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Sinus issues in Cystic Fibrosis

Sinus issues in Cystic Fibrosis

(Content prepared with support from Dr Catherine Banks, Ear Nose and Throat Specialist, Department of Otolaryngology Head and Neck Surgery, Prince of Wales Hospital, Sydney Children’s Hospital, University of NSW)

What are your sinuses?

Your sinuses are located in your head. There are a number of different sinus cavities, some behind your nose, below your eyes and above your eyes. The image below provides a map of the different sinuses we have. They are often referred to as united or unified airways, as the sinuses are linked to the airways in the lungs.

While the purpose of the sinuses is not completely clear, we know that they humidify the air we breathe in, and also help filter out particles/bacteria as we breathe. The sinuses are affected in the same way as the airways in the lungs by CFJust as the lower airways and lungs are impacted by CF. With problems with the CFTR protein the sinus surfaces can fill with thick sticky secretions and be more susceptible to infection and inflammation.

Our sinuses produce secretions equivalent to the volume to 5 cans of coke in 24 hours.

How can your sinuses potentially be impacted by CF?

  • Thick sticky secretions – the CFTR dysfunction that occurs in CF ultimately results in thickened secretions that are unable to be cleared naturally by the sinuses. This results in “stasis” of sinus secretions and provides a favourable environment for bacteria to thrive and grow. In time this can lead to a vicious cycle of infection and inflammation.
  • Post nasal drip – this can result in the thick secretions and infections trailing down the back of the nose and unfortunately these secretions can contaminate the lower airways.
  • Loss of smell – This is an important issue. We know that nutrition is vital in the CF population and compromised smell is common in individuals with CF with sinus disease and can result in reduced appetite.
  • Decline in respiratory health, not responding to usual care – within the unified airway theory, there is robust evidence demonstrating that the upper airway affects the lower airway. The sinuses should be considered and optimised with ENT involvement as necessary if the lower respiratory tract is not improving with usual care.
  • Irritable cough particularly during the night or first thing in the morning – this is likely part of the unified airway and post nasal secretions that can drain into the lower airway while we sleep.
  • Frequent throat clearing – The post nasal drainage and inflammatory mediators can result in the need to throat clear.
  • Polyps – The likelihood of developing sinus polyps in CF increases with increasing age. The polyps represent inflamed lining of the sinuses.  This compounds the inability to adequately clear secretions and infections effectively.
  • Pain – Interestingly, individuals with CF do not often report much pain or discomfort of their sinuses. We do not really understand why this is the case, as often their sinuses clinically look much worse than other patients with chronic rhinosinusitis without CF.
  • Headaches – This can be common in individuals with CF, but doesn’t seem to be correlated with sinus disease.

How do I know if I have sinus issues?

Your health care team may ask you some of these questions, but remember if you are experiencing any of the symptoms mentioned above, or you are curious about your sinuses, talk to your CF team about this.

The main questions that your team may ask you are:

  1. Do you have nasal obstruction/congestion/ or blockage?
  2. Do you have drainage from your sinuses, either posterior (down the back of your throat) or anterior (needing to constantly blow your nose)?
  3. Do you have facial pain or pressure?
  4. Do you have a decreased sense of smell?
  5. Do you have a cough (In the paediatric patients we talk about cough rather than smell).

There is no CF dedicated questionnaire for sinusitis, so a general Chronic rhinosinusitis questionnaire, such as the “SNOT 22”  or “SN-5” questionnaires are recommended.

Older individuals can fill in the “Sinonasal Outcome Test”, which consists of 22 questions, hence it is called the SNOT 22 Questionnaire. Each of the questions are grouped into  Nasal, Ear and Facial, Sleep, Function, and Emotional domains. It provides your specialist or ENT surgeon an idea about how well you are tracking across the different domains.

In children age 2-12 we use a Sino-Nasal 5 Questionnaire (SN-5) this takes less than 5 minutes to complete

Ask your healthcare team about a SNOT 22 or the SN-5. 

An ENT specialist may organise CT scans of the sinuses when they are considering operating. However almost 100% of CF patients will have radiological signs of sinus inflammation on CT scans.  Therefore, imaging may not always be necessary for all patients.

Sampling of sinus secretions may be recommended by your team if you are not responding to the antibiotics being used to treat the bugs identified in your lungs. It is a simple procedure using a sinus flush to collect secretions from the sinuses to send to pathology. Your physiotherapist or CF nurse may assist you with this if necessary.

What might I do if I have sinus issues?

This will depend on what the issues are. but usually involves working  together with your CF healthcare team and/or an Ear Nose & Throat (ENT) specialist to help manage your symptoms and try to keep your sinuses as healthy as possible. Some of these treatments might include:

  • Use of nasal sprays
  • Use of sinus rinses or douches
  • Use of a sinus nebuliser
  • Application of topical antibiotics
  • Surgery may be indicated

What is the role of physiotherapy in managing CF sinus disease?

Physiotherapy can assist with checking in with your sinuses, and your symptoms that might indicate sinus issues. Your physiotherapist may also be able to assist you with education on the best way to deliver nasal sprays or using the sinus flushes/sinus nebuliser. It is important to work together with your ENT specialist and your physiotherapist after any surgery or procedure to your sinuses to make sure they can stay as healthy as possible. This regimen will be slightly different for everyone, so work with your care team to decide what is best for your sinuses.

Some individuals with CF have reported improvements in sinus issues following the commencement and established use of CFTR modulator therapy. Some of these improvements have included improved imaging (CT scans), and improvements in post nasal drip, fatigue (associated with sinus infection), nasal discharge. In fact, many ENT surgeons will delay operating on the sinuses until after modulator treatment has been initiated, as some people have found significant improvements in sinus symptoms.

Helpful resources

These videos may be helpful when commencing sinus irrigations or inhalation therapy. These videos have not been produced by, these are external links to other resources.


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