The hardest part of long-lasting sinus inflammation (chronic sinusitis) is being sure that's really what you have. There are two ways to make the diagnosis. The first is based on a list of symptoms that have lasted a long time. Early treatments are usually started from this best-guess diagnosis.
As time goes on and treatment gets more involved, it becomes important to confirm the diagnosis. This is done with a CT scan. Only with a clear history of long-term problems plus a CT scan showing the changes of chronic sinusitis is the diagnosis certain. Even then, there are several types of chronic sinusitis, and they are treated differently. In people who have already had sinus surgery, the diagnosis can sometimes be made with an in-office camera exam (nasal endoscopy).
The main types are:
Long-lasting bacterial sinusitis
Allergic fungal sinusitis
Sinusitis caused by the shape of the nose and sinuses
Probably several other less-understood causes
Sometimes, even after a careful exam and a CT scan, it can be hard to know exactly what is causing the long-lasting sinus problem.
How is it treated? Can over-the-counter medicines help?
It's important to remember that long-lasting sinus inflammation (chronic sinusitis) ranges from very mild symptoms to severe ones. It's also important to remember that it is usually not dangerous. People can live their whole lives with it — though most would rather not.
Over-the-counter medicines
Pseudoephedrine and Advil or Tylenol help with pain and stuffiness. Occasional use of an Afrin-type spray can relieve a flare-up, but only 5 to 7 sprays a week in total — alternate sides to get the most from this limited-use medicine. Saltwater nose sprays or rinses can also help with some symptoms.
Steroid nose sprays can help. Many of these are now available without a prescription in the U.S.
What can your regular doctor do?
Regular doctors don't often treat long-lasting sinus inflammation. In practice, they usually handle the flare-ups. They can also treat allergies or headaches that are happening at the same time.
If you think you have chronic sinusitis (see the criteria here), talk to your family doctor or see a specialist.
What can a specialist do? (this is how I do it)
ENT doctors deal with chronic sinusitis often. The first decision is whether to treat right away based on an educated guess, or to confirm the diagnosis first with a CT scan.
Treatment starts by getting the most out of medicines: steroid nose sprays, sometimes decongestants, sometimes steroid pills, sometimes a different type of pill called a leukotriene blocker, and a long course of broad antibiotics. Sometimes it helps to choose the antibiotic based on a specially taken culture from inside the nose. Depending on your symptoms, how long things have gone on, and the exam, antibiotics and other medicines may be used for 3 to 5 weeks.
At the end of a long course of treatment, the decision is whether to get a CT scan to make sure the infection is gone, or — if things are going well — to wait and see how symptoms behave over time.
If a CT scan is done after the first round and still shows a lot of sinus disease, the next decision is whether another long course of antibiotics, steroid pills, or different medicines might help. Some findings at this point suggest that more medicine is unlikely to fix things, and surgery should be talked about. Cysts blocking the sinuses, allergic fungal sinus disease, significant nasal polyps (growths in the nose lining), shape problems inside the nose, and stubborn disease that won't respond to good medicine are the main reasons surgery may be considered.