Your Sinusitis Won’t Go Away? Here’s What You Need To Know.

Sinusitis — also known as a sinus infection — is, for the most part, a bacterial infection caused by inflammation of the sinuses. Chronic and recurring long-lasting sinusitis can render you incapacitated and quickly eat up your sick days.

But when your sinusitis won’t go away, what options do you have? This guide walks you through how to identify a sinus infection, what happens if you ignore it, how to treat your chronic sinusitis, and more.

How long should it take for a bad sinus infection to go away?

Before we delve into what to do when your sinusitis won’t go away, let’s figure out whether you have a sinus infection in the first place. The symptoms shared between the common cold, chronic sinusitis, and chronic allergies, are similar — making it rather difficult to deduce which culprit is causing your sinus issues.

One major differentiator, however, is time. A cold (caused by a virus) should go away within a week. If your “cold” lasts longer than 7-10 days, it’s likely that your cold has either turned into a bacterial sinus infection, or you actually had a sinus infection from the very beginning. Whatever the case, if your symptoms persist for more than a week, it’s best to see a doctor.

Once your doctor determines treatment, your sinus infection symptoms (even those of a very bad sinus infection) should begin to subside within a few days.   

Can a sinus infection last for months?

Sinusitis won’t go away at the drop of a hat. It tends to linger and, if left untreated, it can last for months. Again, it’s best to take a trip to your doctor’s office if your symptoms last longer than one week.

Note that there is a chance that long-term sinus issues may be caused by allergens. If this is the case, then your sinus symptoms will likely last until you can escape the allergen or have the allergies treated.

What happens if a sinus infection is left untreated?

For some lucky people, sinus infections may go away if left untreated. Rest and hydration will certainly help with this.

For others, however, sinusitis won’t go away until you seek treatment. If this is the case, a sinus infection left untreated may cause further complications (as chronic sinusitis can actually spread to the eyes and the brain).

When sinusitis spreads to areas around the eyes, you may experience redness and swelling, which can reduce vision. The most severe form of sinusitis reaching the eye is called cavernous sinus thrombosis and can actually cause blindness. It is treated by antibiotics (administered through an IV) and drainage of sinus fluids.

Sinusitis that reaches the brain may cause meningitis and brain abscesses.

Can sinusitis cause death?

Chronic sinusitis can spread to the eyes, blood, and brain, and, in rare circumstances, cause death. For that reason, it’s important to take instances of sinusitis that won’t go away very seriously. If you have a persistent sinus infection, make sure you follow your doctor’s instructions regarding your antibiotics and of course, get plenty of rest.

How to get rid of sinusitis.

If you want to get rid of your sinusitis, you and your ENT will need to work together to discover the source of your sinus infections. For example, your sinusitis might always be precipitated by a cold, or you could have a deviated septum and sinusitis or sinusitis and sleep apnea. Regardless, finding the root cause behind your recurrent or prolonged sinusitis will help determine treatment.

Once the source of your sinus infections is found, you and your ENT will need to discuss treatment options. For those with recurrent sinus issues, one treatment, in particular, has proven itself effective again and again. That treatment option is balloon sinuplasty.

Balloon sinuplasty is a minimally invasive, in-office procedure that takes less than 20 minutes to perform and requires little to no recovery time.

Sinusitis won’t go away? Consider balloon sinuplasty.

Whether this is your first bout with sinusitis that won’t go away or you experience sinus infections on a regular basis, you should know that getting rid of sinusitis is well within reach.

At Sinus Solutions of South Florida, Dr. Napoleon G. Bequer has provided hundreds of patients with relief from chronic sinusitis using the balloon sinuplasty procedure. So if you have sinusitis that won’t go away, contact us online, call us at 561-790-7744, or take our sinus quiz today to see if you’re a viable candidate for balloon sinuplasty.

Related Resources:

• What’s the Difference Between Sinusitis and a Cold?
• Winter Allergies in Florida
• What to Expect After Balloon Sinuplasty
• Sudden Hearing Loss
• Allergies and Chronic Sinusitis

Ear Nose and Throat – When to Worry About Your Lingering Sinus Infection

Sinus infections have a way of making time stand still… in a bad way. When you’re constantly congested, battling headaches, and feeling sinus pressure, even a short duration of sickness can feel like it’s never going to end.

What if it doesn’t? If your lingering sinus infection becomes chronic, it may be time for more aggressive treatment.

Here’s what you need to know about sinus infections and when it’s time to take the next step in treatment.

Sinus Infections, Explained

Most infections in the nose are viral upper respiratory tract infections that resolve within 10 days.

However, if you have persistent colored nasal drainage coupled with extensive symptoms like facial pressure, headache, or fever for more than 10 days, it’s time to see your doctor. You may be experiencing a lingering sinus infection that requires medical treatment.

Lingering Sinus Infection or Chronic Runny Nose?

A lingering sinus infection is different from a chronic runny nose. Chronic runny nose typically comes from allergies or other irritants in the air. However, this can turn into an infection over time.

When the sinuses become infected, the allergies, irritants, or viral cold have caused swelling in the nose that’s blocked the drainage pathways. Consequently, fluid and mucous accumulate in the sinuses, where it has become infected with bacteria.

If you’ve been sick more than 10 days and begin to experience other symptoms like facial pressure, headache, and fever, you’re dealing with more than a chronic runny nose.

What the Treatment for Sinus Infections?

In order to eradicate the infection, you’ll need an antibiotic.

Some people continue to experience a lingering sinus infection even after antibiotics. Sinuses are considered a closed cavity. Removing infection from a closed cavity can require more prolonged antibiotic usage compared to infections that occur in an open cavity (like strep throat).

A sinus infection might require 2-4 weeks of antibiotics plus additional methods to encourage drainage of the sinuses. For a sinus infection to clear completely, we often recommend saline sprays, topical steroid sprays (like Flonase), and decongestants in addition to an antibiotic.

How Long Do Sinus Infections Last?

Many variables affect the duration of sinus infections. Most last more than 10 days, but when a sinus infection lasts more than twelve weeks, it is considered chronic sinusitis.

If after 10 days, your symptoms have not improved, see your primary care doctor. You may have an acute sinus infection.

If it lasts four weeks, you potentially have a sub-acute sinus infection that needs more aggressive treatment.

If symptoms last over 12 weeks, you’re likely dealing with a chronic infection. After such prolonged symptoms, it can be difficult to distinguish sinus headaches from migraine headaches from severe allergies. After 12 weeks, diagnosing and treating the issue requires the medical expertise of an ENT.

When To Visit an ENT

You may opt to visit an ENT if your sinus infection symptoms last more than one month. However, when a lingering sinus infection after antibiotics lasts more than 12 weeks, it’s definitely time to see a specialist.

If your doctor has treated you with antibiotics, saline, steroid sprays, antihistamines, and decongestants and you’re still not better, you’ve entered into a confusing area. You need a thorough exam of your sinus pathways with a fiberoptic scope and a CT scan to properly diagnose the problem.

Related: What Does An ENT Do At Your First Appointment?

If at any point you’re not sure what’s going on and your primary care doctor isn’t sure what’s causing the symptoms, see an ENT for a more specialized exam.

How to Treat A Sinus Infection At Home

In the first two weeks of a sinus infection, patients may use saline sprays, over-the-counter steroid sprays like Flonase, and over-the-counter decongestants.

After 10 days, if the drainage is still colored, an antibiotic is likely necessary. There’s no homeopathic alternative to antibiotics. However, saline spray, topical steroid sprays, and decongestants work well with antibiotics to clear most infections.

Will Sinus Infections Resolve If Left Untreated?

Lingering sinus infections should be treated before they escalate into a more serious issue. If a sinus infection is untreated, it may begin to impact the surrounding areas: the eyes and brain.

Untreated sinus infections can result in orbital and intracranial complications. Orbital refers to an infection that moves from the sinus into the eye. It can even result in an abscess in the eye area, which threatens vision.

Intracranial infections refer to infection in the brain. These can ultimately progress to become a brain abscess or meningitis if left untreated.

Because the sinuses are located close to the eye and brain, the most serious complications of an untreated sinus infection affect these important structures.

How An ENT Treats a Sinus Infection

If you have a lingering sinus infection after antibiotics, an ENT doctor often elects to be more aggressive in treatment than a primary care physician. They may prescribe longer courses of antibiotics, stronger medications, or recommend a procedure to open the sinuses.

If you have persistent sinus problems, the sinuses must first be unblocked. Sometimes, that’s done through a simple balloon sinuplasty and irrigation. Other times, unblocking the sinuses requires a more aggressive procedure like endoscopic sinus surgery. We opt for this procedure when the sinuses become so blocked, tissue and bone need to be removed to create a wider opening.

If you’re dealing with a lingering sinus infection, don’t let it progress to a more serious issue. Call your ENT so they can discover what’s at the root of your problem and find a treatment to bring you relief.

Philip Scolaro, MD

Dr. Scolaro is a board-certified Otolaryngologist servicing the South Plains area. He has been practicing in Lubbock since 1990 and has earned a reputation as a skilled and experienced surgeon. He currently serves as the Medical Director for Covenant High Plains Surgery Center campuses, is a member of Covenant Health Partners and is an adjunct faculty professor for Texas Tech University Health Sciences Center School of Medicine. Learn more about Dr. Scolaro. 

David Cuthbertson, MD

Dr. Cuthbertson is a physician at Ear Nose & Throat Associates of Lubbock. He joined the team at ENT Lubbock from Houston, where he was chief resident of the prestigious Bobby R. Alford Department of Otolaryngology at Baylor College of Medicine. He is board certified in Otolaryngology and Head & Neck Surgery and has quickly built a reputation, not only as an extremely skilled surgeon, but as an approachable and compassionate clinician adept in the newest standards and technologies. Learn more about Dr. Cuthbertson.

Sinusitis: symptoms, duration and complications | PHARMACY

Sinusitis is one of the most commonly diagnosed diseases in the US, affecting about 16% of the adult population per year.

Sinusitis, or rhinosinusitis, is an inflammation of the mucous membrane of one or more of the paranasal sinuses.

Inflammation can be caused by viruses, bacteria, fungus or allergies.

The main symptoms of sinusitis are nasal congestion and discharge, fever, heaviness and pain in the paranasal or frontal region of the face. Also, with this pathology, a throbbing headache is characteristic, which increases with sudden movements and inclinations.

Nasal discharge may be cloudy, greenish or yellowish, sometimes with bloody impurities.

When the infection is caused by a virus, the symptoms of sinusitis are similar to those of the common cold – runny nose, sore throat, sneezing, nasal congestion and cough. The mucus may be clear or slightly colored.

Antibiotics are not effective against viral infection. The main recommendations for treatment are symptomatic and supportive therapy – rest, plenty of warm fluids, the use of saline nasal sprays, over-the-counter painkillers, antipyretics and antihistamines.

Sinusitis caused by a virus usually resolves on its own within 7-10 days. If symptoms last more than 10 days or become more severe, urgent medical attention should be sought.

In bacterial sinusitis, the discharge from the nose is thick, with a green or yellow tint. The nasal passages swell and mucus can run down the back of the throat.

This type of sinusitis requires mandatory antibiotic therapy. Most people with acute bacterial sinusitis recover successfully in 10 to 14 days if antibiotics are taken correctly and responsibly.

When sinusitis is an allergy, the inflammation causes nasal congestion and swelling of the mucous membranes, which blocks normal sinus drainage. Allergic sinusitis most often leads to a chronic course of the disease. Symptoms can be seasonal or year-round, including sneezing, itchy nose, throat or eyes, nasal congestion, and a runny nose.

Treatment consists of antihistamines, avoidance of the allergen, and in some cases immunotherapy.

Chronic sinusitis symptoms may persist for up to several months. Nasal congestion and discharge are the most common symptoms. Also, this disease is characterized by a cough that worsens at night or when waking up in the morning. People with nasal polyps also often have chronic sinusitis.

Nasal steroid sprays are the most commonly used treatment. The cause of chronic sinusitis can also be a fungal infection of the nasal mucosa.

Although most cases of sinusitis are uncomplicated, there are potentially life-threatening conditions that can be complications of acute sinusitis. Due to the fact that the focus of inflammation is located in the skull, where the sinuses, blood vessels that supply the eyes, as well as due to thin septa, the following complications are possible:

• infections of the eye and surrounding tissues;
• thrombosis of the vessels of the nose;
• meningitis;
• brain abscess;
• bone infections.

Based on www.medicalnewstoday.com

Chronic Sinusitis Management Guide | #02-03/99

What are the diagnostic features of acute and chronic sinusitis?

Are antibiotics indicated, and if so, in which case?
Which patients should be referred to specialists?

Reviews concerning the diagnosis and treatment of paranasal sinus diseases (PND) most often raise many new questions, since an accurate diagnosis is complicated by the non-specificity of non-invasive examination methods. Empiric treatment, especially with antibiotics, is generally considered successful, although many cases resolve spontaneously without any treatment.

The purpose of this review is to highlight the current understanding of the nature of PPN inflammation and provide logical and factual justifications for medical or surgical treatment.

Anatomy and physiology. The nasal cavity and RPN are endowed with important physiological functions. Mostly through the nasal cavity passes inhaled and exhaled air, so the nose must have protective mechanisms that can protect the airways from inhaled pathogens and foreign bodies.

The glands of the ciliated epithelium of the nose and the RPN produce a superficial mucous layer. It retains particles of substances, and the cilia, which are in constant motion, push them back into the nasopharynx (see Fig. 1).

Both the maxillary and frontal sinuses are ventilated through channels, which in turn pass through the anterior ethmoidal region. It is very important that these pathways remain open, as normal mucus drainage is essential to keep the sinuses filled with air.

The important role of the anterior ethmoidal labyrinth cells and the middle nasal passage in the physiology of PPN is confirmed by the fact that this area was called the “osteomeatal complex” (Fig. 2). It is thought that mild localized inflammation in this area may lead to secondary infection of the maxillary and anterior sinus. This is largely true, although the pathogenesis of sinusitis is more complex.

Microbiology. Nasal cavity and PPN are inhabited by normal bacterial flora; normally, the same microorganisms are found there as in the infected sinuses. Many infectious processes in the sinuses are viral in nature; bacteria reattach.

In acute sinusitis, Streptococculs pneulmoniae, Heamophiluls influlenzae, and Moraxella catarrhalis are most commonly isolated.

In chronic sinusitis, the same microorganisms are usually present, as well as anaerobes, such as strains of Fulsobacteriulm, Staphylococculs aulreuls, and occasionally gram-negative bacteria, such as strains of Pseuldomonas. In recent years, cases of diagnosis of sinusitis caused by fungi have become more frequent, usually in immunocompromised patients. Aspergilluls strains are most often detected, and the severity of clinical manifestations depends on the patient’s immune status.

Allergic sinusitis, often associated with nasal polyps, is being diagnosed more and more.

Clinic. From the point of view of otorhinolaryngological surgery, the concepts of anatomy, physiology and pathology of PPN have changed radically with the advent of rigid endoscopy of the nasal cavity and the possibility of computerized scanning (CT) of the sinuses.

However, none of these diagnostic methods are available to the general practitioner, who often has to diagnose and treat sinusitis based on clinical symptoms.

Often the complaints of patients with acute and chronic sinusitis coincide, so a timely approach suggests that when trying to distinguish between these conditions, the doctor relies more on pathophysiology than on considerations of the duration of the disease.

Sinusitis is considered acute when the infection resolves with medical therapy without leaving significant mucosal damage. Acute episodes may be recurrent in nature; Chronic sinusitis is a permanent disease that is not amenable to medical treatment alone. In distinguishing between these conditions, the problem is that there are always indications for surgical treatment, although in reality, long-term drug therapy is sufficient for many patients. In addition, surgical intervention is not one hundred percent successful.

In many patients with a history of acute sinusitis, the onset of the disease is preceded by a cold. Symptoms that suggest the development of acute sinusitis:

• purulent nasal discharge;
• nasal congestion;
• pain and tenderness on examination;
• fever and chills.

In some cases, there are local symptoms that suggest involvement of various sinuses. When diagnosing, the most reliable symptom is a complaint of purulent discharge from the nose or their detection during examination (Fig. 3).

If the patient is suffering from headaches or facial pain in the absence of purulent discharge, most likely it is not sinusitis.

In untreated sinusitis, the infection sometimes spreads beyond the sinuses, leading to serious complications. More often this happens when infection of the frontal and ethmoid sinuses; children are most susceptible to complications.

When the infection spreads forward from the frontal sinus, the soft tissues of the forehead become swollen and painful. Initially, cellulitis develops, then subperiosteal abscess. Spread through the posterior wall of the frontal sinus results in intracranial complications such as meningitis, subdural empyema, or anterior lobe abscess.

When the ethmoid sinus becomes inflamed, the infection spreads through the thin bone of the paper plate, leading to damage to the orbit, accompanied by cellulitis and orbital abscess. Untreated eye socket infections almost always lead to blindness.

If complicated sinusitis is suspected, especially if there is swelling of the soft tissues of the eye socket in a child, an urgent consultation with an otorhinolaryngologist is necessary and the diagnosis is clarified by computer scanning.

The clinical picture of chronic sinusitis is varied. As with acute infection, nasal congestion and purulent discharge are constant symptoms. Temperature does not rise or rises moderately, and complaints of general malaise, headache and facial pain are typical. Additionally, many patients complain of a decrease in their sense of smell, while they feel a disgusting smell of pus in the nose.

A simple clinical examination of the nasal cavity with an otoscope can detect large polyps; small polyps are only visible during nasal endoscopy.

Over the past decade, cases of acute and chronic sinusitis in children have increased, especially in North America. Diagnosis and treatment of childhood sinusitis is complicated by many factors.

Recurrent upper respiratory symptoms in children are common and usually indicate tonsil and adenoid disease rather than primary sinusitis. Computed tomography scans of children with upper respiratory tract symptoms often reveal abnormalities of RPN, especially maxillary.

Clinical experience shows that the symptoms of sinusitis in children often resolve themselves with age, and it has not yet been established whether “snotty” adults grow out of “snotty” children.

There is no doubt that chronic sinusitis also occurs in children, especially if there is a dysfunction of the ciliated epithelium. However, most British ENT surgeons believe that, as far as possible, it is necessary to adhere to conservative methods of treating children.

Examination. In general practice, the diagnosis of sinusitis is usually made on clinical grounds.

Planar radiography of the sinuses is extremely non-specific and uninformative for detecting pathological changes. Anomalies on such radiographs are found in half of the population. So, on the x-ray, a thickening of the mucous membrane of the maxillary sinus can be detected, which does not coincide with the results of direct endoscopy. Despite this, planar images are used quite often, especially for chronic symptoms.

The guidelines issued by the Royal College of Radiologists state that planar radiography is not a mandatory routine study in patients with PPN].

A review of planar imaging indicates that it is reasonable to administer a full course of topical steroids without RFI to patients with chronic non-specific sinusitis; if such treatment is ineffective or neoplasia is suspected, the patient should be referred for treatment to a specialist.

The most specific method for assessing the anatomy and pathology of the sinuses is computed tomography, usually in the projection of the coronal suture (Fig. 4).

A CT scan of the sinuses provides accurate information about the patient’s anatomy and the presence of pathological changes (Fig. 5). However, this study should be performed only after a specialized examination, including nasal endoscopy.

• Treatment

Acute sinusitis. In acute sinusitis, there is no consensus on the choice of antibiotic and the duration of the course of treatment. On the one hand, according to the recommendation of North American rhinologists, antibiotics should be taken for at least 14 days or another 7 days after the symptoms disappear. According to some studies, antibiotics have no advantage over placebo when it comes to treating sinusitis-like symptoms in general practice.

The presence of such opposing points of view often only confuses the general practitioner faced with acute sinusitis. The danger of prescribing a long course of antibiotics is the development of antibiotic resistance; in addition, patients often refuse long-term treatment. Inadequate treatment hides the risk of residual infection, while always remaining, albeit small, the likelihood of complications.

Many patients presenting with symptoms of sinusitis recover spontaneously without antibiotics; the task of the doctor is to determine in a timely manner whether there is a possibility of such a recovery.

It is assumed that CT scanning can help to successfully resolve this issue. Patients with fluid levels or sinus opacities need antibiotics, while those with no abnormalities or only mucosal thickening on scans are likely to recover spontaneously.

British general practitioners do not have direct access to CT, and it is unlikely that they will be provided with it for diagnosing acute sinusitis, since the patient is exposed to significant radiation, and besides, the study is quite expensive.

From a purely symptomatic point of view, the presence of purulent discharge from the nose and nasal congestion are more reliable signs of sinus infection than other symptoms, such as headaches and facial pain. For patients with the first group of symptoms, antibiotics are justified.

When choosing an antibiotic, it is necessary to take into account the possibility of the presence of penicillin-resistant strains.

First-line drugs are amoxiclav, erythromycin, and cephalosporins such as cefixime. The same antibiotics can be prescribed for chronic infections; quinolone derivatives such as ciprofloxacin are also useful in this case.

Often, in acute sinusitis, decongestants, both local and systemic, are used as additional means. Local decongestants, such as xylometazoline, reduce mucosal edema and improve air conduction, theoretically speeding up recovery.

Steam inhalations, often with aromatic additives, such as menthol, bring relief to the patient, increasing the sensation of air flow in the nasal cavity, but objectively do not contribute to recovery.

Chronic sinusitis. The presence of chronic PPN infection implies either mucosal disease itself or an anatomic obstruction to sinus aeration. In any case, chronic sinusitis is not amenable to antibiotic therapy alone.

The cornerstone of treatment in this case is steroid therapy, usually with a nasal route of administration. The point of prescribing steroids is to reduce inflammatory edema and improve sinus ventilation.

Topical steroids are prescribed in drops or spray form. Topical betamethasone drops are often effective and should be administered in the correct position (head tilted down) (Figure 7) and used for no more than six weeks to avoid systemic side effects. The advantage of new steroid sprays (triamcinolone, budesonide) is that it is used once a day, which is more convenient for the patient.

Patients should be referred for specialist advice if adequate medical treatment has failed or if more serious conditions such as neoplasia or Wegener’s granulomatosis are suspected. Often, a course of intranasal steroids improves the condition of patients with recurrent acute and chronic sinusitis. Such a course should be carried out before referral to an otorhinolaryngologist.

There are a number of symptoms suggestive of neoplasia and requiring early referral to a specialist: unilateral nasal bleeding, facial numbness, diplopia, deafness due to middle ear effusion, and identification of an intranasal mass on examination.

Surgical treatment is indicated for some patients, and in general surgeons prefer endoscopic ethmoidectomy. Maxillary sinus punctures under local anesthesia are losing their former popularity, as they rarely bring long-term relief and are extremely disliked by patients.

New surgical and anesthetic techniques allow in most centers to perform sinus surgery on the basis of a day hospital and avoid routine postoperative nasal tamponade.

Treatment of facial pain. A significant part of the working time of a rhinologist is the diagnosis of patients with facial and headaches. With the advent of sinus surgery, impressive results have been achieved in the treatment of diseases accompanied by these symptoms.

Often, the symptoms inherent in sinusitis and the complaints typical of migraines and cluster headaches overlap in many ways.

If the patient with facial pain does not have nasal congestion or purulent discharge, and the endoscopy and CT scan are normal, then the problem is likely not in the nose and sinuses and sinus surgery is not effective, although the possibility of placebo exposure should not be discounted. .

Recently there has been interest in so-called contact pain. It is assumed that in this condition, the nasal septum is in pathological contact with the side wall of the nose. This usually occurs when a sharp spur emerges from the septum and rests against the middle nasal concha (Fig. 6). As a rule, patients complain of pain around the central part of the face, radiating to the forehead and eye sockets.

Please note!

• Many PPN infections are caused by viruses, bacterial agents attach secondarily. As a rule, Streptococculs pneulmoniae, Heamophiluls influlenzae and Moraxella catarrhalis are found in acute sinusitis
• Many patients with a history of acute sinusitis are preceded by a cold. Signs that suggest the development of acute sinusitis: purulent discharge from the nose, nasal congestion, pain and tenderness during examination, fever and chills
• The most reliable symptom is a complaint of purulent discharge from the nose or their detection during examination. If the patient suffers from headaches or facial pain in the absence of purulent discharge, it is most likely not sinusitis
• Planar radiography of PPN is extremely non-specific and uninformative for detecting pathological changes. Anomalies on such radiographs are found in half of the population
• Many general practice patients presenting with symptoms of sinusitis recover spontaneously without antibiotics; the doctor’s task is to determine in a timely manner whether there is a possibility of such a recovery
• First-line drugs are amoxicillin/clavulanate, erythromycin, and cephalosporins such as cefixime. The same antibiotics can be prescribed for chronic sinusitis; quinolone derivatives such as ciprofloxacin

are also useful in this case

• Patients should be referred for consultation with an otorhinolaryngologist if adequate medical treatment has failed or if more serious conditions such as neoplasia or Wegener’s granulomatosis are suspected.