As you’ve seen, sinusitis can be either acute or chronic. That’s pretty simple. But what if I told you that chronic sinusitis is actually not one but five or ten or even twenty-five different diseases?

It complicates matters, but it’s true. While modern medicine has a long way to go before we understand chronic sinusitis as well as we do acute sinusitis, it’s increasingly clear that chronic sinusitis is a spectrum of diseases.

I like to use the term Sinusitis Spectrum to explain why patients with chronic sinusitis respond so differently to treatment. A medication that benefits one person may have little or no effect on another. And the same surgery that permanently cures one person may need to be repeated a few years later on another.

Figuring out where you fit on the Sinusitis Spectrum can help you put your own case into perspective. Once you’ve done that, you can focus on the treatments most likely to benefit you.

Locals, Systemics, and Intermediates

For simplicity’s sake, the Sinusitis Spectrum breaks down into three general categories (see Figure below). On one end of the spectrum are people whose sinusitis stems from physical abnormalities within their nasal cavity or sinuses. People in this group have a site-specific, localized problem, so let’s call them Locals.

Everyone with sinusitis can be found somewhere along the Sinusitis Spectrum, based on the cause and severity of his or her disease. The spectrum is divided into three main groups—Locals, Intermediates, and Systemics—with each group responding to the various treatments for sinusitis in different ways.

On the opposite end of the spectrum are those whose sinusitis can be traced to a more general disorder affecting other areas of their bodies, not just their nose and sinuses. You might think of your body as a large system, so we’ll call them Systemics.

In between these two extremes lies a group whose problem is more difficult to pin down. They may have both problems— physical abnormalities within their nasal cavity and malfunctions affecting their entire bodies—or they may have neither.

Often, the source of their problem cannot be easily traced. Conceptually, people in this group fall in between Locals and Systemics, so let’s call them Intermediates. Now let’s examine these groups in more depth and also look at which treatments are most likely to benefit each group.

Locals

Locals have a straightforward anatomical problem. Examples include people whose sinusitis can be traced to any of the following:

• a localized OMC obstruction
• a deviated septum
• an enlarged middle turbinate (also known as a concha bullosa)
• dental problems, such as an infected tooth root that spreads to the maxillary sinus

Signs and Symptoms. You may be in this group if:

• you have symptoms on one side of the face or head and not the other
• your postnasal drip and other symptoms completely clear between sinus infections
• you have no history of allergies or have had negative allergy tests

Treatment. Medication can be effective treatment for Locals, but the symptoms often return once medication is stopped (see Figure below).

That’s because medicine does not address the underlying anatomical problem that caused the infection. If medications don’t work, or if you do not wish to take them indefinitely, surgery to correct the anatomical problem is often effective.

Such treatment might include a procedure known as a septoplasty to straighten the deviated septum, extraction of an infected tooth, or sinus surgery to clear an obstruction of the OMC. Locals are more likely than those with other forms of sinusitis to be cured by surgery; for this reason, it’s often recommended early in the treatment course if nasal endoscopy or CT scans reveal an anatomical defect.

Systemics

Like an engine that idles too fast or too slow, the airway system among Systemics is off kilter. Some stimulus, usually unknown, causes chronic inflammation of the mucous membranes lining the nose and sinuses.

This chronic inflammation often affects the lining of the lungs as well, which is why so many Systemics also have asthma (up to 30 percent). Viewed under a microscope, inflammation of the mucous membranes in the lungs is so similar to that of the nose and sinuses that Systemics may have what can be referred to as one airway disease.

In other words, the underlying process that causes their sinusitis is also causing their asthma. There is a major difference, however, between the way the mucous membranes of the sinuses and the lungs react to chronic inflammation.

For unknown reasons, inflammation in the sinuses leads to the formation of polyps. These grapelike growths, which arise from the inflamed lining of the nose and sinuses, can be quite large in Systemics, causing significant congestion.

Examples of Systemics include people with any of the following:

• CT scans showing blockage or membrane swelling in all sinuses
• polyps on both sides of the nose
• triad asthma, a condition in which patients have asthma, nasal polyps, and an allergy to aspirin

Signs and Symptoms. You may be in this group if:

• you have congestion and pressure on both sides of your face
• you have difficulty breathing through both sides of your nose
• your postnasal drip is thick, yellow or green mucus, and it never seems to go away
• you have lost your sense of smell
• you have severe allergies

Treatment. Systemics are the most difficult group to treat. Surgery to remove polyps and other obstructions may offer temporary relief but often needs to be repeated when the obstruction recurs.

Medications such as oral steroids often help, but they may cause intolerable side effects. In many cases, the challenge is finding a regimen that can be followed in the long term without causing unwelcome side effects.

Intermediates

Intermediates are people who do not fit neatly into either of the two other groups. Examples of Intermediates include people with any of the following:

• CT scans showing involvement of sinuses on both sides of the face, but not all of the sinuses

• allergies severe enough to have required allergy shots at some time in their lives

• allergies in combination with an anatomical obstruction, such as a deviated septum or an enlarged middle turbinate (concha bullosa)

• frequent flare-ups of symptoms during allergy season or in the workplace, suggesting an environmental trigger

Signs and Symptoms. You may be in this group if:

• your nasal obstruction and symptoms alternate from one side of the face to the other
• you have intermittent postnasal drip that becomes thick and discolored during infections
• your symptoms get better but don’t always clear completely between sinus infections

Treatment. Treatment for Intermediates varies depending on where you fit along the Sinusitis Spectrum—in other words, whether you’re closer to Locals or Systemics.

Often, numerous treatment approaches are tried before finding one that is moderately successful. Surgery typically offers mixed results; in most patients, it reduces the frequency and severity of sinus infections but does not provide a full cure.

Don’t worry if you don’t match all the traits for one of the three categories; very few people do. View Table below as a guideline to help you get an idea of your place in the Sinusitis Spectrum. If you’re still uncertain, your doctor may be able to provide guidance.

Symptoms and Treatments Across the Sinusitis Spectrum.

	Locals	Intermediates	Systemics
Symptom	Symptom’s Presence, Severity, and/or Frequency
Nasal obstruction	On one side only	Alternating from side to side	On both sides
Facial pain/ headache	On side or both	On both sides; moderate to severe pain	On both sides; mild to severe pain
Postnasal drainage	Only during infections	Usually present; worse during infections	Constant
Environmental allergies	None or mild	Often have allergies	Often have allergies
Aspirin allergy	No	No	Yes, if triad asthma
Asthma	No	Sometimes	Often
Impaired sense of smell	No	No or mild	Often, sometimes severely
Polyps	None or small; localized	Intermediate size; involving mainly ethmoid region	Large, diffuse; involving all sinuses
Systemics	Location of Disease
	On one side or limited disease on both sides	On both sides, but not all sinuses	All sinuses
Treatment	Is This Treatment Likely to Prove Beneficial?
Nasal irrigation	Yes	Yes	Yes
Use of indoor humidifier during winter months	No	Yes	Yes
Nonantibiotic sinus medications (decongestants, antihistamines, mucus-thinning agents)	May provide partial relief	May provide marked relief, especially if allergies present	May provide partial relief
Nasal steroid sprays	No	Yes, especially if allergies present	Yes
Antibiotics	Yes, but infection may recur months later	Yes, but infection may return weeks later	Yes, but infection often recurs immediately after stopping
Oral steroids	No	May benefit	Yes
Surgery	Often effective	Usually effective, but not curative	Sometimes effective, but often needs to be repeated

Treatment Plan

Decades from now, I expect that most patients with chronic sinusitis will be able to undergo a simple blood test and genetic analysis to determine the precise type of sinusitis they have.

Then we’ll be able to use gene therapy to replace a missing enzyme or add a strand of deleted DNA, eliminating the inflammatory process that serves as the root cause of most cases of sinusitis.

But for now, we know very little about the underlying causes of chronic sinusitis. We tend to lump all sinusitis patients together and treat them with the same regimens, even though they have many different diseases.

Until we understand the answers to fundamental questions about the underlying causes of sinusitis, the best thing you can do to control your symptoms is develop a treatment plan based on where you fit on the Sinusitis Spectrum.

Some of these treatments can be self-administered. Others need to be done in cooperation with your doctor. Next we’ll explore one of the simplest and most effective treatments for sinusitis: nasal irrigation.