Steven Machtinger, MD

Sinuses, Sinus Pain & Sinusitis

What are the sinuses?

The sinuses are hollow spaces inside of the bones of the face. Sinuses are named for the bones in which they are located. Within the cheekbones are found the maxillary sinuses. The bones of the forehead contain the frontal sinuses. Between the eye sockets are the ethmoid air cells, a group of small spaces linked by openings similar to a series of rooms in an apartment. Deep within the skull is a single sinus, the sphenoid sinus. The sinuses communicate with the nasal passages by narrow passages called ostia. The sinuses, more properly termed the paranasal sinuses are lined with the same type of cells lining the nose. These cells are organized in several layers. The mucosal layer, the layer in contact with the environment, is composed primarily of two types of cells. Mucous cells produce a thin sticky, yet watery secretion. The more numerous columnar cells have a surface covered with a thick lawn of cilia that faces the cavity of the sinus. When functioning normally the cilia of adjoining cells move or beat in unison. A layer of mucous on top of the cilia filters the air trapping dirt, pollutants, bacteria, viruses, and allergens. Ciliary beating sweeps these trapped materials and microorganisms out of the sinuses, through the nasal passages, and into the throat where they are swallowed.


Why do we have sinuses?

Biologists have not determined an essential role for the paranasal sinuses. By replacing solid bone with air they make the head lighter. Dinosaurs had very large sinuses. Some paleontologists theorize that dinosaurs vocalized by blowing air through the sinuses. Fortunately for civilized society, we can't do that.


How does disease occur in the sinuses?

This is an easier question to answer. The sinuses connect to the nasal passages by narrow channels. When these channels become blocked dysfunction and disease results. Blockage occurs either because of a deformity of the nasal bones such as in a deviated nasal septum, when allergy or infection causes swelling or when infection causes accumulation of thick, tenacious mucous. When obstruction prevents the free passage of air between the sinuses and the nose, an air pressure difference may occur causing sinus pain or sinus headache.


What are the symptoms of a blocked sinus?

Pain. Maxillary sinus pain is typically felt in the cheeks and may be mistaken for pain in the upper molars. Frontal sinus pain is felt above the eyes and is often confused with tension headache. Ethmoid pain is felt between and behind the eyes and in the temples. Pain originating in the sphenoid sinus may be experienced as pain at the back of the head.


How is sinus pain different from a sinus infection?

Although bacterial normally reside in the nasal passage, a healthy sinus is sterile. Bacteria and viruses gaining access from the nose are trapped in the mucous coat, inactivated or killed by white blood cells, antibodies, and other microorganism-killing proteins secreted by sinus lining cells, and then rapidly removed by ciliary action. When removal of bacteria and viruses by ciliary activity is hindered by blockage of the sinus ostia, their ability to very rapidly increase in number overwhelms the other defense mechanisms of the sinus. An infection ensues.


What are the symptoms of a sinus infection?

Sinus infections may be acute, that is, present for less than a few weeks, or chronic. The primary symptoms of an acute sinus infection are pain, cough, and the production of thick green or yellow mucous. Coughing is due to postnasal drip coming from nasal passages obstructed by mucous. Fever, fatigue, malaise are common. Facial and head pain may be more intense when bending over. The upper molars may ache. Mouth breathing leads to bad breath. In chronic sinus infection, pain is often absent or minimal and fever is uncommon. Otherwise, chronic sinus infection resembles acute sinus infection. The primary symptoms are cough, postnasal drip, and nasal obstruction and discharge. Because pain is not prominent, chronic sinus infection may be mistaken for asthma or bronchitis.


Is it possible to have sinus pain and a nasal discharge without a sinus infection?

Yes. If sinus obstruction and pain are a result of allergic rhinitis there may also be nasal obstruction and discharge. In this case the discharge will be the clear, watery discharge typical of allergic rhinitis.



Allergic Rhinitis

Acute Sinus Infection

Chronic Sinus Infection




Sometimes present











May be present






Bad breath









How is sinus pain best treated?

For immediate relief, a nonsteroidal anti-inflammatory drug such as acetaminophen, aspirin, or ibuprofen is effective. For chronic pain or headache associated with sinus blockage, treatment of the underlying cause is the best course of action. Since the most common cause of sinus pain is untreated or insufficiently treated allergic rhinitis, an evaluation by your primary care physician or by an allergist is appropriate. If allergic rhinitis is found to be present, treatment may consist of avoidance of allergens, medication such as antihistamines or topical corticosteroid sprays, or immunotherapy.


Is allergic rhinitis the only cause of sinus obstruction or pain?

No. A deviated nasal septum, nasal polyps, overuse of over-the-counter decongestant nasal sprays, and sinus infection are other common causes of such discomfort. Allergic rhinitis is found to be the underlying cause of 70 to 80% of all chronic sinusitis.


What causes sinus infections?

The cause of an acute sinus infection (or sinusitis) is usually a viral upper respiratory infection (a "cold") that induces swelling of nasal and paranasal mucosa, creating obstruction, and resulting in entrapment of bacteria in one or more sinus spaces. Even though viral colds may precipitate them, chronic obstruction or a compromised ability of the immune system to fight infections are the underlying causes when sinusitis is either chronic or recurs more than twice a year.


How is sinusitis treated?

Acute sinusitis (literally an inflamed sinus, another name for a sinus infection) generally responds to a 5 to 10 day course of antibiotics and oral decongestants or nasal flushing with salt water. Chronic or recurrent sinusitis may require more aggressive therapy including four to six weeks of continuous antibiotic therapy, decongestants, mucolytics (medications that make thick mucous more watery), nasal irrigation with salt water drops, and even intervention by the otolaryngologist. .


Isn't frequent or protracted usage of antibiotics bad for you?

Frequent or protracted use of antibiotics contributes to the selection of bacteria resistant to the effects of antibiotics. The consequence is increasing difficulty in eradicating infection from the sinuses. Antibiotics may cause other problems such as overgrowth of fungi in the intestinal tract, skin rashes, and drug allergy. Because of these concerns, the best way to treat chronic or recurrent sinusitis is to determine the underlying causes and treat them effectively.


How are the causes of chronic or recurrent sinusitis investigated?

The physician begins by taking a complete medical history and performing a physical examination. Examination of the nasal passages may be supplemented by inspection with a flexible fiberoptic rhinoscope, with X-rays, or with a CT scan of the sinuses. When allergic rhinitis is suspected skin testing is generally performed. An inspection of sinus mucous under the microscope may help determine whether allergy or infection is present. When a defect of the immunes system's ability to fight infection is suspected because infections of the lungs, skin, or intestinal tract as well as those in the sinuses have occurred with some frequency, blood tests for immune function may be obtained.


How are chronic sinus infections treated?

There are two aspects of effective treatment. First, the ongoing infection must be eradicated. Simultaneously, the cause of the chronic condition must be determined and treated. Successful management of chronic sinusitis may take time, commitment, and the cooperation of several physicians including your primary care physician, radiologist, otolaryngologist, and allergist. It may include administration of antibiotics for many weeks, efforts to improve sinus drainage with irrigation, decongest thin tenacious mucous, and decrease inflammation. Improvement of chronically poor drainage out of diseased sinus passages sometimes requires sinus and nasal surgery. Control of inflammation may require local or systemic corticosteroids and immunotherapy.


Is immunotherapy effective for chronic sinusitis?

When allergic rhinitis is determined to be the cause of a major contributor to chronic or recurrent sinus infections, immunotherapy can be of great therapeutic benefit. Immunotherapy reduces nasal and sinus swelling restoring normal drainage of mucous from paranasal sinuses into the nasal passages

Links to sinusitis sites: a great site for an overview of sinusitis, its relationship to allergy, and its treatment

Sinusitis in children


The information above represents the writer's opinions and is not meant as a substitute for evaluation by a physician. The reader is advised to seek sound medical evaluation and guidance before undertaking treatment for any medical condition.

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