Mr Samuel Jayaraj, leading consultant ENT surgeon and Clinical Director at Barts NHS Trust, London, explains how sinusitis can develop, and what options there are for treatment in more chronic cases.
Where are the sinuses located?
The sinuses are spaces in the bones in the front part of the face: in the forehead, between the eyes, in the cheeks and behind the eyes. They are air filled spaces with a membranous lining and this lining produces mucus. The mucus drains from the sinuses into the nose through narrow openings and then passes backwards and down the throat.
How is sinusitis caused?
If the openings get narrowed in any way, it causes sinusitis. Anything that makes the lining swell, such as infection or allergy, blocks the sinuses and they can’t drain properly, which causes the symptoms of sinusitis.
Sinusitis can be categorised into two types: acute sinusitis, lasting for days or weeks, or chronic sinusitis with longer lasting symptoms. Acute sinusitis usually occurs after a cold which causes swelling in the lining of the nose and these blocks the draining ability of the sinuses.
What are the symptoms of sinusitis?
Symptoms can include:
- a bad smell in the nose
- bad taste in the mouth
- colored nasal discharge
Chronic sinusitis has longer lasting symptoms of nasal congestion, catarrh, cough, lethargy, headaches and pressure which is usually in the forehead between the eyes or in the cheeks. These symptoms can have significant effect on quality of life. Individually, symptoms do not sound so serious but the cumulative effects have a big impact on the quality of life, productivity at work, sleep quality, and affect on relationships as well.
How can sinusitis be treated?
Sinusitis can be treated medically or surgically. Medical treatment refers to medication and lifestyle change. The aim of medical treatment is to try and reduce the swelling in the lining of the nose and sinuses to encourage the sinuses to drain naturally so the infection settles. This may involve a number of modalities. There are certain things that can trigger sinusitis like allergy, or environment so these factors need to be addressed. There are washes that can be used in the nose to irrigate the nose to flush out mucus and infected discharge. There are medical drops or sprays that can decongest the nose to make the lining of the nose shrink down quite rapidly to improve the sinus drainage, but these are only safe for short term use.
For longer term use, one can use nasal steroid sprays or drops and these have better effects long term, in the same way that one might use steroid inhalers for asthma. If allergy is the underlying cause of sinusitis, then antihistamines usually play a role in treatment. Antibiotics are important in treating infective sinusitis.
Is surgery ever necessary for sinusistis?
If the patient does not respond to medical treatment, then there are a number of surgical techniques which can try and open up the sinuses and help them drain better but these techniques have evolved such that they are performed in a very conservative way to try and help the sinuses drain naturally without destroying their natural function.
Surgical treatment of sinusitis has evolved dramatically over the last 20 years, and even more so in the last 10 years or so. Traditionally, the treatment of sinusitis included washing out the sinuses in a procedure called an antral washout. This was a very basic technique, aimed at flushing infection out of the sinuses. It rarely provided long term benefit. Then understanding of how we operate in sinuses evolved and surgery is now geared towards helping the natural drainage pathways in the sinuses to work better, and to try and conserve normal anatomy to help the nose and sinuses function more naturally.
More recently, a technique called balloon sinuplasty has developed where rather than removing tissue at all, we try to enlarge the openings into the sinuses by expanding a balloon in the openings to create a more natural sized opening without causing trauma and removing normal tissue.
The benefit of these new techniques is that the surgery can be performed as a day case procedure, and more recently even under local anaesthetic. This means that the recovery period can be much shorter. There is no need for nasal packing after sinus surgery now, which most patients found very traumatic in the past. You can go home the same day and return to work quicker, so the downtime after surgical treatment is much reduced and recovery is much quicker.