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Breathe Easy: Your Sinuses & Your Health

Online Health Chat with Dr. Raj Sindwani

March 3, 2011


Introduction

Cleveland_Clinic_Host: Common sinus problems include sinus blockages, repeated infections, a deviated nasal septum, and narrow nasal and sinus passageways. When your sinuses can’t drain, you often feel pain or pressure, and are at a much higher risk of sinus infections. Most sinus infections can be treated with a combination of preventive measures, allergy control, and medical treatment.

Taking care of your sinuses is important to your overall health and well-being. These hollow air spaces within the bones between your eyes, and behind your cheeks and forehead also play a role in the depth and tone of your voice. With 40 percent of the United States population having allergic rhinitis and 30 to 40 million people having chronic sinusitis, ENTs – ear, nose, and throat specialists -- have found that both conditions can have a significant impact on quality of life, health care expenditures, and loss of productivity.

Raj Sindwani, MD, FACS, FRCS -- a rhinologist who specializes in endoscopic sinus, orbital and skull base surgery -- heads the Section of Rhinology, Sinus, and Skull Base Surgery at Cleveland Clinic. Formerly Chief of the Division of Rhinology at Saint Louis University in St. Louis, MO, Dr. Sindwani completed medical school and his otolaryngology residency at the University of Western Ontario in Canada, and then a fellowship in rhinology (specialty training) at the Massachusetts Eye and Ear Infirmary-Harvard Medical School.

Dr. Sindwani is Editor-in-Chief of the Year Book of Otolaryngology – Head and Neck Surgery and Associate Editor of the American Journal of Rhinology and Allergy as well as a member of several Editorial Boards. He has published extensively in the field of rhinology and has lectured at scientific conferences and institutions around the world.

Cleveland_Clinic_Host: To make an appointment with Raj Sindwani, MD, in the Head & Neck Institute at Cleveland Clinic, please call 216.444.6691 or call toll-free at 800.223.2273, ext. 46691, or visit us online at clevelandclinic.org/sinus. Dr. Sindwani sees patients at Cleveland Clinic Main Campus, as well as the Beachwood family health centers.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Raj Sindwani. We are thrilled to have him here today for this chat. Let’s begin with the questions.


Sinusitis Defined

Stella1965_: How common is sinusitis?

Dr__Raj_Sindwani: Consider these facts:

  • It is among the top reasons for patients to visit their doctors; office
  • It is the fifth most common reason for antibiotic prescriptions and the third most common reason for purchasing over-the-counter medications.
  • Fourteen percent of U.S. adults annually self-diagnose a sinus infection.
  • It costs Americans over $3 billion per year.
  • It has a significant impact on quality of life and productivity.

LenCanHelp: What is rhinosinusitis?

Dr__Raj_Sindwani: Rhinosinusitis is a new term, but it is the same as saying “sinusitis.” The terminology has been modified to indicate more accurately that the inflammatory process that causes sinusitis is also associated with inflammation of the nasal passages (hence the addition of the “rhinitis” part). Rhinosinusitis is defined as an inflammation of the nose and sinuses. In fact:

  • Rhinitis typically precedes sinusitis.
  • Sinusitis without rhinitis is rare.
  • Mucus membranes of the nose and sinuses are contiguous.
  • Symptoms of nasal discharge and nasal obstruction are prominent in sinus infections.

This diverse syndrome has been the subject of intense debate regarding:

  • acute versus chronic definitions
  • causes – bacteria, viruses, fungi, allergy, etc.
  • diagnostic signs/symptoms and appropriate tests
  • therapies – antibiotics, anti-fungals, anti-allergy, anti-inflammatory, etc.

Hoopla1987: Can the body heal itself from a sinus infection? If a sinus infection goes untreated what are the consequences?

Dr__Raj_Sindwani: Yes. The body can and does heal itself form infections (for example, viral infections) all the time. That’s the role of the immune system. Taking antibiotics for bacterial infections can help the body fight off the infection faster. Treating severe bacterial infections is important. In rare cases, if these severe infections are left untreated they can potentially spread to the eye and brain.

JosephBrown: What are the signs and symptoms of acute sinusitis? How do they differ from chronic sinusitis?

Dr__Raj_Sindwani: Signs and symptoms of acute and chronic sinusitis are similar, but tend to be more protracted and duller in chronic rhinosinusitis (CRS). The symptoms include: nasal drainage or post nasal drip, changes in smell, nasal congestion, facial pressure or pain, ear fullness, cough, and fatigue.


Chronic Sinusitis

tdk354: What is chronic sinusitis?

Dr__Raj_Sindwani: Chronic rhinosinusitis (CRS) is a poorly understood inflammatory condition affecting the sinuses. We are unsure what exactly causes CRS. It is characterized by waxing and waning symptoms, including nasal drainage or post nasal drip, changes in smell, nasal congestion, facial pressure or pain, ear fullness, cough, and fatigue. The clinical diagnosis of CRS is usually made based on time course of the disease (symptoms present for more than three months) plus some combination of signs and symptoms, CT scan results, and an endoscopic nasal examination.

TickTock_: I come from a long line of chronic sinusitis suffers. Are sinus disorders genetic?

Dr__Raj_Sindwani: We approach sinusitis as acute or chronic, where chronic sufferers have their symptoms for three months or more. We do not know what causes chronic sinusitis, but immune functioning and allergy, viruses, bacteria, fungus, gastro-esophageal reflux disorder (GERD), and anatomic factors have been implicated. While a direct genetic link is unknown, there certainly may be some genetic/immune factors at play. Similarly, for acute bacterial sinus infections, risk factors include:

  • preceding viral upper respiratory tract infection (URI)
  • allergies/immune problems
  • anatomic blockage
  • nasal polyps
  • dental disease
  • GERD
  • Smoking also may play a role.

jj627: Hello. I am suffering from chronic sinuses and it seems to get worse each year. Is there any other alternative to helping this beyond nasal sprays and pills? The pills tend to make me sleepy even though they read “non-drowsy.” Thanks!

Dr__Raj_Sindwani: It depends on the underlying issue; is it allergies or chronic sinusitis (which is a medical diagnosis)? For allergies, in addition to sprays and pills (everyone is different as far as how they feel on the pills), allergy shots and environmental controls may be recommended. For chronic sinusitis, medical treatment -- including antibiotics, steroids, and irrigations -- may be helpful, with surgery as an option for patients with more severe problems.


Diagnosis

bethannfalls: How does a physician determine the best treatment for acute or chronic sinusitis?

Dr__Raj_Sindwani: Our approach to treatment depends on signs, symptoms, response to maximal medical therapy, and results of special testing such as CT scans.

cdwd: I teach elementary school and seem to keep a "sinus infection," at least that's what my family doctor and ENT diagnose. They prescribe antibiotics and steroids over and over again. My condition improves within 10 days to two weeks and then returns within a month. I've missed many days of work due to feeling very ill with terrible head and body aches and general malaise. The ENT does a scope on every visit, and my sinuses appear clear when he exams me within a week after the family doctor's exam. Is there a better treatment than what is being prescribed for me? Or, have I been misdiagnosed, since rarely do they perform any tests or lab work? Your expert advice would be much appreciated.

Dr__Raj_Sindwani: It is a good thing that you are seeing an ENT, as that is usually the initial step toward an accurate diagnosis. Nasal endoscopy is our best, state-of-the-art method of examining the nose and sinuses. Sometimes, depending on what we see and the patient's history, we may culture mucus seen during the endoscopy. This is often a useful step because it allows us to confirm a bacterial (as opposed to viral) sinusitis, which seems appropriate in your case due to your ongoing exposure to children.

sw15: I get frequent sinus infections that I've tried to treat through a doctor in a number of ways (antibiotics, then going on allergy medications, etc.). I've stopped taking any medications unless it is necessary (i.e., severe SA). I now just try to wash my nose and throat with saline solution twice a day. But this is not a cure, and I still have issues with my nose, especially the drainage, which causes yellow, foul smelling round balls to form behind the covering of my tonsils. This can't be healthy, not to mention it causes bad breath. Is there any way to avoid this and not have these form? Thank you SW

Dr__Raj_Sindwani: The tonsil balls (also known as tonsiliths) that you are describing may be a separate issue from your sinus problems. Our tonsils normally have hills and valleys on their surfaces, within which debris, bacteria, and food particles can collect. And you are correct; this can be a source of bad breath. If this is the case, you can attempt to brush out the debris or gargle to help minimize it. Alternatively, having your tonsils removed (a quick albeit uncomfortable procedure) could take care of the problem more definitively. Regarding your sinuses, a further work up could include nasal endoscopy by an ENT and even a CT scan of the sinuses if maximal medical treatment is not helpful.

33117485: As a former radiation patient that was treated for NPC at the Clinic eight years ago, is there another more effective way of keeping the sinuses open. I do the rinses, but tend to have thick sinus drainage. The sinuses at night do not drain and I tend to wake up with a lot of sinus pressure and pain, especially behind the eyes. I take many sinus over-the-counter medications, but I find myself relying on these medications in order to help me breathe better. Is there any other method(s) I can try besides doing the rinses?

Dr__Raj_Sindwani: Dryness of the nasal and sinus lining is a well-known complication of radiation that can be difficult to manage. Mainstays of treatment include: frequent saline irrigations, saline sprays, ointments applied to the nose, and a humidifier placed at the bedside. In some cases, surgery to open blocked sinuses may be indicated.

foxfire: I have been tested for allergies, which were negative; but every spring as the trees unleaf, I cannot breathe through my nose and feel like I have a bad cold. The symptoms stay most of the summer to fall and slightly through winter. In the winter when I am up and walking around, it is better. One time I was treated with Augmentin® and Medrol® and felt normal. How can I not have an allergy? Thank you, Foxfire

Dr__Raj_Sindwani: A few thoughts. First, allergy testing tests for regional things (allergens) that you may be exposed to locally where you reside. If your allergy testing was done locally, that may not be an issue, but if you have moved to different geographical regions from where the testing was done this possible discrepancy needs to be explored (and repeat testing performed). Second, many conditions that affect the nose have similar symptoms (nasal blockage, drainage, etc.). Classic allergy symptoms include itching, eye irritation, sometimes seasonal patterns to symptoms, and clear runny nose. The fact that you did feel better after antibiotic and steroid treatment might suggest a chronic sinus problem other than allergy.


Sinusitis and Other Disorders

kikidee: Do nasal polyps cause sinus problems?

Dr__Raj_Sindwani: Yes. Nasal polyps grow in the nose like bunches of grapes and can block the flow of mucus out of the sinuses, leading to sinus infections. They can also block odors rom reaching the organ of smell high up in the nose and lead to a decreased sensation of smell, and also physically block the nasal passages causing nasal congestion/blockage.

bertrumst: Do allergies play a role in a sinusitis diagnosis?

Dr__Raj_Sindwani: Allergies are thought to be a leading risk factor for getting sinus infections. The diagnosis of sinusitis and allergies (allergic rhinitis) are often made in the same patient -- and both deserve treatment.

KL: Can a sinus problem cause snoring? Apparently, I snore with my mouth closed and I am worried that a sinus problem is to blame, since I have awoken while in mid-snore and experienced a strong vibration by my cheekbone.

Dr__Raj_Sindwani: Snoring comes from areas of blockage that can occur from the nose to the back of the throat or even lower. Generally, sinus conditions, such as allergies or sinusitis, do not cause snoring. However, physical issues in the nose, such as nasal polyps or a deviated nasal septum, may contribute to snoring. I would suggest a consultation with an ENT specialist to help sort that out.

DaddyDayCare: My son had a deviated septum. He now suffers from recurring sinusitis. Are the two related?

Dr__Raj_Sindwani: We are not sure if a deviated nasal septum can lead to sinus infections, but some ENTs do believe that this is possible, depending on the exact area and severity of the deviation (if it is at or near the sinus drainage points, for example). Although very rare, severe bacterial sinus infections that go untreated can spread to the eye and brain.

slg220: Hi! I've had a history of ENT issues (recurrent sinus and ear infections) since I was six months old. As I have gotten older, these infections are less frequent, but more severe. Do you have any recommendations on how to prevent recurrent infections? Thanks!

Dr__Raj_Sindwani: Preventing infections means focusing on eliminating or controlling risk factors.

Risk factors for sinus infections include:

  • being around children
  • anatomic problems in the nose
  • smoking,
  • allergies, etc.

Many patients benefit from daily saline flushes as well.

TwinsMom: What causes a deviated septum?

Dr__Raj_Sindwani: A deviated septum is usually caused by trauma that may have occurred even years ago. This can cause nasal blockage. Treatment options include steroid sprays and decongestants. However, if the blockage is very bothersome, surgery is often the best course of action.

TwinsMom: Are nasal polyps hereditary? What treatment options are there other than surgery?

Dr__Raj_Sindwani: We do not know what causes nasal polyps and there is no genetic cause identified, although they do seem to cluster in families. If the polyps are not terribly large, the mainstay of treatment involves steroids, either taken in pill form or delivered directly to the polyps in a spray or irrigation fluid.


Sinus Surgery

JJ888: When do you consider sinus surgery a necessary treatment?

Dr__Raj_Sindwani: We consider operating to open blocked sinus passageways after medical treatment has failed and a post-treatment CT scan demonstrates ongoing problems and areas of blockage. Sinus surgery is done to improve quality of life in a patient who continues to do poorly despite medical therapies.

HunnyBear: What is involved in sinus surgery? Is it a painful procedure?

Dr__Raj_Sindwani: Endoscopic sinus surgery is a well-tolerated, minimally-invasive procedure performed under general anesthesia. Using specially designed tiny instruments, we look into the nose with a thin telescope (endoscope) and we enlarge the sinus openings. We then clean out any trapped mucus, pus, or polyps. Most patients experience mild discomfort for a few days after the procedure. There are no cuts or bruises on the faces and we rarely place any nasal packing.

TulipsDaisy: What does sinus surgery accomplish? Are results predictable?

Dr__Raj_Sindwani: Sinus surgery opens the drainage pathways and openings into the sinuses and improves the sinuses’ ability to drain naturally. Many studies have shown that sinus surgery done for the right indications decreases patient symptoms, cuts down on the severity and number of infections one experiences, and generally improves a patient’s quality of life. Although there is no cure for chronic sinusitis, the large majority of patients do very well from this surgery and they often wish they had it sooner.

Rosie: How long is the recovery time after sinus surgery? Can I go back to work immediately?

Dr__Raj_Sindwani: Sinus surgery is performed under a short general anesthetic (patient is “asleep” and does not hear, feel, or see anything). It is performed using an endoscope (telescope) and specially designed instruments placed through the nostrils. It is a very minimally invasive procedure that leaves no cuts or even bruises on the face. I should point out that there are no black eyes and I rarely, if ever, have to use nasal packing. Patients wake up from the surgery, spend a few hours in the hospital, and go home the same day. The recovery is associated with mild nasal/facial discomfort (especially since I no longer use packing), occasional nosebleeds, and a tired feeling from the anesthetic that lasts for a day or two. The only limitation I give patients post-op is no heavy lifting or straining for five to seven days after surgery. Everyone’s recovery is a little different, but most would take a few days off of work.

DerekS: When is sinus surgery absolutely necessary? I’m afraid I’ve been avoiding this option too long. At what point do you recommend surgery?

Dr__Raj_Sindwani: Surgery is considered absolutely necessary in infrequent cases where there is concern over advanced sinus disease or complications from sinusitis. For the large majority of patients, surgery is considered when medical treatment has failed and persistent problems are documented on a CT scan. The option of sinus surgery is then decided upon by the patient and surgeon to improve the patient’s quality of life and daily function.


Non-surgical Treatments

GreenLantern: Where is the best place for sinus pain sufferers to seek treatment?

Dr__Raj_Sindwani: Ongoing problems with recurrent, persistent infections are best evaluated by an ENT physician.

MamaK: How is a sinusitis treated?

Dr__Raj_Sindwani: Acute sinusitis is most often due to a virus (e.g., the common cold, or upper respiratory infection), and supportive care is all that is normally required (over-the-counter medications to help reduce fever, trial of decongestants, rest etc.). In a small number of cases, these infections are not due to a virus, but rather are due to (or turn into) a bacterial infection, called acute bacterial sinusitis. This can be difficult to distinguish, and the diagnosis of acute bacterial sinusitis is made based on time course of illness (symptoms for more than 7 to 10 days) and a combination of signs and symptoms.

Signs and symptoms that an infection is more likely bacterial than viral:

  • Symptoms worsen after five to seven days or persist more than 10 days, or are out of proportion to those typically associated with a viral upper respiratory infection
  • Unilateral mid-facial, periorbital or forehead pain
  • Unilateral purulent (pus-like) drainage
  • Pain worsened by bending over, Valsalva maneuver, or “toothache”
  • Facial swelling, conjunctival infection, meningeal, or other signs of spread outside of the sinus(es)

Medical management of a bacterial sinusitis includes:

  • Oral hydration, saline sprays, humidification
  • Antibiotics
  • Topical decongestants – such as Neo Synephrine® or Afrin® (oxymetazoline) -- for less than five days; oral decongestants – such as Sudafed® (pseudoephedrine)
  • Expectorants to thin mucus (guaifenesin)
  • Oral antihistamines (newer, non-sedating agents do not thicken secretions)
  • Nasal steroid sprays (can diminish edema in sinus pathways)

S lg220: Do you recommend irrigation devices like neti pots?

Dr__Raj_Sindwani: Yes. Irrigation devices can be helpful for some sinus problems and for chronic drainage issues. There is some evidence that using a high volume flush with a squeeze bottle (not spray bottle) may be more effective, especially in patients having had prior surgery.

teenage411: How effective are over-the-counter nose sprays or drops?

Dr__Raj_Sindwani: Saline spray may help acute infections. Using topical decongestant sprays (Afrin®) can also help open up the nasal passages but should not be used more than three to five days. They are addictive and can cause rebound swelling, making you worse off than you were before!

fosterw: I have been given three antibiotics for a sinus infection, and I am still not cleared up. What should I do?

Dr__Raj_Sindwani: If an infection persists despite medical treatment, it may be worthwhile for you to see an ENT doctor. The next steps in further evaluating your condition might include a direct examination of your sinus drainage pathways using nasal endoscopy and performing a culture of the drainage. Sometimes, what appears to be an infection is not actually an infection.

Smith_Tina: Are lifestyle changes recommended during sinus treatment? The reason I ask is because I smoke and haven’t been able to kick the habit.

Dr__Raj_Sindwani: Smoking has been shown to interfere with healthy and normal functioning of the sinuses, and is considered to be a risk factor for sinus infections. Cigarette smoke is also a known irritant to the nose, and can cause allergic-like symptoms in some people.


Out of Breathe

flrp: I am 72 years old and I have had difficulty breathing through my nose for a good number of years. The severity of the problem does impact my sleeping habits. Even during the day my nostrils are blocked. Numerous doctors have looked at the problem over the years, and they all say “Yes, your nostrils are really inflamed.” They have prescribed numerous types of medication, none of which have had any impact on reducing the inflammation and opening the air passages. More recently, I have talked to an ENT doctor, and his recommendation is to operate on my deviated septum. The question is, will that really solve the problem or will there be side effects that could be worse than not doing anything?

Dr__Raj_Sindwani: It depends on how bothersome the blockage is to you personally and how it is affecting your quality of life. Generally speaking, surgery for a deviated septum (and turbinate swelling, --we usually address both) is well-tolerated and done without any cuts or bruises to the face. The patient goes home a few hours after surgery, and some ENTs (like myself) no longer use nasal packing.

cdwd: I've had a narrow nasal passage for many years. In recent years, the swelling of the nasal tissue has grown worse and seems to stay swollen longer. At worse, it swells tightly shut where I cannot breathe through it at all or use warm saline solution or the daily dose of steroid spray prescribed by my primary care physician. Nothing will get through, and a vaporizer brings very limited, temporary relief. I was diagnosed with moderate sleep apnea over a decade ago and have used both CPAP and BIPAP equipment, which have not improved this nasal swelling. I wake every morning with a sore throat and incredible dryness of my mouth, teeth, and lips. Please advise what I can do to improve this condition. Thanks.

Dr__Raj_Sindwani: Nasal blockage can be an anatomic issue as well as a lining swelling. It can contribute to sleep apnea and make it difficult to tolerate the CPAP mask. An examination by an ENT looking for physical reasons for the narrowing in your nose may be appropriate, as we do have effective surgical options in some of these cases (surgery for deviated septum, turbinate swelling, etc.).

mannie: I have been diagnosed with allergies (through testing). I do not have any classic allergy symptoms. My nasal passages swell closed, making breathing through the nose difficult. Traditional allergy medications do not help much. Could my problems be due to something beyond allergies? Anything you can suggest to help with my symptom?

Dr__Raj_Sindwani: If the main issue is nasal blockage, which has been shown to be the most annoying symptom of allergies, there could be an underlying anatomic problem, such as a deviated septum or turbinate swelling.


General Questions

terryhorn: Why do ENT specialists perform nasal endoscopy?

Dr__Raj_Sindwani: Nasal endoscopy is a procedure to look into a patient’s nose with a flexible or rigid telescope. It is the best method we have of actually examining the inside of the nose and the sinus drainage pathways directly. It is a painless procedure that does not require any anesthetic or post-procedure care. It is used to assist in making the diagnosis and in culturing pus to help with antibiotic selection in more complicated situations, and we actually use the rigid endoscope to “see” during sinus surgery.

MarkusR: I was recently scheduled for a nasal endoscopy. What does that entail?

Dr__Raj_Sindwani: This is a minimally invasive and painless procedure done with you awake sitting in the exam chair. We decongest the nose with a topical spray and we pass a telescope (flexible or rigid) to look inside at the sinus passageways. There is usually no anesthesia (not even topical) needed and there are no post-procedure instructions.

WilliamMichael: Do you accept insurance for sinus surgery?

Dr__Raj_Sindwani: Yes. Sinus surgery is a medically indicated procedure that has been shown to significantly improve a patient’s quality of life and positively impact overall emotional, physical, and social functioning. It is covered by insurance.

HillaryPhelps: What is different about your sinus treatment program at Cleveland Clinic?

Dr__Raj_Sindwani: Cleveland Clinic Section of Rhinology (ENT experts in nasal and sinus disorders) has fellowship-trained rhinologists who have had extra training in the medical and surgical treatment of sinus disease, and focus only on these issues. We use state-of-the-art equipment and the latest innovative techniques to diagnose and manage nasal and sinus problems, both medically and surgically. Our specialists are considered leading authorities on the management of both simple and complex sinus problems.

Lola0097: Are there any national organizations that support sinus issues?

Dr__Raj_Sindwani: Yes. The American Academy of Otolaryngology, the American Rhinologic Society, and various local/regional patient support groups.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Raj Sindwani is now over. Thank you again for taking the time to answer our questions about Breathe Easy: Your Sinuses & Your Health.

Dr__Raj_Sindwani: Thank you very much for your questions and your interest in keeping your sinuses healthy.


More Information

  • To make an appointment with Raj Sindwani, MD in our Head & Neck Institute at Cleveland Clinic, please call 216.444.6691 or call toll-free at 800.223.2273, ext. 46691, or visit us online at clevelandclinic.org/sinus. Dr. Sindwani sees patients at Cleveland Clinic Main Campus, as well as the Beachwood Family Health Center.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.
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