Donald Messinger is a corrections officer, but for several years, he was a prisoner to the pain of sinusitis. About eight years ago, Mr. Messinger began having severe nasal congestion and eventually lost his sense of smell. "My nose felt closed up, and I couldn't take a deep breath unless I breathed through my mouth," he recalls. "It was more than uncomfortable. It was difficult to live with."

For years, Mr. Messinger went to an allergist, who treated him for grass, tree, and pollen allergies. When his congestion was particularly bad, the doctor prescribed steroids and an anti-inflammatory nasal spray. "He felt that these medicines would help, but they never really did," he says.  

Ultimately, the allergist ordered a computed tomography (CT) scan, which showed that Mr. Messinger's sinuses were filled with polyps, small sacs formed from inflamed mucous. But there was no recommendation for follow-up treatment. Frustrated,Mr. Messinger turned to Dr. Arie Rosen, a board-certified otolaryngologist at University Hospital and associate professor of surgery at New Jersey Medical School. The ears, nose, and throat (ENT) specialist ordered another CT scan, which confirmed the presence of polyps. Dr. Rosen recommended surgery for their removal. In Fall 2000, Mr. Messinger underwent the same-day procedure, and after about one week, he was back to work and breathing much easier.  

"The difference is like night and day," says the 58-year-old Union County man, who realizes that, despite surgery, his polyps may come back. "Some days I have more congestion than others, but it's very minor--nothing like before."

Sinusitis, in the simplest terms, is an inflammation of the sinuses. When a sinus is blocked due to inflammation, it cannot drain properly.  Incidentally, many people envision their sinuses as the two triangular-shaped areas underneath the cheekbones. These air-filled pockets are the maxillary sinuses, but there are others: the ethmoid sinuses near the bridge of the nose; the frontal sinuses in the brow area; and the sphenoid sinuses located near the center of the skull. Sinusitis can occur in any of these sinuses, but is least likely to affect the sphenoid sinuses.

Sinusitis impairs the quality of many people's lives-about 37 million Americans each year. The facial pain and pressure of this sinus condition, along with the tiredness and irritability it can bring, is not soon forgotten.

One of the complexities of sinusitis is that other conditions have overlapping symptoms. Facial pain and pressure, nasal congestion, and headache can be due to allergies to molds or pollens; chronic rhinitis, an inflammation of the nasal lining; or even a common cold caused by a viral infection. On occasion, fungal infection can cause similar symptoms, as well.

"It is not always easy to distinguish symptoms of sinusitis from other conditions that may have similar symptoms without further testing. What someone thinks is a lingering cold might actually be sinusitis. For that reason many patients can have sinusitis for a long duration before being diagnosed accurately," says Dr. Rosen, named one of New York Magazine's "Best Doctors" this year. "Sinusitis can also be long in duration, lasting 10 days or more. What someone thinks is a lingering cold might actually be sinusitis." 

Doctors make a distinction between acute and chronic sinusitis. While there are different definitions, Dr. Rosen describes chronic sinusitis as recurrent bouts of acute sinusitis that result in permanent changes to the sinus lining. These changes can readily be detected by using a CT scan.

Sinusitis, as common as it is, can be difficult to diagnose. Often, people turn to a specialist after trying a course of treatment that doesn't make them feel better. "The best treatment can't help if the diagnosis is not correct," says Dr. Rosen. "ENTs have a thorough understanding of the physiology of the sinuses and capability to examine them thoroughly, which can help detect any structural or other underlying conditions that may predispose patients to develop chronic sinusitis and have specific training in the diagnosis and management of problems involving the sinuses."

Sinusitis and Children

Children get a lot of upper respiratory infections (about 6 or 7 a year), which can make them susceptible to sinusitis. The symptoms are generally the same as those found in adults, but coughing is also common in youngsters with chronic sinusitis. Dr. Huma Quraishi, director of pediatric otolaryngology at University Hospital and an assistant professor of surgery at New Jersey Medical School, takes a "stepwise" approach to treating these young patients.

"When the sinusitis is chronic-there are three or four bouts of acute sinusitis that don't respond to antibiotics-we need to explore other causes. Allergies could be a factor, or there could be an underlying ciliary disorder, where the tiny hairs that move mucous along are not working properly. We also need to rule out cystic fibrosis or an immunoglobulin problem, which can make a child more susceptible to infection ," she says.

The next step typically isn't sinus surgery, but removal of the child's adenoid tissue, which is located at the back of the throat. Enlarged adenoids become reservoirs for bacteria and a possible contributing factor to the child's sinusitis. This same-day procedure, during which the sinuses may also be irrigated and a culture taken, is done under general anesthesia. There's a small risk of bleeding and infection.

When the adenoidectomy doesn't prove beneficial, then it's time to consider sinus surgery. Dr. Quraishi says the procedure is reserved for the most severe cases because the child's face is still developing, and it's not known how overly aggressive sinus surgery affects mid-face growth. That's why she takes a conservative approach during surgery, removing only the minimal amount of sinus lining. Still, says the board-certified otolaryngologist, the results after surgery are usually quite good.

"Not every child with a runny nose is going to get a CT scan or have surgery," says Dr. Quraishi. "However, there is definitely a role for sinus surgery in children, and we at University Hospital have the expertise to do it."

The Simplest Can Be The Best

When it comes to treating acute sinusitis, sometimes the simplest remedies can be very beneficial. Humidifying the air and using a saline nasal spray can keep passageways moist. Cigarette smoke can irritate the sinus linings, so stopping smoking can be helpful, too. Over-the-counter (OTC) antihistamines and decongestants often relieve the symptoms of sinusitis, but their long-term use isn't recommended. Decongestant nasal sprays can lead to "rebound" congestion, and antihistamines can dry out sensitive tissue.

And while OTCs can make the patient feel better temporarily, they don't eliminate the cause of sinusitis. Usually, it's a bacterial infection that requires a round of an antibiotic, but sinusitis can also be triggered by an allergy or, more rarely, a fungal infection. Once the cause of their sinusitis is identified, the overwhelming majority of sinusitis sufferers can be helped by the appropriate medicine.

However, a small percentage of people with chronic sinusitis don't respond well to antibiotics or other medical therapies. Surgery is considered for them only after a complete medical history, a thorough physical exam, and imaging studies have been conducted and all medical options have been exhausted.

When Surgery is Recommended

Thanks to new surgical techniques and technology, sinus surgery today is less invasive, carries fewer risks, and is more precise than earlier procedures. Functional endoscopic sinus surgery ( or FESS, as it is more commonly known) uses a thin, telescope-like instrument to view the sinuses; other instruments are manipulated by the surgeon to "shave" away and remove diseased areas of the sinuses.

That may sound simple, but the surgeon is operating in a very small and critical area near the brain and the eyes. With the slightest misstep, there's potential to cause a cerebral spinal fluid leak, which can lead to meningitis, or serious visual impairment. Specially trained surgeons like Dr. Rosen and Dr. Quraishi incorporate image-guided surgical technology when operating on the sinuses. Image guidance uses a computer and three-dimensional CT scans to precisely and accurately pinpoint areas and provide a "road map" for the surgeon during surgery. "Image guidance can help to reduce the potential risks involved with endoscopic sinus surgery in some cases, enabling us to directly treat the diseased area," says Dr. Rosen.

Like Dr. Quraishi, Dr. Rosen takes a conservative approach to sinus surgery. "Removing too much of the sinus lining can leave patients with a chronic problem that can't be reversed by additional surgery," he says. "There's a fine line between restoring the natural function of the sinuses and removing excess lining."

FESS is a same-day procedure that most patients easily tolerate. There may be nasal crusting and headaches for a few days following surgery, and usually nasal packing is not needed. Patients with desk jobs can typically go back to work a week after the procedure; those with more physically demanding careers return in about three weeks. In addition to the rare but serious risks of damage to the brain or eyes, FESS also carries possible post-operative risks of bleeding and infection.

FESS can bring tremendous relief to patients with chronic sinusitis and, for those people who also have asthma, can reduce the frequency and severity of that condition. However, it's often not a one-time solution. "The surgery resolves problems within the sinuses, but it is not a cure for chronic sinusitis itself or nasal polyps. As with other chronic conditions, over time, patients can occasionally expect to have additional revision surgery," explains Dr. Rosen, who often performs these "repeat" procedures. "But even one successful surgery can offer dramatic improvement and add to the quality of a patient's life."

You can find Drs. Quraishi and Rosen, along with hundreds of other medical experts, at our online Physician/Services Directory: www.TheUniversityHospital.com

Images courtesy of the American Academy of Otolaryngology.