Given the myriad of tiny structures and narrow passageways inside your nose and sinuses, it shouldn’t be surprising that even a small change in the interior layout of your Nasal House can have significant effects on sinus function.

Let’s take a look at some of the anatomical problems that can trigger sinus infections.

The Deviated Septum

The septum is a thin partition made of flexible cartilage in front and bone in back that divides the nose in half. While it’s rare to have a perfectly straight septum, usually the bend is minor and inconsequential.

However, if the bend is significant what’s known as a deviated septum it can block breathing or the sinus ostia, leading to nasal congestion and infections (see Figure below).

How do you get a deviated septum? There are two ways. Some people are born with one. As a baby travels down the birth canal, its head rotates, compressing the nose to one side.

It’s not uncommon for the soft cartilage in the front of the septum to get pushed off the bony groove on which it rests and become deviated, blocking one nostril.

If the deviation is severe, an ENT specialist may be called on to reposition it within the first days of life, but in most cases, doctors take a wait-and-see approach. The other cause of a deviated septum is a blow to the nose.

Often this trauma occurs during childhood, when the nasal bones are still relatively soft. All it takes is a face-first fall, a ball hitting the nose, or a collision with the head of a sibling while horsing around, to name only a few possibilities.

A deviated septum can also occur in adulthood, as a result of nasal trauma during sports, auto accidents, and the like. Regardless of when or how the trauma occurred, problems from a deviated septum often do not become apparent for many years.

As a person ages, the ligaments that support the nose and septum become more lax, so the deviation tends to become more severe. Eventually, breathing becomes difficult to the point where it interferes with daily activity or sleeping, and the person seeks a doctor’s advice.

In most cases, a deviated septum affects one side of the nose more than the other. Remember how the nasal cycle causes the side of the nose you breathe out of to switch back and forth about every six hours?

Well, a person whose septum deviates to the right will have more difficulty breathing through the right nostril than the left most of the time. Diagnosis of a deviated septum is relatively straightforward and can be made by an ENT specialist on a routine nasal exam.

A sinus CT scan also shows the shape of the septum. But even if the septum is obviously crooked, steroid sprays and decongestants may be all that’s needed to relieve congestion, especially if the deviation exists in conjunction with allergies or other causes of nasal swelling.

If medications don’t work, then an ENT specialist can do a surgical procedure called a septoplasty, which is performed under either local or general anesthesia.

The surgeon makes an incision just inside the nostril, temporarily lifts the mucous membranes on the septum, and shaves down or removes the portion of the cartilage and bone that’s deviated.

Sometimes the surgeon places dissolvable stitches or inserts nasal packing at the conclusion of the procedure. After surgery, there’s usually some swelling, which recedes over the next week or two. Complications are rare but may include bleeding and infection.

Enlarged Turbinates

As you may recall, turbinates are thin plates of bone covered by mucous membranes that warm and humidify the air we breathe. There are three pairs of turbinates: the inferior, middle, and superior.

The inferior turbinates are the largest. Very large inferior turbinates are a common cause of blocked breathing. They usually get that way when years of nasal allergies result in permanent swelling of the turbinate mucous membranes, a condition called turbinate hypertrophy.

The inferior turbinates can be shrunk with an electric needle in a process called cauterization. There’s also a relatively new option known as radiofrequency turbinate reduction, which delivers a measured dose of electrical energy to heat and shrink swollen turbinate tissue.

Cauterization and radiofrequency turbinate reduction are usually done under local anesthesia. Alternatively, enlarged inferior turbinates can be remedied with a surgical procedure known as turbinectomy, in which a portion of the obstructing turbinate bone and/or surrounding mucous membrane is removed.

With the patient under general anesthesia, a surgeon trims the turbinates with a surgical scissors or a microdebrider. The middle turbinates also can become large and block breathing.

Unlike the inferior turbinates, however, their growth is usually the result of enlargement of the bone, not the membranes. The turbinate bone expands when an air-filled compartment develops inside of it.

A widened middle turbinate, referred to as a concha bullosa, can compress the adjacent OMC, leading to recurrent bouts of sinusitis. Enlarged middle turbinates that are believed to be causing sinusitis are often trimmed or removed during sinus surgery.

Although turbinate reduction can provide tremendous benefit, it can actually make things worse if overdone.

Empty Nose Syndrome

In the past, it was fairly routine for ENT doctors to remove the entire inferior turbinates during surgery, and they occasionally removed the middle and superior turbinates as well. We know now that removing too much turbinate bone and tissue from inside the nose can cause a troubling phenomenon called empty nose syndrome (ENS).

To avoid this disorder, surgeons today are much more likely to leave the turbinates or at least a portion of them. Nevertheless, some people who have had extensive nasal surgery struggle with ENS, which has several symptoms. Without turbinates, incoming air remains dry.

Mucus tends to thicken and form crusts that are prime targets for bacterial overgrowth, leading to inflammation and infection. But the hallmark of ENS is a sense that you’re not breathing well through your nose even though you really are.

Turbinates provide resistance to incoming air, so their absence prompts a disquieting feeling that you’re not inhaling enough air. Paradoxically, people with ENS often say they feel congested, when in reality the problem is too much air flow. Treatment involves keeping the nasal passages moist to ease the dryness-related symptoms.

Saline irrigation should be done several times a day and can be supplemented with moisturizing nasal sprays. Infections usually can be kept to a minimum by applying an antibiotic ointment once or twice a day.

Eustachian

Tube Dysfunction Because the ears, nose, and throat are all connected, it’s not uncommon for problems in one area to spill over into another. One example is Eustachian tube dysfunction (ETD). Eustachian tubes are narrow passageways that connect the inside of the ears to the back of the nose in an area known as the nasopharynx.

These tubes equalize the pressure between your ears and the outside atmosphere. When you feel your ears popping in an elevator or on an airplane, that’s your Eustachian tubes opening and closing. ETD occurs when the Eustachian tubes become blocked and don’t open properly.

It can cause a buildup of pressure in the ears, leading to a sense of blockage, decreased hearing, and pain. This condition is likely to occur when you’re flying while you have a cold and the plane begins to descend.

However, anything that causes the inside of your nose to swell, including allergies and sinusitis, can also cause the Eustachian tubes to swell shut, leading to ETD. With sinusitis, the increased mucus produced during an infection typically drains over the Eustachian tubes as it flows from the nose into the throat.

This bacteria-laden drainage causes membranes that surround the Eustachian tubes to become inflamed, which prevents the tubes from opening.

If fluid builds up in the ear, you can develop an ear infection on top of the sinus infection. The same antibiotics prescribed to treat sinus infections usually take care of ear infections as well.

In severe cases of ETD, a surgeon can insert tiny ventilation tubes made of plastic or metal through the eardrums to drain fluid and equalize pressure inside the ear. This procedure is commonly done in children with recurrent ear infections.

A new surgery called Eustachian tuboplasty, in which the opening to the Eustachian tubes in the back of the nose is enlarged with a laser or microdebrider, is now being evaluated for the treatment of ETD.

Triad Asthma

This disease gets its name from its three associated problems: asthma, aspirin sensitivity, and nasal polyps. Triad asthma, which is also referred to as Samter’s triad or aspirin-induced asthma, is a relatively common disorder, thought to occur in up to 10 percent of those with asthma.

People with triad asthma have an overactive enzyme that leads to chronic inflammation of the mucous membranes in the sinuses and lungs. This enzyme, called 5-lipoxygenase, results in the overproduction of certain inflammation-causing substances called leukotrienes.

Although those with triad asthma do not have a true allergy to aspirin in the sense of an immune-triggered response, ingestion of even one aspirin can cause a serious asthma attack. Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin) or naproxen (Aleve), can also trigger an attack, but it’s usually less severe.

This disease typically arises in adults who were not previously known to be aspirin-sensitive, so anyone with nasal polyps who hasn’t taken over-the-counter painkillers since childhood should do so with extreme caution.

The polyps associated with triad asthma usually grow so large that they obstruct nasal breathing and impair sense of smell. Although postnasal drainage is typically present, pain is usually minimal or absent.

The standard regimen of sinusitis medications, including steroid sprays, are effective in some patients, but most require oral steroids, such as prednisone, to shrink their polyps significantly.

Many of those with triad asthma elect to undergo surgery to remove the polyps and improve their quality of life. But no matter the treatment, the polyps usually regrow, requiring future courses of oral steroids and/or surgery.

Vacuum Sinusitis

Vacuum sinusitis is a peculiar ailment in which a person seems to develop sinusitis symptoms without having an infection. We’re not even 100 percent sure it exists, but we do know people sometimes have:

• Symptoms of sinusitis, particularly facial pain, which temporarily get better when they take sinus medications
• A normal CT scan that shows no obstructions of sinus ostia

One possible explanation is that these patients actually have intermittent blockage one day the doors are shut, the next they’re open, and the next after that they’re shut again. So a CT scan taken on a day when the ostia happen to be open will not show an obstruction.

In these patients, when the ostia shut, it’s thought that the interior lining of the sinuses absorbs the oxygen in the sinuses. The resulting negative pressure forms a vacuum in the sinuses that causes pain.

Because vacuum sinusitis is not well understood, ENT doctors are generally reluctant to operate on patients who have normal CT scans. Instead, we usually try steroids and decongestants.

In addition, we look for another diagnosis that may be causing sinusitis-like symptoms, such as migraines, neuritis, or neuralgia.

Sinus Tumors

People commonly worry about tumors when they get sick it’s human nature. When it comes to sinus tumors, there are three important facts to keep in mind. First, they’re extremely rare. Second, when they do occur, they’re nearly always benign.

Third, both benign and malignant (meaning cancerous) sinus tumors usually are detected early because they block the nose and sinuses, causing the same symptoms as an infection.

A benign tumor is an abnormal mass that enlarges but does not spread (or metastasize) to other areas of the body. Note that benign is not synonymous with harmless. Just by getting bigger, a benign sinus tumor can do a lot of damage.

In rare cases, if left untreated, it can even be fatal. The most common benign tumor of the sinuses is known as an inverted papilloma. This type of tumor can usually be completely removed with surgery through the nostril using an endoscope.

To ensure that 100 percent of the tumor is removed, the surgeon cuts out both the tumor and some healthy surrounding tissue; if even one cell is left behind, the tumor will grow back.

We don’t know what causes benign tumors to develop. A malignant tumor is a growth that will metastasize to distant sites in the body. Cancerous tumors are often evident on a CT scan because of their destructive appearance, such as erosion through the bony sinus walls.

There are several types of malignant sinus tumors, including squamous cell carcinoma (the type associated with most lung cancers) and adenocarcinoma (the type found in most breast cancers).

Studies have shown that smokers and people whose work exposes them to wood dust, leather, glue, nickel, or chromium have an elevated risk for malignant sinus tumors.

These malignancies are usually treated with a combination of surgery and radiation. When detected early, many cancerous sinus tumors can be successfully treated and do not return.

Next, we’ll take a look at some special circumstances of sinusitis, such as sinus infections in children and pregnant women.