Diagnosis and treatment
Chronic Sinusitis: Symptoms, Diagnosis, and Treatment
If your nose has been blocked for months, if mucus keeps running down the back of your throat, and if you have already taken antibiotics more than once without solving it, this is probably not one infection after another: it is inflammation that does not clear on its own.
Chronic sinusitis is inflammation of the nose and the paranasal sinuses that lasts more than twelve consecutive weeks. It is not a run of colds, and it is not an infection that came back: it is an inflammatory process that has settled in and does not go away. That is why it responds poorly to what resolves acute sinusitis, and that is why the treatment is a different one.
Sinusitis, rhinosinusitis, and what your scan report calls it
They all point to the same thing, and it is worth clearing up the confusion. Sinusitis is the word everyone uses. Rhinosinusitis is the technically correct name, and it exists because the nose and the paranasal sinuses are lined by the same mucosa and the inflammation never stays in the sinuses alone; when it is chronic, the medical literature calls it chronic rhinosinusitis (CRS). And what you actually read in a CT or MRI report is usually neither of the two: it is a description of what the scan showed, in wording such as mucosal thickening, opacification of one or more sinuses, or chronic sinus disease.
If you got here after reading “mucosal thickening” or “chronic sinus disease” in a report, this page is for you.
When sinusitis stops being acute and becomes chronic
The cutoff is twelve weeks. Nasal symptoms that persist for twelve weeks or more, with no interval of complete improvement, define the chronic form; below that the picture is acute, even if it comes back several times a year. The criterion is set out in the European guidelines EPOS 2020, which is what I follow in assessment and in follow-up (ref. 1).
The difference is not only how long it lasts. Acute sinusitis is usually triggered by an infection and tends to resolve; the chronic form is, in most cases, an inflammatory disease, and infection, when it appears, is secondary to the inflammation rather than the cause of it. This is the distinction that changes management the most, and it is not always made clear.
The symptoms that bring patients to the office
The diagnosis requires at least two persistent symptoms, and one of them has to be nasal obstruction or nasal discharge (ref. 1). The most common ones:
- A blocked nose that air will not pass through, on one side or on both, and that makes sleeping harder. It is the most common symptom in the office, and it can have causes other than sinusitis.
- Nasal discharge, coming out through the nose or running down the throat (postnasal drip), which causes throat clearing and a cough that is worse on lying down.
- Pressure or pain in the face, in the forehead, around the eyes or in the cheeks, worse when you bend your head forward.
- Loss of smell, partial or complete, along with the loss of the flavor of food. It is the symptom patients most underestimate and one of those that weighs most on quality of life.
Tiredness, bad breath and poor sleep are frequent, and are usually put down to other problems.
One important note: the color of nasal discharge is not a reliable sign of bacterial infection. Yellow or green discharge is what happens when defense cells build up, and that occurs in viral and inflammatory conditions too. Color is not an indication for antibiotics (ref. 3).
What keeps the inflammation going
There is rarely a single cause, and during the workup it matters to find every contributing one:
- Structure: a deviated septum, enlarged turbinates and narrowing of the area through which the sinuses drain.
- Allergy: poorly controlled allergic rhinitis keeps the mucosa swollen all year round.
- Polyps: nasal polyposis is a form of the disease in its own right, with different manifestations and different treatment.
- Teeth: infection or dental treatment in an upper tooth can open a communication with the maxillary sinus. It is a frequent cause of one-sided sinusitis, and it can go undiagnosed when nobody thinks of it.
- Environment and habits: cigarette smoke is the best documented environmental factor.
- Associated conditions: asthma, aspirin intolerance, immune disorders and cystic fibrosis.
Sinusitis that occurs on one side only deserves extra attention, because local causes (a tooth, an anatomical change, and more rarely lesions) are more likely.
How the diagnosis is confirmed
Symptoms alone do not settle the diagnosis, and that is one of the differences a specialist assessment makes. Headache and facial pressure are put down to sinusitis far more often than sinusitis causes them, and treating the wrong disease for months is the usual outcome of a diagnosis made from the complaint alone.
So, when there is a suspicion, two tests prove very useful:
- Nasal endoscopy, performed in the consultation itself. It is what shows the mucosa from the inside, the discharge and the polyps, if there are any. I perform it at all three offices, and it can be repeated during follow-up after surgery.
- A CT scan of the paranasal sinuses. I order it whenever chronic sinusitis is suspected. It is the image that shows which sinuses are involved and what the anatomy of that nose is like, and it is what helps separate the headache that comes from the nose from the one that does not.
When an allergic component is suspected, I order allergy testing following the EPOS pathway itself. That result guides whether allergy treatment is added.
Why antibiotics are not the treatment for chronic sinusitis
This is the most frequent question and a major source of misunderstanding about this disease. People with chronic sinusitis have usually already taken several courses of antibiotics, improved a little while they were taking them, and gone back to the same state afterwards. The explanation is that antibiotics do not treat the cause of the disease.
Chronic sinusitis is, in most cases, inflammatory. Antibiotics act on bacteria. In our practice, antibiotics end up being used only in the treatment of acute flare-ups. For the treatment of the condition itself, the evidence does not show a relevant improvement (ref. 1), and they do not replace surgery when surgery is indicated.
Using antibiotics repeatedly for an inflammatory condition has three costs: it does not treat the inflammation, it selects for resistant bacteria, and it delays the treatment that would resolve the problem.
The treatment that acts on the inflammation
Medical treatment covers a few measures that have to be kept up for a prolonged period, depending on the clinical picture and on how intense the disease is:
Nasal rinsing with saline
It removes discharge and crusts, hydrates the mucosa and improves the effect of the spray that comes afterwards. A Cochrane systematic review found a benefit of daily large-volume irrigation with hypertonic saline on the quality of life of people with chronic rhinosinusitis, and found no advantage of low-volume saline spray over the nasal corticosteroid (ref. 2). That is why large-volume irrigation is the one I prefer to recommend in these cases.
Intranasal corticosteroid spray
This is the medication that acts on the inflammation, and it is the mainstay of medical treatment (ref. 1). It calls for continuous use, over weeks, and it does not work as a rescue medication: people who use it only on bad days end up concluding that it has no effect. Correct application technique is part of the treatment as well, and it helps avoid the burning and the bleeding that make patients stop.
Treating what keeps the inflammation going
The allergy, the dental disease, the structural obstruction. Treating sinusitis without treating the cause that feeds it is the most common reason for recurrence.
Biologic therapy, in nasal polyposis
In recent years, medications called biologics have come into use that act directly on the inflammatory pathway of nasal polyposis, and they have changed the picture in some of the most difficult cases (ref. 1). I can prescribe and monitor this medication, and in general I prefer to carry out that follow-up together with the pulmonologist, all the more so when there is associated asthma, since the medication acts on both diseases.
When the case becomes surgical
Medical treatment is not always carried out properly. Using the intranasal corticosteroid for short stretches, or repeated courses of antibiotics, tend to be the most common “attempts”. But when treatment is carried out correctly and does not work, or when the patient has certain other associated changes, surgery becomes part of the therapeutic arsenal.
These are the main indications for surgery:
- Chronic sinusitis that does not improve after complete medical treatment.
- Polyps that obstruct the nose and do not respond to the corticosteroid.
- An anatomical change that prevents drainage and keeps the cycle going.
- Sinusitis of dental origin with a communication into the sinus.
- Complications of sinusitis, which are rare, but which when they happen change how urgent the situation is.
- Patients who have an indication for other nasal surgery, such as septoplasty and turbinate surgery. In those cases sinus surgery can be combined with those other procedures.
The operation used is functional endoscopic sinus surgery (FESS), performed through the inside of the nose, with no external cuts, using endoscopic cameras, specific forceps and devices such as microdebriders (Shaver) and the holmium laser.
The main goal is to remove the points of obstruction and restore the drainage pathways of the paranasal sinuses, making it easier for the nose to work naturally and opening the way for postoperative treatment. Opening those pathways lets medication and nasal rinsing reach the inside of the sinuses, which makes it possible to treat the cases in which inflammation of the mucosa persists.
The technique is not the same for everyone. It depends on which sinuses are involved and on the anatomical profile of that nose, and it is the CT scan that answers both questions before surgery. When there is a deviated septum, I correct the septum in the same operation, because operating on the sinuses and leaving the nose obstructed is solving half the problem.
After surgery, I recommend high-volume nasal irrigation, which is different from day-to-day rinsing, since it has to reach the cavities the surgery opened. Depending on the case, the rinse may include bicarbonate, xylitol or a corticosteroid. Follow-up is done with endoscopy, to see how healing is progressing.
Who surgery is for, and who it is not for
People who have completed medical treatment and still have symptoms, people with structural obstruction, or people with polyps that do not resolve with corticosteroid use may benefit from surgery.
People who have not yet done medical treatment properly, or who have headache without sinus disease confirmed by a test, do not fall within the indication for surgery.
As with any surgery, there are risks. Among them, the most common are bleeding and nasal obstruction.
Another point to clear up: surgery does not cure the inflammatory disease and does not do away with the treatment that follows. In nasal polyposis above all, since polyps can come back and appropriate follow-up, which is part of the plan from day one, helps reduce that risk (ref. 1).
Where I see patients and where I operate, in São Paulo and Alphaville
I see patients in Morumbi, in Itaim Bibi (São Paulo) and in Alphaville (Barueri). Nasal endoscopy is performed in the consultation itself, at all three offices, and it is also what follows the postoperative course.
Surgery is performed at Hospital Israelita Albert Einstein, at Vila Nova Star and at São Luiz.
References
1. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020). Rhinology. 2020;58(Suppl 29):1-464.
2. Chong LY, Head K, Hopkins C, Philpott C, Glew S, Scadding G, Burton MJ, Schilder AGM. Saline irrigation for chronic rhinosinusitis. Cochrane Database of Systematic Reviews. 2016 Apr 26;4(4):CD011995.
3. van den Broek MF, Gudden C, Kluijfhout WP, Stam-Slob MC, Aarts MC, Kaper NM, van der Heijden GJ. No evidence for distinguishing bacterial from viral acute rhinosinusitis using symptom duration and purulent rhinorrhea: a systematic review of the evidence base. Otolaryngology-Head and Neck Surgery. 2014;150(4):533-537.
Frequently asked questions about chronic sinusitis
What does “mucosal thickening” or “chronic sinus disease” mean in my scan report?
It is the wording a CT or MRI report tends to use to describe inflammation of the nose and the paranasal sinuses. In practice, it is the same picture that is called sinusitis or rhinosinusitis. The report describes what the scan showed; the diagnosis puts that together with the symptoms and with the examination.
When is sinusitis considered chronic?
When nasal symptoms persist for more than twelve consecutive weeks, with no period of complete improvement. Below that the picture is acute, even if it comes back several times a year. The diagnosis adds that timing to the clinical assessment, to nasal endoscopy and to the CT scan of the paranasal sinuses.
Is there a cure for chronic sinusitis?
It is a chronic inflammatory disease, so the aim of treatment is control: spending most of the time breathing well, without pain and with a sense of smell. In some cases control is kept up with simple measures; in others it calls for continuous treatment, and in some it calls for surgery so that the treatment can work. What changes the result is identifying what is keeping the inflammation open.
Do I need to take antibiotics for chronic sinusitis?
Most of the time, no. Chronic sinusitis is inflammatory, and antibiotics act on bacteria. They come into the treatment of acute flare-ups, and not as baseline treatment nor as an alternative to surgery when surgery is the indication. The color of nasal discharge is not a reliable sign of bacterial infection.
Do I need a CT scan?
When chronic sinusitis is suspected, yes. The CT scan of the paranasal sinuses shows which sinuses are involved and what the anatomy of that nose is like, and it is what helps separate headache of nasal origin from headache with another cause. It is not a test for when treatment fails: it is a test for the diagnosis.
Does nasal rinsing really work?
Yes, and it is one of the basic measures of treatment. It removes discharge, reduces irritants and improves the effect of the corticosteroid spray used afterwards. Using an adequate volume matters more than rinsing very often, and technique is what makes the difference between the people who benefit and the people who give up in the first week.
When is sinus surgery indicated?
When medical treatment has been carried out completely and for the right length of time, and symptoms continue; when there are polyps that do not respond to the corticosteroid; when there is an anatomical change that prevents drainage; or in the face of complications. The decision depends on the diagnosis being confirmed by a test, and not on the complaint alone.
Does surgery solve it for good?
Surgery opens the drainage pathways and removes what is obstructing them, which lets medical treatment reach where it could not reach before. It does not eliminate the inflammatory disease, and treatment continues afterwards. In nasal polyposis, polyps can come back, and follow-up is part of the plan from the start. As with any surgery, it carries risks, among them bleeding and nasal obstruction.
Dr. José Eduardo Marcondes, physician, otolaryngologist (ENT), CRM-SP 107.711, RQE 43.840. This content is informational, does not replace a medical consultation, and does not supersede the plan of care defined by your own physician.
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