I have had recurring sinus infections for the past year. I have been treated with antibiotics each time. However, whenever I stop taking them, the infection comes back. My ENT put a tube in my right ear in the hope that it would allow the fluid to drain. No luck. I have also had a CT scan, which shows mucosal thickening. I am currently using Flonase and taking various decongestants and sinus remedies, but nothing seems to relieve the headaches and sinus pain. Last week, I even had a prednisone shot. It helped a little, but only for a day or so. Is there any treatment that works or at least relieves some of the pain?

S.F.W.

One reason that chronic sinusitis is chronic is that there is often little rhyme or reason to the treatment plan. But let's not get ahead of ourselves.
Sinuses are "air pockets" within the facial bones. Each sinus is lined with a tissue known as mucosa. Mucosa produces mucus, and mucus is a good thing. A thin blanket of mucus lines the mucosa of the sinuses, nasal cavities and throat. It is analogous to the sticky stuff on a No-Pest Strip, trapping dirt, dust, microbes, pollen and anything else that doesn't belong inside the body. Microscopic "hairs" (cilia) on the mucosal surface sweep the mucus up and out of the sinuses, out of the nose, and into the back of the throat, where you swallow it!

Sinusitis is a generic term for any sinus inflammation. To devise a rational treatment plan for sinusitis, your doctor must attempt to answer a number of important questions regarding the nature of this inflammation. The answers to these questions will determine which medications would be useful and whether an operation might help.

1. Is the inflammation due to infection? Viruses, bacteria and fungi can all cause infection. Viral infection of the nose (the common cold, in other words) can cause mucosal swelling (a stuffy nose), impeding the natural drainage of the sinuses. The self-cleaning ability of each obstructed sinus is hindered, and bacterial infection (acute sinusitis) may result. Undertreatment of acute sinusitis may lead to a smoldering infection known as subacute sinusitis, later followed by chronic sinusitis. Finally, we all have a small number of fungal spores in our nasal cavity at all times -- they are in the air we breathe. Fungal overgrowth within the sinuses tends to promote mucosal inflammation and contribute to obstructed sinus drainage. Very rarely, these fungi actually invade tissues, causing a much more serious disease called invasive fungal sinusitis. Simultaneous infection by all three types of microorganisms is possible.
   
2. Is the inflammation due to an abnormality of the mucosa other than infection? For example, allergies can cause a remarkable degree of mucosal inflammation in the nasal cavity and sinuses. In addition, cigarette smoke and other toxic fumes can damage the cilia, impairing the mucosa's ability to self-clean. Finally, there are certain conditions in which the mucosa is intrinsically diseased. Cystic fibrosis is an example.
   
3. Are anatomic problems promoting sinusitis? One example of such a problem is severe septal deviation. The nasal septum is a structure of bone and cartilage that divides the nose into two cavities. Septal deviation is present when the septum is "pushed over" to one side or another. (This is usually due to trauma, but sometimes the septum becomes deviated as a result of facial growth in childhood and adolescence.) If the septum is severely deviated, it will certainly cause chronic nasal airway obstruction (at least on one side), and it may contribute to sinusitis.
   

Many other anatomical abnormalities can predispose towards sinusitis. These bits of aberrant anatomy may be obvious on physical examination, but sometimes a sinus CT scan is needed to find these problems. Nasal endoscopy (examination of your nose with a flexible fiberoptic camera) can also be extremely helpful for finding such problems.

In this way, every patient with sinusitis must be evaluated individually, and the treatment plan must be tailored to the patient's specific problems. Uninspired treatment plans are doomed to failure and may even worsen the situation. Ear, nose and throat doctors (ENTs) are typically a bit better at this than nonspecialists, but unfortunately not all ENTs are created equally, so you may have to shop around. Ask your physician or friends for a referral.