This is the time of year when many people are getting sick with a cold or flu and then develop nasal congestion and pressure. How do you know when you have a sinus infection? Do you need to see a doctor? This will attempt to help answer those questions.
Sinusitis: Swelling of the lining of the sinuses and nose. The sinuses are the hollow areas within the facial bones that are connected to the nasal openings. The sinuses are lined with mucous membranes, similar to the inside of the nose.
Symptoms: Nasal congestion, purulent discharge, dental pain, facial pain, especially if it’s worse when bending forward. Other signs include fever, fatigue, cough, ear pressure/fullness, bad breath and headache.
When to get help immediately: High fever > 102.5, sudden severe pain in the face or head, double vision or difficulty seeing, confusion or difficulty thinking clearly, swelling or redness around one or both eyes, stiff neck or shortness of breath.
Diagnosis: Highly predictive symptoms of a sinus infection include purulent rhinorrhea and nasal congestion with facial pressure/pain. The diagnosis is supported by the sensation of ear fullness, cough, difficulty smelling and headache. Symptoms that may suggest a bacterial sinus infection include: worsening of symptoms after initial improvement of symptoms. It is generally not possible to distinguish between viral and bacterial sinus infections in the first 10 days of illness even based on history, examination or radiology studies.
Most of the time radiologic tests such as x-rays or CT/Cat scans are not indicated for acute sinus infections. These radiological tests may show sinus fluid levels in both viral and bacterial sinus infections but it cannot distinguish between the two.
In general acute rhinosinusitis (ARS) is the most common type that we see in the medical clinic. It is a symptomatic inflammation of the nasal passages and paranasal sinuses lasting less than 4 weeks.
There are different classifications of sinusitis that are based on the length of symptoms.
1) Acute rhinosinusitis: symtpoms for less than 4 weeks
2) Subacute rhinosinusitis: symptoms for 4-12 weeks
3) Chronic rhinosinusitis: symptoms persist greater than 12 weeks
4) Recurrent acute rhinosinusitis: 4 or more episodes of ARS per year with resolution of symptoms in-between these episodes.
A sinus infection can be either viral or bacterial. Viral sinus infections usually last 7-10 days and most sinus infections are this type. Bacterial sinus infections usually (75%) go away on their own as well, but can take a month or more. In rare cases, patients with a bacterial sinus infection can develop a complication called orbital cellulitis.
It is very challenging for the doctor to determine whether a sinus infection is viral (like a common cold) or bacterial. Antibiotics may be helpful for the bacterial kind of sinus infection but won’t help the viral infection. Even though about most of the sinus infections are viral, 85-98% of the patients with sinus infections in the US are prescribed an antibiotic when seen in the clinic.
Acute bacterial infection occurs in only 0.5 to 2.0 percent of patients with sinus infections and virus is causing the symptoms 98-99.5% of the time.
How do you get a sinus infection? Viral sinusitis begins with direct contact of the virus into the eyes or nasal mucosa by respiratory droplets from someone else. Symptoms usually develop within the next day after exposure from someone else. Bacterial sinus infections occur when bacteria secondarily infect the inflamed sinus cavity. Most of the time this is a complication of a viral sinus infection but can also be a complication from with allergies, mechanical obstruction of the nose, swimming, intranasal cocaine use, impaired mucociliary clearance due to cystic fibrosis, or immunodeficiency.
You are more likely to develop a sinus infection if you smoke or you already have an impaired respiratory tract such as in cystic fibrosis.
Treatment: Since viral sinus infections usually resolve within 10 days, most of the time we use medications to treat symptoms with these symptoms without the use of antibiotics. An exception would be in the case of a patient who is getting worse after initial improvement or patients with severe symptoms are who are clearly worsening or are immunocompromised. For viral sinusitis, treatment aims to relieve the symptoms of nasal pressure/obstruction and runny nose. The medications do not shorten the duration of the illness in viral infections.
Options for treatment include:
1) Analgesics such as ibuprofen, naproxen or Tylenol
2) Topical steroid nasal spray such as Flonase, Rhinocort or Nasonex
3) Oral decongestant such as Sudafed or anti-inflammatory medication such as prednisone
4) Antihistamines such as Benadryl, Zyrtec, Allegra or Claritin
5) Zinc preparations have been used, but if sprayed in the nose they way cause difficulty with smell are not recommended.
6) Nasal saline rinses
Treatment of bacterial sinus infections may include antibiotics, however 40-60% of patients with bacterial sinus infections will clear their infection without antibiotics.
Antibiotics: Studies have shown nearly identical results in adults with the use of amoxicillin, Bactrim or erythromycin compared to other antibiotics. Most of the time we use Amoxicillin, either 875mg twice a day or 500mg three times a day for 10-14 days. If someone has an allergy to penicillin, Bactrim, doxycycline or other antibiotics might be chosen. There are some strains of S. pneumonia bacteria that are becoming resistant to amoxicillin.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
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