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Rhinosinusitis: Am I Getting
Proper Treatment for My Rhinosinusitis?
The following is a brief overview of medical treatments available
for acute rhinosinusitis, chronic rhinosinusitis and nasal polyposis. For more
detailed information see the "Sinusitis
Practice Parameters" published in the Journal of Allergy
& Clinical Immunology (Vol. 102 No.6 Pt. 2).
Treatments for acute rhinosinusitis
Antibiotics
About 60-70% of patients recover from an acute sinus infection
without need for an antibiotic. Treatment with an antibiotic, however,
can shorten the duration of acute rhinosinusitis and also reduce its
severity.
Acute rhinosinusitis usually follows a common cold. The
bacteria that cause acute rhinosinusitis include:
-
Streptococcus
pneumoniae,
-
Hemophilus influenza, type b and
-
Moraxella
catarrhalis.
Many strains of bacteria causing rhinosinusitis are resistant to amoxicillin.
As a result, amoxicillin is not always effective for acute rhinosinusitis,
although it is one of the cheapest antibiotics available.
Decongestants
Decongestants may help to relieve symptoms of nasal congestion,
runny nose, postnasal drainage, sinus pressure and headache. As a
result, they may help people feel better while recovering from acute
rhinosinusitis.
Topical and Oral Corticosteroids
Acute rhinosinusitis is associated with sinus membrane edema or
"thickening" that may compromise drainage from the sinus
ostia. These membrane changes are seen in both acute bacterial
rhinosinusitis and in acute viral upper respiratory infections.
Corticosteroids may be beneficial in acute rhinosinusitis by helping to
restore the sinus openings ("ostia"). However, there is
little information on the use of oral corticosteroids in acute
rhinosinusitis, and some authors specifically recommend against its use for
fear that it might prolong the acute infection. (Gwaltney review
Annals of Otology, Rhinology, & Laryngology - Supplement.
167:22-30, 1995).
Topical corticosteroids may be useful as adjunctive
treatment for acute rhinosinusitis. The use of an intranasal corticosteroid
along with an antibiotic may help reduce nasal membrane swelling and
may have a modest effect to hasten recovery from symptoms of acute
maxillary rhinosinusitis. (Gwaltney review Annals of Otology, Rhinology,
& Laryngology - Supplement. 167:22-30, 1995; Meltzer et al. J
Allergy Clin Immunol. 92 :812-23, 1993;
Barlan et al (Annals of Allergy, Asthma, & Immunology.
78(6):598-601, 1997; Dolor et al. JAMA 2001;286(24):3097-105).
Treatments for chronic rhinosinusitis
Antibiotics
Patients with chronic rhinosinusitis experience frequent
"exacerbations" that are characterized by an increase in
their symptoms of thick nasal or postnasal drainage, discomfort in the
face (cheeks, forehead or around the eyes), nasal congestion, cough
and headache. Patients usually do not have a fever. Antibiotics
are often helpful to relieve these increased symptoms.
The bacteria that are associated with chronic
rhinosinusitis include:
-
Streptococcus pneumoniae,
-
Hemophilus influenza, type b,
-
Moraxella catarrhalis,
-
Staphylococcus aureus,
-
Staphylococcus epidermidis
-
and several species of anaerobic bacteria.
The choice of antibiotics for treatment of chronic
rhinosinusitis is controversial. Several drugs are commonly used, including
amoxicillin/clavulanate, clarithromycin, fluoroquinolones and various
cephalosporins.
There is no consensus as to which drug is most effective. Most experts
advocate treatment with antibiotics for a minimum of three weeks. In
some cases, even longer courses of antibiotics may be needed. Some
experts recommend that antibiotics be continued for at least 1 week
after the patient appears symptom free.
For more information about antibiotic treatment for
chronic rhinosinusitis, see www.jcaai.org/Param/Sinusitis/Treatment.htm
Use of Oral Corticosteroids as Adjunctive
Treatment
The most common approach for corticosteroid adjunctive
treatment is for patients to take prednisone for seven to ten days.
Antibiotics are begun along with the prednisone and continued for 3-4
weeks.
Intranasal topical steroids
Use of topical steroids has been widely advocated for treatment of
chronic rhinosinusitis as one component of a comprehensive medical
treatment program (Journal of Allergy & Clinical Immunology.
99(6 Pt 3):S829-48, 1997). Two studies have demonstrated significant clinical benefit from medical treatment programs that include oral antibiotics, intranasal corticosteroids, decongestant nasal sprays, nasal saline irrigations, and one also included a short course of oral steroids (Subramamiam H. et al. Am J Rhinol 2002;16:303-12; McNally et al. Allergy & Asthma Proceedings 1997; 18(3):169-75)
Decongestants
For information from the Sinusitis Practice Parameters on the use
of decongestants to treat rhinosinusitis see www.jcaai.org/Param/Sinusitis/Treatment.htm
Treatment of Nasal Polyp Disease (Chronic
rhinosinusitis with nasal polyps)
Several studies have shown that topical intranasal steroids help
to reduce the size of nasal polyps and prevent their regrowth after
sinus surgery.
A short "burst" of an oral steroid, such
as prednisone, often helps to reduce the size of nasal polyps and may
help to prevent the need for sinus surgery. Nasal polyps typically
regrow within a few months after the steroid burst. To maintain
improvement after treatment with an oral steroid burst, patients
should always be advised to use a topical intranasal steroid on a
continuing basis.
Optimum delivery of intranasal
corticosteroids and complications of therapy
For most patients with chronic rhinosinusitis, intranasal
corticosteroids should be used on a continuous basis. Side effects are
generally minimal, although some patients experience nose bleeding
from local irritation of the spray. This type of irritation can be
caused by improperly spraying the medicine on the nasal septum. If you
are having problems with the use of an intranasal steroid, please ask
your doctor to help you insert it in the nostril properly.
Is there a special case for nasal polyp
disease associated with aspirin sensitivity?
In patients with aspirin sensitivity, the sinus membranes become
heavily laden with eosinophils. One of the major substances produced
by eosinophils is leukotriene C4, a "mediator" that produces
bronchial spasm, nasal swelling and excessive secretion of mucus. Eosinophils
are one of only a few cell types that produces leukotriene C4. Topical
steroids are strongly recommended for any patient with nasal polyp
disease, including those with aspirin sensitivity. Leukotriene receptor blockers may be useful in treating individuals with chronic rhinosinusitis especially those with nasal polyps (Ulualp et al. Ear, Nose, Throat J 1999;78 (8):604-606; Rarnes et al. Ear Nose Throat J 2000;79 (1):18-20; Ragab et al. Clin Exp Allergy 2001;31(9):1385-1389)
Treatment of Allergic Fungal Rhinosinusitis
Allergic fungal rhinosinusitis (AFRS) is a subset of chronic
rhinosinusitis caused by an intense allergic and eosinophilic inflammatory
response to a fungal species, usually one of the class fungi
imperfecti. Patients with AFRS typically have nasal polyps and produce thick peanut butter like secretions. Surgical removal of the thick secretions loaded with
eosinophils (allergic mucin), which may become impacted, is the mainstay of effective
treatment ("Kuhn et al. Otolaryngol Clin North Am. 30:479-90,
1997). The secretions often contain many fungi.
Oral steroid treatment
Oral steroids are useful in the management of
AFRS, although they
should not be viewed as a substitute for surgery. It is occasionally
necessary to continue a low daily or every other day dose of
prednisone to maintain control of allergic fungal rhinosinusitis. It is
difficult to deliver the liquid intranasal steroid preparation to the
sinus tissues. The delivery can be improved by instructing the patient
to use the inhaler in the head-down-forward position. The patient can
be positioned in one of two ways: lying face-forward on a bed with the
head hung over the side or kneeling in bed with the top of the head on
the mattress. The patient should be instructed to spray the medicine
into the nose and then immediately go into the head-down-forward
position. With practice, the patient may be able to remain in this
position for a minute or longer. When used in this way, intranasal
corticosteroids have been reported to reduce the size of nasal polyps
(Chalton R, Mackay I. Br Med Journal 291: 788. 1985; Canciani M,
Mastrella G. Acta Paediatr Scand; 77: 612-613. 1988) and improve sense
of smell (Mott AE, et al. Arch Otolaryngol Head Neck Surg 123:
367-372, 1997.)
Antifungal drugs
The utility of antifungal drugs to control allergic fungal rhinosinusitis is questionable, and they are not currently standard of care.
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