Sinusitis is an inflammation and infection of the paranasal sinuses that causes impaired sinus mucociliary clearance. It affects approximately 31 million adults and children in the United States. Sinusitis has many similar characteristics to rhinitis, and can also be called rhinosinusitis.

Sinusitis is most often caused by an upper respiratory tract infection or through bacterial infection (Streptococcus pneumoniae, Haemophilus influenzae, or by fungal or viral entities). This is followed by allergic rhinitis, dental infection or manipulation, and trauma to the sinuses. Disease of the anterior ethmoid-middle meatal complex (ostiomeatal complex) is the most frequent local cause of chronic sinusitis.

• Upper respiratory infections
• Allergic rhinitis
• Immunodeficiency, Kartagener's syndrome, and cystic fibrosis
• Nosocomial sinusitis from foreign nasal bodies
• Nasal polyps, nasal septal deviation, and spurs
• Anatomic abnormalities that narrow the ostiomeatal channels
• Cold air, cigarette smoke, decongestants, and metal vapors

• Inflammation and edema of nasal mucosa, purulent sinonasal secretion (yellow or green), or postnasal drip
• Headache, pain, sinus tenderness, or toothache
• Cough or pharyngitis
• Fever, in half of patients
• Loss of smell
• General malaise

• Upper respiratory tract infection (common cold)
• Tension and vascular headaches
• Meningitis
• Brain and epidural abscesses
• Viral, allergic, or vasomotor rhinitis
• Tumors or cysts

Physical findings may include tenderness, purulent sinonasal obstruction and secretion, and postnasal drip. Look for three of the following findings: maxillary toothache, colored nasal discharge, poor response to nasal decongestants, abnormal sinus transillumination, ­purulent secretions

• Culture and biopsy for chronic and fungal sinusitis
• Microscopic examination shows sheets of polymorphonuclear neutrophils as well as bacteria
• Skin test to determine underlying allergy
• Blood test to reveal immunoglobulin serum levels and antibody response to specific antigens (i.e., allergies)
• Nasopharyngeal culture

• Bacterial titers exceeding 1,000 CFU per ml, primarily S. pneumoniae, H. influenzae, and Branhamella (Moraxellla) catarrhalis for acute sinusitis
• Anaerobes of the Bacteroides, Fusobacterium, Streptococcus, Veillonella, and Corynebacterium species as well as anaerobic gram-positive cocci for chronic sinusitis (some studies show this to be inaccurate with anaerobes found in as few as 7.6% of cases)
• Gram-negative bacteria, such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter species for nosocomial sinusitis
• Normal ciliated epithelium replaced by stratified squamous epithelium in chronic sinusitis
• Goblet cell hyperplasia, mononuclear cell infiltration, and basement membrane thickening
• Edema, inflammation, and thickened mucosa

• Computed tomography (CT)—shows the ostiomeatal complex as well as other sinuses; evaluates disease, anatomic obstructions, fine bony structure, and soft-tissue complications; diagnoses fungal sinusitis
• Conventional sinus radiograph—diagnoses maxillary and frontal sinus disease; poor for ostiomeatal complex
• Flexible fiberoptic rhinoscopy—reveals purulent drainage in sinus ostia
• Transillumination—maxillary and frontal sinuses; often inaccurate

• Endoscopy exam—differentiates between purulence and allergic mucosal thickening; reveals ostiomeatal disease
• Irrigation of the maxillary antrum—distinguishes between purulence and allergic mucosal thickening; identifies tumors

Nonsurgical treatment includes antibiotics, decongestants, avoiding allergens, steam or mist inhalation for drainage and symptom relief, and hydration to thin secretions. Surgical treatment for restoration of ventilation and mucociliary functioning is attempted when nonsurgical measures have failed.

• Antibiotics—For first cases of sinusitis, amoxicillin (500 mg tid) is generally used. With penicillin resistance and treatment failure, use broad-spectrum antibiotics such as cefuroxime (Ceftin, 250 to 500 mg bid), cefaclor (Ceclor, 500 mg bid), amoxicillin/clavulanic acid (Augmentin, 500 mg bid), clarithromycin (Biaxin, 250 to 500 mg bid), or an azithromycin (Zithromax) pack for patients allergic to penicillins. Antibiotics are taken for 10 to 14 days in acute cases and for up to six weeks in chronic cases.
• Decongestants—Oral decongestants, such as pseudoephedrine (60 mg tid to qid), cause urinary retention in older male patients; monitor their use with hypertensive patients. Nasal sprays, such as oxymetazoline (Afrin, tid), should be used for three to five days only; there is a risk of tachyphylaxis and rebound if used longer.
• Nasal steroid spray for allergic/chronic sinusitis (e.g., triamcinolone)

Surgical therapies include functional endoscopic surgery (FESS)—to remove diseased tissue (reduced comorbidity and damage to normal anatomy compared to external surgery); external surgery—for osteomyelitis, orbital or intracranial complications, and failure of FESS

A combination of physical medicine and herbal or homeopathic treatment is often effective for treating both acute and chronic rhinosinusitis.

• Vitamin C (1,000 mg tid), zinc (30 to 60 mg/day ), beta-carotene (15,000 IU/day) to support immunity.
• Bromelain (500 mg tid between meals) and quercetin (500 mg tid between meals) are anti-inflammatory
• Avoid mucus-producing foods, such as dairy products, bananas and any known allergens. Drink plenty of fluids. Decrease sugar intake.

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Wild indigo (Baptisia tinctoria)—specific for upper respiratory and sinus infections, increases phagocytosis
• Eyebright (Euphrasia officinalis)—anticatarrhal, specific for sinus
• Licorice (Glycyrrhiza glabra)—antiviral, soothing, especially with exhaustion and/or heartburn; avoid with hypertension
• Coneflower (Echinacea purpurea)—stimulates the immune system
• Goldenseal (Hydrastis canadensis)—antiviral, antibacterial, digestive tonic

A combination of all of the above herbs, equal parts, may be very effective. 1 cup tea or 30 to 60 drops tincture every two to four hours. May add:

• Jamaica dogwood (Piscidia piscipula) or St. John's wort (Hypericum perforatum), in equal parts, may be added for pain relief.
• Garlic/Ginger tea—two to three cloves of garlic (Allium sativum) and two to three slices of fresh ginger (Zingiber officinale). Steep 5 to 15 minutes and drink, breathing in the steam. Stimulates immune system and stimulates drainage, prevents sinus problems from extending into lungs.
• Essential oils for bath or steam. For a steam, place 2 to 5 drops in a pot, bring to a simmer and hold head over the pot. For a bath, add 5 to 10 drops of oil to the bath. Eucalyptus (Eucalyptus globulus), lavender (Lavandula angustifolia), and thyme (Thymus vulgaris) are specific for upper-respiratory infections. Lavender and rosemary (Rosmarinus officinalis) are also calming. These essential oils have antiseptic properties.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Arsenicum album for sinusitis with watery, excoriating discharge
• Kali bichromicum for sinusitis with thick "gluey" discharge, postnasal drip, especially with ulceration
• Pulsatilla for thick, bland, greenish discharge, especially if patient is weepy and is not thirsty
• Nux vomica for sinusitis with coryza, and a stopped up feeling, especially if patient is impatient and/or angry

• Contrast hydrotherapy. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. Use washcloths over the sinus area. Alternate three minutes hot with one minute cold. Repeat three times to complete one set. Do two to three sets/day.
• Nasal lavage to shrink membranes/increase drainage. Mix salt and water to taste like tears. Rinse each nostril by holding head over sink and letting water run from upper nostril to lower nostril. Keep nostrils lower than throat to prevent salt water draining into back of throat.
• Craniosacral therapy (osteopathic/chiropractic) can be very effective at decreasing the frequency of infections/headaches.

May be helpful for both acute and chronic sinusitis.

Patients not responding to therapy should see an otolaryngologist.

Fungal sinusitis should be suspected for patients who do not respond to antibiotic therapy and for immunocompromised patients.

Avoid known allergens, cold air, cigarette smoke, topical drugs, swimming, and metal vapors, and follow a diet that reduces mucus production.

Orbital infection from acute ethmoid sinusitis requires hospitalization, surgical drainage, and intravenous culture-specific antibiotics.

• Osteomyelitis of the frontal bones (Pott's puffy tumor), especially in children
• Intracranial spread of infection results in meningitis, subdural empyema, and abscesses; male adolescents are most at risk.
• Sphenoid sinusitis—delayed diagnosis is associated with serious morbidity and mortality.
• Otitis media—frequently present with children
• Abscess—extradural, subdural, brain, or retrobulbar

An acute sinus infection lasts no longer than 8 weeks; a chronic sinus infection lasts for at least 4 weeks after initiation of treatment.

Tetracycline is contraindicated in pregnancy.

Barkin R, Rosen P, eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1996.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:122-123.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:684-685.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:286-290.

Middleton E, ed. Allergy: Principles and Practice. 5th ed. St. Louis, Mo: Mosby-Year Book; 1998.

Rakel RE. Conn's Current Therapy. 50th ed. Philadelphia, Pa: WB Saunders Co; 1998.