Sinus Disease
Chronic sinusitis.
Sinusitis becomes chronic when the lining of the nose and sinuses stays inflamed for twelve weeks or longer. It is common, it is often treated with antibiotic after antibiotic that never quite clears it, and it is usually manageable once the diagnosis is made properly and the treatment is matched to the cause.
General education only. Your diagnosis, options and coverage are individual, and are established at your consultation.
The Condition
Twelve weeks is the line.
Acute sinusitis is the familiar week or two of a cold that settles in the sinuses: it is almost always viral, and it gets better. Chronic rhinosinusitis is a different disease. The lining of the nose and sinuses stays inflamed for twelve weeks or longer, the natural drainage pathways narrow or close, and the sinuses cannot ventilate or clear themselves. The result is a set of symptoms that fluctuate but never fully leave: nasal blockage, thick discharge from the front of the nose or down the back of the throat, pressure or fullness across the cheeks, forehead or between the eyes, and a sense of smell that is reduced. Fatigue, a cough that is worse at night, ear fullness and bad breath often come with it.
The diagnosis needs two things: the symptoms, lasting long enough, and objective evidence of inflammation, seen on nasal endoscopy or on a CT scan. That second part matters, because a number of conditions produce facial pressure and congestion without any sinus disease at all. Many people who have been told for years that they have "sinus headaches", and who have no discharge or blockage to go with them, turn out to have migraine. Getting that right early saves a great deal of unnecessary treatment.
In some patients the inflamed lining also grows nasal polyps. Chronic sinusitis with polyps behaves differently, responds to different treatments, and has its own page.
Symptoms of chronic rhinosinusitis
- Nasal blockage or congestion, most days, for three months or more
- Thick discharge from the nose, or dripping down the back of the throat
- Pressure or fullness in the face, worse when bending forward
- A reduced or absent sense of smell
- Cough, throat clearing and ear fullness, especially at night
- Sinus infections that clear with antibiotics and return within weeks
Having several of these does not confirm the diagnosis, and having few does not exclude it. The examination does that.
Why It Happens
Inflammation, anatomy, and what keeps them going.
Chronic sinusitis is rarely one thing. Inflammation of the lining, from allergy, from the immune system's own tendencies or from repeated infection, makes the tissue swell; narrow drainage pathways, sometimes narrowed further by a deviated septum, close off as a result; and once a sinus cannot drain or ventilate, the inflammation sustains itself. Asthma and aspirin sensitivity travel with the more inflammatory forms of the disease. An infected upper tooth can seed a maxillary sinus. Smoking and some workplace exposures irritate the lining continuously. Less commonly, a fungal reaction, an immune deficiency or an inherited condition is behind persistent disease, and part of the assessment is knowing when to look for those.
This is why antibiotics alone so rarely settle it. They treat bacteria, which are sometimes part of a flare, but they do nothing about the inflammation or the anatomy that allowed the flare to happen. Several courses in a year is a pattern that should prompt assessment rather than another prescription.
Not just infection
Chronic rhinosinusitis is primarily an inflammatory disease. Bacteria may be involved in flares, but they are not usually the cause.
Two types
With nasal polyps and without. The distinction is made on endoscopy and shapes both the medical and the surgical plan.
Linked conditions
Asthma, allergic rhinitis and aspirin or NSAID sensitivity are common companions and are asked about specifically.
Migraine mimics it
Facial pain or pressure without blockage, discharge or smell loss is more often migraine than sinusitis. The examination tells them apart.
Assessment First
How the diagnosis is made.
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History
Which symptoms, for how long, what pattern; what has been tried and for how long; allergies, asthma, aspirin sensitivity, dental problems, smoking and previous operations.
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Nasal endoscopy
A thin camera passed into the nose after a topical spray, showing the drainage pathways, any pus or polyps, and the state of the lining directly. This is where the diagnosis is usually confirmed or excluded.
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CT imaging, when it changes the plan
A CT of the sinuses shows which sinuses are involved and the anatomy of the drainage pathways. It is ordered when symptoms persist after a proper trial of medical therapy, or when surgery is being considered, rather than routinely.
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Looking further, when indicated
Allergy testing, cultures of infected material, or blood tests when the pattern suggests an unusual cause.
Your Options
The options, with their trade-offs.
Medical therapy first, and taken seriously. Surgery when it has been earned. Set out side by side so you can weigh them yourself.
| Option | What it involves | Trade-offs to weigh |
|---|---|---|
| Structured medical therapy | Daily intranasal corticosteroid used correctly, large-volume saline irrigation, treatment of allergy and asthma where present, and courses of medication used deliberately when a flare calls for them. Generally continued long-term, because the disease is chronic. | Asks for daily consistency over months. Controls most disease without surgery; it does not reopen a drainage pathway that anatomy has closed. |
| Antibiotics, used selectively | For a clear bacterial flare, ideally directed by a culture from endoscopy rather than guessed at. | Repeated courses for chronic symptoms rarely change the disease and carry their own risks. They are not a substitute for treating the inflammation. |
| Endoscopic sinus surgery | Through the nostrils under general anesthesia, usually as day surgery, opening the natural drainage pathways and preserving healthy lining, so that the sinuses ventilate and medication can reach them. Generally OHIP-insured when medically indicated. | An operation, with the risks reviewed at consultation: bleeding, infection, scarring, recurrence, changes in smell, and rare but serious injury near the eye or skull base. Surgery works with ongoing medical therapy afterwards, not instead of it. |
| No treatment | A legitimate choice when symptoms are tolerable, or after understanding what each treatment asks of you. | The disease is not dangerous in most people, but untreated it usually continues. You can return if your situation changes. |
Where polyps are present, the newer biologic medicines join this table. They are discussed on the nasal polyps page.
When not to wait
Sinus infection can, rarely, spread beyond the sinuses. Swelling or redness around an eye, double or blurred vision, a severe headache with fever or a stiff neck, confusion, or swelling of the forehead are emergencies: go to the nearest emergency department. The same applies to a sinus infection in someone whose immune system is suppressed.
Common Questions
Chronic Sinusitis, answered plainly.
Usually not for chronic symptoms. Chronic rhinosinusitis is primarily inflammatory, and antibiotics treat bacteria. They have a place in a clear bacterial flare, ideally guided by a culture taken at endoscopy, but repeated courses for symptoms that keep returning rarely change the course of the disease and are a reason to be assessed rather than re-treated.
Sometimes, in part. Allergic rhinitis inflames the same lining and can drive or worsen chronic sinusitis, so allergy is asked about and tested for when the history suggests it. Allergy alone, though, does not usually produce thick discharge, persistent facial pressure or smell loss; those point to the sinuses themselves.
Surgery reopens the drainage pathways and removes diseased tissue; it does not remove the tendency of the lining to inflame. Most patients breathe better, get fewer infections and respond better to medication afterwards, and most continue some medical therapy. It is offered when examination, imaging and a genuine trial of medical therapy say it is the right tool, not as a first resort.
Because the scan is what shows which sinuses are involved and what the drainage anatomy looks like, which is what a surgical plan is built on. It is ordered when it will change the plan: when symptoms persist after proper medical therapy, or when surgery is being considered. It is not needed to start medical treatment.
Possibly, if they come with blockage, discharge or smell loss, and if the examination or scan shows sinus disease. Facial pain or pressure on its own, with a clear nose, is more often migraine, which responds to very different treatment. Establishing which it is early spares years of the wrong therapy.
Assessment first. Then the options are yours.
An OHIP-insured assessment begins with a referral from your physician or nurse practitioner. The office contacts you once it is received.