Managing and Treating Sinus Infections with Dr. Mohamad Chaaban

Podcast Transcript

Cassandra Holloway:  Hi, thanks for joining us. You're listening to the Health Essentials podcast brought to you by Cleveland Clinic. I'm your host, Cassandra Holloway. Today we're broadcasting virtually as we are practicing social distancing. We're joined virtually by Dr. Mohamad Chaaban. Dr. Chaaban, thank you so much for taking the time to speak with us today.

Dr. Chaaban:  Thank you so much for having me.

Cassandra Holloway:  Today we're going to be talking about the world of sinus infections, which can range from manageable to chronic, to feeling downright pretty miserable when you have one. We'll be getting Dr. Chaaban's advice on treatment, when to see a doctor and even how to tell the difference between COVID-19 symptoms and a normal sinus infection.

But before we dive into everything, we want to remind listeners that this is for informational purposes only and does not replace your own doctor's advice. So, Dr. Chaaban, let's start off by, can you talk to us a little bit about your practice at Cleveland clinic and what type of patients you typically see?

Dr. Chaaban:  Thank you again. So I'm an otolaryngologist or in other words, ear, nose and throat specialist, with specialized training in rhinology, which is really the practice of seeing sinasal disorders, infections, tumors CSF leaks, deviated septum. My practice primarily is focused on sinasal disorders. But I also see regular amount of ear, nose and throat disorders at Cleveland Clinic.

Cassandra Holloway:  So whole gamut of deviated symptoms and nose disorders and sinus infections and all that good stuff?

Dr. Chaaban:  Correct, yes.

Cassandra Holloway:  So according to the CDC, 28.9 million adults are diagnosed with a sinus infection every year. So we know that many people are affected and many people are suffering because of this condition. What type of symptoms might a sinus infection cause?

Dr. Chaaban:  So typically the sinus infection usually most of them start off with a viral upper respiratory infection. So at the beginning maybe just nonspecific symptoms of fatigue, fever, sore throat. Then you tend to have that nasal discharge. And then when it turns out to be an acute bacterial sinus infection you get the typical symptoms of an acute bacterial sinusitis.

And usually we look for specific symptoms like the first one is nasal obstruction. The second is nasal discharge, whether that is anteriorly, where patients complain of actual discharge of mucus coming off from the nose. Or something that is referred to as postnasal drip or postnasal drainage. The third cardinal sign, symptom of acute sinusitis is basically facial pressure or pain, for example, in the cheek sinus area or front, the frontal area. And the fourth one is decreased or absent sense of smell. These are the four cardinal symptoms of acute bacterial sinusitis.

Cassandra Holloway:  Interesting. So, those are the four, you said cardinal signs of that. Are there any weird symptoms like neck pain or dizziness or vomiting that you typically see? Kind of the off the spectrum symptoms that people should be concerned about?

Dr. Chaaban:  Oh, definitely. So basically if you have... Usually the site of the pain, or it's usually specific to the sinus infection site. For example, if you have cheek pain, then you expect the patient to have a maxillary or cheek sinus infection. If you have neck pain, usually I see it. It's not very common but I see it was the sphenoid sinusitis. The sphenoid sinus is a sinus that's deeply recessed in the back of the nose. You can get pain at the top of the head and sometimes neck pain as well.

But when I see neck pain, I also sometimes get concerned maybe the patient has an infection that is outside the confines of the sinuses. So I would want to make sure we ask the patient or we check for any neck stiffness, light sensitivity, severe headaches, that usually is pointing us towards something more complicated than just a simple sinus infection. And going back to the nausea, basically, if patient has post nasal drainage, we tend to see nauseum and sometimes vomiting. And typical viral infections, we can see dizziness, which is described as lightheadedness. But you can also get fluid behind the ears and that may manifest as dizziness as well.

Cassandra Holloway:  And is the sinus infection viral or bacterial?

Dr. Chaaban:  It's a very good question. So most acute sinusitis that we describe as bacterial, most of them start off as viral. And then 2% of these, up to 2% of these viral rhinosinusitis, they turn into bacteria. So mostly the ones that we describe as acute sinusitis, we're mostly talking about bacterial sinusitis.

Cassandra Holloway:  And what about bloody noses? Are those typically a symptom? I know if your nose gets dry, that might affect it. Do you ever see bloody noses as a symptom of sinus infections?

Dr. Chaaban:  It's a very good question. So the patients who have acute sinusitis, they are very inflamed, they're congested, and they tend to want to get the mucus out of the nose. So that severe or heavy nose blowing can lead to epistaxis or nosebleeds. It's not a very common symptom that tends to be needed to be treated, but it's something that can come along with your range of symptoms that you have with sinusitis.

Cassandra Holloway:  Sure. So since we're talking a little bit about symptoms, and COVID-19 is likely on a lot of people's minds lately. It seems like there's some crossover a little bit with that irritated throat or the fatigue. I just want to ask what's the difference between a sinus infection and experiencing symptoms of COVID-19? What advice do you have for listeners on how to tell the difference?

Dr. Chaaban:  Sure. That's a great question. So, as we know that the sinusitis starts off with being a viral infection and COVID-19 is a viral infection. So initially you may see some symptoms that are similar or you can't tell if the patient has either one of them, like what you just described. The fatigue, the sore throat, the crackling in the throat and the dryness. But typically the COVID-19 is a viral flu like disease where you get symptoms of fever, sore throat that continues on. And usually the patient with sinusitis, usually you need to have at least 10 days of persistent symptoms for you to make the diagnosis of bacterial sinusitis. Or you get patients who get initially better, and then that was followed by something we call double sickening where the patient gets worse afterwards. And that points out to an acute bacterial sinusitis. Most importantly for listeners right now, I would say that if you have dry cough or shortness of breath, those are really two more important symptoms of COVID-19 as opposed to regular sinus infection.

Cassandra Holloway:  Gotcha. That's helpful I think for a lot of people right now. Especially if they're fighting a sinus infection and it's scary, you start coughing and you're like, is this it? So, going along those lines, obviously COVID-19 is very contagious, is a sinus infection, also contagious?

Dr. Chaaban:  So initially what starts off as a viral rhinosinusitis, it is contagious just like any other virus, upper respiratory virus. But when it becomes bacterial, it's no longer contagious of that sort.

Cassandra Holloway:  Gotcha. So let's talk a little bit about causes. What causes a sinus infection or puts someone at risk for getting a sinus infection?

Dr. Chaaban:  So typically the extent of hypothesis of getting a sinus infection, it really starts off was swelling and blockage of the mucociliary clearance from the sinuses. And that swelling of the opening of the sinus leads to development of a bacterial overgrowth, and then an infection happens after that. So people, there are some risk factors. For example, I can tell you allergy is one of them. There's a big link between the allergy and acute rhinosinusitis. But is no definitive evidence whether if you treat allergies, like for example, people who get allergy shots, that you can actually prevent acute sinus infection. But there is a link between the two. Others are forced viruses. When you have an upper respiratory infection, a viral infection may lead to an acute sinusitis, bacterial sinusitis.

If you have sometimes dental work or dental or teeth infections, because the roots of the molar teeth, they really sometimes get into the sinus, you can get infections from that. In my prep, that's usually dental causes are more or less caused sub-acute or chronic infections because they get undiagnosed. And they usually are unilateral on one side. It's very uncommon to have infections on both sides, with their teeth. But that could be a risk of course, for you to develop a sinus infection or root work by your dentist can cause that. And other than that, if you have chronic sinusitis or nasal polyps, you can get on and off flare ups, we call them flare ups, which is acute infection on top of your chronic infection.

Cassandra Holloway:  Sure. So say you think you have a sinus infection. I guess my question is two parts. Who do you schedule an appointment with? Do you see an ear, nose or throat specialists? Do you see your primary care doctor? And then once you're there at the doctors, how is it diagnosed?

Dr. Chaaban:  Very good question. So at the beginning, it starts off with an upper respiratory infection, like a viral infection. And those usually can be treated at home. Self-care could be sufficient for those. Once you get the infection, either more than 10 days of persistent symptoms, or if you get that double sickening that we talked about before, which is the period of worsening following an improvement of symptoms. That typically happens after five days where the patient is doing okay, and suddenly they get worse.

In those two situations, I recommend that they see perhaps at that time a primary care specialist. For them to see us, our specialist, ear, nose, and throat doctors, usually I look at this for acute infections in three reasons. The first reason if you have a patient with recurrent acute infections, if a patient's having four times per year acute infections that we want to know, are there any reasons to predispose that patient for those infections? Examples would be like anatomical variations of the nose, deviated septum, something of that sort that could be predisposing the patient for those recurrent acute infections.

Another reason, if you have a complicated sinusitis. We always go back and talk about those alarming signs. If you have alarming signs that the infection is spreading somewhere else, like in the eye. Either decreased vision, double vision, eye swelling, or the neck pain that you asked me before or neck stiffness, then I think the immediate referral is warranted at that point. And the third thing, if you have infection that was given antibiotics by a primary care doctor and has not gone away, or has turned into sub-acute or chronic infection, those are the three reasons why they would seek an ear, nose and throat doctor as opposed to primary care.

Cassandra Holloway:  So that's interesting, you said a chronic sinus infection, or just getting them chronically, is defined by four times a year?

Dr. Chaaban:  That's a good question. So there's a difference between... We define chronic infection or chronic sinusitis as the persistence of symptoms for more than 12 weeks. But it has to be accompanied by an endoscopic, which is a scope we put in the nose, or a CT scan evidence of actual inflammation in the sinuses. So recurrent acute is a different entity. We define it as recurrence of acute infections, which have the same criteria that we talked about, which is basically for you to diagnose an acute infection one time, you have to have two of the four cardinal symptoms that we've talked about. And then usually it's, as we said, more than 10 days, and the whole process should be less than four weeks for you to diagnose a single acute rhinosinusitis. When you get then a period of you're completely normal and you get another infection. And another one, when they become four or more per year, that entity is called recurrent acute sinusitis, and it's different than chronic rhinosinusitis.

Cassandra Holloway:  Sure. So let's say I am below that 10 day maximum for seeing a doctor, say I'm on day four or five of not feeling too well. And I'm experiencing some of these symptoms. What's the quickest way to self-treat myself with over the counter medicines? What do you recommend before I see a doctor? What do you recommend I do?

Dr. Chaaban:  Very good question. So it's symptomatic treatment. If you have pain, if you have fever, I would take a fever pain killer, fever reducer like acetaminophen or ibuprofen. If you're having pain in the sinuses, then warm compressors can help with that. And if you're having a lot of mucus in the nose a saline rinse, neti pot for example, would be helpful to get rid of all the mucus in the nose. And sometimes I tell my patients cautiously to take nasal decongestants because you can't take them for too long, but those are the things that you can do at home to self-treat, at the beginning of the phase of the sinus infection.

Cassandra Holloway:  And then what's on the other side of that? Say, I come in to see you, walk me through some of the treatments that would be available to me if I qualified for the chronic sinus infections. Or if it's a little bit more severe, what are my treatment options?

Dr. Chaaban:  Once you reach the point of having acute bacterial rhinosinusitis, more than 10 days or double sickening, then we recommend starting antibiotics. Long time ago it used to be very common. We prescribed right and left antibiotics, but we always have to remember that there are adverse effects and adverse side effects of antibiotics. That's why we have to really select which patient would be best to receive them. So yes, going back to your question. Yes, I would say more than 10 days or double sickening, we give an antibiotic. Nasal steroids can help as well. They have a minor effect, but they can help. We can prescribe it. And there are over the counter as well. Oral or nasal decongestants are helpful. As long as we don't have a patient with hypertension or anxiety because oral decongestants can cause that as well. We also recommend continuing nasal saline, if they started before. Or nasal irrigation as well to get at all the mucus in the nose.

Cassandra Holloway:  What about surgery? Is surgery ever an option in a severe case?

Dr. Chaaban:  So that's a good question. So when they come to see me, usually there's either a failed round of antibiotics for seven to 10 days. And that case, then I usually tend to look in the nose with a camera. I obtain a culture of the sinus. See what's growing in there. Maybe we need to change the antibiotic. That's something that the primary care doctor may not be able to culture in the nose and test from inside of the nose, where the sinus openings are. And all the complicated sinus infection like an orbital complication or intracranial complication, then that points me more towards going to surgery, as opposed to just treating with antibiotics only. And in chronic sinusitis that has failed medical management. That includes antibiotics, nasal steroids, irrigation with saline. And in recurrent acute, that entity that we talked about before, in those patients, if I still see evidence of narrowing of the sinuses, then there is an indication that we go ahead and do sinus surgery for them.

Cassandra Holloway:  Is that pretty severe? Is it an outpatient surgery? Or, what does that entail when you have sinus surgery?

Dr. Chaaban:  So by and large, this is an outpatient surgery, as long as the patient doesn't have comorbidities that require them to be an inpatient. And this has evolved over time from really doing surgery under the cheek and different ways. And right now we have really minimally invasive approaches. For example, I'm not sure if you heard about balloon sinuplasty, for example? We can offer that to patients which is a simple procedure. You insert a balloon in the opening of the sinus and you dilate the opening. And it can go into a conventional endoscopic sinus surgery where you open up the sinuses, much larger than just a balloon. And obviously if you have polyps, you will remove them as well as part of the chronic inflammation. And you take deeper cultures, you open up the sinuses and relieve them, move the mucus that's dropped as well.

Cassandra Holloway:  So the last thing I want to talk about here is prevention. So how can a listener reduce their risk of getting a sinus infection?

Dr. Chaaban:  So just because the sinus infection starts off with a viral URI, if you prevent getting a viral infection, that would be very helpful. And right now we're all doing this by, avoiding contact with sick contacts and washing our hands and everything. So anything that you can do to avoid a viral URI or upper respiratory infection is very helpful. Washing hands, avoiding sick contacts. Getting the flu shot is also important because you're avoiding that not a hundred percent chance, but you're avoiding 40% to 60% chance of getting the flu. And in that case, you're indirectly avoiding getting a sinus infection. And also if you are smoking, you shouldn't be smoking, or don't start smoking. Because that is also can lead to acute and chronic infections. And not only that, can also make your sinus infection last longer, because smoking can inhibit those hair like structures in the cells, inside your nose that actually propel the mucus out. So you get more stagnation of the mucus in the nose as opposed to clearing them out, when you smoke from that perspective.

Cassandra Holloway:  What are your thoughts on using a humidifier? Does that help with the dryness in the nose and combating some of that infection?

Dr. Chaaban:  Yes, definitely it does. Using a humidifier is very helpful. And just like using the saline irrigation, part of the reason why you're doing it is also, you're watering inside the nose and humidifying the nose. Which is part of the function of the nose, but cannot be done at the time when you have an acute infection.

Cassandra Holloway:  Awesome. Who knew there was so much fascinating information about sinuses and treating sinus infections? Since we know they're so common and so many people are suffering from them. But there's things you can do to prevent your risk, and there's treatment available. So thank you for your time, Dr. Chaaban. You've offered some really great advice for our listeners. I know a lot of people will find this advice helpful, especially during the current time when things seem a little crazy and you've offered some great advice.

Dr. Chaaban:  Thank you so much for having me.

Cassandra Holloway:  So to make an appointment with a Cleveland Clinic, ear, nose and throat specialist, call (216) 444-8500. If you want to listen to more Health Essentials podcasts, featuring experts at Cleveland Clinic, subscribe wherever you get your podcasts from or visit clevelandclinic.org/hepodcasts. Also, don't forget to follow us on Facebook, Twitter, and Instagram @clevelandclinic, all one word, to stay up to date on the latest news and information about your health and wellness. Thanks again for listening and stay well.