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Recurrent Acute Sinusitis

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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.

Are all sinus infections from bacteria?

No, most sinus infections start from viral infections (like the cold, flu, various rhinoviruses or coronaviruses). Many families with young children will see an uptick in sinus infections as their kids are bringing ‘crud’ home from school and daycare.

Can you prevent sinus infections with antibiotics?

Tough question. It is usually not recommended to try and prevent a sinus infection ahead of time by taking an antibiotic. There are some cases for certain immune system weaknesses where we might do this, but for the average person we should not do this.

Will surgery prevent sinus infections?

The severity and the frequency of sinus infections can be reduced with surgery or balloon sinuplasty treatments if you are someone getting 4 or more sinus infections yearly. We fully expect that a normal healthy person will get 2 or 3 mild cold viruses each year which will cause sinus problems for a few days then clear up. Surgery helps patients who dont clera viruses quickly.

Can’t you just figure out the bacteria and kill it?

Sort-of! We try! But we know there are many factors that lead to infections. Your own body’s inflammatory system is often as much to blame as the actual bacteria (fact: we can treat a sinus infection with a strong immune system blocker and you will feel better faster than with an antibiotic, but the effect is not lasting). We use advanced testing in the office to try and find the bacterial culprit, but sometimes naming the bacteria just doesn’t matter much.

Do you see patients with acute sinus infections?

Yes! We usually have time, and have slots available on the schedule either with doctors or the physician assistants to see new sinus infections. Give us a call!