Treatment:

General Treatment Approaches

The primary objectives for treatment of sinusitis are reduction of swelling, eradication of infection, draining of the sinuses, and ensuring that the sinuses remain open. Fewer than half of patients reporting symptoms of sinusitis need aggressive treatment. Home remedies can be very useful.

Treatment of Acute Sinusitis.

• Support treatment with only saline nasal irrigation, decongestants, antihistamines, and expectorants are appropriate for a minimum of 7 - 10 days for patients with mild-to-moderate symptoms, and may be used for longer.
• Antibiotics are not helpful for patients with mild-to-moderate symptoms, so they should not be prescribed for at least the first 7 days.

Treatment of Chronic Sinusitis.

• A broad-spectrum antibiotic (one that can eliminate a wide range of bacteria) may be helpful. Some patients benefit from prolonged therapy.
• A corticosteroid nasal spray. Some doctors also recommend oral corticosteroids (such as prednisone) for patients who do not respond to nasal corticosteroids or for those patients who have nasal polyps. Prednisone is also used for patients who have allergic fungal sinusitis.
• Saline nasal irrigation is often needed on an ongoing basis.
• If the condition dramatically improves after 1 - 2 months, antibiotics are stopped. The patient should continue with both the steroid and saline nasal solutions. If there is no improvement after this time, surgery may be considered. For some people with chronic sinusitis, however, the condition is not curable, and the goal of treatment is to improve the quality of life.
• A thorough diagnostic work-up should be performed to rule out any underlying conditions, including but not limited to allergies, asthma, any immune problems, gastroesophageal reflux disorder, and structural problems in the nasal passages. If a primary trigger for chronic sinusitis can be identified, it should be treated or controlled if possible.

Hydration

Home remedies that open and hydrate sinuses may, indeed, be the only treatment necessary for mild sinusitis that is not accompanied by signs of acute infection.

• Drinking plenty of fluids and getting lots of rest when needed is still the best bit of advice to ease the discomforts of the common cold. Water is the best fluid and helps lubricate the mucous membranes. (There is NO evidence that drinking milk will increase or worsen mucus, although milk is a food and should not serve as fluid replacement.)
• Chicken soup does, indeed, help congestion and aches. The hot steam from the soup may be its chief advantage, although laboratory studies have actually reported that ingredients in the soup may have anti-inflammatory effects. In fact, any hot beverage may have similar soothing effects from steam. Ginger tea, fruit juice, and hot tea with honey and lemon may all be helpful.
• Spicy foods that contain hot peppers or horseradish may help clear sinuses.
• Inhaling steam 2 - 4 times a day is extremely helpful, costs nothing, and requires no expensive equipment. The patient should sit comfortably and lean over a bowl of boiling hot water (no one should ever inhale steam from water as it boils) while covering the head and the bowl with a towel so the steam remains under the cloth. The steam should be inhaled continuously for 10 minutes. A mentholated or other aromatic preparation may be added to the water. Long, steamy showers, vaporizers, and facial saunas are alternatives.

Nasal Wash

A nasal wash can be helpful for removing mucus from the nose. A saline solution can be purchased at a drug store or made at home. (Mix 1 teaspoon of table salt with a pinch of baking soda in 2 cups of warm water.) Perform the nasal wash several times a day. Researchers have reported that daily irrigation of the nasal passages with a hypertonic saline solution relieves sinusitis symptoms and also reduces antibiotic use and the occurrence of acute exacerbations. Patients in the study had 72% fewer sinus infections, a 69% improvement in breathing, and they reduced medication usage by more than half.

A simple method for administering a nasal wash is:

• Lean over the sink head down.
• Pour some solution into the palm of the hand and inhale it through the nose, one nostril at a time.
• Spit out the remaining solution.
• Gently blow the nose.

The solution may also be inserted into the nose using a large rubber ear syringe, available at a pharmacy. In this case the process is:

• Lean over the sink head down.
• Insert only the tip of the syringe into one nostril.
• Gently squeeze the bulb several times to wash the nasal passage.
• Then press the bulb firmly enough so that the solution passes into the mouth.
• The process should be repeated in the other nostril.

Antibiotic Use in the Treatment of Sinusitis

Overview on Antibiotics and Their Overuse. Sinusitis is the fifth most common diagnosis for antibiotic prescriptions. And, there is much evidence that antibiotics are inappropriately prescribed for many patients:

• Most acute sinusitis cases clear up on their own.
• Antibiotics generally help only a very small number of children with persistent nasal discharge for at least 20 days. Even when antibiotics are helpful, benefits are modest in reducing duration of the infection.
• The intense and widespread use of antibiotics (not only for sinusitis but also for ear infections and other upper respiratory tract infections) has led to a serious global problem, which is bacterial resistance to common antibiotics.

When to Use Antibiotics. Because up to 70% of sinusitis cases resolve on their own, doctors generally wait 7 - 14 days before prescribing antibiotics. However, antibiotics may be prescribed sooner if severe symptoms develop. These symptoms include:

• Fever greater than 39° C (102.2° F)
• Facial pain or headache
• Severe swelling around the eyes

Chronic sinusitis is often the result of damage to the mucous membrane from a past, untreated acute sinus infection. The aerobic and anaerobic bacteria present in chronic sinusitis are often different from those that cause the acute form. The role of antibiotic treatment for chronic sinusitis is controversial. Special types of antibiotics may be used, and treatment may be needed for a longer time.

Some patients with chronic sinusitis may need intravenous antibiotic therapy, particularly those with underlying medical disorders that can worsen their condition. This therapy is typically given 2 weeks before surgery and continued for about a month afterwards.

Antibiotic Regimens.

• The standard first-line antibiotic treatment for acute uncomplicated bacterial sinusitis is a 10 - 14 day course of amoxicillin. Trimethoprim-sulfamethoxazole is an alternative choice.
• For more complicated illnesses (chronic illness, chronic sinusitis, symptoms lasting longer than 30 days, children in day care or younger than 2 years old, smokers, recent antibiotic use, or unresponsiveness to initial antibiotic course), the doctor may prescribe a different type of antibiotic, such as amoxicillin-clavulanate, cephalosporin, or a macrolide.
• If the patient does not respond after 21 - 28 days, the doctor may switch to another broad-spectrum antibiotic, such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime. Other choices include clarithromycin or azithromycin (macrolides) or levofloxacin (a fluoroquinolone).

Side Effects of Antibiotics. Most antibiotics have the following side effects (although specific antibiotics may have other side effects or fewer of the standard ones):

• The most common side effect for nearly all antibiotics is gastrointestinal distress.
• Antibiotics double the risk for vaginal infections in women. Taking supplements of acidophilus or eating yogurt with active cultures may help restore healthy bacteria that offset the risk for such infections.
• Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening, anaphylactic shock.
• Certain drugs, including some over-the-counter medications, interact with antibiotics; patients should inform the doctor of all medications they are taking and of any drug allergies.

Managing Sinusitis in Patients with Allergies

Patients often have various combinations of allergies, sinusitis, and asthma. Treating each condition is important for improving them all. In addition to decongestants, pain relievers, and expectorants, other remedies are available for people who suffer from nonbacterial sinusitis during allergy season.

• Anti-Inflammatory Drugs. Nasal spray corticosteroids (commonly called steroids) are important for reducing the inflammatory response in the nasal passages and airways. They are important in the treatment of asthma and are now considered to be the most effective measure for preventing allergy attacks. Leukotriene-antagonists are also useful for sinusitis symptoms.
• Antihistamines. Antihistamine tablets relieve sneezing and itching and can prevent nasal congestion before an allergy attack. Many brands are available by prescription and over the counter. Because they thicken mucus and make it harder to drain out from the sinuses, they should not be used for sinusitis.
• Immunotherapy. Immunotherapy, commonly referred to as allergy shots, may be considered for patients with severe seasonal allergies that do not respond to treatment. Immunotherapy is the only treatment that affects the cause of allergies. In one year-long study using immunotherapy, over half of young patients participating experienced improvement in overall sinusitis symptoms, and nearly all felt better in general. Immunotherapy also may prevent asthma and the development of new allergies in children. Newer immunotherapeutic approaches using specially designed antibodies and vaccines are also showing promise.
• All drug treatments have side effects, some very unpleasant and, rarely, serious. Patients may need to try different drugs until they find one that relieves symptoms without producing excessively distressing side effects.

Emergency Treatment

Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull need emergency care. High dose antibiotics are administered intravenously, and emergency surgery is almost always necessary in such cases.

Severe Fungal Sinusitis. Sinusitis caused by severe fungal infections is a medical emergency. Treatment is aggressive surgery, and high-dose antifungal chemotherapy with a drug such as amphotericin B can be life saving. The use of high-pressure oxygen (hyperbaric oxygen) is showing promise as additional therapy for potentially deadly fungal infections.