Online Health Chat with Raj Sindwani, MD

October 17, 2017


Description

Each of us has four paired cavities (spaces) in our head that are connected to the nose by narrow channels. These cavities, known as sinuses, produce thin mucus that drains out of the channels of the nose. This drainage helps keep the nose clean and free of particles and bacteria.

Normally, sinuses are filled with air. But when sinuses become blocked and filled with fluid, bacteria can grow and cause an infection (bacterial sinusitis).

Conditions that cause sinus blockage include:

  • The common cold
  • Allergic rhinitis (swelling of the lining of the nose due to allergies)
  • Nasal polyps (small growths in the lining of the nose)
  • A deviated septum (the wall between the left and right nostril is crooked)

Allergies, such as hay fever, can also cause swelling and poor drainage of the sinuses.


About the Speaker

Raj Sindwani, MD is section head of rhinology for Cleveland Clinic’s Head & Neck Institute. He specializes in sinus disorders, skull base surgery for tumors and cerebrospinal fluid leaks, and endoscopic orbital surgery for Grave’s disease and blocked tear ducts. Dr. Sindwani is one of the most experienced rhinologists in the state and one of only a few fellowship-trained rhinologists, having obtained subspecialized fellowship training at Harvard Medical School, Cambridge, Mass.


Let’s Chat About Sinusitis, Sinus Disorders and Sinus Surgery

Mucus Mentions

kirk371: Is there anything that can be done for chronic throat clearing or postnasal drip? I have been to ear, nose and throat (ENT) doctors and a gastroenterologist; have had a barium swallow, throat stretching and endoscopy; and used nasal sprays and pills to thin mucus. I was wondering if surgery is an option. I have good days with no problems, and sometimes hours or days with constant throat clearing. Any help would be appreciated. Thank you.

Raj_Sindwani,_MD.: Nasal drainage and postnasal drip have a variety of causes, ranging from allergies and nasal irritation to reflux, etc. We do our best to try and pinpoint the cause before recommending treatment. For postnasal drip that we think is related to the environment or unknown causes, we suggest saline irrigations using a high-volume, high-pressure device available over the counter. This can be helpful when used regularly over time. There are also several medications that can help decrease drainage, including steroid sprays and anticholinergic sprays, which can "shut the tap" off of nasal mucus production.

earl359: I have been having a fairly constant cough for quite some time now. I notice that at times, after I eat supper, I cough up a lot of mucus and have to spit it out. It is a clear mucus. I’m sorry for the graphic picture I am detailing. I also seem to have a tickle in the lower part of my throat at all times that triggers coughing spells. It seems to be concentrated in both my lower throat and also going into my lungs. I started taking Mucinex a few weeks ago, and I am coughing up a lot more. The Mucinex has done well at thinning it out so I can cough it up easier, but it is not slowing it down much or taking it away. I have read online that there seems to be an epidemic of this type of thing going around. From what I have read online, could it be the adenovirus? I was wondering if you could please comment about what this problem might be. Do you think I may have that? I find it a bit strange that there are so many people who are getting this and it isn't being reported on much.

Raj_Sindwani,_MD.: Cough is a very common symptom that can have a lot of causes and contributing factors. Again, this can range from postnasal drip and allergies to reflux to primary lung conditions or even sinusitis. If your cough has been going on for months, it probably isn't a virus (like adenovirus) or infection.

kirk371: What is the high pressure device called?

Raj_Sindwani,_MD.: You could try a Neilmed sinus irrigation bottle, but there are other brands out there also.

rachelepapp: Can constant drainage of mucus into and from the nose and into the throat  be a sign/symptom of cancer?
 
Raj_Sindwani,_MD.: This is a very common symptom that generally does not make us suspicious that someone could have a cancer.


Surgery Suggestions

Nanat426: My husband has bad allergies and a deviated septum. His nose is almost always congested. Sometimes his CPAP helps more than other times. His ENT prescribed a nasal steroid, which helped but it started really hurting his nose so he quit using it. He won’t use medications other than Afrin when he really needs to sleep. He's been told he could have surgery, but has heard many horror stories of the surgery not working and the condition becoming worse. Do you have any suggestions? Thanks so much.

Raj_Sindwani,_MD.: It sounds like your husband has been recommended for a septoplasty to correct the bent bone and/or cartilage in his nose (his deviated septum). This has been shown to improve nasal breathing for many people, and is actually a very well-tolerated procedure. It is usually done under general anesthesia as an outpatient with approximately five to seven days of recovery at home. When done well, this is associated with no bruising or black eyes and only mild to moderate discomfort, with an occasional nosebleed over the first few days. Although techniques vary, I rarely, if ever, place any nasal packing or splints in the nose following this or any nasal surgery. This can greatly improve the patient's experience while still providing excellent results. We used to place packing and splints routinely, and patients uniformly hated it! Thankfully, those days are over.

Yusif Bayram: Hello. I tend to get chronic frontal sinusitis and it can be painful. Then, I got medications, so I don't have any pain now. My septum is deviated, and I wish to have  septoplasty soon. My questions are: What is the procedure to prepare for surgery? How should the status of my sinusitis be before surgery? Is there any kind of medication that is compulsory before septoplasty in someone who has sinusitis?

Raj_Sindwani,_MD.: In preparation for nasal or sinus surgery, we recommend that patients avoid NSAIDs or any over-the-counter or herbal remedies for 10 days. Some of these things can thin the blood and increase your risk of bleeding. Depending on the status of your sinuses, if you are having an acute flare-up, a course of antibiotics may be prescribed pre-operatively by your surgeon. You should always review the medications you are taking with your doctor , so he or she can guide you on which ones to take in relation to the operation.

Gal: Can you describe what is done during the surgery to correct a deviated septum? Would a person in their sixties be at any risk for having this procedure done?

Raj_Sindwani,_MD.: Straightening a deviated septum (a procedure known as septoplasty) is done under general anesthetic so you don't hear, see or feel anything. While you are asleep, we make a small incision deep in the nostril to access the bent bone and/or cartilage, and it is then shaved down or removed. A few simple, dissolving sutures are used to bring things back together. Some people still do place nasal packing or splints to help support the area, which are left in place for five to seven days. I rarely, if ever, use packing/splints as mentioned in a previous answer. Please see the link for more information.

Double Disorders

principal11: Can you discuss the connection between recurrent sinusitis and immunodeficiencies? More specifically, how do you test for/differentiate between recurrent sinusitis caused by an immunodeficiency and recurrent sinusitis as a result of other causes? If given an immunodeficiency diagnosis, what does treatment look like? Thank you.

Raj_Sindwani,_MD.: This is actually a complicated question and requires a full examination, looking for causes that can predispose someone to getting recurrent sinus infections. This list is quite long and includes factors such as having young children at home who attend day care, smoking, allergies, nasal anatomy, polyps and a variety of immune system problems. When we are suspicious of an underlying immunodeficiency in a person who has recurrent infections in different parts of the body (skin infections, UTIs and sinusitis), then we can assess with different blood tests. These tests tell us the status of the immune system. Treatment is then based on the results and targets the specific type of immunodeficiency identified.

wolf: Hello. I was just wondering what you could tell me about sinus cysts? I have a few in my sinus cavities and they create a lot of blockage.

Raj_Sindwani,_MD.: Usually, sinus cysts are small, benign growths that occur completely within a sinus cavity (most commonly in the cheek or maxillary sinuses). They have a characteristic look to them on a CT scan and are thought to be incidental findings that do not cause symptoms and do not require treatment or removal. Sometimes, if the cysts are atypical in appearance, very large or interfering with sinus function, we would consider removing them.

thomp: Are there any risks associated with sinus cysts? Based on a CT, I've been told I have a larger cyst in one of my sinuses. They didn't recommend removing it or any follow up action, but I occasionally feel slight pain or pressure in the area. The ENT who informed me of the cyst indicated they can sometimes disappear. A CT a couple years later still showed the cyst, but I don't know if there was a size change since it was for a non-ENT purpose. Can or should sinus cysts disappear with time? If so, what time frame is typical (months, years, decades)? If a sinus cyst isn't getting smaller with time, is additional action recommended?

Raj_Sindwani,_MD.: Sometimes, sinus cysts can disappear. Other times, they just get smaller or may even increase in size. The time course for this is highly variable and in part unknown because we do not routinely repeat CT scans for surveillance. These usually do not cause any symptoms.

wolf: I have the sinus cysts and they have told me that during a sinus infection, the cyst becomes inflamed and has gotten to the size of a large grape. I have sinus infections multiple times a year. Should I get them removed or is it not needed?

Raj_Sindwani,_MD.: It's difficult to make a diagnosis without looking at the CT scans. It's rare to have to remove them.


Medication Methods

Wunter16: Does the medical community generally believe that prescribing antibiotics for recurring bouts of chronic sinusitis is no longer advisable due to concerns over antibiotic immunity?
 
Raj_Sindwani,_MD.: Absolutely. Over-prescribing antibiotics is not advised in any setting because it can build resistant organisms, expose the patient to side effects and result in unnecessary costs. Sometimes, knowing when not to prescribe something can be a challenge. As care providers, we try to educate our patients so they understand the reasoning for not giving an antibiotic.

Joy: After suffering with chronic sinus infections for the past 25 years, my allergist started a new protocol with me about a year ago. In each nostril, I spray one burst of Afrin followed in five minutes by a spray of Rhinocort, and I have had zero sinus infections. I have no stuffiness and no Afrin rebound. My question is: Do you know of any reason why I can't continue with this protocol indefinitely? Thank you.

Raj_Sindwani,_MD.: Generally, we advise that people use Afrin (an over-the-counter decongestant spray) for very short courses of only three to five days because it is addictive and can cause a rebound swelling of the lining of the nose, making nasal blockage worse. More recently, there have been some different "protocols" as you describe, suggesting that using an Afrin combination can be stretched out for longer periods of time. We are still not sure of the long-term complications of this type of approach. For example, you might get a similar benefit over the long term by using just the Rhinocort, but dosed twice daily. Sometimes, addressing physical causes of blockage within the nasal passages, such as a deviated septum for example, could also provide lasting improvement in one's nasal breathing.

kirk371: I have tried azelastine with no help. Is there any other name brand I could try?

Raj_Sindwani,_MD.: Sure. There are several brands of topical antihistamines  you could try, such as Astelin and Astepro. There are also some combination products such as Dymista, which have both a topical antihistamine and a steroid spray in one bottle.

kirk371: Are Astelin and Astepro over-the-counter or prescription?
 
Raj_Sindwani,_MD.: I believe that those are prescription.


Symptoms and Solutions

thomp: I have sinus symptoms that occur daily (congestion, pain, dryness/pressure sensation, drainage, etc.), and they periodically flare up for periods of time longer than two weeks severely enough to seem like a sinus infection. These sorts of symptoms didn't exist prior to moving to the Cleveland area. I've not been able to tolerate prescription nasal sprays, so instead I try to minimize symptoms by taking Claritin and using a saline nasal spray. There had been suspicion that inflammation of my nasal turbinate’s may be playing a role, and I know I also have a deviated septum. Can a deviated septum cause sinusitis? Are there other alternatives that can manage nasal turbinate inflammation? Since the symptoms didn't appear until moving to Ohio, might it make sense to work with an allergist to identify and minimize exposure to allergens that may have prompted the sinusitis that began with the move to Ohio?

Raj_Sindwani,_MD.: Allergies are definitely a known risk factor for sinusitis, and managing them can help with sinus infections. The management of allergies, when you know what you are actually allergic to, includes environmental controls, topical sprays, allergy pills and shots. It's possible that a very severely deviated nasal septum could cause blocked breathing and interfere with sinus function, predisposing you to sinus infections. You also mentioned turbinate inflammation, which can cause congestion and also be a sign of allergies or environmental irritation. We usually treat swollen turbinate’s with steroid sprays and can also provide procedural options if necessary.

principal11: How do you definitively diagnose and treat sinusitis? Is it possible that sinusitis can have fungal causes? Does untreated/recurrent/chronic sinusitis affect the eyes? Can it lead to other complications?

Raj_Sindwani,_MD.: The diagnosis of sinusitis is usually made by history and physical examination. Most episodes are viral, but the gold standard test to diagnosing bacterial sinusitis is a culture. This is when we sample some of the mucus from the person's nose and send it to the lab, which identifies the exact bug (bacterium) causing the infection and which antibiotic would work best to treat it. We use culture techniques in situations of chronic or severe infections. You are correct. Although rare, untreated bacterial sinus infections can actually spread to nearby structures including the eye and the brain.

Wunter16: Is it best to just let recurrent sinus infections "run their course" using Mucinex-D and a Neti Pot to alleviate systems, as I do until I’m feeling better? Thank you.

Raj_Sindwani,_MD.: Since most sinus infections are viral and will run their course in about a week or so, we do recommend supportive care as you describe. When infections persist longer than seven to 10 days or when symptoms continue to get worse, we generally turn to prescribing an antibiotic.


Closing

That is all the time we have for questions today. Thank you, Dr. Sindwani, for taking time to educate us about Sinusitis, Sinus Disorders and Sinus Surgery.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online.

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To make an appointment with Dr. Sindwani or any of the other specialists in Cleveland Clinic’s Head & Neck Institute, please call 216.444.8500, toll-free at 800.223.2273 (extension 48500) or visit us at clevelandclinic.org/headandneck for more information

About Cleveland Clinic Head & Neck Institute
Cleveland Clinic's Head & Neck Institute Section of Nasal & Sinus Disorders is dedicated to providing the highest level of care to patients with complex sinonasal disorders. The Section’s physician(s) emphasize comprehensive strategies that combine both medical treatments and sinus and nasal surgery. In addition, the Section has earned both national and international recognition for its clinical and basic science research, and the Section has an active program for resident, fellow and practicing physician education.

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