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.
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 (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.
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 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.
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 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?
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 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.

Antihistamines

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 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.
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 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.
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 STABILIZERS.
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.

Decongestants

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 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.
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 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.
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 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.
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 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.
Answer: 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?
Answer: 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?
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?
Answer: 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 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.