Sinusitis: Acute and Chronic Sinusitis

Sinusitis, also known as rhinosinusitis, is a common condition that is characterized by the inflammation of the mucosa or lining of the nasal cavity and sinuses. It is an extremely common condition that affects an estimated 35 million people per year in the United States alone, and accounts for almost 18 million office visits each year.

At Mount Sinai, our Division of Rhinology, Sinus Surgery and Allergy is recognized as a leader in the field. Our multidisciplinary team includes allergists, pulmonologists, and physician assistants, specializing in sinus disease. Additionally, we conduct various research studies on sinusitis and offer clinical trials to our patients who suffer from refractory chronic sinusitis or have failed surgery.

About the Sinuses and Sinusitis

The sinuses are air-filled cavities that occupy a large portion of space within our skull. Often times these cavities become inflamed due to infection, environmental allergies or autoimmune problems. This inflammation can then cause blockage of the sinuses which then can fill with fluid. A variety of conditions can cause this blockage such as seasonal allergies, upper respiratory tract infections (also known as the common cold), nasal polyps, and deviated septum amongst other things. Once this blockage occurs and fluid fills the cavities, patients can experience the symptoms of sinusitis which include headache, nasal obstruction, decreased sense of smell, facial pain, ear pain, thick purulent mucous and fevers.

Sinusitis is categorized by clinicians, depending on the severity and length of disease. The classifications are as follows:

• Acute sinusitis: Sinus infection lasting less than 4 weeks
• Chronic sinusitis: Sinus infection lasting greater than 12 weeks
• Recurrent acute sinusitis: 4 or more sinus infections per year with each infection lasting 7-10 days 

Acute Sinusitis

Acute sinusitis is a very common ailment amongst the U.S. population and affects almost 90 percent of all adults at some point in their lifetime. Each year, nearly 37 million adults suffer from sinusitis. Acute sinusitis may be caused by either a virus or bacteria and it is important to distinguish between the two. Both acute bacterial rhinosinusitis (ABRS) and viral rhinosinusitis (VRS) are characterized by the presence of purulent nasal discharge that is accompanied by either nasal obstruction or facial pain-pressure-fullness. The key characteristic that distinguishes the two is duration of symptoms. For patients with ABRS, symptoms should be present for greater than 10 days or experience worsening of symptoms after initial improvement. When symptoms last for less than 10 days, a viral sinusitis is the underlying cause. This distinction helps avoid the need for unnecessary antibiotic use.

The most common bacterial pathogens that cause ABRS in adults are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Additional bacterial pathogens such as Staphyloccocus aureus and anaerobic species are also implicated. Upper teeth infections, especially those involving the molars, may results in acute sinusitis that may be severe and spread outside the sinuses.

The treatment for acute sinusitis focuses on management of patient symptoms. Pain is the number one reason why patients seek medical attention. Medical management for acute sinusitis includes nasal saline irrigations, over the counter analgesics such as ibuprofen, topical nasal steroids, decongestants, and guaifenesin (mucous thinner). Antibiotics can be deferred for mild,moderate, and select severe bacterial sinus infections. The use of antibiotics to treat acute bacterial sinusitis is based on an individual basis. 

Chronic Sinusitis

Chronic sinusitis (CRS) is a condition that has tremendous direct and indirect costs to our healthcare system. Patients experience significant loss in quality of life that is greater than those who suffer from congestive heart failure or coronary artery disease. The negative impact of chronic sinusitis on work productivity is well documented and an underappreciated consequence of this condition.

A critical misunderstanding is that people are under the impression that chronic sinusitis is an infectious process. The reality is that it is an inflammatory disease with occasional exacerbations associated with infection. Patients may have coexisting conditions such as allergies, asthma, or immunodeficiency. In addition severe cases of CRS may be a manifestation of more serious conditions such as autoimmune disease (Sarcoid, Wegener’s Granulomatosis, Churg-Strauss Syndrome), ciliary dyskinesia or cystic fibrosis.

The diagnosis of CRS requires the presence of symptoms for at least twelve weeks. Patients will experience mucopurulent drainage, nasal congestion, facial pain-pressure-fullness, or a decreased sense of smell. In addition to the subjective symptoms patients must have an endoscopic exam that demonstrates polyps or mucus draining from the sinuses or a CT scan showing inflammation in the sinuses. In patients who have had prior surgery it is critical to perform a complete evaluation of the immune system.

Medical management for chronic sinusitis focuses on control of inflammation through the use of nasal saline irrigations, topical nasal steroids, allergy control, and antibiotics only in acute infectious exacerbations. The ability to obtain an endoscopic culture enable more focused antibiotics delivery to treat the infection.

Surgery is reserved for those patients who fail medical management and is used as an adjunct NOT a replacement for medical therapy. Functional endoscopic sinus surgery (FESS) enables clearance of infection from the sinuses and permits the delivery of topical therapy to each individual sinus for ongoing disease control. At Mount Sinai we focus on endoscopic (incision-less) surgery to treat the sinuses as well as minimally invasive techniques such as balloon sinuplasty. In rare cases, open surgery for the sinuses is performed and our team is well equipped to handle all facets of sinus surgery. 

Recurrent Acute Sinusitis

Recurrent acute sinusitis deserves special attention because it is a separate entity from garden variety ABRS. Patients have four or more episodes of acute bacterial rhinosinusitis with the absence of symptoms between episodes distinguishing it from CRS. The symptoms that need to present to make the diagnosis are identical to ABRS; however, antibiotics are used more frequently for this condition. Patients should be ruled out for immunodeficiency and CT imaging should be done in order to rule out a structural predisposition to the development of acute sinusitis.