The most difficult thing about chronic sinusitis is adequately identifying it. There are two way to diagnose chronic sinusitis. The first is the initial method, and involves certain criteria based on symptorms. Initial treatments are based on this presumptive diagnosis.
As time moves on, and treatment becomes more involved, it becomes necessary to confirm the diagnosis. This is done with a CT scan. Only with an appropriate history of long term problems, and a CT scan showing changes of chronic sinusitis, is a diagnosis certain. Even then there are several types of chronic sinusitis, and they are treated differently. In patients who have already had their sinuses opened surgically, a diagnosis can be made with an endoscopic exam in the office.
These are:
Chronic bacterial sinusitis
Allergic fungal sinusitis
Anatomic chronic sinusitis
Probably multiple other underlying causes
In some cases, even after examination and CT scan, it can be difficult to know the underlying process causing chronic sinusitis.
How is it treated? Can any OTC treatments be helpful?
It is important to remember that chronic sinusitis runs a gamut from fairly minor symptoms, to persistent severe symptoms. It is also important to remember that chronic sinusitis is usually not dangerous. People can live their whole lives with chronic sinusitis, most would rather not.
OTC – medicines
Pseudoephedrine and Advil/Tylenol help with the symptoms of pain and congestion. The occasional use of Afrin type sprays can relieve flare ups of congestion and pain but should only be used 5 to 7 squirts per week total, alternate sides to get the most out of this limited use medicine. Saline nasal sprays, or saline rinses can be helpful to relieve some symptoms.
Steroid sprays can be helpful, but they are only available by prescription in the U.S. They are readily available on the internet by mail order as they are OTC in most other countries.
What can a primary care doctor do?
Primary care physicians do not often treat chronic sinusitis. As a practical matter, primary care usually treats flare ups. They can also treat concurrent allergies or headaches.
If you think you have chronic sinusitis (see the diagnostic criteria here), you should discuss this with your family doctor, or see a specialist.
What can a specialist do? (this is how I do it)
ENT doctors are very familiar with chronic sinusitis, it is a common problem. Initially a decision will be made to treat based on an "educated guess" or to confirm the diagnosis with a CT scan.
Treatment begins with maximizing medicines: steroid nasal sprays, sometimes decongestants, sometimes oral steroids, leukotriene receptor antagonist and long duration broad spectrum antibiotics. On occasion it can be helpful to base antibiotics on specially collected cultures. Depending on the symptoms, duration, and physical exam; antibiotics and other medicines may be used for 3 to 5 weeks.
At the end of a prolonged treatment regemin, a decision is made as to whether to confirm resolution of the process by obtaining a CT scan, or if things are going well, to see how symptoms progress over time.
Assume that at the end of the first regimen of antibiotics a CT is decided on. If it shows significant persist ant sinus disease, a decision is made as to if another long round of antibiotic might be helpful, perhaps oral steroids, or other medicine changes. Some findings at this juncture would suggest that the problem will likely not be remedied by further medicines and some type of surgical intervention should be discussed. Obstructing cysts, allergic fungal disease, significant polyps, anatomic obstructions, prominent disease despite adequate medicines are the common findings that may benefit from surgical intervention.