Question: What is the appropriate medical therapy for
Answer: Once the diagnosis of sinusitis is made,
medical therapy is instituted. The exact therapy chosen by your doctor
will depend upon the underlying cause. Therapy is aimed at relieving
obstruction of the nose and sinuses, particularly at the osteomeatal
complex. In addition, therapy is targeted in such a way as to treat any
infection that may be present.
In general, medical management of sinusitis may include one or more
of the following:
Antibiotics, topical and systemic decongestants, topical nasal
lavage, nasal saline sprays, humidification, mucolytics,
decongestants, and steroids. Other treatment options are also
possible and are discussed below.
Medical therapy must be undertaken under a doctor's care. Some medications for sinusitis
must not be taken if a patient has other medical conditions. For example, if a patient has high
blood pressure, or if a patient is pregnant, certain medications must not be taken.
Question: What is the goal of medical treatment?
Answer: Treatment is aimed at eliminating causative factors and
the inflammatory and infectious components. Ideal management includes preventative
including the use of specific medications in proper dose and duration.
Question: When I get a sinus infection, is there
anything else that I should do besides taking an antibiotic?
Answer: Yes! Reversing the obstruction to the flow of sinus secretions is
critical in reducing the incidence and severity of bacterial and fungal infections. Medications
prescribed by your doctor to reduce sinus inflammation and blockage help your body's immune
defenses fight back!
Therefore, the use of topical corticosteroids, the use of nasal decongestants and mucous
thinners, the use of nasal salt water (saline) washes, the use of antihistamines in patients with
allergic rhinitis, and other measures are important and effective when treating a sinus infection,
and in preventing sinus infections in susceptible individuals, and moderating symptoms when
Of course, these treatments should only be undertaken under the direction of an
QUESTION: What should a patient do about her sinuses if she is pregnant?
Nasal congestion is a common complaint during pregnancy. Particularly for patients with a
pre-existing sinus condition this can become a significant problem. Unfortunately, a number
of the medications that are used to treat sinusitis are NOT safe during pregnancy.
We advise that all medications be approved by your obstetrician. The sinus specialist and
the obstetrician, working together, should be able to help you manage your sinuses as you
proceed through your pregnancy.
Antibiotics - General Information
Introduction: Antibiotics are medicines designed to treat bacterial infections.
In many cases of sinus infections, your physician may prescribe an antibiotic for you based on
bacteria are most likely to be causing the infection. At times, your doctor's choice of antibiotic
may be based on the bacteria that can be identified from a sample of pus taken from your nose
sinuses (i.e., a culture). Sometimes, more than one antibiotic will be prescribed to increase the
likelihood of completely eliminating an infection.
Dosing: You should take your antibiotic exactly as prescribed. Unless you are
you should complete the entire course of the antibiotic, even if you start feeling better before
you are due to
finish. By failing to complete the entire course of your treatment, you may be increasing the
number of resistant bacteria. This could make further antibiotic therapy ineffective.
Most of the time, antibiotics are prescribed to be taken by mouth. Occasionally,
more resistant or serious infection (such as when bone is infected, or if resistant bacteria are
causing the infection), intravenous antibiotics may be needed.
Adverse effects: As with any medication, antibiotics can cause side-effects. Any
antibiotic can cause an allergic reaction, ranging from a skin rash, with or without itching,
to a swollen mouth or tongue, wheezing, and/or trouble breathing. In all cases of an allergic
reaction, you should stop taking the drug immediately and call your physician. Most allergic
reactions will resolve with little or no treatment. A drug reaction, somewhat different from an
allergy, can develop from using antibiotics and cause fever and/or joint pain and swelling.
Perhaps the most common adverse effect of antibiotics is the gastrointestinal symptoms they
produce. These can include stomach pain, nausea, vomiting, and diarrhea. If these symptoms are
mild and tolerable they are probably not of concern, but if they are severe, you should stop the
antibiotic and inform your physician. In rare cases, antibiotics can cause a severe diarrhea
as "pseudomembranous colitis." Patients with this disorder have severe watery diarrhea (not
simply loose stools). In this case you should stop the antibiotic and notify your doctor or your
family physician immediately. Do not try to treat yourself with an anti-diarrheal medication or
hope that a severe diarrhea problem will subside.
Because antibiotics alter the normal bacteria in the body, as well as the disease-causing
bacteria, they can cause other side-effects. A yeast infection, most commonly in the mouth or
vagina, is one such complication.
To minimize the risk of both diarrhea and yeast from antibiotics, many doctors recommend
ingestion of Lactobacillus acidophilus, popularly known as acidophilus. This can be important
because with chronic sinusitis you may need to be on antibiotics for an extended period of time.
Acidophilus can be found in two forms; yogurt with active cultures, and capsule preparations.
recommend eating 8 ounces of yogurt with active cultures daily while on antibiotics, and to
continue doing so for another week or two following completion of your course of antibiotics.
Some brands of yogurt do not contain active cultures, so read the container carefully. Although
yogurt is the preferred source of acidophilus, acidophilus capsules are an acceptable alternative
you have a milk allergy or for some reason cannot eat yogurt. You can purchase acidophilus
tablets at most health food stores.
Be sure to inform your doctor if any of the following apply to you: impaired kidney
rash when previously given an antibiotic, ulcerative colitis, mononucleosis (mono), anemia,
abnormal liver function, myasthenia gravis, pregnancy, breast feeding, other medications, mitral
valve prolapse or prosthetic devices.
Antibiotics - Advanced Information (for
Question: What is the typical microbiology of a
Answer: Acute rhinosinusitis has causative organisms similar to acute
otitis media. 75 percent of culture obtained from antral puncture in patients with acute
sinusitis contain either Streptococcus pneumoniae or Hemophilus influenza (both beta lactamase
and -). Moraxella catarrhalis is also a common pathogen, especially in children, where it rivals
Viruses are also prevalent. They mimic bacterial infection and often predispose to bacterial
Staphylococcus aureus is frequently found in nasal cultures (even 30 percent of normal
people) but rarely in antral puncture cultures, suggesting it is a contaminant. However, in
hospitalized or immunosuppressed patients, the pathogenicity of Staphylococcus aureus is more
likely. Anaerobic organisms on acute sinusitis suggest dental disease as the source.
Hemophilus influenza 38%
Streptococcus pneumonia 37%
Other hemophilus spp 8%
Streptococcus pyogenes 6%
Moraxella catarrhalis 5%
Alpha Streptococci 3%
Gram negative bacilli/mixed anaerobes 3%
Question: What is the best antibiotic for
Answer: A host of information has surfaced in the medical literature
about appropriate antibiotic therapy for acute bacterial rhinosinusitis and chronic rhinosinusitis.
While this is still a subject of ongoing debate, here is one proposed approach to antibiotic
Antibiotics are designed to kill bacterial pathogens or prevent their growth, and studies
suggest that their use shortens the course of an infection and helps prevent complications.
However, excessive and inappropriate use has led to the development of resistance. Pathogens
are adept at mutation, transformation, conjugation and plasmid development. The end result is
that Streptococcus pneumoniae and Hemophilus influenza are no longer readily eradicated by
the usual course of therapy with antibiotics.
Guidelines promoted by the American Rhinologic Society and the Sinus & Allergy Health
Partnership (Otolaryngol Head Neck Surg June 2000) established a new methodology for
with this problem. Proper use of the guidelines should improve patient care.
The guidelines recognize that patients who have been exposed to an antibiotic within 4 to 6
weeks of their current infection are likely to be infected with a resistant pathogen.
Thus, for patients who are evaluated for Acute Bacterial Rhinosinusitis (ABRS) who have
NOT been exposed to antibiotics within the previous 4 to 6 weeks, first line therapy is limited
high-dose amoxicillin, amoxicillin-clavulanate, cefpodoxime, and cefuroxime axetil.
For adult patients with moderate infection and prior antibiotic use, the agents that are
indicated are amoxicillin-clavulanate, or one of the fluoroquinolones (gatifloxacin, levofloxacin,
moxifloxacin) or combination therapy amoxicillin or clindamycin for gram positive coverage
PLUS cefixime or cefpodoxime axetil for gram negative coverage.
Very similar first-line agents are recommended in the pediatric patient population
with the exception of the fluoroquinolones, which still have no pediatric indication. Despite
the recent reports of shorter course therapy, the guidelines still recommend 10-14 days of
Question: How long should a patient take
antibiotics for acute sinusitis?
Answer: The usual recommendation is 10-14 days of antibiotic therapy.
However, this is probably an empiricism. Patients who respond promptly rarely finish the full
course. Several recent studies aimed at reducing antibiotic usage have shown that courses of
3,4,5, and 8 days yield similar cure rates as a 10-day course, at least in early disease in adults
with mild symptoms. This should be expected, since uncomplicated sinusitis has a high
probability of spontaneous resolution and nonbacterial (viral) cause.
Question: Tell me more about bacteria cultures in sinusitis.
Answer: The sinuses produce about one liter of mucus a day, most of
which is swallowed without awareness. Nasal mucus has a bacterial concentration of 10,000 to
100,000 bacteria per ml. Compared to aerobes and facultative anaerobes, five times more
anaerobes appear in this mucus.
In expert hands, rigid endoscopy with culture of the osteomeatal complex is a highly reliable
test to identify acute bacterial maxillary sinusitis. When compared to material aspirated from a
sinus puncture for the three most common bacterial causes of acute sinusitis (Hemophilus
influenza, Streptococcus pneumonia, and Moraxella catarrhalis), endoscopy has a sensitivity and
specificity of 80-85%. Transportation time of the specimen from patient to laboratory may
influence the result.
Question: What antibiotics are approved by the FDA
for treatment of acute sinusitis?
Answer: The FDA requires sinus puncture and aspiration to be done on a
number of patients before a drug can be approved. Therefore, most studies have been done on
maxillary sinus secretions.
As of April 2000 the FDA had approved a number of antibiotics for use in acute sinusitis.
No antimicrobials have been approved for the treatment of chronic sinusitis.
- Augmentin (Amoxicillin-Clavulanate)
- Ceftinere (Omnicef)
- Cefprozil (Cefzil)
- Cefuroxime Axetil (Ceftin)
- Ciprofloxacin (Cipro)
- Clarithromycin (Biaxin)
- Gatofloxicin (Tequin)
- Levofloxacin (Levaquin)
- Loracarbef (Lorabid)
- Moxifloxacin (Avalox).
Question: Which antibiotics
are well-tolerated in general, and which ones aren't?
Answer: In general, all the agents used in
treatment of bacterial sinusitis are well-tolerated. Of course, this varies
from patient to patient. Clarithomycin often causes a fairly unpleasant
metallic taste. Doxycycline may cause phototoxicity. Doxycycline and
Moxifloxacin do not accumulate in the presence of decreased renal
function, which is common in elderly patients.
Question: What if a patient is
taking magnesium, iron, zinc, or other supplements?
Answer: The bioavailability or absorption of
Ceftin, Doxycycline, and the Floroquinolones can be effected by
divalent and trivalent cations such as Magnesium, Iron, Zinc,
Aluminum, and so forth. Therefore, if these are taken within four to
eight hours of Gadifloxacin, Levofloxacin, or Moxifloxacin
administration, the antibacterial effect may be diminished by 50% or
more for the entire 24 hours because these agents are given only once
Question: Do Histamine II
blockers affect the absorption of Quinolones?
Answer: No, Histamine II blockers do not affect
the absorption of Quinolones.
Question: Which antibiotics may be used during
Answer: Many antibiotics are category B, that is
to say no teratogenic effects were seen in non-human animals. However, there
have been no adequate and well controlled studies in pregnant women.
Therefore, no antibiotics should be prescribed unless prescribed by an
The following antibiotics are category B drugs. Amoxicillin,
Zithromycin, Ceftin, Ceprozil, Cefuroxime Axetil, and Lorocarbef.
Question: Which antibiotics have a liquid form available?
Answer: Amoxicillin, Augmentin, Zithromycin,
Ceftin, Ceprozil, Cefuroxime, Axetil, Ciprofloxacin, Clarithromycin,
Doxycycline, and Lorocarbef.
Question: Which antibiotics have, in general, the least
Answer: Amoxicillin, Augmentin, Azithromycin,
Ceftin, Ceprozile, Cefuroxime, Erthyromycin, Gadifloxacin, and
Question: Which are least expensive?
Answer: Amoxicillin, Doxycycline, and
Question: How do you
distinguish between a bacterial infection and a viral infection?
Answer: It is extremely difficult to distinguish
mild bacterial sinusitis from viral sinusitis (the common cold) during
the first five days. Some patients are overtreated. If
antimicrobial therapy is believed appropriate for this type of patient, the
best initial agents are either Amoxicillin or Doxycycline, both of which
are inexpensive. Duration of therapy is very controversial, but earlier
studies have shown that bacteria persists in large amounts in the sinus
after symptoms of acute bacterial sinusitis have resolved. In addition,
sinus mucosal healing is variable. Therefore, for acute bacterial
sinusitis, we favor 10-14 days of antibiotic therapy. Alternatively,
Azithromycin is given for only five days because of
its long half-life in
tissues. For chronic sinusitis we recommend 21-28 days of antibiotic
therapy. Long-term follow up studies with varying lengths of therapy
are needed to settle the issue.
Question: What should the
family doctor or internist do when a patient fails to respond to
Answer: Patients who fail to respond to initial
antibiotic therapy for bacterial sinusitis should have a limited CT scan
of the sinuses, and a consultation should be made with an
otolaryngologist. This specialist will usually perform a nasal
endoscopic evaluation and possibly obtain a specimen for culture and
sensitivity. If the CT scan shows no fluid accumulation that would
require surgical drainage, a change of antibiotic may be considered.
Good second-line agents include Augmentin, Zithromycin, Ceftin,
Cefuroxime, Gadifloxacin, and Moxifloxacin.
Question: Give me some important summary
considerations or a recap.
- Viral sinusitis is common and cannot be clinically distinguished
from bacterial sinusitis for five to seven days.
- Viral sinusitis responds to placebo just as well as antibiotics; that is
to say, it is self-limited.
- If a patient is still sick after one week of presumed viral
rhinosinusitis, antimicrobial therapy plus a decongestant is beneficial.
The appropriate length of antimicrobial therapy has not been established
for acute bacterial sinusitis. 3-21 days of therapy have been used
with many experts recommending 10-14 days for an initial episode
and longer therapy of 21-28 days for patients with acute
exacerbations of chronic sinusitis.
- The agents effective for acute bacterial sinusitis are also effective
for acute bacterial exacerbations of chronic sinusitis; however, the
prevalence of anaerobic bacteria in the latter is increased.
- For patients with mild acute bacterial sinusitis, initial therapy with
Amoxicillin or Doxycyline is reasonable. For those patients
who fail therapy or who have moderately severe disease all of
the FDA-approved oral agents should be effective but
Augmentin, Zithromycin, Ceftin, Gadifloxacin, or
Moxyfloxacin are preferred.
- Patients who are ill enough to be hospitalized should receive IV
antibiotics pending appropriate culture and sensitivities. These may
include Vancomycin and Ceftriaxone or in the case of severe beta-
lactam allergy, Vancomycin and Chloramphenicol plus Ciprofloxacin.
- Overall, the efficacy of the second-line oral agents listed do not
differ significantly. Therefore, other factors such as previous therapy,
cause, convenience, potential drug interactions, problems, safety, and
antimicrobial resistance patterns are important as to which agent to use
for empiric therapy for bacterial sinusitis.
OTHER MEDICAL THERAPY:
Nasal Saline Solutions
Question: Tell me about nasal lavage or nasal saline
Answer: Daily frequent use of saline nasal spray or irrigation is
recommended to cleanse thick
secretions from the nose and sinuses. This simple economical treatment is effective but is
Saline nasal spray is available over-the-counter as sterile physiologic saline solution in spray
bottles. Alternatively, saline solution may be prepared at home with 1/4 tsp of salt dissolved in
of tap water. A pinch of baking soda may be added. The patient should place the solution in a
spray bottle or ear bulb syringe for lavage. Two to four puffs of nasal saline spray should be
administered at least three times a day. The alternative more aggressive method is lavage with a
bulb syringe while leaning over the sink with the mouth open. Repeated full syringe wash and
aspiration is recommended at least three times daily to wash out the secretions if they cannot be
effectively removed with saline spray alone.
Not every patient wishes to perform nasal lavage, but some find it the most important
treatment of all!
Question: Tell me more about NASAL
Answer: The nasal and sinus cavities are normally able to clear mucus
on their own through "mucociliary transport." Up to one quart of mucus is produced daily and
is swallowed. Sometimes swelling of the nose from either allergy, irritation, or infection can
prevent this self-cleaning. In these cases, irrigations (nasal flushing or washing) are used until the lining
of the nose and sinuses can recover and revert to normal.
Irrigations may be carried out with a spray
bottle, a rubber bulb syringe (like the kind used
for cleaning infants' noses) or a water-pik device (set on the lowest setting). Whichever device
is used, it should be sterilized on a daily basis so that bacteria are not reintroduced
into the nasal cavity with each irrigation. Sterilization may be performed with a weak solution of
Betadine (available in pharmacies as a douche).
Irrigation solutions can be made from saline (salt
water), baking soda, and/or antibiotics. When irrigating the nose, the irrigation solution will run
out the front of your nose or down the back of your throat. Although a small amount of this is
harmful if swallowed, larger amounts may produce bloating or fullness in the abdomen. It is
therefore best to perform the irrigations while leaning forward over a sink so that the solution
drip or be spit out. Occasionally, we recommend adding a prescription antibiotic (usually
gentamicin) to the irrigation solution to inhibit bacterial growth. Patients on a salt-restricted diet
should probably avoid using salt in the irrigation fluid (i.e., saline) and may use sterile water.
Homemade preparation of irrigation:
1 pint of boiled water
1/2 teaspoon salt
1/4 teaspoon baking soda
Let cool and irrigate nose with 1/4 to 1/2 cup on each side.
Question: What about steam inhalation?
Answer: In addition to irrigations, steam inhalation also has a beneficial effect on the nasal lining.
Various steam-producing inhalation devices are commercially available. Room humidifiers
may also provide some symptomatic improvement in some people. However, they can become
a source of aerosolized mold and bacteria if they are not cleaned regularly.
Question: Tell me about humidification of air.
Answer: Humidification of inspired air and hydration are other methods
recommended to clear thick secretions. In general, a cool mist humidifier, hot steamy showers, and
drinking 8 full glasses of water per day are effective.
Question: Anything I should know about vaporizers?
Answer: Vaporizers must be cleaned thoroughly and frequently. While
they can be helpful in conditioning air, they can harbor mold and other organisms if they are
not cleaned thoroughly and frequently.
Question: What is a netty pot?
A netty pot is a device of Indian origin that delivers nasal irrigation to wash out a patient's
nose. Some patients find netty pot irrigations to be very soothing.
Over-the-Counter Decongestant Sprays
Question: What about over-the-counter nasal sprays?
Answer: Topical nasal decongestants, in the form of drops or sprays, can
effective in immediately shrinking the swelling of the lining of the nose. However, these
sprays should be used no longer than 2 or 3 consecutive days, for prolonged usage may result
in "rebound" swelling of the nose. Rebound swelling (known as "rhinitis medicamentosa")
can be extremely difficult to treat.
For treatment of acute sinusitis, the
topical decongestant Oxymetazoline (also known as Afrin decongestant
spray) two puffs in each nostril twice a day for three days
provides rapid and effective vasoconstriction. This decreases the
obstruction of boggy turbinates and decreases the inflammation that
blocks the osteomeatal complex.
However, prolonged use of topical decongestant for greater than three
days can lead to rebound congestion or rhinitis medicamentosa.
Pediatric strength Oxymetazoline frequently works well in adults and
has less rebound congestion.
Over-the-counter topical nasal decongestant sprays are
powerful nasal decongestants. For acute, urgent situations they are extremely helpful in
opening the sinus and nasal passageways. However, patients with high blood
pressure should avoid these sprays.
The nasal mucosa becomes "addicted" to these sprays if they are over-used.
What is meant by this is that the decongestant spray loses its effectiveness and instead the
patient experiences a "rebound effect" where the nasal blockage worsens unless the patient
takes a "hit" or gets a "fix" of the nasal decongestant spray. Used chronically, nasal
decongestant spray can also affect blood pressure.
For these reasons, most sinus specialists recommend that decongestant nasal sprays be
used only sparingly.
Steroids - Topical Sprays and Oral
Question: Tell me about corticosteroids.
Answer: Steroids are anti-inflammatory medications that
are used in the treatment of sinusitis in both a topical (nasal spray) and systemic (pill) form.
Because topical steroids are quite effective for allergic rhinitis,
systemic steroids are used less commonly than steroid sprays.
Steroids help prevent and decrease swelling of the lining of the nose and sinuses. They
also help to decrease the size of polyps and may prevent them from recurring once they have
Because steroids can also decrease the immune response, there are certain risks associated
with their use. The risks associated with topical nasal steroids are relatively limited because
they do not have the same degree of widespread effect on the body that may occur with oral
steroids. However, adverse reactions may still occur and are described below.
Question: Tell me about topical nasal steroids.
Answer: Topical nasal steroids, along with antibiotics, are considered primary
therapy for chronic sinusitis. While antibiotics treat the infectious
component, topical nasal steroids treat the inflammatory component,
thereby reducing edema of the osteomeatal complex.
Several preparations are available. These agents are highly
active topically. The small amounts that are absorbed systemically are
rapidly metabolized by the liver and therefore significant systemic
side-effects are not expected at the recommended doses.
These drugs include:
Beclomethasone Diproprionate (brand name Vancenase or Beconase),
Flunisolide (brand name Nasarel),
Triamcinolone acetonide (brand name Nasocort),
Budesonide (brand name Rhinocort),
Fluticasone (brand name Flonase), and
Mometazone furoate (brand name Nasonex).
Individuals should be advised to be patient, because the topical nasal
steroids have a delayed onset of full action with clinical improvement
expected after 7-10 days. There is some immediate effect, but full effect
can take 7-10 days. Some recommend an oral steroid for an initial five
days when a more rapid effect is desirable.
The patient must understand that nasal steroids are not as effective on a
haphazard, as needed basis, and that these medications require regular
daily administration. The
maximum recommended dose should be used for at least the first four
weeks to control symptoms. Otolaryngologists and Allergists often
advise continued use at this dosage for two months or longer. The
dosage may be weaned when symptoms are well-controlled.
Most of the topical nasal steroids are available as aerosol or aqueous
preparations. Regardless of preparation, local side-effects may include
burning, irritation, sneezing, drying, crusting, bleeding, and rarely
Question: Tell me more about topical nasal steroid
Answer: Nasal steroid sprays deliver a steroid
dose to the lining of the nose. Because this dose affects the lining of the nose without being
completely absorbed by the body, the adverse effects on the patient's body are reduced. For
this reason, topical nasal steroids are relatively safe and effective medications for the
treatment of nasal swelling and congestion in patients with and without allergies.
Question: Do nasal steroid sprays have any
potential adverse effects?
Answer: Nasal steroids may have some local effects on the lining of
the nose such as nasal drying, crusting, and bleeding. More extensive local effects such as
nasal septal perforations are rare but may occur, especially if the preparations are used more
frequently than recommended. Nasal steroids may also produce irritation of the throat.
Although steroid nasal sprays usually do not carry the same degree of risk that systemic
steroids do, some of the same serious side-effects can occur (see section on oral steroids below).
Question: Tell me more about systemic (oral)
Answer: Systemic steroids are sometimes necessary for the treatment
of nasal polyps or swelling of the nasal lining.
Steroids are normally produced by our bodies and are an essential part of our daily
functioning. When oral steroids are taken, the body's natural production of steroids decreases.
If oral steroids are discontinued suddenly, the body may not have sufficient time to respond
and increase its natural steroid production back up to the normal rate. Therefore,
the patient's steroid
prescription is written so that you will slowly decrease your daily steroid dose (i.e. tapering)
prior to stopping completely.
It is not infrequent to have some increased appetite or to retain some fluid when
on oral steroid therapy. Patients should therefore watch their diet. An initial high dose may also
make patients hyperactive, and they may feel somewhat down as the dose is decreased.
However, with appropriate management of the steroid dosage, these effects can usually be
Individuals at risk for osteoporosis, especially women who have undergone
menopause, should have a bone density study performed every 1-2 years if they are on
long-term steroids. An annual ophthalmologic examination is also recommended.
Systemic steroids should be avoided if the patient has a history of a
bleeding abnormality, tuberculosis (TB), glaucoma, significant clinical depression, or an
immune deficiency. If the patient has a history of a stomach or intestinal ulcer, he or she
should inform the doctor. If steroids are required in these cases, the doctor will prescribe
some medication to protect the stomach.
Question: Tell me some of the adverse effects of
Answer: The risk of cataracts, glaucoma, high
blood pressure, high blood sugar (as with diabetes), mood changes, stomach irritation or ulcer
disease, bone-thinning (osteoporosis) and menstrual irregularities may occur with oral steroid
use. Thus, if a patient has a history of any of these problems, they should be sure to inform
A serious but very rare adverse reaction to oral steroids (avascular necrosis) can result in
permanent damage to an affected joint. Fortunately, this is very uncommon. However, patients
should inform their physician if they develop significant joint pains while taking oral steroids.
Patients should not stop their steroid medication suddenly without consulting their
Question: Do you have anything else to say
Answer: It would be worthwhile to summarize and
repeat certain points about oral steroids. It is increasingly recognized
that oral corticosteroids can provide significant temporary relief in
patients whose rhinosinusitis responds incompletely to decongestants,
antihistamines, topical nasal steroids or surgery.
Some of the more common side-effects that might be encountered include increased
appetite or fluid retention with oral steroid therapy. Patients should therefore
watch their diet. Patients may also experience mood swings. An initial high dose may
make patients feel hyperactive or experience insomnia, and they may feel
somewhat down or depressed as the dose is decreased.
Some of the less common side-effects include the risk of cataracts, glaucoma, high
blood pressure, high blood sugar (as with diabetes), stomach irritation or ulcer disease,
bone-thinning (osteoporosis), loss of potassium, and menstrual irregularities. The
risk of these may increase with oral steroid use. If a patient has a history of any of these
problems, they should be sure to inform their doctor.
Some of the rare side-effects must also be noted. A serious but very rare adverse reaction
to oral steroids -- avascular necrosis -- can result in permanent damage to an affected joint,
including chronic debilitating pain that may result in the need for joint surgery. Fortunately,
this is very uncommon. However, patients should inform their physician if they develop
significant pains while taking oral steroids.
With appropriate management of the steroid dosage, side-effects can usually be
minimized. Below are instructions for taking this medicine to decrease side-effects and
- Take between 6AM and 8AM, when the body secretes a natural steroid named cortisol.
- Avoid excessive consumption of stimulating substances, such as decongestants or
caffeine. They may add to the increased energy level causing irritability, restlessness, and
- Avoid steroids during pregnancy, breast feeding or if there is a history of bleeding
abnormality, tuberculosis (TB), significant clinical depression, or immune deficiency.
- If oral steroids are discontinued suddenly, the patient's body may not have sufficient time to
respond and increase its natural steroid production back up to the normal rate. Therefore,
steroid prescriptions are usually written so that patients will slowly decrease their daily steroid dose
(tapering) prior to stopping completely.
The following are recommended to monitor for complications during long-term use of
Annual ophthalmologic examination
Bone density scan
The vast majority of patients we have treated with systemic corticosteroids do not suffer
significant side-effects and tolerate the medication well. However, we believe it is best to
inform patients of the potential risks.
Question: Tell me about antihistamines.
Answer: ISome chronic sinusitis
sufferers have allergies that may contribute to swelling in the nose and sinuses.
If a patient has a significant history of underlying
allergies, antihistamines may be necessary to help control the allergic
Antihistamines are designed to oppose the effects of
histamine, the main chemical released by the body in allergic reactions. Antihistamines do not truly alter allergic susceptibility but can lessen the uncomfortable
symptoms of an allergic reaction.
Antihistamines should be used to treat
allergic sinusitis but should not be used to treat non-allergic sinusitis because they potentially
thicken the secretions and
lead to crust formation which can further obstruct the nasal and sinus
Antihistamines are most effective when taken before an anticipated allergic
reaction (such as before visiting a friend with a cat if you have a cat allergy.
If taken after an allergic reaction is already in
progress, the helpful effects may be delayed. Therefore, in patients with significant allergies, the
medication is typically taken on a regular basis.
Adverse effects: Many antihistamines have a sedating effect, and the drowsiness
they produce is usually the most undesired side-effect. The more recently developed
non-sedating antihistamines such as Claritin, Zyrtec and Allegra, are exceptions to this rule.
Side-effects of antihistamines include dry mouth, blurry vision, and difficulty
Question: Tell me more about antihistamines.
Answer: Antihistamines are important in the
treatment of inhalant allergies. Antihistamines work by competing with
histamine for H-1 binding sites on the respiratory mucosa. Histamine is a
mediator for immediate allergic reactions and anaphylactic reactions.
Antihistamines work to prevent these reactions, and therefore are most
effective when given before exposure to allergens.
Antihistamines are effective in relieving symptoms such as itching,
sneezing, rhinorrhea, and post-nasal drip. The primary side-effect of the traditional
is sedation. They can also cause significant dryness and crusting within the nose.
The second generation antihistamines are considered non-sedating and have less tendency
cause excessive dryness.
Traditional or "first generation" antihistamines include
diphenhydramine (Benadryl, chlorpheniramine maleate (Chlor-Trimeton),
hydroxyzine (Atarax), and promethazine (Phenergan). Meclizine is
also useful for control of dizziness or vertigo. Hydroxyzine is used as a
tranquilizer and Promethazine is useful for control of nausea.
Second generation antihistamines include loratidine (Claritin) and
Third generation antihistamines include Cetirizine (Zyrtec) and
Topical antihistamines (nasal sprays) include azelastine (Astelin) and
Question: Tell me about Astelin
Answer: Astelin is an antihistamine nasal spray.
It can be used in patients with nasal allergy symptoms and can be used
in addition to an oral antihistamine.
Question: Tell me about MAST CELL
Answer: Cromolyn sodium is a non-steroidal
anti-inflammatory medication prescribed for patients with allergies. It acts to prevent the body's
release of chemicals (mainly histamine) that produce allergic symptoms (such as nasal
congestion, itchy eyes and nose, and wheezing). It does this by stabilizing the membrane
walls of the cells that contain these chemicals. The mast cells are thus resistant to allergic
reaction and less likely to release these chemicals when incited by an allergen.
These agents are used in the prevention of allergic reaction and, therefore, must be used
before allergy symptoms occur. They should be taken on a regular basis in patients with
extensive and unpredictable exposure to allergens (substances which induce an allergic
reaction). In patients with more limited allergies, who can predict their exposure, cromolyn
sodium can be used 30 to 45 minutes before the allergen is encountered (e.g., a person
allergic to grass would spray his or her nose before mowing the lawn). Because there is
currently no long-acting cromolyn preparation available, the medication must be administered
at least four times per day.
Adverse effects: The most frequent adverse reactions to cromolyn include nasal
burning and sneezing, nasal bleeding, post-nasal drip, and rashes.
Question: Tell me about decongestants.
Answer: Because the treatment of chronic
sinusitis requires a more prolonged course than acute sinusitis, topical
decongestants are not recommended. When topical decongestants are
used for more than three to five days, a "rebound effect" with worsened
symptoms will typically result.
Instead, oral systemic decongestants such as Pseudoephedrine and
Phenylpropenalanine are often used during the treatment,
especially if significant congestion is detected on exam.
However, oral decongestants may raise blood pressure, and patients
and their doctors should monitor blood pressure and may need to
discontinue oral decongestants if blood pressure is affected.
Since higher concentrations are present
in the bloodstream, systemic decongestants are more likely to produce side-effects. These
include high blood pressure, anxiety and sleeplessness, and the "jitters." Decongestants can
also cause blurry vision (in patients who suffer from glaucoma) and difficulty urinating in
patients with prostrate problems.
Patients should let their doctor know if they are currently taking any medications for
since these medications can have serious adverse effects when they interact with either topical
or systemic decongestants.
Mucolytics, Anti-Fungals and Macrolides, and Others
Question: Tell me about mucolytics.
Answer: Mucolytic agents are drugs that thin mucus and secretions
so they can drain out of the sinuses more easily. They may be helpful for people suffering
from thick post-nasal drip. Often, they are found in combination preparations with
decongestants and/or antihistamines. Most are well-tolerated and have few side-effects. Some
patients develop stomach upset when taking mucolytics.
A common mucolytic agent is
Guaifenesin. This has long been used and is considered effective as a
mucolytic and expectorant in bronchitis. Guaifenesin (brand name Humibid) is considered
effective in liquifying the annoying thick secretions associated with
Guaifenesin is the most common expectorant found in cough syrups.
For chronic sinusitis, the recommended daily dose is up to 2400 mg.
This is available in tablet or liquid form and may also be found in
combination with oral decongestants. In higher doses Guaifenesin acts
as an emetic and, occasionally, the dose used in chronic sinusitis must be
limited because of GI discomfort. Other mucolytics, such as saturated
solutions of Potassium Chloride or Ammonium Chloride, are
Question: Tell me about leukotriene esterase inhibitors.
Answer: Leukotriene esterase inhibitors include
Zyleutin and Zyflo. These are medications that are used in pulmonary
diseases such as asthma. Their exact biochemical effect is to interfere
with a unique inflammatory pathway and thereby diminish
inflammation and swelling. Because they do not work in the same way
as steroids, they can have an additive effect when used in conjunction
with steroids and other medications.
Question: Tell me about Singulair.
Answer: Singulair is a medication often used in asthma. It has specific anti-inflammatory
works by blocking a specific inflammatory route that is not typically affected by other
anti-inflammatory agents. Singulair is also sometimes useful in patients with sinusitis.
Question: Tell me about Sporonox.
Answer: Sporonox (generic name Itraconazole) is an antifungal
medication. There is a current theory that some sinusitis is due to fungus. In these cases, it is thought
anti-fungal medication may be of benefit, just as antibiotics are of some benefit to many patients
with chronic bacterial sinusitis.
Sporonox has some potentially serious side-effects, including the risk of damage to the
Therefore, it must be given only under the care of a physician. Liver function tests are obtained
before, and periodically during, treatment. Treatment is terminated if the patient's blood tests are
elevated by the medication, or if the patient develops any concerning symptoms such as
Sporonox also has an effect of increasing the effectiveness of prednisone. So, if a patient
prednisone is given Sporonox and reports improvement, the improvement may not necessarily
have been caused by an anti-fungal effect, but it may have been caused by the effect of
the action of the prednisone.
There is anecdotal evidence that this treatment can be beneficial, but there is not yet strong
evidence in the medical literature. Certainly, Sporonox is a medication that should not be used
Question: Tell me about Macrolides.
Answer: Macrolides are a class of antibiotics. An example is
In Japan, these antibiotics are used commonly in patients with sinusitis -- not for their
effect but for their effect on the immune system. Research has indicated that macrolides
up-regulate (improve) certain aspects of the immune system and can thereby help the body fight
sinusitis. However, one criticism of this use of the Macrolide antibiotics is that there is a risk
bacteria could become resistant to these antibiotics if they are over-used, thereby potentially
creating a difficult problem due to infection with resistant bacteria.
When Symptoms Persist Despite Medical
Question: Do guidelines exist that help in determining
when surgery is warranted?
Answer: Yes. Doctors refer to these guidelines as the "indications" for
surgery. Indications for surgery may be absolute, meaning that surgery is absolutely necessary,
they may be termed "relative indications," meaning that the patient and the doctor must weigh
potential risks and benefits, but that surgery may be considered a viable option given the
patient's history and physical findings.
Question: What are some absolute indications for sinus
Answer: Absolute indications for sinus surgery include bilateral
extensive and massive obstructive nasal polyposis with complications, complications of adult
rhinosinusitis (such as subperiosteal or orbital abscess, meningitis, or brain abscess from
progression of sinus disease), chronic rhinosinusitis with mucocele or mucopyocele
formation, invasive or allergic fungal adult rhinosinusitis, cerebrospinal fluid rhinorrhea, and
the diagnosis of a tumor of the nasal cavity or paranasal sinuses.
Question: What are some relative indications for FESS
in chronic sinusitis?
Surgical intervention for chronic sinusitis is reserved
for those patients in whom maximal medical therapy has failed. Functional
endoscopic sinus surgery has become the most widely accepted approach for patients
requiring surgical intervention for chronic sinusitis. The goal is to return the sinuses to as
near a normal anatomic state as possible. This surgery is intended to correct conditions
that impede mucocilary clearance of the sinuses, especially through the osteomeatal
complex. Respect of the normal drainage patterns of the sinuses and elimination or
improvement of obstruction of these drainage pathways promotes the resolution of
mucosal hypertrophy and infection and the return to a normal disease-free state.
Most cases of chronic sinusitis treated by otolaryngologists are
successfully treated with medical therapy. When medical therapy fails, the surgical alternative is a consideration.
Relative indications for sinus surgery include persistent chronic adult rhinosinusitis
despite medical therapy. Associated factors exist that may alter the threshold for
surgery; these include congenital variations in the anatomy of the nasal cavity and paranasal
sinuses, mucociliary dysfunction, allergic fungal sinusitis, reactive airway disease, and others.
A relative indication for FESS exists in adults who have persistent troubling symptoms
despite medical therapy and who have persisting endoscopic and/or CT scan
evidence of sinusitis, anatomic obstruction, and persistent disease despite medical
therapy. Endoscopic evidence of
persisting sinusitis may include polyps, mucosal hypertrophy, edema, and pus from a sinus orifice.
Question: What are some relative indications in
recurrent acute sinusitis?
Answer: Recurrent acute sinusitis refers to the situation where a patient
repeated acute sinus infections but is relatively symptom free between these infections. Relative
indications for FESS in adults and in children over 12 who have recurrent acute sinusitis
- Four or more episodes of infection during the past 12 months
- A trial of immunotherapy for allergic rhinosinusitis or absence of allergy
- Presence of an anatomic variant, especially one contributing to OMC obstruction
- Prophylactic use of medical treatment without benefit.