Could my sinus pressure and inflammation be contributing to my anxiety and depression?

Addressing Sinus Pressure and Anxiety/Depression Connection

A referral to an ENT specialist is warranted for this patient, as there is a significant bidirectional relationship between chronic rhinosinusitis symptoms and anxiety/depression that requires proper evaluation and management. 1

Assessment of Symptoms

The patient's presentation includes:

• Increasing anxiety and depression
• Head and sinus pressure (particularly back of head/neck and near nose)
• Dizziness
• No congestion or drainage
• Perception that inflammation is exacerbating anxiety

Potential Diagnosis Considerations

1. Chronic Rhinosinusitis (CRS)

   • CRS is associated with a significantly increased prevalence of depression (9-26% physician-diagnosed, with up to 40% undiagnosed) 2
   • Patients without nasal polyps (CRSsNP) are more likely to experience comorbid depression than those with polyps 3
   • Perceived stress correlates with symptom severity in CRS patients 4

2. Bidirectional Relationship

   • The European Position Paper on Rhinosinusitis (EPOS 2020) recognizes the impact of psychological problems on subjective symptom severity scores 1
   • Patients with higher stress scores have significantly stronger symptoms including postnasal discharge, thick discharge, disturbed sleep, fatigue, and sadness 4

Management Approach

Step 1: ENT Referral

• An ENT referral is appropriate given the patient's symptoms of head/sinus pressure and perceived inflammation affecting mental health
• The ENT can perform nasal endoscopy and consider imaging to evaluate for structural abnormalities or inflammation

Step 2: Imaging Considerations

• CT scan of sinuses may be indicated if the ENT evaluation suggests inflammatory sinus disease
• Imaging helps determine the extent of disease and guides treatment options

Step 3: Mental Health Assessment

• Screen for depression and anxiety using validated tools
• Consider that rhinitis/sinusitis symptoms or diagnosis should be evaluated in patients who have anxiety or depression, as the interrelationship of the upper and lower airway suggests that therapy for the upper airway will improve overall control 1

Step 4: Integrated Treatment Plan

• For sinus symptoms:

  • If CRS is confirmed, treatment may include intranasal corticosteroids, saline irrigation, and possibly antibiotics if indicated
  • Address any structural abnormalities identified

• For anxiety/depression:

  • Consider that stress and depression should be addressed in patients with poorly controlled symptoms
  • Additional education to improve self-management and coping skills may be helpful 1
  • Psychological therapies including cognitive behavioral therapy, hypnotherapy, and mindfulness meditation may be offered as adjunctive therapy 1

Important Considerations

1. Comorbidity Impact:

   • Depression is associated with worse baseline and post-treatment symptom scores in CRS patients, though they still benefit from treatment 2
   • The psychological ramifications of untreated rhinitis can lead to low self-esteem, shyness, depression, and anxiety 1

2. Quality of Life:

   • CRS significantly impacts quality of life, with effects comparable to other chronic conditions
   • Treatment of upper airway conditions can improve both physical symptoms and mental health outcomes

3. Diagnostic Pitfalls:

   • Avoid attributing all symptoms to anxiety/depression without proper ENT evaluation
   • Similarly, don't dismiss mental health concerns as merely secondary to sinus issues
   • Consider that patients with CRSsNP have higher rates of depression (38%) compared to controls (14.8%) 5

By addressing both the potential sinus pathology and mental health concerns simultaneously, we can provide comprehensive care that addresses the patient's complete symptom profile and improves overall outcomes.