Is It Sinus Congestion or a Sinus Infection?

A 2016 study published in the Journal of the American Medical Association (JAMA) showed that 30 percent of antibiotics prescribed in clinic visits were unnecessary, and this country needs more superfluous antibiotic prescribing like we need another hole in our heads.

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Seven of the holes already in our heads are the sinuses in our facial bones: the frontal sinuses just above the nose, the maxillary sinuses in our cheek bones, and the sphenoid sinuses and the ethmoid sinus in the back of the nose.

The JAMA article found that sinusitis was the leading indication for an antibiotic prescription in the doctor’s office, possibly because all of us — doctors included — have a hard time telling the difference between sinus congestion and a sinus infection.

To understand that better, a brief anatomy lesson on the inner workings of the schnoz might be helpful.

The nose is more than a place to rest your glasses. Its primary role is to be an air conditioner — in the truest sense of the term — for the lungs. That’s why the skin that lines the nose has a rich blood supply, so it can both warm and humidify the air. That’s also why some of the skin cells secrete mucus, which traps dusty particulates and also captures potential invaders like bacteria and viruses.

That mucus is then swept along to the back of the nose by cells containing broom-like hairs called cilia. These cilia beat in a coordinated manner, sweeping the mucus out of the sinuses, into the nose and then back into the throat, where it is swallowed and incinerated in the acidic cauldron of the stomach.

Like a mystical eastern religion, in the schnoz, everything is flow. And when this flow is interrupted, problems develop. Our sinuses drain into our nose through small holes called “ostia,” the Latin word for “small hole.”

When the skin lining the nose and sinuses gets swollen — most commonly due to a viral infection, less often due to allergies — those holes plug up and the sinuses cannot drain. That’s sinus congestion, a deep pressure and tightness. You know it when you feel it.

The vast majority of cases of “rhinosinusitis” (nose and sinus inflammation) are triggered by a cold virus, according to the Infectious Disease Society of America’s (IDSA) clinical practice guideline. That virus cripples the mucus-making and cilia-sweeping cells. In addition, the firefight between our immune system and the invader causes the tissue to swell, and battlefield debris piles up because it cannot be removed.

Typically, a viral infection and the congestion it brings will clear up in seven to 10 days. An antibiotic cannot kill a cold virus, so sufferers just have to wait it out with analgesics, decongestants, hot tea — whatever works for them.

But in 0.5 to 2 percent of those cases, the congestion and lack of healthy flow allows a secondary bacterial infection to take hold. As is the case with all of our skin, our nasal and sinus passages are loaded with normal, healthy bacteria that outcompete the bad bacteria. But for complex microbiological reasons, the virus infection gives these unfriendly pathogenic bacteria the upper hand.

Given these facts, the IDSA guidelines recommend antibiotics under any of three scenarios:

• symptoms that persist for 10 days or longer, or
• the onset of high fever (>102 F), severe facial pain and pus from the nose for three to four consecutive days at the beginning of the infection, or
• what’s referred to as a “double sickening,” where an infection improved for the first five to six days, but then suddenly became severe

Many patients enjoy describing the color of their mucus, so physicians will often just sit quietly and listen, even though they know there’s no clinical usefulness to the fact that a patient used a paint sampler to peg his mucus color as somewhere between “Limited Lime” and “Canary Yellow.” Also, there is no benefit to blowing one’s nose so hard that one’s eyeballs are actually jettisoned from the eye socket for a period, like in an animated Tim Burton movie.

So, there are a small number of cases where a nose and sinus infection can turn bacterial and therefore benefit from antibiotics. But even then, a recent research letter in the Journal of the American Medical Association - Internal Medicine argues that many antibiotic prescriptions run too long.

Although the IDSA recommends just five to seven days of therapy for uncomplicated cases, the study found that 91 percent of antibiotics prescriptions (excluding the antibiotic azithromycin, which the IDSA doesn’t even recommend for sinusitis) were for 10 days or more.

Oops. All those extra days just expose patients to further risk of side effects without offering further benefit. It’s this “just in case” and “more is more” kind of attitude on the part of patients and physicians that is fueling our dangerous overuse of antibiotics.

Don’t we all want them available — and working — when we really need them?