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Medical Treatment of Sinusitis
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General Information

Question: What is the appropriate medical therapy for sinusitis?
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?
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?
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?
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?
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?
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?
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.
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?
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).
No antimicrobials have been approved for the treatment of chronic sinusitis.

Question: Which antibiotics are well-tolerated in general, and which ones aren't?
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?
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?
No, Histamine II blockers do not affect the absorption of Quinolones.

Question: Which antibiotics may be used during pregnancy?
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?
Amoxicillin, Augmentin, Zithromycin, Ceftin, Ceprozil, Cefuroxime, Axetil, Ciprofloxacin, Clarithromycin, Doxycycline, and Lorocarbef.

Question: Which antibiotics have, in general, the least food/drug interactions?
Amoxicillin, Augmentin, Azithromycin, Ceftin, Ceprozile, Cefuroxime, Erthyromycin, Gadifloxacin, and Moxifloxacin.

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

Question: How do you distinguish between a bacterial infection and a viral infection?
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?
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.


Nasal Saline Solutions

Question: Tell me about nasal lavage or nasal saline spray.
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.
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?
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.
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?
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?
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.
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.
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 septal perforation.

    Question: Tell me more about topical nasal steroid sprays.
    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?
    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 (oral) steroids do, some of the same serious side-effects can occur (see section on oral steroids below).

    Question: Tell me more about systemic (oral) steroids.
    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 minimized.

    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 steroids.
    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 their doctor.

    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 physician.

    Question: Do you have anything else to say about steroids?
    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 increase effectiveness:

    • 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 insomnia.
    • 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 oral steroids:

    Annual ophthalmologic examination
    Bone density scan
    TB test

    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.
    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 response.

    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 passageways.

    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 urinating.

    Question: Tell me more about antihistamines.
    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 antihistamine 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 to cause excessive dryness.

    Traditional or "first generation" antihistamines include diphenhydramine (Benadryl, chlorpheniramine maleate (Chlor-Trimeton), meclizine (Antivert), 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 terfenadine (Seldane).

    Third generation antihistamines include Cetirizine (Zyrtec) and fexofenadine (Allegra).

    Topical antihistamines (nasal sprays) include azelastine (Astelin) and levocabastine (Livostin).

    Question: Tell me about Astelin nasal spray.
    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 STABILIZERS.
    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.
    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 depression, 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.
    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 chronic sinusitis.

    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 occasionally used.

    Question: Tell me about leukotriene esterase inhibitors.
    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.
    Singulair is a medication often used in asthma. It has specific anti-inflammatory effects. It 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.
    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 that 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 liver. 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 abdominal pain.

    Sporonox also has an effect of increasing the effectiveness of prednisone. So, if a patient on 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 improving 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 routinely.

    Question: Tell me about Macrolides.
    Macrolides are a class of antibiotics. An example is erythromycin. In Japan, these antibiotics are used commonly in patients with sinusitis -- not for their anti-bacterial 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 that 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 Treatment

    Question: Do guidelines exist that help in determining when surgery is warranted?
    Yes. Doctors refer to these guidelines as the "indications" for surgery. Indications for surgery may be absolute, meaning that surgery is absolutely necessary, or they may be termed "relative indications," meaning that the patient and the doctor must weigh the 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 surgery?
    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?
    Recurrent acute sinusitis refers to the situation where a patient has 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 include:

    1. Four or more episodes of infection during the past 12 months
    2. A trial of immunotherapy for allergic rhinosinusitis or absence of allergy
    3. Presence of an anatomic variant, especially one contributing to OMC obstruction
    4. Prophylactic use of medical treatment without benefit.
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