Acute sinusitis with severe frontal headache

By: Dr Cheong Jack Pein 

Updated : 25 Aug 2021

Sinusitis

Having a prolonged stuffy nose that doesn’t improve? You may have a sinus infection, also known as sinusitis.

What is sinusitis?

The sinuses are hollow air-filled empty spaces in the bones of the face and head that most likely exist to support and stabilize the brain in the event of head trauma. The sinuses are lined with a thin layer of cells that typically produces little amount of mucous to keep the sinuses healthy as well as flush away germs.

Sinusitis occurs when the lining of the sinuses are infected, become swollen or oedematous, and also produce excessive mucus discharge. The swollen lining tissues may disrupt the drainage of mucus.

 

Sinusitis can be classified into three groups, i.e., acute, subacute, and chronic sinusitis. Acute sinusitis usually lasts less than four weeks; subacute, 4-12 weeks; and chronic, if more than 12 weeks.

Symptoms of sinusitis are: 

  • Nasal blockage

  • Thick yellow mucus discharge from the nose or mucus that trickles down the back of the throat

  • Facial pain, pressure, or "fullness"

  • Altered sense of smell (hyposmia or cacosmia)


The term rhinosinusitis is considered more appropriate, where "rhino" indicates the "nose" since  nose cavity is almost always congested whenever the sinus cavity is inflamed.

Anatomy of Paranasal Sinuses

anatomy of paranasal sinuses

The paranasal sinuses lie within the head near the nose and around the eyes.
 

Four groups of paranasal sinuses :

  1. The ethmoidal sinuses are located between the eyes.

  2. The maxillary sinuses lie below the eyes.

  3. The sphenoidal sinuses lie behind the eyes.

  4. The frontal sinuses are located above the eyes.

What are the different ways the sinusitis can present?

Acute sinusitis:

This term describes an abrupt onset of flu symptoms such as drippy nose (post nasal throat stickiness or drips), stuffy nose, as well as facial pain (cheek and forehead) that does not go away after 10 days. It reacts well to decongestants as well as antibiotics.


Chronic sinusitis:

This term describes the collective symptoms of nasal congestion, watery drainage, facial pain/pressure, and also reduced sense of smell for at least 12 weeks.

Who are usually at risk of getting sinus infection?

Sinus infection can occur to any individual. Individuals with nasal allergies (allergic rhinitis), nasal polyposis, bronchial asthma and also abnormal nose structures such as turbinates hypertrophy or deviated nasal septum, are all more most likely to obtain sinus problems. Cigarette smoking is another important risk factor. 

What triggers sinusitis?

Sinusitis can be triggered by an infection with bacteria, virus or fungi that causes nose inflammation and also obstructs the sinuses flow. Common causes are:

  • Seasonal and nasal allergies, consisting of hatreds mold

  • Common cold or flu

  • Polyps (growths)

  • A deviated nose septum:

    • The septum is the cartilage that divide the nose into 2 cavities. A deviated septum to one side of the nose will reduce air flow on one side of the nose, which may contribute to the obstruction of the sinuses.

  • A weak body immune system caused by illness or medicines use (such as chemotherapy drugs).

  • Cigarette smoking enhances the risks for sinus infections.

illustration of deviated nasal septum causes sinusitis

What are the symptoms of sinusitis?

  • Post nasal drip (mucus drips down the throat or backflow)

  • Nasal discharge (thick yellow or green discharge from nose) 

  • Stuffy or blocked nose

  • Facial pain or pressure (particularly around & behind the eyes, forehead and cheek area), headache and pain in the teeth or ears

  • Bad breath (halitosis)

  • Cough (caused by mucus backflow into throat)

  • Tiredness/ fatigability

  • May have fever

Frontal headache symptom presenting in acute sinusitis.

Frontal Headache: Pressure-like pain especially over the forehead and around the eyes is the typical presenting symptom among individuals with acute sinus infection. 

What other conditions are often associated with chronic sinusitis?

Asthma:

The cellular linings of the nose as well as sinuses are similar to the linings of the lungs. Concerning one in 5 individuals with persistent rhinosinusitis also has asthma. Individuals probably to have bronchial asthma are those who have chronic rhinosinusitis and nasal polyps.
 

Aspirin intolerance:
Some individuals with chronic rhinosinusitis, nasal polyps, as well as bronchial asthma also have a condition called aspirin intolerance. The symptoms of aspirin intolerance which is the worsening of nose block and difficulty in breathing, in the first couple of hours after taking the aspirin, ibuprofen, naproxen, or various other nonsteroidal anti-inflammatory medicines (NSAIDs).

How does a doctor determine if you have sinus infection?

The medical diagnosis of a sinus infection (sinusitis) is usually based on your signs and symptoms and also a physical exam. If the illness continue and also isn't settled with medical treatment, a CT scan check might be done.

If a person has had 2 or more of the signs and symptoms provided above for a duration of at least three months, chronic rhinosinusitis is very likely. Additionally, there must be proof of sinus disease that can be seen on a sinus computed tomography (CT) scan or with an office procedure called sinus endoscopy.

A sinus CT scan is an imaging procedure that takes about 10 to 15 mins and involves a collection of radiographs of the head and face. The radiographs give an in-depth images of the sinus cellular linings and also the evidence of mucous or polyps within the sinus spaces.

 

In some cases direct sinus visualization with a tiny rigid or fiber-optic endoscope will certainly be done and also a sample swab might be taken for culture & antibiotic sensitivity test in laboratory.

Sinus endoscopy is an office procedure in which a clinician makes use of a thin tube attached to a camera to see inside the nose and sinus openings (meatuses). Endoscopy likewise permits the medical professional to take an example of mucus leaking from inside the sinuses to analyze under the microscopic lense. Samples of mucus from the nose (which are easier to acquire) are not agent of what is found in the sinuses.

diagnostic endoscopic examination of nose and sinuses

Picture shows the clinical examination of nose and sinuses assisted by a rigid endoscope. This procedure is often done as office-based and topical anaesthetic drug is always given.

Endoscopic view of left nose showing acute sinusitis condition.

Diagnostic endoscopic examination of left nasal cavity showing thick mucopurulent discharge from the left middle meatus.

Post sinus surgery FESS picture

Endoscopic picture of left nasal cavity showing the post-sinus surgery (FESS) changes. The picture shows the exteriorized ethmoid sinuses and frontal sinus drainage.

endoscopic view of Post sinus surgery.opened sphenoid sinus

Endoscopic view of post-sinus surgery showing the widened sphenoid sinus in the left nose.

Is chronic sinusitis curable?

Chronic rhinosinusitis can not be fully cured in a lot of instances, yet the symptoms can be managed so that they are not so prevalent. Patients with persistent rhinosinusitis usually need life-long treatment to maintain the symptoms free intervals. Several therapy are available, yet not all therapies are appropriate for all people.

Possible treatments for persistent rhinosinusitis include:

Lifestyle modification:--

Individuals with chronic rhinosinusitis who smoke cigarettes are advised to stop smoking. Smoking cigarettes could worsen the sinusitis illness. 

Individuals who have nasal allergic reactions may have to modify their home or work conditions to reduce direct exposure to the irritants, such as regular cleaning of bed sheets to eliminate dust mites.

Daily nasal saline washing:--

Many people with chronic rhinosinusitis agree that washing their nasal and sinus passages daily with saline water helps in reducing the signs and symptoms. Washing the nose prior to applying medications will allow nasal medications to be taken in easier.

A variety of devices, consisting of press bottles, syringes, and also Neti pots, might be utilized to carry out nasal wash. These products are easily purchased over the counter without doctors' prescriptions.

Steroid nasal sprays & nasal drops:--

All types of rhinosinusitis have some elements of inflammation (ie, irritation and swelling within nasal cavity), lots of patients will require medicines to reduce the inflammation.

Glucocorticoids (frequently called "steroids") are very reliable anti-inflammatory drugs. They additionally reduce mucous as well as help reduce any type of polyps that may appear. Making use of steroids in spray forms will directly deliver the drugs into the nose and likewise avoiding the requirement for oral steroids, which may cause more side effects in the remainder of the body where the steroids is not required.


If drops are prescribed, you should put them right into the nose while existing in details positions. In the United States, steroids do not come in nasal decreases, yet a medicine called budesonide (brand name Pulmicort Respules) can be liquified in saline as well as utilized as a nasal laundry.

Antibiotics:--

Although persistent rhinosinusitis is typically caused by inflammation as opposed to infection, sinus infections may occur and worsen the pre-existing sinus problems. Consequently, some individuals will require to take antibiotics. It is often advised to take a complete long course of antibiotics, which sometime may last for several weeks, to fully treat a persistent rhinosinusitis. However, prolonged use of antibiotic may lead to antibiotic resistance and other unwanted adverse effects arise from the drugs.

Should I have surgery for sinusitis? Is surgery compulsory for sinusitis?

The doctors usually try to get the signs and symptoms of chronic rhinosinusitis under control with medicine first, some individuals may require surgical treatment to re-establish the sinus flows and eliminate caught mucus or nasal polyps.

 

Indications of surgery will include the following:
 

  1. When chronic rhinosinusitis conditions do not get better with the medical therapies as pointed out above as well as there is evidence of continuing sinus problems on sinus computed tomography (CT), such as total obstruction of several sinuses.

  2. When the nasal polyps do not shrink or resolved with medical treatment.

  3. Patients with allergic fungal rhinosinusitis normally have one or even more sinuses that are completely obstructed on sinus CT scan. Often these sinuses show up on the CT filled with thick, thick mucus that is difficult to remove in any kind of various other means except surgery. During the surgery, sample mucus can be obtained to be sent for fungal study.

  4. When there is a serious deviation of the septum or various other sinus structural issues causing severe nose block or difficult sinus drainage.

  5. Surgery can be very beneficial in the therapy of chronic rhinosinusitis, although on its own, it is hardly ever sufficient to be considered as long-term solutions. The elements that triggered the sinus cellular linings to become inflamed and secrete extra mucus to begin with should still be resolved. Thus, most patients will need certain medications to control the nasal and sinus inflammation after a sinus surgery.

Take-home message

In majority of the cases, chronic rhinosinusitis cannot be cured, although medical therapy can considerably minimize the symptoms and thus improves quality of life. The ideal approach to treatment is to seek and identify the the trigger factors that directly lead to development of chronic rhinosinusitis. In most cases, post-surgery patients will need to continue the medications indefinitely in order to reduce the recurrences of the sinus problem.