When a cold won't go away

FOR six months, Denise Tortora had a constant headache. She was congested, had postnasal drip and felt off balance. At night, she was so stuffy she could not sleep. "I was walking around in a fog," says the 39-year-old conference organiser and mother of two from West Orange, New Jersey.

Denise did not have a series of bad colds. It was not just allergies. But it took several visits to doctors before she was told she had sinusitis, or inflammation of the sinuses. More than thirty million Americans receive the same diagnosis.

Sinusitis is more than just a stuffy nose: A 1995 study found that chronic sinusitis sufferers had significantly more pain than people with chronic conditions such as congestive heart failure or sciatica. They also had to curtail their social activities more, says researcher Ralph Metson, M.D., an associate clinical professor at Harvard Medical School, in Boston.

Left untreated, sinusitis can be dangerous. Although this is rare, a sinus infection can spread to the eyes and brain, threatening vision or causing meningitis. Severe infections can also create scar tissue and adhesions in the nasal passages, making the sufferer more prone to subsequent attacks.

All stuffed up

Although the terms are often used interchangeably, sinusitis is a catchall diagnosis for any inflammation of the sinuses, while sinus infection refers specifically to inflammation caused by a germ. Sometimes, sinusitis leads to a sinus infection. "The sinus cavities, which drain into the nose through tiny pinpoint openings called ostia, are lined with mucous membranes," explains Metson. "When those membranes become swollen because of a cold or allergy, for example, they block the ostia and inhibit drainage. Then bacteria can build up and infection can result."

Doctors divide sinusitis into three categories. Acute sinusitis lasts less than four weeks; subacute sinusitis lasts from four to twelve weeks; and chronic sinusitis can have sufferers like Denise experiencing symptoms for more than twelve weeks.

"An acute infection is like a cut that becomes red and inflamed for a short time and then gets better," says James Hadley, M.D., clinical associate professor of otolaryngology (ear, nose and throat medicine) at the University of Rochester Medical Center, in Rochester, New York. "But a chronic infection is like having a splinter under the skin. Until you get the splinter out, things stay irritated."

Chronic and repeated infection rates are high: A 1996 survey conducted for the American Academy of Otolaryngology - Head and Neck Surgery found that 57 per cent of Americans who report sinus trouble say they get infections at least twice a year. More than a third say they have gotten sinusitis over 20 times. According to the National Centre for Health Statistics, the number of chronic sinusitis sufferers jumped five million in the five years from 1990 to 1995, the most recent span for which data are available.

The sinus-asthma link

The increase in sinusitis cases is partly explained by better diagostic tools, which enable doctors to detect very mild cases. Poor air quality is another factor. "Basically, anything that irritates the nose can predispose one to sinusitis," says Metson. "There are sinus-irritating smoke particles, hydrocarbons, sulfur compounds and nitrous oxides in the air. In sealed buildings, heat and air-conditioning can dry the mucous membranes."

There is also a correlation between the number of asthma cases - which have doubled in the last fifteen years - and sinusitis. Experts believe that the same immune-system over-reaction that causes inflammation in the bronchial passages, leading to an asthma attack, can inflame the sinuses. Traditionally doctors prescribed steroid pills to treat asthma, which also helped reduce inflammation in the sinuses. Today, many asthma patients use inhaled steroids, which work on the lungs but not the sinuses.

Swollen and susceptible

Virtually everyone is at risk for sinusitis because the triggers - such as colds, air pollution and dry heat - are hard to escape. But some people are more prone than others. High on the list are those who have suffered from sinusitis in the past or who have allergies. "Their membranes may not ever have a chance to heal all the way," says Hadley. "During the next event, they block off again quickly."

People who have anatomic sinus-blocking abnormalities are also more susceptible. A deviated septum (the centre section of the nose is shifted to one side) and polyps (small growths on the mucous membrane) can narrow the sinus openings, block drainage and lead to an increased rate of infection. Overall, about 10 per cent of Americans have deviated septums, estimates Metson, and less than 5 per cent have polyps. But of those who have respiratory allergies, asthma or other breathing problems, as many as one third have polyps.

Data from the National Center for Health Statistics indicate that sinusitis is more prevalent in women than in men, but experts can point to no scientific studies explaining the gender difference. In 1995, the rate for men was 135 per 1,000; for women it was 167 per 1,000. "Perhaps women are simply more likely to seek help from physicians," says Hadley.

New tools

Your primary care physician can treat infrequent, uncomplicated cases of sinusitis. If you have more than three attacks in one year or your symptoms last longer than three months, you should see a specialist. If you suspect allergies, consult an

allergist. An otolaryngologist will use a procedure called endoscopy. This involves passing a small, thin telescope through the nose into the nasal cavities to see areas of blockage and any physical abnormalities causing them. The procedure is slightly uncomfortable. If you have a chronic infection, you may need a sinus tap - a needle is inserted into the sinuses to remove mucus so it can be cultured to determine the exact type of bacteria. A CAT scan may be ordered to pinpoint inflammation.

Treatment usually involves a combination of therapies. Antibiotics (a ten-to-fourteen day course for acute infections; four to six weeks for chronic sinusitis) can tackle the infection. Over-the-counter pain relievers can ease discomfort. Nasal decongestant sprays can decrease swelling and widen sinus openings, but should be used for no more than five days; mucus thinning agents such as nasal saline can help get things flowing again.

Nasal steroid sprays block inflammation for those with chronic sinusitis caused by allergies. Antihistamines can dry up nasal secretions resulting from allergies; the newest nasal sprays work only on the nose and won't produce side effects such as drowsiness or increased blood pressure. Leukotriene modifiers, a new anti-inflammatory, may also provide some relief from sinusitis for asthma sufferers.

Patients with chronic sinusitis may be on a selection of these medications for years in order to get their sinuses in good working order. And while 80 per cent are helped by the drug therapy, 20 per cent still suffer. In some cases that's because an anatomic defect like a deviated septum, polyps, or scar tissue from repeat sinus infections is contributing to the blockage. Surgery may then be recommended. The latest tool in the sinusitis arsenal is a computerised-image guided system that lets surgeons see each move during surgery.

"When my otolaryngologist diagnosed blockage and a deviated septum, I decided to go ahead with sinus surgery," says Denise Tortora. "My doctor did say I should get fewer sinus infections and they would be less intense. He was right. In the first year after surgery, I got two or three infections and they were not nearly as painful as in the past. The next year, I got only one or two. I feel so much better now. I have my life back."

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Quick relief

FOUR simple steps to prevent sinus inflammation:

* Use a bedside humidifier.

* Drink three extra eight-ounce glasses of fluid a day.

* Hold your head over a bowl of hot water for ten minutes when congested.

* Use a saline nasal spray two to four times a day if you're prone to sinusitis attacks. Besides adding moisture, "the spray will get our mucus, so there's more room for drainage," says John A. Anderson, M.D., an Allergist and Clinical Researcher in Tucson.

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The cold wars

EVEN doctors can have a hard time distinguishing between a cold, allergies and sinusitis - that is because sinusitits often comes on the heels of a cold or allergy attack. What is more, all three maladies can share symptoms such as congestion, coughing and headache or facial pressure.

The number-one thing doctors look for in diagnosing sinusitis is duration. Allergy symptoms tend to fade when you eliminate the allergy trigger - be it pollen or the cat. Head indoors or go away on vacation and the problem clears up. As for a cold: "Your body should be able to fight it off in about five days," says Nancy Ott, M.D., an allergist and clinical associate professor of paediatrics at the University of Minnesota Medical School, in Minneapoalis.

Another sinusitis clue is a thick, copious, yellow or green nasal discharge for more than five days. Colds and allergies tend to produce thin, watery white-to-clear secretions.

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