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Recurrent Acute Sinusitis

Minor, early sinus infections are often called “acute sinusitis“.  Usually these infections last 10 days or less and are usually thought of as being caused by viruses rather than bacteria.  Sinus infections lasting longer than 10 days or infections that tend to worsen after an initial improvement are likely caused by bacteria and may require more specific medical treatment.  Typically these infections are treated with a first-line antibiotic such as amoxicillin (however recent investigations as to whether this is necessary have been reported lately).

Infections lasting several weeks begin to shift into the realm of chronic rhinosinusitis (CRS) where a specialists’ visit, imaging, or endoscopic nasal culture  may be helpful in sorting out the condition and making the best treatment recommendations.   While Acute vs Chronic Sinus Infection is fairly intuitive to sort out, there is an intermediate condition that remains frustrating and under-studied: Recurrent Acute Sinusitis (or Recurrent Acute Rhinosinusitis, RARS). RARS is basically the condition of relapsing episodes of short-lived sinus infections.

Studies have shown these can have quality-of-life and reduced productivity impairments similar to Chronic Rhinosinusitis.  Unlike CRS however, patients are more likely to be managed by recurring visits to their primary care provider or walk-in clinic.  Patients are also less likely to have inflammatory changes on CAT-scan imaging (in large part because most insurers pay for cat scanning only following a long course of antibiotics, which we know will temporarily resolve acute sinusitis, so the CAT scan may be timed to “miss” the sinus infection).   Every day I see patients who have been managed with recurring visits to the walk-in clinic, maybe 4-6 times annually for a short course of an antibiotic.  Usually these infections will clear quickly but then keep coming back, and back, and back…  

Treatment of RARS is somewhat open to debate.  Many studies find surgical treatment of RARS to have similar positive effects of surgical treatments for the more standard CRS.  A number of anatomic variants seen on CT scans are closely associated with the diagnosis of recurrent acute sinusitis (including Haller cells, variant middle turbinates, narrow sinus openings, and septal spurs).   The tool of balloon sinus dilation / sinuplasty and our subsequent improvement in other office sinus surgical techniques gives greater access to treatments for RARS.  Now we do not need to have the greater risk and recovery-time of endoscopic sinus surgery to adequately address these anatomic problems.  Balloon sinuplasty to treat RARS is very valuable at improving quality of life and reduced sick days, with only very small risks compared to more aggressive surgery and anesthesia.  

Most patients with recurrent acute sinusitis will benefit from an allergy evaluation as well.  Skin allergy testing can be useful at determining environmental triggers for nasal swelling, which may be the precursor for infection.   Nasal turbinates are normal structures within the nose that can become swollen and inflamed.  Turbinate hypertrophy and very reactive inferior turbinates create much of the misery of acute sinusitis on their own.  These structures can swell to triple their baseline size, create pressure in the face and make much drainage.  Turbinate swelling is what causes most of the nasal blockage felt with infections.