Hi all,
after much procrastination,  :-)
I finally got around to writing up something on the most common
questions we get asked around here, as an addendum to our FAQ.

I also added a section on "Common Mistakes in Treating Sinusitis."
Because after more extensive discussions with folks on this NG, we have
identified some mistakes that patients, and their doctors, make over and
over again in treating this difficult condition.

There's still a lot more to fill in here, as you'll see, and I welcome
any assistance.

Common Questions About Sinusitis
--------------------------------

1.  I've tried X.  I've tried Y.  I've tried Z.  But I'm still sick.  Is
there anything else I can try?

Yes, this is the main reason folks come to this NG--to find out what
else they can do to treat their sinusitis.

Much of this has already been covered in the rest of the FAQ.

Another place to turn is

http://www.sinuses.com/faq.htm

or, for more technical advice:

http://www.sinuses.com/md.htm

2.  I've had an X-ray, but it doesn't show anything really bad.  Yet I'm
still sick.  What can I do?

To diagnose sinus disease, ordinary X-rays aren't used often anymore,
because they are known to have a high percentage of false negative
results.  That is, X-rays often seem to show the sinuses are normal
even though the patient does have sinusitis.

The CT scan has largely replaced the X-ray for diagnosing sinus
disease.  If your physician will not order a CT scan for you, get a
second opinion.

3.  I've had a CT scan, but the CT scan doesn't show anything really bad.
Yet I'm still sick.  Should I have an MRI?

Unfortunately, even CT scans have a small percentage of false negative
results (showing normal sinuses even though sinusitis is present).  On
this newsgroup, over the years, a number of folks (including yours
truly!) have reported that surgery found problems in their sinuses
that the CT scan apparently missed.  At the very least, the
ENT/surgeon should review the CT scan films himself--not depend on a
report from the radiologist.  CT scans can be subject to
interpretation; so taking the CT scan films to another ENT for a
second opinion might be worthwhile.  But despite those measures, CT
scans can miss things.  Not often, but it does occur.  A good
physician will be aware of this, and will balance the results of the
CT scan against the rest of your examination, and against your
symptoms and medical history, in order to arrive at a proper diagnosis
and course of treatment.

If a CT scan is unsatisfactory, it's unlikely that an MRI will do the
job either.  An MRI is best used for diagnosis of bone disease or possibly
tumors--not sinusitis.

4.  I've had a nasal swab taken, but it didn't show any really bad
infection.  Yet my symptoms suggest I have an infection.

The bacteria in the sinuses may well be different from those in the
nostrils.  A nasal swab will not reveal the types of bacteria that are
infecting the sinuses.  A proper culture must be taken right from the
opening (ostium) of the infected sinus.  That requires an endoscope,
which an ENT has, but a primary care physician or family physician
usually does not.

4.  What is the best antibiotic for sinusitis?

There is no one "best" antibiotic.  Sinusitis can be caused by a
variety of pathogens--bacterial, viral, and fungal.

Some ENTs are coming to believe that many sinus infections are either
viral or fungal, and only some sinus infections are purely bacterial
in nature.  Viral respiratory infections tend to be self-limiting in
healthy patients who are not immunocompromised.  The role of fungal
infection in sinusitis is currently a major "hot" topic of research;
for more information, go here:

http://www.sinuses.com/fungal.htm

Antibiotics work only on bacterial infections.  And different strains of
bacteria are
sensitive to different types of antibiotics.

Some general guidelines:

A sinus culture might help reveal just what bacteria are causing the
infection.  That would help pinpoint a specific antibiotic to target
those bacteria.

Failing that, the alternative is to choose a broad-spectrum antibiotic
(one that works on a wide variety of known possible sinusitis bacteria).

Sinus infections are stubborn, and the usual 10-day course of oral
antibiotic is often insufficient.  Once the course of antibiotic is
over, the remaining bacteria will multiply all over again.  14 days is
minimum; 3 - 4 weeks is better; and there are even cases of patients
needing to be on antibiotics for months to completely eradicate the
infection.

Some common antibiotics are known to be ineffective
against sinusitis in adults:  Erythromycin, penicillin, and
tetracycline.  (However, there are antibiotics in each of those
classes--Biaxin, amoxicillin, and doxycycline--that do work.)

For more information, go here:

http://www.sinuses.com/md.htm

5.  My ENT is recommending a septoplasty.  Should I have it?

The purpose of septoplasty is to straighten a deviated septum that the
CT scan shows is helping to block the sinuses.  But if you already
have chronic sinusitis, then more extensive surgery may be needed to
repair the sinuses themselves.  Get a second opinion from another
ENT/surgeon.

6.  My ENT is recommending a Caldwell-Luc (and/or naso-antral window)
procedure.  Should I have it?

The Caldwell-Luc and naso-antral window procedures used to be the
mainstay of sinus surgery.  The advent of functional endoscopic sinus
surgery (FESS) has largely replaced these older procedures.
Nevertheless, there are some cases where Caldwell-Luc is still
warranted:  especially if there is a problem inside the maxillary
sinus that is difficult or impossible to reach endoscopically.  It is
strongly suggested that a patient get at least a second opinion (and
maybe even a third!) before proceeding with Caldwell-Luc.

7.  My ENT is recommending turbinate reduction.  Should I have it?

8.  How can I find a really great ENT (sinus surgeon)?

A good ENT is more likely to be found at a world-class renowned
otolaryngology department of a major medical center.  The magazine
"U.S. News & World Report" does an annual survey to identify the best
hospitals in the U.S., in each of the major departments--including
otolaryngology.  Go here:

http://www.usnews.com/usnews/health/hosptl/tophosp.htm

9.  I found an alternative remedy for sinusitis (on the Internet, on TV,
in a newspaper, in a magazine, etc.)  Anybody know anything
about it?

The value of alternative medicine to treat sinusitis has never been
satisfactorily proven.  But even if one desires to go that route,
there is still a difference between alternative medicine and
self-treatment.

If one tries to treat sinusitis himself with alternative medicine,
then he must know enough to steer clear of all the quack nostrums
being peddled under the guise of "alternative medicine."

One book that may be useful is "Sinus Survival," by Dr. Robert Ivker.
It's better still if one seeks the advice of a competent practitioner
of alternative medicine.  The American Holistic Medical Association
has a directory of holistic practitioners in most states of the U.S.,
at

http://www.holisticmedicine.org/public/public.shtml

10.  My mucus is {opaque white, yellowish, yellow, day-glo orange-yellow,
green, brown, bloody, clear, etc.}.  Does this color indicate sinusitis?

Most ENTs seem to agree that badly discolored mucus (green, brown,
day-glo yellow) indicates sinusitis.  The inflammation of sinusitis
can cause bloody mucus.  Yellowish mucus is more problematic.  But
sinusitis can sometimes be present even with clear or white mucus.

11.  What is the relationship between sinusitis and {allergy, rhinitis,
GERD, chronic fatigue, asthma, etc.?

The short answer is that they can co-exist.  Allergies (allergic
rhinitis) can cause swelling of sinus tissue, leading to sinusitis.
So can non-allergic rhinitis.  Fatigue is a common systemic effect of
chronic sinusitis.  Sinusitis can worsen asthma.

The relationship of GERD and sinusitis is still a "hot topic" in
otolaryngology.  Sinusitis can cause stomach upset (leading to GERD),
due to swallowing infected mucus.  GERD may conceivably lead to
sinusitis, as stomach contents back up into the throat and beyond,
into the nasopharynx.

12.  My symptoms seem to get much worse whenever I <fill in>.  What's up
with that?

13.  OK, I've tried irrigating, but no fluid comes out of my nose, it's so
stuffed up.  What should I do?

It may mean that your sinuses are so blocked that all that saline
you're squirting into your sinuses isn't draining out properly.  The
saline in your sinuses will then add to the congestion rather than
relieving it.  In that case, it might be a good idea to stop using the
irrigation and see a physician.

Common Mistakes In Treating Sinusitis
-------------------------------------

1.  Misdiagnosis

Sinusitis is frequently misdiagnosed for any of several conditions.
The symptoms in the nasopharynx are sometimes mistaken for allergy
(allergic rhinitis), "non-allergic rhinitis," or the common cold.  The
common cold is a viral infection, and in otherwise healthy
individuals, it is usually self-limiting, lasting up to 2 weeks.  If
the "cold" lingers for several weeks or longer, with no improvement,
it is probably not just a "cold."

Sinusitis can produce lower respiratory symptoms that can be
misdiagnosed too.  Purulent post nasal drip can cause a productive
cough of purulent mucus, which may be mistaken for bronchitis or even
asthma.

2.  Failure to investigate the root cause

Sinusitis occurs when sinuses are unable to drain properly.  It is
extremely important that your physician discover why your sinuses are
not draining properly.  If he just treats your immediate attack of
sinusitis (say by prescribing an antibiotic), he may stop the attack.
But without fixing the cause, the chance of a relapse--another flareup
of sinusitis--at some point in the future, is very high.

Unfortunately, the search for the root cause can be time-consuming and
expensive--and sometimes, even fruitless.

Patients see their doctors when they are experiencing acute symptoms.
If the doctor is able to cure their acute symptoms with antibiotics,
the patient may be inclined to dispense with the search for the
cause.  Unfortunately, the acute sinusitis may then recur; and this
pattern, if repeated too often, can lead to chronic sinusitis.  Thus
it is important to continue the search for the root cause.

3.  Failure to recognize false negative results in medical tests

No medical test is 100% reliable.  Simple sinus X-rays are not used
much anymore because of a high incidence of false negatives (failing
to detect sinusitis even though it's there).

But even sinus CT scans have about a 5-10% rate of false negatives. A
number of us on this NG have experienced aspects of sinusitis that
were not detected by the CT scan.

An experienced physician should be aware of the limitations of even
modern diagnostic tools, and not put blind faith in any one tool.  An
accurate diagnosis may require several tools (CT scan, endoscope,
etc.) used in conjunction with a detailed patient history and
symptomatology.

4.  Undertreatment (often applies to antibiotics)

5.  Overly conservative surgery (e.g. septoplasty only)

6.  Inappropriate surgical procedure (turbinate reduction, Caldwell-Luc,
etc.)