September 26, 2016

Basic knowledge for a complex problem

As we enter prime ragweed season, those of us who suffer from chronic sinusitis may be faced with the unwelcome resurgence of a familiar foe.

According to a recent article in the Journal of the American Medical Association, chronic sinusitis affects 3-7 percent of the general population and accounts for more than $9 billion in health-care expenditures annually. Considering the broader impact of this condition, in terms of missed work and decreased productivity, the estimated costs balloon to approximately $13 billion per year. As we note the significant impact sinusitis has on the everyday lives of so many, a basic understanding of what sinuses are is in order.

The sinuses are hollow, air-filled spaces in the skull that surround the nasal cavity. Most people have four pairs of individually named sinuses. Their exact function is a topic of debate; however, commonly held assertions include lightening the weight of the skull, providing a “crumple zone” for the skull to cushion against facial trauma, and enhancing vocal resonance. The sinuses are covered with a mucus-producing lining that contain microscopic hairs called cilia. Cilia function to sweep mucus and debris out of the sinus. As one can imagine, any process that impedes their function would result in stagnation of mucus and debris within the sinus. Stagnation of material within the sinuses is, at its core, the underlying problem when someone suffers from sinusitis.

Those of us who evaluate patients with sinusitis typically differentiate chronic sinusitis from acute sinusitis when considering our approach to treatment and this distinction can be drawn by considering the duration of symptoms. With regard to acute sinusitis, symptoms typically resolve in four weeks or less, whereas patients with symptoms that exceed 12 weeks duration are considered to have chronic sinusitis. Stratifying patients into acute versus chronic is essential because the underlying mechanisms between the two can be quite dissimilar. The vast majority of acute sinusitis cases are caused by rhinoviruses, the same infectious agent that brings about the common cold. Chronic sinusitis, however, is frequently the end-product of a multitude of conditions that result in a persistent inflammatory state within the sinuses with the underlying infectious agents more likely representing bacteria rather than viruses.

People who suffer from chronic sinusitis know the usual symptoms well. They include thick and discolored discharge from the nose, reduction in smell sensation, facial pain and/or pressure, and nasal obstruction and/or congestion. These symptoms can have a significant impact on the sufferer’s quality of life. In fact, a 1995 article published in the Journal of Otolaryngology- Head and Neck Surgery demonstrated that patients with chronic sinusitis report more significant bodily pain scores and lower social functioning scores than patients who suffer from other chronic conditions such as congestive heart failure and obstructive lung disease. The risk factors for developing chronic sinusitis are vast and include entities such as asthma, cigarette smoking, gastroesophageal reflux, prior facial trauma, deficiencies in immune system function, dental infections and anatomic or structural abnormalities (e.g., a deviated nasal septum or nasal polyps). Another major risk factor is having environmental allergies – a problem that heavily impacts our region of the country. According to the Asthma and Allergy Foundation of America’s 2016 report on the spring allergy capitals in the United States, seven of the top 30 worst cities for people afflicted with environmental allergies are actually within a 350-mile radius of the Shreveport-Bossier City area including Baton Rouge, New Orleans, Jackson, Little Rock and Dallas.

So, what is one supposed to do? Frankly, the spectrum of treatment approaches to sinusitis is as varied as the potential factors that may cause it in the first place. As previously discussed, most occurrences of acute sinusitis are caused by viruses. Most of these cases are expected to resolve on their own, and simple measures such as getting ample rest, drinking plenty of fluids, using a humidifier, performing nasal saline irrigation, and taking over-the-counter pain relievers and decongestants can help ease discomfort until symptoms abate. When symptoms have persisted for more than 7-10 days, however, a visit to your primary care physician or ENT specialist may be in order as these cases may be bacterial in nature, thus requiring more extensive medical treatment.

Antibiotics, such as Augmentin or Levaquin, are the mainstay treatment of bacterial sinusitis. Antibiotics are often prescribed along with adjunctive therapies including decongestants, mucus-thinning agents and steroids, which are powerful antiinflammatory drugs. In patients who suffer from chronic sinusitis, symptoms are likely to recur even after all the aforementioned actions have been taken if the underlying problem has not been properly addressed. For example, if the underlying problem is allergic disease, better control of allergies can help decrease the severity and recurrence of sinusitis. Allergies are usually managed by avoidance of known triggers and/or use of allergy medications such as steroid nasal sprays and antihistamines. Some allergy sufferers may even require desensitizing allergy shots to combat their condition. Another example of an underlying element that may contribute to persistent sinusitis is anatomic or structural abnormalities that hinder ventilation of the sinuses. Conditions such as a deviated nasal septum or nasal polyps may not respond adequately to medications alone and, in some instances, may only be corrected through surgery.

Unfortunately, some patients will continue to suffer from unrelenting sinusitis despite what is called “maximal medical therapy” which includes several rounds of antibiotics, administration of oral and nasal steroids, control of superimposed allergies and acid reflux and use of decongestants and mucus-thinning agents. These particular patients are usually referred to an ENT specialist for evaluation and consideration of possible surgical treatment. The goal of surgical intervention is to improve the ability of the involved sinuses to ventilate by widening their natural openings into the nasal cavity. This can be accomplished surgically in several ways, one of which is a newer, minimally invasive technique called balloon sinuplasty. This safe and effective procedure is a viable option for some chronic sinusitis patients, and in some cases, it can be performed without a trip to an operating room for general anesthesia.

In summation, sinusitis is a relatively common condition with varied causes that can negatively impact quality of life. While most cases can be managed well with control of underlying factors and use of both overthe-counter and prescription medications, evaluation by an ENT specialist is often required when these measures have proved unfruitful.

Dr. Chuka Ifeanyi, ENT Highland Clinic physician, is board-certified by the American Board of Otolaryngology. Dr. Ifeanyi specializes in the diagnosis and treatment of disorders affecting the ear, nose, throat, and the head and neck of both children and adults. Same-day appointments may be available for both new and established patient base. Dr. Ifeanyi can be reached at 318-798-4440 to schedule at his Highland Clinic Suite 206, or every other Thursday at the Minden Medical Center.