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Rhino-sinusitis is the combination of rhinitis and sinusitis.
As part of the same air passages, and lined by the same mucous membrane, the nose and sinuses tend to be affected by the same problems. Rhinitis is commoner than sinusitis, and causes similar symptoms. Most cases of sinusitis start off as rhinitis, so we usually get rhinosinusitis rather than pure sinusitis. Nearly all cases of sinusitis are in fact rhinosinusitis.
The sinuses are air-filled spaces in the bones of the face and skull. There are five main pairs of sinuses:
Air in the sinuses lightens the structure of the head, and provides resonance for the voice.
The nose is much more than an ornament on your face that you happen to breathe through. It is a very active organ, constantly working to provide clean, humidified air at the correct body temperature to the lungs. The normal adult nose is around four inches (10 cm) long, front to back. The side walls have projections, the turbinates. Like the fins on a radiator, they increase the surface area of mucous membrane in contact with the air. There are three pairs, the superior, middle and inferior turbinates. They lie horizontally, front to back, stacked one above the other along the side walls of the nose. They look a bit like the fingers of a glove. The largest is the inferior turbinate. It is about the size of your little finger. The superior turbinate is tiny in humans, it has a specialised membrane for the sense of smell. The nose, sinuses, trachea (windpipe) and bronchi (tubes carrying air to lungs) are all lined with the same soft tissue mucous membrane. Also known as respiratory mucosa, this lining is specialised for breathing in air. It constantly produces a surface coating of wet mucus, which moisturises and humidifies the air. The mucous membrane lining the nose and sinuses has some further modifications, to guard and protect the entrance to the lower airways and the lungs.
The mucous membrane of the nose
Your lungs need fully humidified air at body temperature to work properly. Your nose can turn dry air fully humidified, and raise freezing cold air to body temperature, in under a second, before it reaches the throat. Heat comes from blood, flowing just under the surface mucosa. Much more blood flows through the nose than it needs for itself. It is like a radiator. A fast rate of bloodflow and a big surface area are needed, but not all the time. It depends on the temperature and humidity of the air you are breathing in, and the rate of airflow you need. The main area for control of blood flow is the turbinates. The turbinates are made of erectile tissue - like the sexual organs, they can swell up and shrink down considerably. Careful regulation of bloodflow and surface area allows us to survive in a variety of climates. But get it wrong, and you might end up with too much pooling of blood, swollen engorged turbinates, and a blocked nose which won't clear when you blow it.
Even fresh air contains microscopic impurities. The lining of your nose is designed to clean and filter it. The process is called muco-ciliary clearance.
Under extremely high powered magnification, the surface of the mucous membrane looks hairy - tiny, short hairs, like a velvet lawn, or a carpet pile. Only this carpet doesn't need a Hoover. It cleans itself. And it beats as it sweeps as it cleans. The surface of the carpet is wet, and sticky. It oozes and seeps liquid. Tiny glands constantly pump out onto the surface a thin film of sticky mucus. This coating acts like flypaper. It traps airborne particles, including
The mucus, and anything stuck in it, are swept to the back of the nose by the cilia (silly - ah). The cilia are microscopic hair-like projections that form the pile of the carpet. They beat like tiny oars in the film of mucus, constantly moving it along, a wet sticky conveyor belt. The mucus is in two layers. An upper gel layer is very sticky and thick, for trapping particles on the surface. A lower sol layer bathes the stalks of the cilia. This layer is thin and watery, to allow the cilia to swish easily through it. At the peak of their stroke, like an oar dipping into the water, the tips of the cilia catch onto the mucus layer and move it along. The cilia must work together, all beating in the same direction, otherwise they won't achieve much.
The contaminated mucus is either swallowed, spat, sneezed or coughed out, while fresh mucus is produced by the mucous membrane. It is normal to have mucus coming from the back of the nose and into the throat.
The type of mucus has to be just right. Too thin and it won't stick, it will just run like water. Too thick and the cilia won't be able to move it. It will build up in clumps. If it isn't kept moving, germs will breed in the mucus, like they do in a stagnant pond. They may form a biofilm, which is resistant to antibiotic treatment, and acts as a reservoir for recurrent infections.
Mucus production and blood flow are controlled for you automatically. Sensitive organs and nerve endings in the mucous membrane trigger automatic reflex changes. Hormone levels in the blood also have an effect. Some work directly on the mucosa, others work through the nerve supply. There are many layers of control. A complicated set of responses is designed to keep the air conditioner working efficiently. The nose can adjust very rapidly to changes in the external environment, and to the body's requirements for airflow. Excessive or inappropriate triggering of normal reflexes is a cause of some nasal symptoms.
External factors affecting the nose include:
Sneezing is a normal healthy reflex. It is designed to stop you breathing in something that might harm you. The sensitive lining of the nose detects a hazardous irritant. It reacts by triggering an explosive sneeze. This physically blows away the irritant. The sneeze is often followed often by excessive watery running of the nose in an attempt to wash away any remaining irritant. The problem is when the nose mis-identifies harmless substances as irritant, and this triggers excessive and inappropriate sneezing. Sneezing is common in the early stages of a cold. Sometimes sneezing will persist for a long time afterwards. This is because infection can bring the body's defences to a high state of alert. The alarm is triggered for things that aren't really going to harm you - like airport security confiscating old ladies' nail scissors. The commonest cause of persistent excessive sneezing is allergy.
As well as the physical mechanism of mucociliary clearance, there are chemical defences in the mucus. Natural antibacterial and antiviral substances are produced, together with white blood cells which can recognize and destroy foreign material. These chemical weapons are deployed when the body detects a threat. Sometimes, the side-effects of the chemical weapons on the body - pain, swelling, blockage, interference with normal function - are worse than the effects of the foreign material. This is especially the case in allergy, but excessive reactions against fungal material, and certain products of bacteria including biofilms, may well underly the development of nasal polyps and other chronic inflammatory diseases of the mucous membrane.
Inflammation is the active response of the body to injury. The injury could be from germs invading the body - an infection - or it could be from physical trauma, chemical irritation, burns or any other noxious agent. Sometimes the inflammatory response is triggered by mistake, for no good reason, by harmless substances. This is the basis of allergy and auto-immune inflammation. Inflammation does not mean the same as infection, though infection is one of the commoner causes of inflammation. Inflammation is divided into two stages: Acute and Chronic.
The acute inflammatory response happens immediately after injury. It normally lasts no more than a few days or weeks. After that, things will either resolve & go back to normal, or become Chronic. The classic signs of acute inflammation are:
Chronic means long-term - months or years. Chronic rhino-sinusitis is less dramatic than the acute inflammation. It is less painful, or there may be no pain at all. Temperature is normal or only slightly raised. The main physical signs are
Anyone can get acute rhinosinusitis, but some are more prone to it.
The commonest cause of acute rhinosinusitis is a cold virus. This infection can paralyse or even destroy cilia. Impaired mucociliary clearance then opens the way for secondary infection by resident bacteria. Resident bacteria are germs are present in the normal nose. They live quiet, unassuming lives, hidden in the hair follicles and skin of the nostrils. Most of the time they cause no trouble. But they are loitering with intent, awaiting their opportunity. Any who stray deeper into the nose are picked up and swept away by the mucociliary clearance system. If a sinus opening or mucociliary clearance pathway gets blocked by swollen mucous membrane, stagnant mucus builds up. Mucus that is not kept moving, like a stagnant pond, provides a fertile breeding ground for bacteria. As soon as the mucociliary defence mechanism is down, the bacteria move in and replicate, producing toxins. The body's response is to pump extra blood and white cells to the area - the acute inflammatory response. Unfortunately this causes yet more swelling of the mucous membrane, resulting in more congestion and blockage - a vicious circle. The escalation of hostilities turns the nose and sinuses into a battleground. Chemical warfare ensues, with collateral damage inevitable.
Anything which interferes with the normal functions of the mucous membrane predisposes to rhinosinusitis. Some people are born with poor quality mucous membrane. Rare causes of severely impaired mucociliary function from birth are:
Physical narrowing of the sinus openings and mucociliary clearance pathways can also predispose to recurrent sinusitis.
Non-allergic rhinitis used to be called vasomotor rhinitis. It results in excessive swelling and /or mucus secretion by the mucosa. There is defective control of the nasal reflexes. Another descriptive term is hyper-reactive rhinopathy. The cause is unknown.
Rare causes of chronic sinusitis are
Polyps are benign soft swellings of the mucosal lining of the nose and sinuses. They can be the size of your thumb, though most are smaller. Often described as being like grapes, they are more like raw oysters, slippery and squashy. You can have half a dozen, or a dozen, packed up each side. Some polyps have a stalk, others arise from a broad base. They contain a lot of water and irritant chemicals with some cells from the immune system. To the pathologist, under the microscope, a polyp looks like a local allergic reaction. Polyps can arise from any part of the nose or sinus lining. The ethmoid sinuses and middle turbinates are most commonly affected. Polyps have no nerve endings, and are not painful, unlike the turbinates which are very sensitive. Polyps often occur in asthmatics. They tend to come back after they have been removed. Not all polyps are benign. You can get a malignant (cancerous) polyp. These are rare. They look different to the trained eye. Histological examination by a qualified pathologist will tell us what kind of polyps you have.
The symptoms of sinusitis are usually mixed with symptoms of rhinitis. Rhinitis alone can cause:
Acute sinusitis is usually painful, chronic sinusitis usually isn't. The site of pain depends on which sinuses are involved, but often more than one set of sinuses is involved at the same time.
If the mucus from an infected sinus is able to drain, rather than being blocked up, thick green or yellow mucus appears. This can discharge via the nose or as a "post nasal drip".
Although most cases resolve completely, sinusitis can, rarely, have serious complications, especially in children.
Traditional washing of the nasal lining with salt water, alkaline nasal douches (sodium bicarbonate and salt) and various mineral extracts is useful when the mucus is abnormally thick, and in dry arid environments. Rinsing can
Steroid nasal drops and sprays work by reducing the body's inflammatory response. They are slow to act - you may not notice much benefit for several days or even weeks - and need to be taken regularly, not just for an acute attack. They will gradually reduce swollen mucosa, and can even shrink polyps.
Modern nasal steroids such as Beconase™, Rhinocort®, Flixonase™ and Nasonex® are proven safe for long term treatment. They should not be confused with dangerous anabolic steroids abused by some athletes - you will be perfectly eligible for the Olympics on these treatments. Potential side-effects of being “on steroids” are minimal because the total dose is small, and very little of the small dose taken is absorbed into the body. However, you might get local side-effects, such as nosebleeds. Occasionally, nosebleeds can be bad enough to stop you taking nasal steroids.
Sometimes a short, sharp course of steroid tablets such as Prednisolone ec is used to shrink polyps. The risks of steroid side-effects from short courses of treatment are fairly small, but long term steroid tablets are likely to give rise to serious side-effects. No one should take steroid tablets longer than necessary.
The general principle of steroid treatment is to use the minimum amount which will keep things under control. Everyone is different, some need large doses, some small. We don't really know until we've tried, and assessed the the response to treatment. You will know yourself if you are feeling better. We can tell by nasal sinus endoscopy whether the polyps are shrinking.
We treat nasal polyps with steroids in the same way we treat asthma. The conditions are very similar. Many patients have both nasal polyps and asthma. In both cases, we want to control the disease using the least amount of steroid. A fairly high dose may be needed for initial control. After this kick start, the dose is gradually stepped down. If and when we reach a dose where symptoms begin to come back, the dose is increased to the previous level. We may need to adjust the dose and type of steroid over several months. This way, treatment is tailored to suit the individual patient.
However, steroids do not help everyone. If there is a bony narrowing, or polyps which are too large and established to be shrunk by steroids, surgical treatment may be needed.
You may be advised to use steroid drops such as Flixonase Nasules™ in the head down and forward position. This is because most cases of sinusitis start with swollen mucosa high up in the nose and ethmoid sinuses, between the eyes. This is where the maxillary and frontal sinuses open, and where most polyps start.
To make sure the drops get to the affected area, you can either:
After putting in the drops, keep your head down for at least one minute to allow them to percolate into the narrow spaces.
Lying on your back, and tipping your head backwards over the edge of the bed, is another option. It is not quite as good as the head down and forward methods.
Just sniffing up the drops where you stand is not really much use. Half will go straight down your throat, and half will run out. The drops won't reach high up, between the eyes, where they are needed.
Sinus endoscopy (sometimes called FESS) is the modern way to diagnose rhino-sinusitis and plan treatment. It is normally done as an out-patient.
The rigid nasal sinus endoscope has an angled lens which lets the surgeon see into all the nooks and crannies of the nose, showing the exact location of any narrowings, bony deformities, polyps and the source of any pus drainage.
Further information on rigid nasal sinus endoscopy
All information and advice on this website is of a general nature and may not apply to you. There is no substitute for an individual consultation. We recommend that you see your General Practitioner if you would like to be referred.
© 2006 - 2008 All rights reserved
Mr James W. Fairley BSc MBBS FRCS MS (Lond)
GMC No. 2719566
Enquires: Mrs Sylvia Fairley RGN RCNT Dip Nurs (Lond)
tel 01233 642244 fax 01233 662840
Sandyhurst House Sandyhurst Lane Ashford Kent TN25 4NX
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