Sinusitis refers to an inflammatory condition of the sinus cavities of the head which is usually caused by the presence of pathogenic (disease-causing) bacteria and therefore pus. Sinusitis can also rarely be fungal in origin. Sinusitis seems to be either the most overdiagnosed or the most underdiagnosed infection in modern man; considerable debate arises over what constitutes sinusitis, meaning what constitutes a sinus infection worthy of antibiotic treatment.

The sinuses serve to lighten the bony skull (and apparently to provide a good living to ENT doctors and allergists). They are connected to the nasal passages through narrow openings, which are prone to obstruction because of their small size and the fact that they are lined with the same respiratory tract lining as the rest of the area. This lining is quite prone to swell with a cold or allergy attack, closing off the small openings and setting up good conditions for bacterial growth.

There are five major sets of sinus cavities in the human skull.

  • The anterior and posterior ethmoid sinuses are present at birth. They lie on either side of the nasal passages in the space between the nose and the eye sockets.
  • The maxillary antra, or rudimentary sinuses, are also present in the newborn. They lie on either side of the nose, under the eyes.
  • The frontal sinuses begin to form around two to four years, and are completely pneumatized (air-filled) by 5 to 9 years. They are those suckers above the eyes in the forehead that produce that nasty headache.
  • The sphenoids are above and to the rear of the ethmoids as best I can tell. They are present by age three.
  • The mastoids arise from the middle ear cavity and are present in rudimentary form at birth. They slowly and irregularly form, so that they are generally complete by adolescence. Properly speaking, infection of the mastoids is mastoiditis, and its discussion belongs elsewhere, but technically they are sinus cavities.

The argument over sinusitis and the treatment of sinus infections stems from the observation that if you simply treat every green snotty nose and call it sinusitis, you will 1) be right many times and 2) wrong as many or more times and needlessly subjecting the patient to yet another round of unnecessary antibiotics. Telling where the yellow-green tail-end-of-the-cold mucus shades imperceptibly into the sinus drainage mucus can be just plain difficult.

The hallmark of sinusitis is said to be daytime cough lasting more than nine or ten days. The classic sinusitis patient has some combination of persistent purulent (pus) nasal discharge, fever, facial pain, headache, and nagging cough. Patients are often reluctant to put up with nine or ten days of daytime cough and drainage before demanding action. Patients would seem to rather be told they or their children have "sinus infections" than "colds," for reaons having less to do with the medical questions involved but much to do with human nature. So you see the physician's dilemma.

Another dilemma is when to do xrays. Sinus xrays are really the only way to be totally sure the patient has sinusitis. Sort of sure. The information gleaned from xrays is often a matter of some interpretation, that is not exactly cut-and-tried. Swelling of the mucous membranes is visible on the xray films, and may or may not indicate sinusitis that warrants antibiotics. Some films are pretty definitely positive for sinus infection; some are pretty definitely equivocal. It is a judgement call. And excessive use of xrays is not without risk to the patient, especially a very young patient. In light of concerns about radiation exposure with CT scans in children, that proceedure should be done with great reservation.

Treatment of sinusitis is open to some disagreement as well. A recent (2001) review by the federal Agency for Healthcare Research and Quality found that in multiple studies there were no clear differences in outcomes among different antibiotics (so your child does not need the most expensive, broad spectrum, resistance-inducing antibiotic), and that studies found no convincing data to support the use of antihistamines and decongestants.

I hope your sinuses aren't acting up.

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