Chronic Sinusitis

What chronic sinusitis is

The sinuses are air-filled spaces in the bones of the face that drain into the nose through narrow channels. In chronic rhinosinusitis, the lining of the nose and sinuses stays inflamed and swollen. Mucus drains poorly, the nose blocks, and inflammation persists, sometimes with bacterial flare-ups.

It is distinct from:

• Acute sinusitis: under 4 weeks, usually after a cold.
• Recurrent acute sinusitis: 4 or more separate episodes a year, with full recovery between them.

Symptoms

Diagnosis requires at least two of the following for 12 weeks or more, one of which must be nasal blockage or discharge:

• nasal blockage or congestion
• thick, discolored discharge from the front of the nose or down the back of the throat (post-nasal drip)
• facial pain, pressure or fullness
• reduced or lost sense of smell

Other common symptoms: cough (worse at night), bad breath, tiredness, ear fullness, dental ache and headache.

Types

See nasal polyps.

Causes and risk factors

Chronic sinusitis results from a mix of immune and anatomical factors:

• allergic rhinitis and asthma
• nasal polyps
• deviated nasal septum or other blockages of sinus drainage
• smoking and secondhand smoke, pollution
• dental infections (maxillary sinusitis on one side)
• immune deficiency
• cystic fibrosis and primary ciliary dyskinesia
• gastroesophageal reflux (possible contributor)

Diagnosis

Symptoms alone are not enough, because they overlap with allergies, migraine and other conditions. Doctors confirm inflammation by:

• Nasal endoscopy: a thin camera in the nose shows swelling, pus or polyps.
• CT scan of the sinuses: shows thickened linings and blocked drainage. Usually done if surgery is considered or the diagnosis is unclear.
• Allergy testing, and blood tests for immune problems in recurrent or severe cases.
• Cultures of discharge during flare-ups.

Treatment

Everyday treatment

• Saline irrigation: rinse with a large volume of saline once or twice a day using a squeeze bottle or neti pot. Use distilled, sterile or previously boiled water, never straight tap water.
• Steroid nasal sprays: fluticasone, mometasone or budesonide used daily, aimed toward the outer side of the nostril. It can take weeks for full effect.
• Steroid rinses: budesonide added to saline rinses delivers more medicine to the sinuses.

For flare-ups and polyps

• Short courses of oral steroids to shrink polyps.
• Antibiotics for proven bacterial flare-ups. Long courses of low-dose macrolides are used in some people without polyps.
• Treating allergies and asthma.
• Aspirin desensitization for aspirin-exacerbated respiratory disease, under specialist care.

Biologic medicines

For severe chronic sinusitis with nasal polyps that persists after surgery or steroids: dupilumab, omalizumab and mepolizumab reduce polyp size and improve smell and breathing.

Endoscopic sinus surgery

Functional endoscopic sinus surgery (FESS) opens the drainage channels and removes polyps. It improves symptoms for most people who have not responded to medical treatment. Ongoing saline and steroid treatment is needed afterward, because inflammation can return.

Complications

Rare but serious: infection spreading to the eye socket (orbital cellulitis), bone, or brain (meningitis, abscess), and blood clots in sinus veins. Chronic sinusitis can also worsen asthma and cause persistent loss of smell.

Frequently asked questions

What are the symptoms of chronic sinusitis?

The main symptoms are a blocked nose, thick discharge or post-nasal drip, facial pressure or pain, and a reduced sense of smell, lasting 12 weeks or more. Cough, bad breath, tiredness and ear fullness are also common.

Is chronic sinusitis an infection?

Not mainly. Chronic sinusitis is primarily long-term inflammation. Bacteria can cause flare-ups, but antibiotics alone rarely cure it. Daily saline rinses and steroid sprays treat the underlying inflammation.

Does chronic sinusitis ever go away?

It can be controlled and sometimes resolves, especially when triggers like allergies, smoking or a blocked drainage pathway are treated. Many people need ongoing daily treatment to keep symptoms away.

When is sinus surgery needed?

Surgery is considered when symptoms persist despite several months of saline rinses, steroid sprays and other medicines, or when nasal polyps or structural problems block drainage. A CT scan helps the surgeon plan.