General Information

Question: What is the appropriate medical therapy for sinusitis?
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 controlling the inflammatory and infectious components. Ideal management includes preventative measures, 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 they occur.

Of course, these treatments should only be undertaken under the direction of an experienced physician.

QUESTION: What should a patient do about her sinuses if she is pregnant?
Answer: 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 what 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 or 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 having side-effects, 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, for a 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 skin 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 known 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 daily 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. We 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 if 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 function, 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 doctors)

Question: What is the typical microbiology of a sinus infection?
Answer: Acute rhinosinusitis has causative organisms similar to acute otitis media. 75 percent of culture obtained from antral puncture in patients with acute maxillary 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 Hemophilus influenzae.

Viruses are also prevalent. They mimic bacterial infection and often predispose to bacterial infections secondarily.

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 bacterial sinusitis?
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 treatment:

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 dealing 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 to 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, or 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 therapy.

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. They are:

• 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 daily.

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 pregnancy?
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 obstetrician.

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 food/drug interactions?
Answer: Amoxicillin, Augmentin, Azithromycin, Ceftin, Ceprozile, Cefuroxime, Erthyromycin, Gadifloxacin, and Moxifloxacin.

Question: Which are least expensive?
Answer: Amoxicillin, Doxycycline, and Trimethoprim/Sulfamethoxazole (Bactrim).

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 initial therapy?
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.
Answer:

• 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 spray.
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 unfortunately underused.

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 8oz 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 IRRIGATIONS.
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 not 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 may 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?
Answer: 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 be very 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 been removed.

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: