Antibiotic therapy for chronic sinusitis is controversial and may be most appropriate for acute exacerbation of chronic sinusitis. Medical therapy should include both a broad-spectrum antibiotic and a topical intranasal steroid to address the strong inflammatory component of this disease.
Antibiotic therapy might need to be continued for 4 to 6 weeks. These include amoxicillin-clavulanate, cefpodoxime proxetil, cefuroxime, gatifloxacin, moxifloxacin, and levofloxacin.
Currently used topical intranasal steroids such as fluticasone Flonase , mometasone Nasonex , budesonide Rhinocort AQ , and triamcinolone Nasacort AQ have a favorable safety profile and indications for the pediatric age group. A short course of oral steroids may be used for extensive mucosal thickening and congestion or nasal polyps. To temporarily alleviate the drainage and congestion associated with sinusitis, decongestant nasal sprays oxymetazoline Afrin and phenylephrine hydrochloride Neo-Synephrine may be used for 3 to 5 days.
Long-term use of topical decongestants can cause rhinitis medicamentosa, which is rebound congestion caused by vasodilatation and inflammation.
Oral decongestants pseudoephedrine may be a reasonable alternative if the patient has no contraindication such as hypertension. Mucolytic agents guaifenesin can help to decrease the viscosity of the mucus for better clearance and are often found in combination with decongestants.
Some mucolytics are now available over the counter. Saline spray or irrigation can help clear secretions. Topical corticosteroids are not indicated for acute sinusitis but may be helpful for chronic sinusitis, nasal polyps, and allergic and nonallergic rhinitis. Antihistamines are not indicated for sinusitis but may be helpful for underlying allergic rhinitis.
If medical therapy fails or if complications are suspected, an otolaryngology consultation is warranted. This may begin with a nasal endoscopy for better visualization of the nasal cavity and ostiomeatal complex. The otolaryngologist can also perform endoscopically guided sinus culture. If surgical therapy is being contemplated, newer techniques of functional endoscopic sinus surgery are performed to clear sinuses of chronic infection, inflammation, and polyps.
This may be combined with somnoturboplasty i. Endoscopic sinus surgery is commonly performed on an outpatient basis using local anesthesia and has less morbidity than traditional open surgery for chronic sinus disease. This is commonly referred to as the aspirin triad of aspirin sensitivity, asthma, and polyposis. Although most of these patients undergo sinus surgery and polypectomy, additional therapy with nasal steroids, leukotriene modifiers, and aspirin desensitization, followed by mg aspirin twice daily, should be considered.
Laboratory evaluation may be necessary to look for an underlying disorder that can predispose to sinusitis. The evaluation may include a sweat chloride test for cystic fibrosis, ciliary function tests for immotile cilia syndrome, blood tests for HIV, or other tests for immunodeficiency, such as immunoglobulin levels. Any patient with recurrent acute or chronic sinusitis should have an allergy consultation to rule out allergy to dust mites, mold, animal dander, and pollen, which can trigger allergic rhinitis.
An allergy consultation will provide immediate hypersensitivity skin testing to delineate which environmental aeroallergens exacerbate allergic rhinitis and predispose to sinusitis. Medical management and environmental control measures are discussed. Treatment options such as medications, immunotherapy, or both allergy shots are considered. Additional evaluation for comorbid conditions such as asthma, sinusitis, and gastroesophageal reflux are addressed and treated.
Allergists are also trained in aspirin desensitization for treatment of patients with the aspirin triad. Orbital extension of sinus disease is the most common complication of acute sinusitis. This complication is more common in children. Immediate management includes broad-spectrum intravenous antibiotics, a CT scan to determine the extent of disease, and possibly surgical drainage of the infection if there is no response to antibiotics.
Extension to the central nervous system can also occur. The most common intracranial complications are meningitis usually from the sphenoid sinus, which is anatomically located closest to the brain and epidural abscess usually from the frontal sinuses.
Because of the extent of sinus blockage and the strong association with polyps, surgery is usually indicated to remove the inspissated allergic mucin and polyps, followed by systemic corticosteroids to decrease the inflammatory response.
Commonly, nasal steroids are also added for topical treatment. Studies are currently being conducted to establish the role of antifungal agents or inhalant allergen immunotherapy for the treatment of AFS. URTIs of viral origin should run their course, with gradual improvement in symptoms daily until complete resolution of symptoms occurs by day 7 to 10, with supportive treatment only and no antibiotics.
When a secondary bacterial infection is suspected and antibiotics are given for acute sinusitis, the expected clinical outcome would be resolution of the infection and associated symptoms. The data on outcomes of medical management of chronic sinusitis are showing that we can control symptoms to a degree, although with a high rate of recurrence.
Hamilos reported a retrospective series of patients treated medically for chronic sinusitis. Treatment included systemic steroids for 10 days, antibiotic coverage for aerobic and anaerobic organisms for 4 to 6 weeks, nasal saline irrigation, and topical steroid nasal spray. There were symptomatic and radiographic improvements in 17 of 19 patients, but 8 of 19 had persistent ostiomeatal complex abnormalities. In addition, relapse of sinusitis has been significantly associated with nasal polyposis and a history of prior sinus surgery.
Overall, we have many treatment options for the sinusitis patient: antibiotics for the bacterial infection; steroids, systemic or topical, for the inflammatory component; and surgery for the anatomic and structural abnormalities that can predispose to sinusitis.
Although these have helped with initial improvement, we still see a high rate of recurrence of sinus disease. This forces us to address the role of comorbid conditions such as allergic rhinitis , environmental irritants e. Definition Prevalence Pathophysiology Signs and symptoms.
Diagnosis Therapy References. Definition Sinusitis is inflammation of the sinuses, which are air-filled cavities in the skull. Figure 1: Click to Enlarge. Figure 2: Click to Enlarge. Box 1: Conditions that Predispose to Sinusitis Allergic rhinitis Nonallergic rhinitis Anatomic factors: Septal deviation Paradoxical middle turbinate Ethmoid bulla hypertrophy Choanal atresia Adenoid hypertrophy Hormonal conditions e.
Figure 3: Click to Enlarge. Figure 4: Click to Enlarge. References Slavin RG. The diagnosis and management of sinusitis: A practice parameter update. J Allergy Clin Immunol. Diagnosis and Treatment of Acute Bacterial Rhinosinusitis. Rockville, Md: U.
Spiegel JH. Sinusitis [entire issue]. Otolaryngol Clin North Am. Ivker R. Respiratory disease: Sinusitis, upper respiratory infection, otitis media. Clin Fam Pract. Hamilos DL. Chronic sinusitis. Winstead W. Prim Care. Dykewicz MS.
The microbiology and management of acute and chronic rhino-sinusitis. Curr Infect Dis Rep. Clin Infect Dis. Diagnostic criteria for allergic fungal sinusitis. Clinical practice guideline: Management of sinusitis. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Executive summary. Wald ER. Microbiology of acute and chronic sinusitis in children and adults. Am J Med Sci. The condition is caused by bacteria that live in the nose, throat and, sometimes, the mouth.
Types of bacteria which commonly cause bacterial sinusitis include: [1] [2] [5]. As detailed above, bacterial sinusitis often follows a cold or flu infection. The diagnosis is based on the symptoms and physical examination. In severe cases or cases that do not respond to treatment, a nasal endoscopy may be done to aid diagnosis and treatment.
An endoscope is a small, flexible tool equipped with a camera, which allows the doctor a detailed view of the inside of the nose and sinuses. A nasal decongestant will be administered, and the nose will be numbed by an anesthetic spray.
If the endoscopic exam is not helpful or if the doctor wants to carry out further examination, a ct scan may be ordered. A CT scan can be helpful in assessing the sinuses and confirming the diagnosis in complicated cases. Most cases of bacterial sinusitis will get better without antibiotics, usually within 14 days.
Antibiotics are usually only prescribed for people who have severe or ongoing symptoms, or whose infection may be complicated by various other medical factors. Viral sinusitis does not respond to antibiotic treatment. Although most cases of bacterial sinusitis clear up without the help of a doctor, affected people should seek medical assistance if: [2]. In many cases, home remedies may be sufficient. Some people find breathing humid air or steam, such as in a warm shower, helps to relieve symptoms.
Also, holding a warm pad over the painful area helps to relieve discomfort. Nasal irrigation with saline solution is helpful in reducing congestion in the nose. It is also very important to stay well-hydrated, so affected people should be sure to drink enough fluids. Analgesic and anti-inflammatory medications, such as ibuprofen or paracetamol, may help to reduce pain and swelling in the nose and face.
Decongestant sprays or tablets are also often helpful in relieving symptoms. Decongestants commonly used are pseudoephedrine and phenylephrine, or corticosteroids such as fluticasone. Good to know: If over-the-counter decongestant nasal sprays or drops are being used, they should not be used for more than three days in a row as they may cause rebound congestion if used for longer. These products do not shorten the duration of bacterial sinusitis but may relieve symptoms. Antibiotic treatment is usually only needed if the infection does not improve within days, the person has another medical condition which may affect recovery, or if: [5] [6].
These are indications that the bacterial infection is severe. Antibiotic treatment is usually prescribed for about 10 days, but shorter courses may be as effective, depending on the bacteria involved. The choice of which antibiotic to use will be based on which bacteria the treating physician thinks are likely to be involved in the infection.
Surgery is not usually needed for acute bacterial sinusitis. It is only necessary in some cases of chronic sinusitis that do not respond to other forms of treatment. Endoscopic treatment, where a small camera-equipped probe is used to guide and perform the procedure, is one option.
In this surgery, the endoscope is used to widen the natural drainage pathways in the sinuses and nose, which improves mucus drainage and cuts down on congestion and the chance of infection. Rarely, acute bacterial sinusitis may cause an abscess to form near the eye or the brain. In these cases, surgical treatment will be needed to drain the abscess. Good to know: Complications from bacterial sinusitis are rare, affecting only about one in every ten thousand people with the disorder.
Taking care to prevent the spread of colds or the flu in the home and community can help prevent some cases of bacterial sinusitis. Seeing a dentist regularly may help to prevent tooth infections, a possible cause of bacterial sinusitis. Q: Can bacterial sinusitis cause a sore throat? A: Bacterial sinusitis may be accompanied by postnasal drip, an uncomfortable condition where excess mucus can irritate the throat.
Additionally, if bacterial sinusitis was preceded by a viral upper respiratory illness, a sore throat may have been a feature of this. If you feel unwell with a cough, a headache and a scratchy throat, check out the Ada app for a free symptom assessment.
Q: Where are the paranasal sinuses? A: There are four pairs of paranasal sinuses: the maxillary, frontal, ethmoid and sphenoidal. The maxillary sinuses are located below the eyes, and the frontal sinuses are above the eyes. Both of these are near the front of the head, near the inner corners of the eyes. The ethmoid sinuses are located in the ethmoid bone, which separates the brain from the nasal cavity; the sinuses themselves are between the eyes.
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