had fewer infections as well.
Children up to age five who are at risk for pneumonia or complications of influenza, such as children with sickle disease, those with immune deficiencies, or children with chronic medical conditions.
Other children age two to five who are higher risk for serious pneumococcal infections should be considered for vaccinations. They include African or Native Americans, children in group child care, socially or economically disadvantaged children, or those who have had frequent or complicated acute middle ear infections within the past year. (In one study, the vaccine reduced the number of ear infections episodes by 6%.)

The recommended schedule of immunization for Prevnar (PCV7) is four doses, given at two, four, six, and 12 to 15 months of age. Infants starting immunization between seven and 11 months should have three doses. Children starting their vaccinations between 12 and 23 months only need two doses. And those who are over two years old need only one dose.

Pneumococcal Vaccine in Older Children and Adults. Because the vaccine is inactive, it is safe for pregnant women and people with immune deficiencies. Many experts now recommend the vaccine for the following older children or adults:

All people over 65 years old. (Anyone vaccinated more than five years previously should be revaccinated.) According to a 2001 survey, over half of older people have now received a pneumococcal vaccination. Older African American and Hispanic adults, however, are far less likely to be vaccinated that older Caucasian people. This is particularly disturbing, since the mortality rates from pneumonia in these minority populations, particularly African Americans, are higher than in Caucasians.
Individuals with immune deficiencies (e.g., HIV) or are undergoing treatments to suppress the immune system.
Patients with kidney disease or kidney transplants. Older people who have had transplant operations or those with kidney disease may require a revaccination after six years.
Patients with problems in the spleen.
Alcoholics (especially those with cirrhosis).
Adults with any condition that increases the risk for pneumonia should be vaccinated. 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. (Anyone at risk for serious pneumonia should be revaccinated six years after the first dose.)

When the vaccine is administered to pregnant women, it may actually protect their infants against certain respiratory infections. 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.

Side Effects of the Pneumococcal Pneumonia Vaccine. Side effects include pain and redness at the injection site, fever, and joint aches. Children are more likely to have fever within 48 hours if they receive other vaccines at the same time and also after the second dose. Rarely, such local reactions can be severe. Even if a person is mistakenly re-vaccinated before the effects of the first vaccination have worn off, the risk for severe side effects is very low. Allergic reactions are very rare.

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 fluids and getting lots of rest when needed is still the best bit of advice to ease the discomforts of the common cold. Water is the best fluid and helps lubricate the mucous membranes. (There is no evidence that drinking milk will increase or worsen mucus, although milk is a food and should not serve as fluid replacement.)
Chicken soup does indeed help congestion and achiness. The hot steam from the soup may be its chief advantage, although laboratory studies have actually reported that ingredients in the soup may have anti-inflammatory effects. In fact, any hot beverage may have similar soothing effects from steam. Ginger tea, fruit juice, and hot tea with honey and lemon may all be helpful.
Spicy foods that contain hot peppers or horseradish may help clear sinuses.
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.

Medications for Mild Pain and Fever Reduction

Many people take medications to reduce mild pain and fever. Adults most often choose aspirin, ibuprofen (Advil), or acetaminophen (Tylenol).

The following are recommendations for children:

Acetaminophen (Tylenol) or ibuprofen (usually Advil or Motrin) is the pain-reliever of choice in children. Most pediatricians advise such medications for children who run fevers over 101 degrees F. Some suggest alternating the two agents, although there is no evidence that this regimen offers any benefits, and it might be harmful.
Aspirin and aspirin-containing products are virtually never recommended for children or adolescents. Reye's Syndrome, a very serious condition, has been associated with aspirin use in children who have flu symptoms or chicken pox.

It should be noted that some studies are suggesting that these anti-fever agents may actually reduce the body's immune response against cold and flu viruses and prolong symptoms. A 2000 study, for example, reported a longer flu duration in people who took aspirin or acetaminophen (although people still felt better). (In the study, these drugs did not appear prolong other illnesses, including Rocky Mountain spotted fever and shigellosis.) Nevertheless, most doctors strongly recommend lowering fevers in children, since high fevers can sometimes cause seizures.

Nasal Wash

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 homemade 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 symptoms. Further, one preliminary study found that over-the-counter saline nasal sprays that contain benzalkonium chloride as a preservative may actually worsen symptoms and infection.

Some physicians, however, advocate a traditional nasal wash that has been used for centuries and is different from that used in the study. It contains no baking soda and uses more fluid for each dose and less salt. The nasal wash should be performed several times a day.

Simple method for administering a nasal wash is the following:

Lean over the sink head down.
Pour some solution into the palm of the hand and inhale it through the nose, one nostril at a time.
Spit the remaining solution out.
Gently blow the nose.

The solution may also be inserted into the nose using a large rubber ear syringe, available at a pharmacy. In this case the process is the following:

over the sink head down.
Insert only the tip of the syringe into one nostril.
Gently squeeze the bulb several times to wash the nasal passage.
Then press the bulb firmly enough so that the solution passes into the mouth.
The process should be repeated in the other nostril.

Decongestants

Decongestants administered in nasal spray form may be used for short-term treatment. They thicken secretions in the nasal passages however, and may reduce the ability to clear out bacteria.

Nasal-delivery decongestants are applied directly into the nasal passages with a spray, gel, drops, or vapors. Nasal forms work faster than oral decongestants and have fewer side effects. They often require frequent administration, although long-acting forms are now available. Ingredients and brands of nasal decongestants include the following:

Long Acting Nasal-Delivery Decongestants. They are effective in a few minutes and remain so for six to 12 hours. The primary ingredient in long-acting decongestant is the following:

Oxymetazoline: Brands include Vicks Sinex (12-hour brands), Afrin (12-hour brands), Dristan 12-Hour, Good Sense, Nostrilla, Neo-Synephrine 12-Hour.
Xylometazoline: Inspire, Otrivin, Natru-vent.

Short-Acting Nasal-Delivery Decongestants. The effects usually last about four hours. The primary ingredients in short-acing decongestants are the following:

Phenylephrine: Neo-Synephrine (mild, regular, high-potency), 4-Way, Dristan Mist Spray, Vicks Sinex).
Naphazoline (Naphcon Forte, Privine).

Dependency and Rebound. The major hazard with nasal-delivery decongestants, particularly long-acting forms is a cycle of dependency and rebound effects. The 12-hour brands pose a particular risk for this effect. This effect works in the following way:

prolonged use (more than three to five days), nasal decongestants lose effectiveness and even cause swelling in the nasal passages.
The patient then increases the frequency of their dose. The congestion worsens and the patient responds with even more frequent doses, in some cases to as often as every hour.
Individuals then become dependent on them.

Tips for Use. The following precautions are important for people taking nasal decongestants:

When using a nasal spray, spray each nostril once. Wait a minute to allow absorption into the mucosal tissues, and then spray again.
Keep the nasal passages moist. All forms of nasal decongestants can cause irritation and stinging. They also may dry out the affected areas and damage tissues.
Do not share droppers and inhalators with other people.
Use decongestants only for conditions requiring short-term use, such as before air travel or for a single-allergy attack. Do not take them more than three days in a row. With prolonged use, nasal decongestants become ineffective and result in the so-called rebound effect and dependence.
Discard sprayers, inhalators, or other decongestant delivery devices when the medication is no longer needed. Over time, these devices can become reservoirs for bacteria.
Discard the medicine if it becomes cloudy or unclear.

Oral Decongestants. Oral decongestants also come in many brands, which mainly differ in their ingredients. The most common active ingredient is pseudoephedrine (Sudafed, Actifed, Drixoral). The alternative decongestant, phenylpropanolamine (PPA) was taken off the market. [ See Warning Box, Decongestants and Phenylpropanolamine.]

Side Effects of Decongestants. Decongestants have certain adverse effects, which are more apt to occur in oral than nasal decongestants and include the following:

Agitation and nervousness.
Drowsiness (particularly with oral decongestants and in combination with alcohol).
Changes in heart rate and blood pressure.
Avoid combinations of oral decongestants with alcohol or certain drugs, including monoamine oxidase inhibitors (MAOI) and sedatives.

Individuals at Risk for Complications from Decongestants. People who may be at higher risk for complications are those with certain medical conditions, including disorders that make blood vessels highly susceptible to contraction. Such condition include the following:

Heart disease.
High blood pressure.
Thyroid disease.
Diabetes.
Prostate problems that cause urinary difficulties.
Migraines.
Raynaud's phenomenon.
High sensitivity to cold.
Emphysema or chronic bronchitis. (Such individuals should particularly avoid high-potency short-acting nasal decongestant.)
People taking medications that increase serotonin levels, such as certain antidepressants, anti-migraine agents, diet pills, St. John's Wort, and methamphetamine. The combinations can cause blood vessels in the brain to narrow suddenly, causing severe headaches and even stroke.

Anyone with these conditions should not use either oral or nasal decongestants without a doctor's guidance. Other groups who should also use these agents with caution are the following:

Anyone who is pregnant should not use these agents without consulting a physician.
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. Such symptoms cause changes in blood pressure, drowsiness, deep sleep, and, rarely, coma.

Warning Box: Decongestants and Phenylpropanolamine (PPA)

In response to reports of an increased risk of stroke in young women who took products, including oral decongestants, containing phenylpropanolamine (PPA), the Food and Drug Administration (FDA) began taking action to ban it from the US market in November of 2000.

Many agents contained this product. Nearly all, however, have now been withdrawn from the market or reformulated. A number of brands that previously contained PPA have now substituted other active ingredients (usually pseudoephedrine) and are safe to use. They include, but are not limited to the following:

Alka-Seltzer Plus Cold Medicine.
Coricidin D Cold, Flu and Sinus Tablets.
Dimetapp DM, Dimetapp Elixer.
Robitussin CF.
Contac Day/Night Allergy & Sinus.
All Triaminic products.

Anyone with old forms of these medications or any decongestant should check the labels and discard them if they contain phenylpropanolamine.

It should be noted that the incidence of stroke tended to occur in people who took diet suppressants containing PPA rather than decongestants with the ingredient. In any case, serious events were still very rare. Furthermore PPA has been used in dozens of medications for over 50 years. Extreme concern, therefore, is unwarranted.

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 for Acute Sinusitis

Sinusitis is the fifth most common diagnosis for antibiotic prescriptions. And, there is much evidence that antibiotics are inappropriately prescribed for many patients. Of great concern is the emergence of common bacteria strains that are now resistant to many standard antibiotics. One of the primary causes of the increase in resistant bacteria is the world-wide overuse of antibiotics.

Although antibiotics may prevent complications and reduce the risk of recurrent or chronic sinusitis, few well-conducted studies have been performed to confirm or refute their benefits in most cases for which they are prescribed. In fact, studies in 2000 and 2001 found no significant benefit from treating children who suffered from acute sinusitis with amoxicillin or amoxicillin-clavulanate (Augmentin) compared to the use of a placebo (an inactive pill). In the 2001 study, 87% of children improved regardless of their treatment.

Because the great majority of sinusitis cases resolve themselves on their own, experts recommend antibiotics for the following:

Patients with severe sinusitis that does not clear up within seven days (some experts say 10 days), and,
Symptoms that include one or more of the following: green and thick nasal discharge, maxillary facial pain, or tooth pain or tenderness.

Some experts recommend waiting three weeks before beginning antibiotics in patients who have no symptoms of complications. For patients who show signs of complications, antibiotics should be administered quickly. When appropriately prescribed, they are very effective in relieving symptoms and eliminating bacteria. If there is no improvement after two weeks of treatment, x-rays should be taken to determine any complications or underlying causes. In some cases, a stronger antibiotic may be needed, although it is also possible antibiotics were not appropriate to begin with. [ See Box Antibiotic Options for Acute Sinusitis.]

Typical Regimens. Most standard oral antibiotics require a seven to 10-day course with a tablet taken three or four times a day. Many people fail to complete such regimens. 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. Newer antibiotics are now available that can be taken once a day or for fewer days, which may also reduce the risk for resistant strains of bacteri. They tend to be expensive, however, and may not be covered by some health plans or insurers.

Side Effects of Antibiotics. Most antibiotics have the following side effects (although specific antibiotics may have other side effects or fewer of the standard ones).

The most common side effect for nearly all antibiotics is gastrointestinal distress.
Antibiotics double the risk for vaginal infections in women. Taking supplements of acidophilus or eating yogurt with active cultures may help restore healthy bacteria that offset the risk for such infections.
Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock. Of interest is some evidence suggesting that the allergy may not recur in a significant number of adults. Skin tests are available to help determine if some previously allergic people could use these important antibiotics.
Certain drugs, including some over-the-counter medications, interact with antibiotics; patients should inform the physician of all medications they are taking and of any drug allergies.

Antibiotic Options for Acute Sinusitis

The following are classes of antibiotics used for acute sinusitis under certain circumstances. The first choices for acute bacterial sinusitis are amoxicillin, trimethoprim-sulfamethoxazole, and erythromycin. They are inexpensive and successful in 90% of cases. Other, more expensive agents may be useful in specific situations.

Beta-Lactams

The beta-lactam antibiotics share common chemical features and include penicillins and cephalosporins. Their primary action is to interfere with bacterial cell walls.

Penicillins. The most widely prescribed antibiotic for acute sinusitis has been amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation). This form of penicillin is both inexpensive and at one time was highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly, both among S. pneumoniae and H. influenzae . Amoxicillin-clavulanate (Augmentin) is known as an augmented penicillin and is often used. It which works against a wide spectrum of bacteria.

Ampicillin, also a form of penicillin, is an equally inexpensive alternative to amoxicillin but requires more doses and has more severe gastrointestinal side effects than amoxicillin.

Cephalosporins. These agents have also become effective against S. pneumoniae . They are often classed by generation. The later-generation agents cefpodoxime and cefuroxime have the best record to date for coverage against bacteria that infect the upper respiratory tract and are a good choice for penicillin-allergic patients with mild to moderate sinusitis who have been treated in the previous four to six weeks.
- First generation include cephalexin (Keflex), cefadroxil (Duricef, Ultracef), and cefaclor (Ceclor). These are not used for upper respiratory infections, although cefaclor may have some effectiveness against effective against H. influenzae.
- Second and third generation include cefuroxime (Ceftin), cefpodoxime (Vantin), loracarbef (Lorabid), cefditoren (Sprectracef), cefixime (Suprax), and ceftibuten (Cedex). These are effective against a wide spectrum of bacteria and are increasingly used. They are not effective, however, against S. pneumoniae bacteria that have developed resistance to penicillin.
Macrolides and Azalides
- Macrolides and azalides are antibiotics that also effect the genetics of bacteria. Some of these agents are also being used for bacterial sinusitis for patients allergic to penicillin and who have mild to moderate symptoms. (They also may be appropriate for patients who have taken antibiotics within four weeks.) They include erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). These antibiotics are effective against S. pneumoniae and M catarrhalis , but there also is increasing bacterial resistance to these agents. Except for erythromycin they are effective against H. influenzae . Clarithromycin has anti-inflammatory actions and might be especially useful for certain patients with chronic sinusitis. A new once-a-day formulation (Biaxin XL) is now available.
Trimethoprim-Sulfamethoxazole
- Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) is also a first line antibiotic for sinusitis. It is less expensive than amoxicillin and particularly useful for patients with mild sinusitis who are allergic to penicillin. It is no longer effective, however against certain streptococcal strains. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious.
Fluoroquinolones

Fluoroquinolones (also simply called quinolones) interfere with the bacteria's genetic material so they cannot reproduce. They include ciprofloxacin (Cipro), levofloxacin (Levaquin), sparfloxacin (Zagam), gemifloxacin (Factive), gatifloxacin (Tequin), moxifloxacin (Avelox), and ofloxacin (Floxin). The newer fluoroquinolones, particularly levofloxacin, gatifloxacin, moxifloxacin, and sparfloxacin are currently the most effective agents against the common bacteria that cause sinusitis. Levofloxacin is the first drug approved specifically for penicillin-resistant S. pneumoniae , although studies are now finding resistance to this agent as well. They are recommended for adults with moderate sinusitis who have already been treated with antibiotics within six weeks or who are allergic to beta-lactam antibiotics. Some of the newer fluoroquinolones also only need to be taken once a day, which makes compliance easier.

Lincosamide

Lincosamides prevent bacteria from reproducing. The most common lincosamide is clindamycin (Cleocin). This antibiotic is useful against many S. pneumoniae bacteria but not against H. influenzae.

Tetracyclines

Tetracyclines inhibit bacterial growth. They include doxycycline, tetracycline, and minocycline. They can be effective against S. pneumoniae and M. catarrhalis , but bacteria that are resistant to penicillin are also often resistant to doxycycline. Tetracyclines have unique side effects among antibiotics, including skin reactions to sunlight, possible burning in the throat, and tooth discoloration.

Ketolides

Telithromycin (Ketek) is the first antibiotic in the ketolide class. It is showing great promise in treating many of the otherwise antibiotic-resistant bacterial strains and has now been approved for treating community acquired pneumonia (CAP), chronic obstructive lung disease, and acute sinusitis.

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Sinusitis

WHAT IS SINUSITIS?

The Paranasal Sinuses

Defense System in the Sinuses

Sinusitis

WHAT CAUSES SINUSITIS?

Conditions that Predispose The Sinus Passages to Acute Bacterial Infection

Conditions Leading to Chronic or Recurrent Sinusitis

Infectious Agents that Cause Sinusitis

It should also be noted that sometimes bacteria or other organisms do not appear to be directly involved with chronic sinusitis.

WHO GETS SINUSITIS?

General Risk Factors for Sinusitis after a Cold

Young Children and Sinusitis

The Elderly and Sinusitis

People with Asthma, Allergies, or Both

Hospitalization

People with High-Risk Medical Conditions Affecting the Sinuses

Miscellaneous Risk Factors

WHAT ARE THE SYMPTOMS OF SINUSITIS?

General Symptoms of Acute Sinusitis

General Symptoms of Recurrent Acute and Chronic Sinusitis

Site-Specific Symptoms

Symptoms of Sinusitis by Specific Site

Site

Acute Symptoms

Chronic Symptoms

Symptoms indicating medical emergency:

HOW SERIOUS IS SINUSITIS?

Complications of Bacterial Infection in the Sinuses

Complications of Fungal Infection in the Sinuses

Asthma

HOW IS SINUSITIS DIAGNOSED?

Ruling Out Other Causes of Sinusitis Symptoms

Diagnostic Approach to Acute Sinusitis

Physical Examination

Transillumination

Imaging Techniques

Sinus Puncture and Bacterial Culture

Nasal Endoscopy (Rhinoscopy)

HOW CAN SINUSITIS BE PREVENTED?

Lifestyle Habits for Preventing Colds

Zinc

Vitamins

Echinacea

Warnings on Alternative and So-Called Natural Remedies

Viral Influenza Vaccines

Pneumococcal Vaccines

HOW IS ACUTE SINUSITIS TREATED?

Hydration

Medications for Mild Pain and Fever Reduction

Nasal Wash

Decongestants

Warning Box: Decongestants and Phenylpropanolamine (PPA)

Expectorants

Antibiotics for Acute Sinusitis

Antibiotic Options for Acute Sinusitis

Beta-Lactams

Macrolides and Azalides

Trimethoprim-Sulfamethoxazole

Fluoroquinolones

Lincosamide

Tetracyclines

Ketolides