"Doc, I've got sinus" is a phrase I often hear as we begin to interview a patient in my Otolaryngology (ENT) practice at ENT Associates of Alabama office at Grandview. And while I understand the patient's colloquial use of "sinus,” to an ENT doctor, sinusitis is a specific problem affecting the paranasal sinus' (air-filled bone spaces that surround the nasal cavity) as opposed to rhinitis, which involves inflammation and /or infection in the nasal cavity. So I want to take the opportunity to explain the differences between the two terms and how we treat each entity.
I certainly don't fault our patients for not knowing the difference between sinusitis and rhinitis because to them it can feel the same: congestion, runny nose, post nasal drip, facial pain , headaches and discolored drainage, just to name a few of the symptoms. And it can take a few studies or medication trials for the doctors to get it right.
Rhinitis is inflammation in the nasal cavity and it specifically involves the nasal turbinates, membranes in your nose that under normal circumstances moisturize the air you breathe, producing about a quart and a half of hydrating mucous so that when the air reaches your lungs, it is moisturized and is at body temperature. So rhinitis can be infectious (colds or viruses and also bacteria). Rhinitis can be triggered by allergies to pollen, mold or dander or irritants like chemicals and smoke as well as barometric pressure changes or dry air. All of these possible causes of rhinitis feel the same to the patient so our job is to figure out the trigger and then find the best treatments. Most of the treatments for rhinitis are designed to influence the turbinates, which have become swollen accounting for congestion or the excess production of the mucous.
A favorite first line of rhinitis treatment for me are two types of nose sprays that I like because they are going directly to the turbinates topically and have few side effects. One category are the nasal steroid sprays (Flonase, Nasocort and others – I have no financial affiliation with any products mentioned) that reduce the swelling of the turbinate to help congestion and to reduce drainage. And no matter what the underlying trigger for the rhinitis, these help. A second category of sprays are antihistamine sprays (Astelin, Patanase) which deliver antihistamine topically to the turbinate and help dry up the drainage and assist with congestion. Both sprays can be used at the same time. There is a product called Dymista that has them already combined. These can be used for long-term maintenance of symptoms. Possible side effects include burning in the nose or nosebleeds. This can usually be remedied by using saline nasal spray regularly.
Another category of medications are oral antihistamines which block the release of histamine, one the substances that triggers allergy reactions systemically and swelling of the turbinates locally. The gold standard is Benadryl: it is strong but can have side effects of sedation and dry mouth. So non- sedating antihistamines were developed ( Allegra, Zyrtec, Claritin,Xyzal). One reason they are mostly non-sedating is they are not as strong. But they may be strong enough to handle the patient's symptoms. These can also be used long-term.
Another unique pill medication is Singulair, which blocks the release of leukotrienes, another inflammation-causing substance found in allergic reactions. Singulair is used for allergies and asthma but not for infectious causes of rhinitis and can be used long-term.
Another type of medication for congestion are the decongestants both in a spray form (Afrin, Neosynephrine) and in pill form, Sudafed. These medications are to be used short-term for relief of congestion. If a patient uses them long-term, there are usually significant underlying issues that need to be evaluated, such as nasal blockage from nasal polyps, chronically enlarged turbinates or a deviated septum (the cartilage and bone wall that separates your nasal cavity). Your nose can become dependent on the decongestant sprays and the oral decongestants can raise blood pressure and make you feel jittery. Also, there are combination products (Allegra-D, Zyrtec -D) that combine the antihistamine with the decongestant. If the package says "D" there is Sudafed in it.
Yet another rhinitis product are mucolytics (Mucinex) that thins the mucus, which makes the drainage thinner and easier to clear and has a drying effect.
True sinusitis involves an infection of the sinus cavity, causing fluid and mucus to be trapped in the sinus space. Some form of rhinitis usually is the trigger for the sinusitis which causes the natural drainage openings to be impaired or occluded. Sinuses normally assist in filtering air to remove irritants and supply additional mucus to the nose. Treating sinusitis can involve antibiotics, oral steroids, and nasal rinses. And because sinusitis is accompanied by rhinitis, the various rhinitis remedies are used also.
Now you know what is rattling around inside the head of your ENT doctor when you say, "Doc I've got sinus!”
Scott Elledge, MD practices Otolaryngology with ENT Associates of Alabama at Grandview Medical Center. He has been in private practice in the Birmingham area since 1994.
