Sinusitis

Causes

• Infections:
  • Viral infections: The most common cause of acute sinusitis, often following a common cold or flu.
  • Bacterial infections: Can develop if a viral infection lingers and leads to a secondary bacterial infection.
  • Fungal infections: Less common but can occur, especially in people with weakened immune systems.
• Allergies: Allergic rhinitis (hay fever) can cause inflammation and swelling of the nasal passages and sinuses, leading to blockage.
• Nasal polyps: Small, noncancerous growths in the nasal passages or sinuses that can block drainage.
• Deviated septum: A displacement of the wall that divides the nostrils, which can narrow one or both nasal passages and obstruct sinus drainage.
• Other conditions:
  • Asthma
  • Cystic fibrosis
  • Immune system disorders
  • Dental infections (rarely, can spread to sinuses)
  • Exposure to irritants like cigarette smoke or air pollution.

Symptoms

• Nasal congestion or stuffiness: Difficulty breathing through the nose.
• Thick, discolored nasal discharge: Often yellow, green, or cloudy.
• Pain, pressure, or tenderness in the face: Especially around the eyes, forehead, cheeks, or nose. This pain may worsen when bending forward.
• Postnasal drip: Mucus dripping down the back of the throat, causing a cough or throat clearing.
• Reduced sense of smell (hyposmia) or taste.
• Headache: Often described as a pressure headache.
• Sore throat.
• Cough: May be worse at night.
• Fatigue.
• Fever: More common with acute bacterial sinusitis.
• Bad breath (halitosis).
• Ear pressure or fullness.

Diagnosis

• Medical history and physical exam: The doctor will ask about your symptoms, their duration, and any relevant medical conditions. They will examine your nose and face, looking for redness, swelling, or tenderness.
• Nasal endoscopy: A thin, flexible, lighted tube (endoscope) may be inserted into the nose to visualize the nasal passages and sinus openings for inflammation, polyps, or pus.
• Imaging tests:
  • CT scan of the sinuses: Provides detailed images of the sinuses and can identify blockages, inflammation, or structural abnormalities. This is often used for chronic or recurrent sinusitis.
  • X-rays: Less commonly used for sinusitis diagnosis but may be considered.
• Cultures: Nasal or sinus cultures may be taken to identify the specific bacteria or fungi causing the infection, especially if the infection is severe, persistent, or not responding to treatment.
• Allergy testing: If allergies are suspected as an underlying cause.

Treatment

• For Acute Viral Sinusitis:
  • Symptom relief: Rest, fluids, saline nasal sprays or rinses, over-the-counter pain relievers (e.g., ibuprofen, acetaminophen), and decongestants. Antibiotics are not effective for viral infections.
• For Acute Bacterial Sinusitis:
  • Antibiotics: Prescribed if symptoms are severe, worsening, or persist beyond 7-10 days.
  • Nasal corticosteroids: Reduce inflammation and help clear blockages.
  • Saline nasal rinses: Help clear mucus.
• For Chronic Sinusitis:
  • Nasal corticosteroids: Often a long-term treatment to reduce inflammation.
  • Saline nasal rinses: Daily use to clear mucus and irritants.
  • Antibiotics: May be used for longer durations (e.g., 3-4 weeks) or in low doses for their anti-inflammatory effects.
  • Oral corticosteroids: Short courses may be used for severe inflammation.
  • Antifungal medications: If a fungal infection is identified.
  • Biologic drugs: For severe chronic sinusitis with nasal polyps that doesn't respond to other treatments.
  • Surgery (Endoscopic Sinus Surgery): Considered when medical treatments are ineffective, especially if there are structural blockages like polyps or a deviated septum. Surgery aims to open and enlarge the sinus drainage pathways.
• For Allergic Sinusitis:
  • Allergy management: Allergen avoidance, antihistamines, nasal corticosteroids, and potentially allergen immunotherapy.

When Sinusitis Needs Treatment, and When It Does Not

Sinus infections are among the most common reasons antibiotics are prescribed, and among the least likely to benefit from them. Knowing the few patterns that do need treatment, and the measures that help everyone else, avoids both the side effects and the six-week wait for a course that was never going to work.

Viral or bacterial: the ten-day rule

Only a small minority of sinus infections are bacterial. The features that suggest one are symptoms lasting ten days without any improvement, or a clear worsening after initial improvement, or severe symptoms with high fever and facial pain from the start. Green or yellow discharge is not one of them; it is normal in viral illness. Our when antibiotics help a sinus infection article works through the decision.

If antibiotics are warranted

Amoxicillin-clavulanate or amoxicillin for five to seven days is the standard choice, with doxycycline for people allergic to penicillin. Watchful waiting with a prescription to fill only if symptoms fail to improve is a reasonable alternative. Fluoroquinolones such as levofloxacin are reserved for when those fail, because their side effects outweigh their benefit for routine sinusitis.

Rinses and nasal steroids do most of the work

Saline rinsing clears mucus and allergens and shortens symptoms, and a daily steroid spray such as fluticasone reduces the swelling that blocks drainage. Rinse water must be distilled, sterile, or boiled and cooled, never straight from the tap, because of the rare but fatal ameba infection that Florida tap water can carry. Nasal decongestant sprays are limited to three days to avoid rebound congestion. Untreated allergies, rhinitis, and postnasal drip drive many recurrent episodes, and our year-round Florida allergies guide covers managing them.

Chronic sinusitis is a different condition

Symptoms lasting twelve weeks or more are chronic rhinosinusitis, which is inflammation rather than infection and does not respond to repeated antibiotics. A CT scan and nasal endoscopy show whether polyps are present, and treatment is long-term nasal steroids and rinses, with dupilumab or surgery for polyp disease that fails them. Our ear, nose, and throat team manages the workup.

The signs that cannot wait

Swelling or redness around the eye, double vision, a severe headache, a stiff neck, confusion, or a high fever that will not settle can mean infection spreading beyond the sinus and needs emergency care the same day. The CDC and the American Academy of Otolaryngology publish patient guidance on sinus infections.

If sinus symptoms have lasted more than ten days without improving, or keep coming back, schedule a visit.