A cold? the flu? allergies? or a sinus infection? how do you know what you have?
Posted on October 23rd, 2013

As you wake from a night of restless sleep the alarm clock is ringing and the loud clanging makes your head pound. You reach to shut it off and realize in addition to that nasty headache, you're tongue feels like cardboard.  You open your mouth and move your tongue around trying to moisten your mouth but a night of mouth breathing has left it as dry as the Gobi. When you try to breath through your nose its completely blocked. It doesn't help that during the night someone has stuffed bricks in your sinuses. With a groan you drop back onto the bed and put a pillow over your head. Its going to be a long day.
This time of the year sniffling patients are lining up at their doctors offices looking for some kind of relief from the type of misery described above. Is it the flu, a nasty cold, severe allergy symptoms, or a sinus infection? All they know is they need some relief. All of these conditions can cause uncomfortable nasal congestion but the treatment for each can be very different so how do you know which one you have?

It would be great if the doctor could swab your throat, take some blood, or do a scan and tell exactly what was causing these symptoms but sadly no such test exists yet. In order to determine the source of our misery doctors have to rely on the oldest and still most important of medical tests. Its called the medical history. Ask the right questions and listen to the answers. There are clues in the details of your symptoms and if a doctor knows the right questions to ask he can usually figure out what's going on despite the lack of any useful diagnostic tests for these conditions. The history of your illness, what symptoms you have, when they started, whether they have gotten better or worse, how long they have lasted, what other symptoms accompanied your stuffy nose can all help us figure out why your day started off so badly..

So how do you tell what the problem is when you have a stuffy nose? Here are some clues.

Diagnosis

1) A Cold also called an Upper Respiratory Infection or URI

URI's can be caused by any of 100 or more viruses. These illnesses can last from a few days to a few weeks. Sometimes patients will say " I know this isn't a cold because I always get over a cold in a couple of days" but cold viruses can vary greatly in their severity and duration. Some colds may only last a couple of days but others can last a couple of weeks.

In additional to nasal congestion patients suffering from colds may have other symptoms like scratchy throat, mild body aches, headaches, and sometimes a low grade fever. Usually the symptoms gradually worsen over the first 3 days, then plateau for several days, and finally improve over the next few days to two weeks.
2) Allergies

We may imagine allergies as a spring time problem but in fact allergies can occur any time of the year. In the spring tree pollen fills the air and can be seen as a dusty green layer on our cars. Grass pollen is a major summer nuisance. Ragweed pops up in the early fall and the wet leaves of late fall can be a breeding ground for molds. When winter finally brings its cold chill and we close our windows you would think all this allergy stuff would end but the warm and dry air in our homes creates ideal conditions for dust mite allergies. In short, there is no season when we are free from the possibility of allergies.

Allergies can cause symptoms that people often confuse for cold symptoms and its easy to see why. We're all familiar with the typical watery eyes and runny nose that everyone seems to be suffering from in the allergy commercials but few people realize that a persistent cough, sore throat, fatigue, and headache can also be common allergy symptoms. What gets confusing is that someone who is suffering from allergies can have one of these symptoms, some of them, or all of them. For example its possible to have just a cough and sore throat without a runny nose or sneezing. Sometimes patients just have fatigue and nothing else. The classic picture of sneezing and watery eyes does sometimes occur but the majority of people who have allergy attacks don't have that classic set of symptoms. Unlike colds though, allergies usually will not cause body aches and you won't get a fever ( temp of 101 or more).

In general if a patient has any of these symptoms and its been only a week or two it may be difficult to know whether they have an allergy or a cold unless they have a fever or body aches. Unfortunately for the prospects of making a diagnosis most people with colds don't have a fever either and many don't have body aches.

After a couple of weeks the picture usually becomes clearer. Most people suffering from a URI will be well on their way to recovery at that point but a person who reports several weeks of constant or waxing and waning symptoms without a fever and no sign of resolution is much more likely to be suffering from allergies. A history of seasonally recurring symptoms is also another clue that this could be allergies.

Finally, patients will often comment "I know this isn't allergies because I don't have allergies" with the mistaken belief that allergies are a childhood phenomena and if they didn't get them as a child they are out of the woods. In fact the opposite is true. Most adults who have allergies developed them at some time in their adult life despite an allergy free childhood. So don't assume that your runny nose has to be a cold just because you are 35 and have never had allergies before.
3) Sinus Infection

Often times a patient is diagnosed with a sinus infection when they have severe sinus congestion or sinus pain. Its a common belief that these symptom indicate a bacterial infection especially if the patient reports that they are producing green mucous as well, but studies have cast doubt on this idea.

Research has shown that most people with prolonged sinus congestion do not have a bacterial infection and the color of the mucous does not correlate with the presence of bacteria either. The majority of these situations appear to be caused by viral infections and allergies, while others may be due to a fungus infection. For this reason antibiotics are really not helpful in most of the cases where patients are diagnosed with a sinus infection. It can be confusing for patients because they are usually given antibiotics for these conditions and ultimately they do get better but the evidence is that they would have gotten better just as quickly without the antibiotics and with a lower risk of side effects.

There are  some cases in which bacteria may be the culprit. Bacterial sinus infections sometimes arise when congestion has persisted for a while and bacteria has a chance to colonize the collection of mucous. Eventually these bacteria may invade the tissues lining the sinus cavity causing a sinus infection. In such cases a patient will usually report a period of persistent or waxing and waning sinus congestion for several weeks which is then punctuated by the development of a fever or a sudden worsening of pain around or behind the eyes.

No matter what their previous experience, patients should never insist that they have a sinus infection and demand antibiotics. Too often faced with this situation and not wanting to be confrontational a doctor will write a prescription for antibiotics. This will pacify the patient for another 10 days but which buys some time but exposes the patient to potential side effects and usually does nothing to shorten the course of the illness.
4) The Flu

This is probably the easiest of the above conditions to diagnose. Patients with the flu can certainly have nasal congestion, watery eyes, and a cough or sore throat just like a cold or allergies but the thing that distinguishes the flu from the other conditions are the body aches and fever. Patients suffering with the flu often have debilitating body aches. Its not uncommon for me to hear a flu sufferer say with a groan of exasperation  "Doc everything hurts, even my hair hurts" as they struggle to lift their head just high enough off the exam table to look at me with their glassy eyes. They usually have a fever over 101 and sometimes more than 104 with chills and shakes that make the body aches even worse.

Unlike the other conditions there is a test that will confirm if a patient has the flu. If the doctor is unsure or they need confirmation they can do a culture. To do this the doctor inserts a soft swab deep into the nasal passage to collect a specimen. A quick test will sometimes be done in the office but this test can suffer from a high rate of false negatives. The specimen can be sent for a  viral culture which takes several days but is more reliable.

Treatment

1) URI and Flu

Symptomatic Relief:
There are many products advertised for treating colds but despite all the hype they all have some combination of the following common ingredients in them.

All cold and flu remedies have one or more of the following five ingredients:
  • Nasal Congestion: Pseudoephedrine or Phenylephrine
  • Fever, Headaches, Body aches: Acetaminophen or Ibuprofen
  • Expectorant: Guaifenesin
  • Cough Suppressant: Dextromethorphan
  • Sleep: Any of a number of antihistamines such as Doxylamine or Diphenhydramine
NyQuil for example contains pseudoephedrine, acetaminophen, and doxylamine while Maximum Strength Mucinex contains phenylephrine, acetaminophen, and diphenhydramine and Tylenol Cold Multi-Symptom contains phenylephrine, acetaminophen and dextromethorphan

Other versions of these products will contain different combinations of ingredients but despite the fancy commercials and marketing hype none of them have any special magic. They all include various ingredients from the menu of 5 listed above.

In addition to the liquids and pills there are nasal decongestant sprays which may be useful sometimes. Sprays like Afrin contain oxymetazline that constricts the blood vessels in the nasal membranes shrinking those membranes and opening the nasal passages. They usually work very quickly in 5-10 minutes and can give dramatic relief of symptoms. The disadvantage of these sprays is that the body becomes tolerant to them quickly and if continued for too long the patient will experience a rebound effect when they stop the medication. The rebound effect is a swelling of the nasal tissues that causes congestion that can be as bad or worse than the original symptoms. For this reason these sprays should only be used intermittently and only for a few days at a time.

When buying a cold or flu remedy you should purchase one that only contains the ingredients you need.

Antiviral medications:

URI's are always caused by viruses. There are a number of different viruses that can cause a URI and currently there are no effective antiviral medications for any of these viruses.   Treatment is therefor limited to symptom relief. Antibiotics will absolutely never help when you have a cold.

The Flu is caused by various strains of the influenza virus as opposed to colds which can be caused by many different viruses. There are several antiviral medications which are effective against the influenza viruses to some degree. These are not miracle drugs though. Anti-influenza drugs will shorten the course of the flu but only by about a day on average. They can also  decrease the severity of the symptoms but in order to get any of these benefits the medications must be started within 48 hours of the first symptoms. These drugs can have side effects such the most common of which is nausea. Rapid resistance to these drugs has also been reported during flu outbreaks. For all of these reasons many experts do not recommend using anti-influenza medications in otherwise healthy individuals who develop the flu.

Others:

Vitamin C, ZInc, Echinacea as well as many other home remedies and herbal supplements have been used to treat colds. Some of these products may have benefits in limited circumstances. Searching for accurate and reliable information about these products is not easy. Most of the information on the internet is from companies that prmote these products or from fans of the products. There is almost a religious following of people devoted to home remedies and they all seem to have web sites so separating fact from fiction can be difficult. Fortunately the National Institute of Health has created a division devoted to researching alternative treatments through standard scientific methods and much of this information is available on line. For more information on any of these products visit the National Center for Complementary and Alternative Medicine (NCCAM).

2) Allergies

Anithistamines:  Allergies are usually treated with antihistamines. Older antihistamines tended to be sedating. These include diphenhydramine (Benadryl) and brompheniramine (Dimetap) among many others. in the past two decades a number of non-sedating antihistamines have come to market. several are now available over the counter including loratadine (Claritin) and fexofenadine (Allegra)

Nasal Corticosteroid Spray:  If antihistamines alone don't control the symptoms a nasal spray may be used which contains corticosteroids. Unlike antihistamines, these products require a prescription. They include fluticasone (Flonase), mometasone furoate (Nasonex), triamcinalone (Nasacort), and beclomethasone dipropionate (Vanceril) among others. These spray are unlike the sprays mentioned above. They contain steroids which reduce inflammation. They do not work as quickly as the decongestant sprays but they do not create dependance or rebound effects and can be used as long as needed. The will not work for colds and flu however.

Oral Steroids:  When first line treatments like antihistamines and nasal sprays are not sufficient to control symptoms doctors will sometimes use a short course of steroids taken by mouth. The oral form of steroids have a much more potent effect than the nasal spray form but come with some risk of potential side effects so they are reserved for patients with severe symptoms that have failed other treatments.
3) Sinus infections

A sinus infection in many ways is similar to an abscess. An abscess is a pocket of fluid in which harmful bacteria are growing. Because there is this pocket of fluid the bodies natural defenses don't work as well. It is more difficult to get white blood cells to the source of the infection because there are no blood vessels running through this space. White cells do eventually make it to the source of infection but they are not as effective as we would like them to be. Eventually a mixture of bacteria and white cells accumulate and we call this puss. If the abscess is not opened and drained the collection may grow in size and the bacteria may eventually enter the blood stream causing a more serious infection. Antibiotics may be of only limited value since blood flow is needed to distribute them to the source of infection so the same problem that prevents white blood cells from being fully effective affects antibiotics as well. The only way to treat an abscess is to drain it and then use antibiotics to mop up the remaining infection.

A sinus cavity is a lot like an abscess. To begin with a sinus cavity is a large empty space. When we get a cold or allergies the space may fill with fluid. Normally this fluid drains on its own through a small opening that exists in each sinus cavity but if the tissues that line the sinus are inflamed enough the opening may become very small or may close all together. If this condition persists for long enough and the right type of bacteria are present an infection may develop.

Its important to understand though that congestion and sinus pressure themselves are not proof of a sinus infection. They are merely the conditions that may, if given enough time, lead to a sinus infection. Usually if congestion is treated properly and early enough the infection itself will never occur. Even when a true sinus infection does occur, just like with an abscess, antibiotics alone may not cure the problem. Getting the sinuses to drain is just as important as starting the correct antibiotic.

So lets say its 2 weeks after that fateful morning when you awoke feeling miserable with a brick in your sinuses. You have been muddling along using over the counter medications and home remedies but today when you woke up something was different. Now you have a fever and that pressure behind your eyes has turned into a throbbing pain. It wasn't like that when you went to bed last night or in any of the preceding 14 days since this all began.  Deciding that you have been patient long enough you make an appointment to go to the doctor. Upon telling the doctor your tale he examines you and finds your temperature is 101.  He agrees that you probably have developed a sinus infection and that there is a reasonable chance that it may be bacterial.

The Antibiotics of choice in these situations are drugs such as Amoxacillin, Augmentin, or Levaquin and there is a good chance you will be put on one of these for about 2 weeks.

Another approach to treating sinus infections is to treat the drainage issue in addition to the possible infection. To accomplish this we may add a decongestant or an oral steroid to the antibiotics. These medications can open up the sinus passages so the mucous drains. In a way its like draining an abscess and this will usually result in more rapid resolution of symptoms. This approach has the added benefit of treating any possible allergy condition that may have lead to the sinus congestion.



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