What is the best course of action to diagnose and treat my sinus problems and breathing difficulties?

Evaluation and Management of Sinus Problems and Breathing Difficulties

Start with intranasal corticosteroid spray as your primary treatment for chronic nasal congestion and breathing difficulties, while pursuing diagnostic evaluation with nasal endoscopy and CT imaging if symptoms persist beyond 8-12 weeks or fail to improve with initial medical therapy. 1

Initial Diagnostic Approach

Your symptoms require differentiation between several conditions that commonly cause nasal congestion and breathing problems:

• Duration matters critically: If symptoms have persisted beyond 8-12 weeks, you meet criteria for chronic rhinosinusitis (CRS) and require objective documentation of inflammation 2, 1
• Acute vs. chronic: Symptoms lasting less than 4 weeks suggest acute rhinosinusitis, while 8+ weeks indicates chronic disease requiring different management 2, 1

Key Symptoms to Assess

The American Academy of Allergy, Asthma, and Immunology requires at least 2 of the following for CRS diagnosis 2, 1:

• Mucopurulent drainage (anterior or posterior)
• Nasal obstruction/congestion
• Facial pain, pressure, or fullness
• Decreased sense of smell

Important distinction: Pain is much less prominent in chronic sinusitis compared to acute disease 2

Objective Confirmation Required

You cannot diagnose chronic rhinosinusitis on symptoms alone - objective evidence is mandatory to distinguish CRS from other causes like allergic rhinitis, vasomotor rhinitis, or even neoplasm 2

Recommended Diagnostic Tests

1. Nasal endoscopy (strongly recommended first-line): Directly visualizes the nasal passages, middle meatus, turbinates, and can identify 2, 1:

   • Nasal polyps
   • Purulent mucus or edema in the middle meatus
   • Mucosal inflammation
   • Anatomic abnormalities

2. CT scan without contrast (imaging of choice): Required when 2, 1:

   • Symptoms are vague or equivocal
   • Disease persists despite optimal medical treatment
   • Surgical intervention is being considered
   • Coronal cuts through the ostiomeatal complex provide best detail 2, 1

Critical caveat: CT scans show abnormalities in approximately one-third of asymptomatic people, so imaging alone without symptoms is not diagnostic 3

Treatment Algorithm

For Chronic Symptoms (8+ weeks)

First-line medical therapy 1:

• Intranasal corticosteroids: Primary treatment that reduces inflammation, promotes drainage, and does not cause rebound congestion like decongestant sprays 4, 5

  • Can be used safely for up to 6 months in adults (age 12+) before requiring physician reassessment 4
  • Works by decreasing mucosal swelling and white blood cell influx 5

• Saline irrigation: Adjunctive therapy to promote drainage 3

Second-line considerations 2, 1:

• Oral corticosteroids: Short course when initial treatment fails, nasal polyps are present, or marked mucosal edema exists 1
• Antibiotics: Controversial role in chronic sinusitis; consider only if infectious component is suspected with purulent discharge 2
  • Duration of 10-14 days minimum for acute bacterial sinusitis 2
  • Longer courses may be needed for chronic infectious sinusitis 2

For Acute Symptoms (less than 4 weeks)

Antibiotics indicated only if 1, 6:

• Symptoms persist beyond 10-14 days without improvement
• Severe symptoms with fever, purulent discharge, and facial pain
• Amoxicillin is first-line: 1.5-4g/day for 10-14 days 1, 6
• Switch to high-dose amoxicillin-clavulanate if no improvement in 3-5 days 6

Common pitfall: Overdiagnosis and unnecessary antibiotic use - most upper respiratory symptoms under 10 days are viral and do not require antibiotics 2, 6

Underlying Conditions to Evaluate

If you have chronic or recurrent symptoms, evaluation should include 2:

• Allergic rhinitis: Most common predisposing factor; requires allergy testing (skin or blood IgE testing) 2, 5
• Immunodeficiency: Consider if associated with recurrent otitis media, bronchitis, or pneumonia; measure quantitative IgG, IgA, IgM levels 2
• Anatomic abnormalities: Septal deviation, middle turbinate deformity, accessory structures blocking drainage 2
• Nasal polyps: Particularly if associated with asthma or aspirin sensitivity 2

When to Consider Surgical Referral

Consult an otolaryngologist for functional endoscopic sinus surgery if 2, 1:

• Significant anatomic obstruction (septal deviation compressing middle turbinate, ostiomeatal complex obstruction)
• Obstructing nasal polyps after trial of oral corticosteroids
• Recurrent/chronic symptoms with radiographic evidence of ostiomeatal obstruction despite aggressive medical management
• Suspected neoplasia, fungal disease, or granulomatous disease requiring biopsy 2

Important principle: Maximize medical treatment for underlying rhinitis before proceeding with surgery 2

Warning Signs Requiring Immediate Evaluation

Stop treatment and seek urgent care if you develop 1:

• Facial swelling or erythema over affected sinus
• Vision changes or abnormal eye movements
• Proptosis (eye bulging)
• Periorbital inflammation/edema/erythema
• Any signs of intracranial or central nervous system involvement

These suggest serious complications requiring immediate intervention 1

Expected Timeline

• Intranasal corticosteroids: If no improvement after 1 week of use, stop and consult your doctor - you may have an infection requiring different treatment 4
• Antibiotics (if prescribed): Should see improvement within 3-5 days; if not, alternative antibiotic needed 2, 6
• Most patients with chronic rhinosinusitis benefit from continued individualized medical therapy even after surgery 2