We see many patients with facial pain, sinus pressure, and postnasal drainage who are quite certain that they have a sinus problem. Many times they do, but there are instances when a patient has symptoms of a sinus-related condition, but it turns out that the problem has a completely different origin. Our job is to determine what is actually causing the patient’s discomfort and recommending the right course of treatment. Countless patients have been misdiagnosed and have been taking sinus medications for years — with absolutely no relief. That's because they haven't been treated for the right problem(s).
The following is an overview of some of the conditions that cause patients to have symptoms of a sinus problem, when in actuality, it they are suffering from something completely different, A few of these conditions include deviated septum, dental problems such as TMJ, nasal polyps and reflux.
The septum is the bone and cartilage that form a dividing line in the middle of your nose, separating the right and left sides. The septum is a large bone and most people are familiar with the floppy part in front of their nose that's made out of cartilage, but there is also a portion of bone that is in the back of your nose and sinuses. Ideally, the bone should be in the middle of your nose so there's an equal amount of space for airway passage on both sides.
Some people are born with a deviated septum, for others it develops a little later, such as during their early teen years, and some cases of septal deviation are due to trauma. Sometimes the symptoms of a deviated septum are so mild that a person won't even know they have a problem. More severe symptoms include nasal obstruction, headaches, sinus infections, snoring, trouble breathing at night and chronic nosebleeds.
Treatment for Deviated Septum
A deviated septum is treated by a surgical procedure called a septoplasty. There is a newer less invasive form of septoplasty where an endoscope is used to remove the deviated septum. An endoscopic septoplasty can be assisted by TRACT, a newly approved balloon that when inflated in the nose, destabilizes the septum and makes the endoscopic removal easier. Dr. Atkins was the second surgeon in the country to perform a septoplasty using TRACT and has had great success using this technique. Many septoplasties are now performed in the office under IV sedation, so the patient doesn’t have to go to the hospital.
A lot of people use this term to describe a lot of different symptoms, but it's mostly used to describe difficulty breathing through your nose. Nasal breathing is responsible for nearly 70 percent of airflow into your lungs. If you feel like your nose is blocked and you can't take air in through it, you are experiencing some type of nasal obstruction. This can happen on one or both sides of your nose and it can move from one side to the other. Nasal obstruction can be seasonal or year-round and some patients experience it 24 hours a day, while others only have a problem at night when they're sleeping. The causes are usually pretty simple to identify and can include a deviated septum, chronic sinus infection, allergies, enlarged inferior turbinates (another type or bones in your nose) or nasal polyps.
Nasal congestion or a stuffy nose, is one of the most common complaints we see in our office. For some people, it is just a nuisance, but for others it's severely impacts their quality of life. Patients frequently use the terms “nasal obstructions” and “nasal congestion” interchangeably.
To some patients, nasal congestion can mean difficulty breathing through their nose, and in others, it will mean that they breathe fine through their nose, but they feel pressure and fullness further up their nose in the center of their sinuses. The patients who are having difficulty breathing through their nose should refer to section on nasal obstruction (above). Of those who are having pressure and fullness in their sinuses, this is typically due to a chronic infection, allergies or deviated anatomy such as a septal deviation or abnormally narrowed sinus passages.
Treatment for Nasal Congestion and Obstruction
There is good news for patients with sinus polyps. In the past, the only option we had was surgical treatment which involved just removing the polyps and hoping they didn't come back; this was historically very ineffective and patients had frequent recurrences of their polyps.
Now, due to technologies such as Propel, patients undergoing polyp surgery can have small absorbable devices placed in their sinus cavities that dissolve during the month following the surgery.
These small devices contain steroids which dissolve into the sinus passages and help cut down on the recurrence. The other advantage of these devices is that they have a spring type effect that keeps the sinuses open. That's very important for post-operative care, because many patients need to use nasal steroids and saline rinses after their polyps are removed, but their sinuses often close down making the rinses ineffective.
By keeping the sinuses open, thus allowing the medicines to get into the root of the sinuses, the results have improved dramatically for patients suffering from sinus polyps.
There are two distinct types of runny nose — watery drainage out the front of your nose and the thick heavy drainage down the back of your throat. If you are experiencing the latter, then skip to the section on post-nasal discharge (below).
There are many types and causes of a runny nose. Most people have experienced the short-term runny nose that accompanies a cold or bout with allergies. Those typically clear up on their own or with the help of temporary treatment such as OTC allergy medication. Then there is the everyday constantly runny nose, where you have to always grab for a tissue, etc. The condition is often worse while eating, or going in and out of buildings where there are temperature changes.
Typically, a runny nose is caused by chronic rhinitis. There are many causes of chronic rhinitis including allergies, irritation of the lining inside your nose and vasal motor rhinitis, which is hyperactivity of a nerve inside your nose that makes your nose run all the time.
Treatment for Runny Nose
Treatment is sometimes successful with oral medications, antihistamine nasal sprays or nasal sprays which act as drying agents. When these are not successful, there are surgical options such as Clarifix, which is an in office procedure that's very simple to perform.
It involves freezing the overactive nerve on each side of your nose for about 30 seconds in an effort to block the signals it's sending to your nose that's causing it to run all the time. For more details on Clarifix click here.
"Sinus headaches" mean a lot of things to different people. Most patients refer to any facial pain or pressure as a sinus headache. In their truest definition sinus headaches are headaches or facial pain/pressure brought on by changes in barometric pressure. There are many causes of facial pressure and pain that are not sinus related. This is not to say that the sinuses don't hurt during these other conditions it's just that the pain is not coming from the sinuses.
These other causes include migraines, cervical neck problems, particularly in patients who have had neck trauma such as whiplash or who work at a computer constantly with poor posture that's leading to neck problems. Some of the nerves in the neck wrap around the head and can trigger pain in the sinuses. Temporomandibular Disorder also known as TMJ, is also a common cause of sinus headaches.
Dr. Atkins has been treating sinus headaches since 1991. Over the years he's developed a very successful program for the diagnosis and treatment of sinus headaches. The key to the treatment is considering all the possible causes and then determining whether the sinuses are actually a factor or not and if so determining the best way to manage these sinus problems. To be clear there's no one test that can diagnose sinus headaches. It takes patience, listening to the patient, asking the right questions and considering all possible causes of facial pain/pressure/headache.
Treatment for Sinus Headaches
The medical treatment for sinus headaches is to eliminate or control whatever is causing inflammation in the sinuses such as allergies and recurrent infections. For example, narrowed or blocked sinus passages can harbor bacteria, which can cause chronic sinus infections. In such cases, if more conservative treatment such as medication does not help, surgery is an option.
Surgical treatment to open the sinuses has greatly improved over the last few years because of balloon sinuplasty (BSP). By dilating blocked sinus passages when they are contributing to sinus pain and pressure, you can achieve a significant reduction in sinus headaches. Some patients need slightly more aggressive surgery such as BSP and a septoplasty at the same time.
Post Nasal Drainage
Mucus is usually swallowed throughout the day without you ever even knowing. But for people with post nasal drainage (PND), it can be very problematic. Whatever the cause, it can lead to throat irritation, chronic cough, sinus problems and more.
Post nasal drainage refers to chronic drainage down the back of the throat often associated with hoarseness, cough, throat clearing, etc. Some patients experience only a couple hours of PND in the morning; others suffer from it 24 hours a day. There are many causes of PND. The four most common causes are: having a chronic sinus infection, allergies, laryngopharyngeal reflux and chronic rhinitis. The excessive drainage is caused by an overactive nerve in your nose that is telling your nose to produce more and more mucus.
Many of our patients experience post nasal drainage due to laryngopharyngeal reflux (also called LPR or silent reflux). Laryngopharyngeal reflux refers to stomach acid that is getting into your throat in the back of your sinuses, which irritates the sinuses, causing them to create an excessive amount of mucus. Many patients realize this is a problem because they have ongoing active reflux. There are other patients who experience significant acid back-up into their throat and back of their nose. They usually aren’t aware of it because it happens primarily at night while they're sleeping.
Not everyone with reflux has a lot of heartburn or indigestion. In fact, many people with silent reflux never have heartburn. This is because the acid that refluxes does not stay in the esophagus long enough to irritate it and cause heartburn. Consequently, this is why LPR is called silent reflux because it can be difficult for patients to realize that they are experiencing it.
Chronic hoarseness, throat clearing, and cough, as well as a feeling of a lump in the throat or difficulty swallowing, may be signs that you have LPR. Some people have hoarseness that comes and goes, and others have a problem with too much nose and throat drainage of mucus or phlegm. If you have any of these symptoms, and especially if you smoke, you should talk with us about LPR.
Laryngopharyngeal reflux can usually be diagnosed by taking a good history and doing a fiberoptic laryngoscopy. A fiberoptic laryngoscopy is a painless exam that is done in the office. It allows us to get a close up view of the larynx (or voice box). LPR causes certain changes in the throat that can be seen on fiberoptic laryngoscopy.
Treatment for Silent Reflux
With medication, most patients will begin to notice some relief in their symptoms in about six weeks. However, it is generally recommended that the medication be continued for several months. If the symptoms completely resolve, then you can start tapering off the medication. Some people will be symptom free without the medication, while others may have relapses which require resuming treatment.
Surgery to prevent reflux is rarely needed. Diet modifications and current medications have allowed LPR to be treated without surgery most of the time. If surgery is needed, it involves tightening the muscle at the top of the stomach to prevent the reflux from happening. This is done by a general surgeon in consultation with a gastroenterologist.
Sinus polyps are due to excessive swelling of the lining inside the nose that leads to grape-like growths of sinus membranes that can block a portion of the sinuses or all the sinuses and nasal passages.
The severity of symptoms depends on the size and location of the polyps. Sometimes they are diagnosed while evaluating a patient for other chronic sinus problems, or other times they're the primary reason why a patient comes in to be seen.
Treatment of Nasal Polyps
There is good news for patients with sinus polyps. In the past, the only option we had was surgical treatment which involved just removing the polyps and hoping they didn't come back; this was historically very ineffective and patients had frequent recurrences of their polyps. Now, due to technologies such as Propel, patients undergoing polyp surgery can have small absorbable devices placed in their sinus cavities that dissolve during the month following the surgery. These small devices contain steroids which dissolve into the sinus passages and help cut down on the recurrence.
The other advantage of these devices is that they have a spring type effect that keeps the sinuses open. That's very important for post-operative care, because many patients need to use nasal steroids and saline rinses after their polyps are removed, but their sinuses often close down making the rinses ineffective. By keeping the sinuses open, thus allowing the medicines to get into the root of the sinuses, the results have improved dramatically for patients suffering from sinus polyps.
Unexpected Causes of Sinusitis
Sometimes the diagnosis of sinusitis can be overlooked or delayed because symptoms of a chronic sinus infection can also indicate many other health problems. Some of these conditions include:
- Cedar Fever
- Allergy Flare-up
- Allergic Rhinitis
- Sleep Apnea
Dental Problems and Chronic Sinus Infections or Sinusitis
One of the more common causes of sinus problems that people don't really think about is dental problems. A bad tooth or cracked tooth or sometimes just the smallest bit of infection at the tip of a tooth can lead to a sinus infection. These types of sinus infections typically don't respond to the antibiotics that you would give a person for a sinus infection because those antibiotics are not very effective at treating dental bacteria. Sometimes there's evidence on a CT scan of the sinuses that there's a dental problem; other times it's a little more difficult to diagnose.
Fortunately, some of our methods for sampling bacteria are very effective at detecting dental bacteria. When a result shows a predominance of dental bacteria from a sinus culture, there's a good probability that there's an existing dental problem. Patients with an immune deficiency are very aware that they are prone to sinus infections, while other patients who are on biologic agents for rheumatoid arthritis, etc., oftentimes suffer an increase in sinus infections. All of these are taken into account when assessing the causes of sinus infection.