Sinuses are air-filled cavities located within the bones of the face and skull. They are lined with mucous membranes and play a crucial role in humidifying and filtering the air we breathe, as well as producing mucus to keep the nasal passages moist and trap foreign particles. Most of us have four pairs of sinuses as shown in the image below.
Frontal Sinuses
The frontal sinuses are paired cavities that lie behind your frontal bone within your forehead. Obstruction of the drainage pathway and associated infection can cause frontal sinusitis, resulting in symptoms such as headaches, pressure, and tenderness over the forehead.
Ethmoid Sinuses
The ethmoid sinuses are a complex system of small, air-filled cavities located between the eyes, behind the bridge of the nose. They consist of numerous thin-walled cells separated by delicate bony partitions called ethmoidal air cells. They can be divided into anterior ethmoid (towards the front) and posterior ethmoid (towards the back). Inflammation of the ethmoid sinuses can lead to symptoms such as facial pain, nasal congestion, and postnasal drip.
Maxillary Sinuses
The maxillary sinuses are the largest of the paranasal sinuses and are located within the maxillary bones (which are behind your cheeks). Infection or inflammation of the maxillary sinuses can cause symptoms such as facial pain, and pressure in the cheeks and toothache (although often infections in the root of your teeth can trigger infection within these sinuses).
Sphenoid Sinuses
The sphenoid sinus is located deep within the skull, behind the nose and eyes. Inflammation or infection of the sphenoid sinus can cause symptoms such as headache, earache, and neck pain.
Understanding the Diagnosis and Management of Sinusitis with or without nasal polyps
What is sinusitis?
Sinusitis refers to inflammation of the paranasal sinuses. This inflammation can result from various factors, including viral or bacterial infections, allergies, structural abnormalities, or immune system dysfunction.
It can cause symptoms such as nasal congestion or blockage, nasal discharge, facial pain and reduction or loss in sense of smell. It is a very common condition affecting up to 10% of the population and can significantly impact upon your quality of life.
Acute Sinusitis typically lasts less than 12 weeks and is often preceded by an upper respiratory tract infection (often starting as a cold or cough) whilst Chronic Sinusitis persists for 12 weeks or longer and may be associated with underlying conditions such as allergies or nasal polyps (these are non-cancerous growths arising in the lining of your nose due to inflammation).
How is it diagnosed?
In order to diagnose this condition we will ask you certain questions in your medical history to determine what symptoms you have and identify any specific contributory factors. This is usually followed by a thorough examination, including inspection of the nasal passages and sinuses using a camera inserted into your nose (nasendoscope). This will allow us to detect any structural abnormalities, assess the extent of inflammation within the lining of your nose, or if there are any nasal polyps. It is likely that we will need to organise further diagnostic tests such as a CT or MRI scan, allergy tests or blood tests, which all provide invaluable information in guiding further treatment options.
How is it managed?
Here we discuss the management of sinusitis from conservative (lifestyle modifications), medical (medical therapies) and surgery.
Lifestyle Modifications
In addition to medical treatment, for some patients, certain lifestyle modifications can help manage sinusitis and reduce the risk of recurrence:
Avoidance of triggers: Identify and avoid triggers that may exacerbate sinusitis symptoms, such as allergens, environmental pollutants, tobacco smoke, or strong odors.
Nasal hygiene: Practice good nasal hygiene by using nasal saline washes and/or sprays regularly.
Humidification: Some patients find some symptomatic improvement with the use of a humidifier. This adds moisture to the air in your home, especially during dry winter months or in environments with low humidity.
Medical Management
Symptomatic relief: Over-the-counter pain relief such as paracetamol or ibuprofen can help alleviate facial pain, headache, and fever associated with acute sinusitis. Nasal saline washes (irrigation) or decongestants may also provide temporary relief from nasal congestion (we would suggest not using nasal decongestants for longer than 7 days).
Nasal corticosteroids: Nasal steroid drops and sprays are highly effective at reducing inflammation, improving sinus drainage, and relieving symptoms of chronic sinusitis. We will guide you on different types of steroids and duration of treatment.
Antibiotics: Antibiotic therapy may be indicated for bacterial sinusitis or acute exacerbations of chronic sinusitis. Often we consider a long-term course as there is evidence to suggest that this improves outcomes.
For patients with sinusitis accompanied by nasal polyps, further treatments include:
Oral steroids: Short-term oral corticosteroids to reduce inflammation and relieve symptoms during acute exacerbations of chronic sinusitis with nasal polyps. (We generally do not recommend long-term oral steroids for this condition due to the risk side effects.)
Biologic therapies: These offer more novel treatment options. Biologic medications (such as dupilumab) have shown promise in the treatment of chronic sinusitis with nasal polyps associated with conditions such as asthma according to recent research. These medications target specific inflammatory pathways involved in the development of nasal polyps and can help reduce symptoms and prevent recurrence. Although the results of research studies are promising, they are not freely available for nasal polyps in the UK.
Surgery
Surgery: In cases of severe sinusitis, with no relief from medications, surgery may be necessary to improve the sinus drainage pathways and remove diseased tissue or causes of obstruction. Endoscopic sinus surgery (ESS) is a minimally invasive procedure that we perform (usually under general anesthesia), in which we use cameras (endoscopes) to visualize and access the sinuses, allowing for precise removal of polyps, diseased tissue, or bony obstructions. We will be discussing this in more detail in the following section.
Conclusion
Effective management of sinusitis, with or without nasal polyps, involves a comprehensive approach that addresses underlying inflammation, infection, and structural abnormalities. Often patients benefit from a combination of medical and surgical management resulting in a significant improvement in their quality of life.
