Sinusitis diagnosis and treatment

- [Voiceover] So, let's talk about the diagnosis of sinusitis. Being a pretty common disease, you may have gone to the doctor yourself and had the diagnosis of sinusitis, and you may have noticed there weren't a lot of fancy tests or labs or anything like that. That's because, by and large, the diagnosis of sinusitis is made by symptoms alone. And I'll remind you, the main symptoms of sinusitis are nasal or postnasal drip, sinus pain or pressure, nasal congestion, or a decreased ability to smell. There are some other symptoms that may be present as well. For instance a cough, particularly a cough that's worse when lying down, a headache, ear pain or pressure, and fevers. So, if you're showing enough of these symptoms, you can be given the diagnosis of sinusitis. But sometimes the symptoms aren't entirely clear-cut, or something is just a little bit off about the way the symptoms are coming together. In that case, there are some other tests that can be done to diagnose. Sometimes, a practitioner will actually look inside your nose to get a look at that nasal or postnasal drip, and that's called a rhinoscopy. Remember, the root word, rhino, means nose. Now, x-rays have been done in the past, and are still occasionally performed, but by and large, x-rays aren't really recommended, because they are not very sensitive for sinusitis, especially sinusitis of the anterior ethmoid sinuses, just because those don't show up very well on x-rays. So, I'll put a little, not recommended, here. Now, the gold standard for diagnosing sinus disease is a CT scan or a CAT scan. This is very very sensitive for sinus disease. So, let's jump over to a normal CAT scan of somebody's sinuses, to take a look at what it looks like, and then we'll look at an abnormal one. So, this is an axial image. In other words, a cut through the patient's sinuses, as if you were looking down on them from the top, and this image over here is a coronal image, as if you were looking at them from the front. And I'll just point out a couple of the sinuses here. This is a normal maxillary sinus. We can see that on the other side here. And we have some ethmoid sinuses up here. Note on these images that they're filled in with black. That's air or basically empty sinuses, which is the way they ought to be. So, let's go to an abnormal scan. Here we have the same two images, one in axial, and the other in coronal, and you can see the same sinuses. The maxillary sinus is here, and the ethmoid sinus is here. But notice, they're not entirely filled in with black now. They have this rim of gray tissue that surrounds it, and in the case of the ethmoids, completely fills them in. That gray tissue is the inflamed mucosa. So, let's go back, and I'll just remind you that most of the time the diagnosis is made over here, with symptoms alone, and these other tests are only if needed in special circumstances. But there's a little bit of a wrinkle when you're diagnosing sinusitis, and that is there are multiple different types of sinusitis. I'll just erase this here, to give us a little bit of space. Those different types of sinusitis are split and defined based on the time frame of the symptoms, based on the time frame of the disease. So, here I'm going to make a little chart, and I'll label my axes. This up and down y-axis, we will plot the symptoms on, and the x-axis is time, and I'll put some labels down here, roughly about here, and I'll call this four weeks, eight weeks, 12 weeks, 16. So, on the y-axis I've said we're plotting symptoms, and that's just the generic symptoms. It could be any of the symptoms that we've listed over here. And this is just how long the symptoms have been going on in any particular patient. So, let's say the symptoms have lasted under four weeks. We're about right here. Anything in this time frame is called acute sinusitis. But sometimes the symptoms last longer than that, and they might wax and wane a little bit, but generally are pretty steady over the course of 12 weeks. So, if it's more than four weeks but under 12 weeks, this is subacute, and if the symptoms last beyond that, out indefinitely, this is chronic sinusitis, and this will make a difference in a little bit, when we talk about treatment. But before we can talk about treatment, we have to puzzle out one more thing about the sinusitis in question, because it's going to have a big impact on how we treat it. We'll move down a little bit here. The thing that we have to further define about the sinusitis in question, and again, we're talking about infectious sinusitis here, is whether it's caused by a virus or a bacteria. It's impractical and not very successful to try and actually isolate the virus or bacteria that's responsible for sinusitis, and we've talked before about how the vast majority of sinus infections are actually viral. So, the best way to actually figure it out again has to do with the time course, but this is a slightly different time course. I'm still going to draw another graph here, and again, we'll put symptoms here, and we'll put time down here, but our time axis is going to be a little bit different. Instead, this is going to be in days. So, here we have one, two, three, four, five days, and here we have six, seven, eight, nine, 10 days, et cetera. So remember, for all adult patients with sinus infections, about 98 percent of them are going to be viral. And these have a characteristic time course, as far as the symptoms go. The symptoms start pretty early and then kind of plateau, but by day 10, they ought to start decreasing. They don't have to be completely gone, but by day 10, you should clearly be feeling better. So, this is a viral pattern of disease. I'll draw another curve of symptoms here, but this time, by day 10, there's no clear evidence that the symptoms are getting better. This is a classic bacterial pattern of disease. But there's a couple more patterns to be aware of. A pattern that follows a typical viral course and starts to get better but then suddenly gets worse is another way a bacterial pattern can present, and that double hump of symptoms that you see with this particular curve has a fancy name, and it's called the "double sickening" or the double worsening, depending on where you read it. And the thought in this situation is that it originally was a viral disease, but then a bacteria got set up in your sinuses, and it converted into a bacterial disease. And one final way that things can present. If you have a sudden and rapid severe onset of symptoms, and those symptoms include a fever, that pattern is also typical for bacteria. So, now what do we do about it? Let's talk about treatment. So, for acute viral sinusitis, the most common type, there's not a lot we can do to actually treat the disease itself, but we can treat the symptoms. One of the first lines of treating the symptoms is going to be a decongestant. These have variable efficacy when looked at in trials and tend to work better in adults than in kids, but they're safe and over-the-counter, for the most part, and are usually worth a try. Mucolytics, kind of along the same vein. These are medications that keep the mucus that's produced thin enough that your body can clear it pretty easily, also often over-the-counter, and something that's often overlooked is just simple hydration. Making sure that your body has a good volume status ensures that the mucolytics and decongestants can do their work and that that mucus never gets so sticky that it gets stuck in there. And don't forget about pain control either. These are often painful diseases, and both over-the-counter and, in severe cases, prescription pain medications can really help quite a bit. But let's say it's beyond 10 days, or we meet those other criteria we talked about for a bacterial infection. Well, all of the things that we just talked about still apply, but in addition, for bacterial disease we can give antibiotics. And most people will recommend 10 to 14 days of antibiotics. This goes for subacute sinusitis as well. For chronic, which is presumed, for the most part, to be bacterial, again, all of the above apply, but we have to give the antibiotics for longer. A lot longer, in fact. Most people will recommend four to six weeks. Now, in some cases the sinusitis can be really severe, and the patient is at risk for complication, or recurrent disease is causing major problems. Usually after consultation with a specialist, another option can be considered, and that is surgery. There's a variety of different things that can be done, but the most common thing is to open up the walls of the sinuses, to allow them to drain better. So, let's go back to our CT scan. In this patient, for instance, if the decision was eventually made to go to surgery, the wall of the maxillary sinus here, or here, along with this structure here called the turbinate, could physically be removed, and that would look something like this. The goal of this type of surgery is to allow for better passage of sinus contents out into the nasal cavity. Again, sinus surgery is usually only performed in the most severe of cases, if all other treatments have failed, or the patient is at risk for severe complications.