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It's been said that they warm and filter each breath you take, that they add resonance to your voice and lighten the weight of your skull. That's some of the good news about sinuses. The bad news is sinusitis, and each year more than 37 million Americans develop it. As many as 75 percent of people with asthma also get sinusitis. And it can lead to bronchitis and other lung diseases if left untreated. Dr. Mark Titi of our Allergy & Asthma Center is an allergist, folk art painter, sportsman, and all-around outdoorsman. He offers some insight into this widespread, puzzling and painful problem. Q: Dr. Titi, what are sinuses and where are they? Dr. Titi: Sinuses are cavities within the skull, related to the nose. Each sinus has a pathway that goes between the sinus cavity and the nasal cavity. So, there should be air flowing between these two areas. The frontal sinuses are above Q: I mentioned some of the good things about sinuses; that they warm and filter each breath you take, that they add resonance to your voice and they lighten the weight of your skull. Anything else good about them? Dr. Titi: They can protect your brain from impact and prevent injuries. If you are unfortunate and have facial trauma it puts an air cushion between whatever may be impacting your face and the brain tissue. Dr. Titi: Yes, they are airspaces surrounded by bones and respiratory membranes. Q: Kind of like bubble packaging? Dr. Titi: Right, exactly. Q: Now the bad news. What is sinusitis? Dr. Titi: Sinusitis is an infection within the sinus cavities which means there is most likely bacteria growing in the sinuses producing the infection. Bacterial sinusitis is by far and away the most common; followed by viral and fungal infections. Q: What's the difference between acute sinusitis and chronic sinusitis? Dr. Titi: Chronic sinusitis usually lasts for more than six weeks. Patients may also be considered to have chronic sinusitis when they frequently have acute sinusitis that keeps coming back perhaps four to six times a year. Q: In looking at some of the figures I noticed that, in the United States, every year or so sinusitis seems to increase by a couple of million people. Why do you think this is happening? Dr. Titi: That is an interesting question. Whenever a disease increases in prevalence you do have to wonder if the way it is being coded is different. In the past a lot of patients were diagnosed with what was called recurrent bronchitis but now they are frequently told they have asthma when they are seen. The same thing could be occurring with sinusitis. It might have been called an upper respiratory tract infection in the past, but now it's called sinusitis. It may be that doctors are more sensitive in picking it up, that is one possibility. Q: But it might be…? Dr. Titi: Some people would blame indoor or outdoor pollution. Indoor pollution could include things like wood stoves, coal stoves; even things like potpourri, candles… possibly in some patients who are sensitive to that type of thing, it could be a trigger. Outdoor pollution could be a factor as well. There is some evidence that pollution can increase the allergic response and the allergic response is certainly a big part of the cause of sinusitis. It could be that pollution is causing more allergies and sinusitis is occurring as a complication. Allergies tend to cause swelling of the membranes. This causes blockage of these small pathways (tunnels) I mentioned before that are supposed to let the sinuses air out and bingo, the patient develops sinusitis. Q: The primary complaint I hear from people who have sinusitis is, “Oh my head, my head, my head.” I am wondering if a headache, particularly in the morning, is one of the primary symptoms of sinusitis? Dr. Titi: Very frequently it is although patients may certainly have headaches throughout the day. The location of the headache is important. If it occurs in the cheekbone area it is almost always a sinus headache or a sinus infection. Headaches only above the eyes could also be due to a sinus headache or sinusitis, but there are other possible causes. A sinus headache may just come and go. Some patients have sinus headaches without having sinusitis. Q : For example? Dr. Titi: For instance, some patients may have a sinus headache when a weather front is coming in. They say they can tell the weather by their sinuses. People with sinusitis tend to have a more persistent headache. In general they will have some pressure in the cheekbone areas but then again there are a lot of patients who have it more in the frontal area which is above the eyes. They may feel it at the bridge of the nose. Those are the three most common places. Then again, sometimes the pain is under the ears or in the back of the head. Q: It sounds confusing. Dr. Titi: It can be, but the interesting thing about headaches is that there is a lot of overlap. Patients who have a headache above their eyes may have a tension headache or they might have migraine headaches and sinus headaches. I would say most of the patients I see as a specialist probably have at least two types of headaches, sometimes three. Q: What are some of the other symptoms, other than headaches that might lead you to a diagnosis of sinusitis? Dr. Titi: Certainly nasal congestion and colored nasal discharge. If they have postnasal drainage that might be a sign of sinus infection. Some patients have postnasal drainage every day of their lives but when they get a sinus infection the drainage worsens. That could be a sign. They may cough, particularly at times when their sinuses drain and that would usually be within a half-hour of lying down at night. Q: Does the color of the mucus make a difference? Dr. Titi: If it is yellow or green, that does suggest there is an infection. You can get that temporarily with a cold for a couple of days. That makes the diagnosis of sinusitis more difficult if the patient presents early in the course because they might just have a cold. But, if they have a history of having recurrent severe head colds that do not clear up in a reasonable amount of time that may be an indication it is actually bacterial sinusitis. Dr. Titi: Yes, this frequently happens and dentists are all aware of this. Patients come in and they say their teeth are hurting. It is a little easier to tell it is a sinus related problem when they just say their upper teeth hurt because the lower part of the sinus cavity is just a few millimeters away from the roots of the upper teeth. There are many more symptoms… about 15 to 20 different ones which could be signs of a sinus infection. A patient may have a lot of pain or pressure when she bends over, or she may have halitosis or bad breath when she normally doesn't. This can come from the mucus or the infection. . Q: Some of these symptoms you mention sound like they could indicate a cold or flu, maybe mononucleosis. It must be a very puzzling thing for an allergist to diagnose. Dr. Titi: Yes, at times. Q: Yes is the simple answer? Dr. Titi: Yes is the simple answer. Probably because of the experience that we have in treating this it is not so difficult. And, actually, they have done studies comparing a doctor’s abilities to listen to the symptoms and making the diagnosis on clinical grounds versus doing an x-ray and they found the correlation was quite high between the doctor believing sinusitis was present and actually seeing it on an x-ray. Now, we don’t usually x-ray every patient. Usually we go by the signs and symptoms and the history and also their response to therapy in the past with the antibiotics and other medications. Q: Can a cold or hay fever cause sinusitis? Dr. Titi: Yes, that's very common. Most sinus infections start with allergies and/or Q: What about medications that some people take to provide relief such as aspirin and Ibuprofen? Sometimes can they cause sinusitis? Q: What's special about these patients? Dr. Titi: They usually have asthma as well and they tend to be overly sensitive to medicines like aspirin and Advil. If they take one of these medicines, there is a chance they could have a severe asthma attack. It could be so serious that Q: What do you recommend then? Dr. Titi: When we see nasal polyps it is generally recommended that patients try to avoid this class of medication. Even though we say that there is only about a Q: Can a structural abnormality like a deviated septum have something to do with it? Dr. Titi: A deviated septum could be a cause of sinusitis. That's when the bone in the center of the nose curves off to one side. Many patients have mild to Q: What if you choose to ignore sinusitis? Dr. Titi: If it is not too bad, there may not be any complications. Sinus infections can clear without antibiotics. It tends to be a slow and painful process but most of them probably would clear. There is a chance you could get a complication. It's not too common but some of the things that can occur would include periorbital cellulitis; that is an infection in the eye socket. It's very rare, more common in children than adults. With good strong antibiotics you almost never see it. In rare cases a sinus infection could lead to meningitis, an infection of the fluid space surrounding the brain. Q: What's the most common complication? Dr. Titi: Probably the most common complication we see is sinusitis leading to lower airway conditions such as asthma or bronchitis. Frequently we think it makes the asthma worse, and in some cases we think it may actually cause the asthma. But it is very common for a patient who has asthma to develop a sinus infection and then develop worsening of their asthma in which case they may need oral steroids or something similar to treat it. Q: So what do you do to prevent it? Dr. Titi: If it is allergy related we would use aggressive allergy treatments which could include anything from environmental control measures to medications, sometimes multiple, and also including allergy injections. Q: What do you mean by environmental control measures? Dr. Titi: An environmental control measure is anything you would do to try to prevent Q: How do you do that? Dr. Titi: It could include measures like putting covers on your mattresses to prevent the person from breathing in dust mite particles. It might include things like trying to stay indoors in air conditioning when the pollen counts are Q: How about vaporizers? Dr. Titi: Vaporizers may help sinusitis or they may make it worse. If a patient is allergic to molds or dust mites, vaporizers would tend to put moisture in the room and to encourage the growth of mold spores and dust mites. Q: Isn’t it true about moisturers, like vaporizers or humidifiers, that they may help but if you are going to have them you have to keep them really clean, keep up on maintenance? Dr. Titi: Exactly I think some people do clean them regularly, but others give up or forget after a while. Q: What about using a hot, wet compress on your head? Dr. Titi: That can be helpful. It's usually very temporary but if the person has tried other therapies they might find they need a cool or warm pack or something Q: Steroid nasal sprays? Dr. Titi: Steroid nasal sprays can be very helpful. For example, Flonase, Nasacort, Rhinocort or Nasonex fall into this category. Q: I also read about salt water washes that you can make yourself. Dr. Titi: Yes you can and your allergist will tell you what ingredients to use and directions for using the wash or what we call a lavage. Q: What about decongestants like Afrin? Dr. Titi: Afrin is a nasal decongestant spray. Those sprays are very problematic because if you use them it for more then three days you will tend to get rebound and your nose will get stuffy and you will have more headaches. Oral decongestants are usually helpful. But, In some patients they can have side effects. Q: For example? Dr. Titi: They can possibly increase blood pressure a little. They could possibly stimulate the heart to cause palpitations. They can also affect prostate function in males. So, you do have to understand the patient’s medical history when prescribing those and it is very important for patients to read the warnings on the Q: Does pressure in the cabin make the sinus, that hollow area, swell or pop? Dr. Titi: Some patients can have significant sinus headaches and usually more common ear pressure when they are descending because of the pressure increasing in the cabin. That part of it we don’t think usually causes a sinus infection. We think it is more likely viruses being recirculated in the plane.The problem with the ear pressure and the sinus pressure could easily be counteracted with the Afrin spray if the person is allowed to take it. Q: Or some other nasal decongestant? Dr. Titi: An oral decongestant may also work but Afrin tends to work the best. Q: Is surgery an option? Dr. Titi: Yes. Usually it is called endoscopic sinus surgery. The surgery involves tiny instruments that go in through the nose and widen some of the holes in the nose. They do tend to remove different tissues within the nasal cavity and sinus cavity. In rare cases you can develop scar tissue but I would say in general the sinus surgery helps nasal congestion and helps sinus headaches the patients may have. It may not actually stop the sinus infection cycle but usually if a patient does have a sinus infection after surgery it is my experience they tend not to be quite as severe or prolonged or cause as much pain or nasal congestion. Some patients do extremely well with it. It is like many other medical treatments somewhat variable in terms of how a particular patient will respond to it. Q: It sounds to me like sinusitis is definitely not something to self-treat. When is the right time to see an allergist? Dr. Titi: Probably when the patient has had frequent sinus infections. I am thinking in the range of three to four sinus infections per year or more or if it is requiring multiple courses of antibiotics to clear an infection. Certainly if there are complications such as ear infections or asthma, or asthma related reactions. These are frequently the situations we are asked to see the patient. We also may be asked to see the patient or the patient may ask to see us when they have had a CT scan and the CT scan is negative and it doesn’t explain why the patient is having recurrent sinus infections. We would recommend patients have an allergy evaluation before they have any surgical procedure performed. Q: That sounds wise. Dr. Titi: Yes. We would also probably check their immune system to make sure there is not some deficiency of the immune system that is causing their recurrent infections. Q: Dr. Titi, sinusitis was your choice for this Q and A. Why? Dr. Titi: I would say this is probably one of the most common problems that I Q: And when you are successful? Dr. Titi: When we are successful our patients are very happy and it is very rewarding for all of us.
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