Chronic Sinusitis

When you get a sinus infection, one of two things happens: you get better or you don’t. If your symptoms are gone within a month, or even two or three, you had acute sinusitis.

But if the pain, congestion, drainage, or other symptoms last longer than three months, you have chronic sinusitis. What’s so magical about the three-month time period?

Nothing. It’s just an arbitrary cutoff that experts in the field have agreed to. If a health problem persists for longer than three months, it seems reasonable to label it as chronic. This time frame, not the cause or symptoms, is the main thing that distinguishes acute sinusitis from chronic sinusitis.

The mechanics of the infection and the way you feel when you’re sick are essentially the same for both. Aside from the duration, about the only significant difference is that people with acute sinusitis are more likely to run a fever. In practical terms, however, there is a real difference.

People who have acute sinusitis tend not to think of themselves as having a serious problem. They have an episode of sinusitis, which slows them down for a few days or weeks, but then it goes away, and they get on with their lives.

People with chronic sinusitis, on the other hand, are engaged in an ongoing struggle. Their sinusitis symptoms persist or keep returning, which can have a major impact on their overall health and quality of life.

How a Common Cold Can Lead to Sinusitis

We have a good understanding of what causes acute sinusitis and how to treat it. Most cases are preceded by a bad cold, also known as an upper respiratory infection, or URI for short. Such colds are caused by viruses.

Although there are dozens of cold-causing viruses, rhinovirus (literally, “nose virus”) is a common culprit. Most of the time, the common cold goes away without medical treatment, and no further problems ensue.

But in a small percentage of cases less than 5 percent the cold transitions to acute sinusitis. This progression is most likely to occur in people who have narrow or blocked sinus ostia, a condition that predisposes them to sinusitis. Why?

Sinus drainage is often impaired during a cold because of swelling that occurs in the nasal cavity. When people with narrow ostia get a cold, their partially blocked sinuses may shut down completely, trapping mucus in the sinus. This scenario enables bacteria in the sinuses to multiply, causing an infection.

Acute sinusitis is usually caused by one of three bacteria: Streptococcus pneumoniae (also called pneumococcus), Haemophilus influenzae (H flu), and Moraxella catarrhalis (M cat). The infection sets off a chain of events that causes a constellation of symptoms, including facial pressure or headache, nasal drainage, and congestion.

By the time you develop acute sinusitis, the virus that caused the initial cold is usually no longer present (not that this makes you feel any better). Instead, you now have what’s known as a secondary infection, meaning an infection that’s bacterial rather than viral.

This secondary infection is likely to be more persistent than the initial infection, due to the vicious cycle of sinusitis. The bacteria cause swelling, which prevents the ostia from draining properly, which leads to more bacterial growth, which causes more swelling and the cycle repeats.

Despite bacteria’s propensity for reproducing, in most cases the body’s immune system successfully overcomes the infection, and sinusitis recedes before you go to a doctor or take medication. But if you notice no improvement after seven to ten days of having sinusitis, a call or visit to the doctor is advisable.

Easing Symptoms

Acute sinusitis will make you feel lousy for several days. Here are some things you can do to ease the discomfort while the infection runs its course:

  • Pick a painkiller. An analgesic relieves pain from sinus pressure and headache. I tell patients to take whichever pain reliever they’re accustomed to using: acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or aspirin can all help.
  • Don’t dry out. Avoid dehydration by drinking at least three extra glasses of water a day. This additional fluid intake thins the mucus trapped in your sinuses, enabling it to drain more easily.
  • Irrigate your nose. Rinsing your nasal passages with salt water, a practice known as nasal irrigation, can help drain infected mucus. I’ll discuss this technique in detail later.
  • Seek steam. Keeping your nasal passages moist also aids drainage. You can do this by carefully holding your face over a pot of boiling water and inhaling the steam. The steam from a bowl of chicken soup or hot tea may be beneficial. And a long, steamy shower can also help.
  • Use ice. Putting ice on the affected sinus may relieve pain. You can use an ice mask from a drugstore, a cold compress, or a bag of ice.

Medications for Acute Sinusitis

If you do go to the doctor with acute sinusitis, there’s a good chance you’ll end up taking two types of medicines: antibiotics and decongestants. If your doctor recommends only one medicine, it’s most likely to be an antibiotic.


Penicillin and amoxicillin were once effective antibiotics for the treatment of sinusitis. During the past thirty years, however, many bacteria have developed resistance to these antibiotics.

Although amoxicillin is still commonly prescribed as a first-line antibiotic for patients with acute sinusitis, it fails to clear the infection in up to 30 percent of cases. Many doctors now prescribe Augmentin, which contains amoxicillin and another medication, clavulanate.

The addition of clavulanate ensures elimination of resistant strains of H flu and M cat. A doctor may choose a different antibiotic for patients who are allergic to amoxicillin, such as azithromycin (Zithromax), clarithromycin (Biaxin), or telithromycin (Ketek).

Although most antibiotics are prescribed for ten days, azithromycin comes in both three-day (Tri-Pak) and five-day (Z-Pak) preparations; these are adequate for many cases of acute sinusitis.

Other commonly prescribed antibiotics include cefpodoxime (Vantin) and cefdinir (Omnicef ). I’ll discuss these and other antibiotics in more detail later.


Decongestants are available over the counter in two forms: nasal sprays (such as Afrin, Dristan, and Neo-Synephrine) and pills (such as Sudafed). They act by shrinking the swollen mucous membranes that line the nose and sinuses, particularly around the engorged turbinates and blocked ostia.

Ideally, a decongestant enables you to breathe better during an infection and hastens the end of your sickness by opening your ostia long enough to allow the infected mucus to drain.

Spray Decongestants

The advantage of sprays is that they offer near-instant relief. This is because their active ingredient (oxymetazoline or phenylephrine) is applied in high concentration directly to the affected area. However, sprays carry a major drawback, what’s known as rebound.

If they’re used too long, once the medication wears off, the swelling returns and now it’s even worse than when you started using the spray. For this reason, such nasal sprays should be used for no more than two or three days and only for acute infections, not chronic.

If rebound does develop, it can be very difficult to stop using nasal sprays. People can become dependent on them, needing a spray every few hours just to breathe through their noses, even during the night.

They may carry a bottle of nasal spray with them 24-7 and have extra bottles in their glove compartment, medicine cabinet, and nightstand. I’ve treated many patients who became hooked on these sprays for years, long after the initial infection for which they originally took the medication had left their body.

One way to reduce the risk of dependence is to use a shorteracting or milder spray. For instance, Neo-Synephrine, which is available in a mild-strength four-hour dose, is less likely to cause rebound than Afrin, which is only available in the longer-acting twelve-hour formula.

If you or someone you know does become dependent on nasal sprays, breaking the habit isn’t easy, but it can be done. Some people go cold turkey.

It may mean one or two sleepless nights, but after forty-eight hours, they’re breathing through their nose again without the need for sprays. If attempts to stop on your own fail, a doctor can prescribe a combination of steroid pills and nasal steroid sprays during the withdrawal period.

This combo blunts the rebound effect and can make recovery quite a bit easier. It’s worth noting that rebound is not just an issue for people with acute sinusitis.

Anyone with blocked nasal breathing, including people who just have a bad cold, can get hooked on nasal sprays. The bottom line is that they can help you get through the most difficult spell during a bout of nasal congestion, but you should stop using them after two or three days.

Oral Decongestants.

The active ingredient in oral decongestants is pseudoephedrine, which shrinks swollen mucous membranes. Because oral decongestants are not applied directly to the affected area, they are slower acting than sprays and do not provide the same immediate relief.

They can nonetheless be effective, draining infected mucus and enabling you to breathe more easily. Furthermore, you can take them for long periods without the risk of rebound.

But oral decongestants also have drawbacks. The medication in pills circulates through your entire body, so you may experience certain side effects.

Oral decongestants cause rapid heartbeat or palpitations in some people and are not recommended for those with hypertension. They also can make you feel jittery and cause insomnia. If that’s the case, it’s best to avoid taking them at night.

My Choice of Medications for Acute Sinusitis

When I see patients with their first episode of acute sinusitis, if their symptoms are relatively mild, I’ll usually prescribe a ten-day course of the antibiotic amoxicillin (250 mg three times a day).

If there’s not significant improvement in their discomfort within three to five days, I may switch them to Augmentin (500 mg twice a day for ten days), which will cover most resistant organisms.

If symptoms are severe at the outset or they’ve already been treated with a first-line antibiotic like amoxicillin and their symptoms returned, I’ll prescribe Augmentin. A five-day course of Zithromax (Z-Pak) or Ketek (Ketek Pak) is also very effective for acute sinusitis, but they’re more expensive.

I usually reserve these antibiotics, as well as Biaxin, for patients who cannot take amoxicillin or Augmentin because of a penicillin allergy. If facial pain or pressure is the main problem and the patient has little or no associated congestion, I’ll only prescribe an antibiotic.

If, however, the patient is having difficulty breathing through the nose, I’ll add a decongestant to the mix. For moderate congestion, I recommend over-the-counter Sudafed (a 30-mg pill three or four times a day) or an over-the-counter sinus medication that contains pseudoephedrine as one of its active ingredients.

For congestion so severe that a person has difficulty functioning during the day or sleeping at night, I’ll also recommend a decongestant spray, such as the four-hour dose of Neo-Synephrine (three times a day for two or three days).

Surgery for Acute Sinusitis?

Surgery is almost never used to treat acute sinusitis. However, in rare cases it may be necessary, particularly if the bacterial infection breaks through one of the bony sinus walls. The most common site for this complication to occur is at the very thin bone that separates the ethmoid sinus and the eye socket.

This bony portion is known as the lamina papyracea (literally, “paper plate” in Latin). An abscess forms near the eye and can lead to vision loss unless it is drained. An episode of acute sinusitis can be painful and frustrating.

But in most cases, it eventually goes away either with or without the aid of a physician. If the infection does not subside or keeps returning, then you may have chronic sinusitis.

Next, I’ll explain how chronic sinusitis is actually many different diseases what I call the Sinusitis Spectrum and help you develop a treatment plan that’s right for you.