How is sinusitis treated?
The goal in treating sinusitis
is to re-open the narrow communication between the sinuses and the nasal cavity
(See "What are sinuses?").
This in turn promotes movement of mucus out of the sinus and re-establishes
normal oxygen levels within the sinuses. In chronic sinusitis, the principal way
to accomplish this goal remains medications. In some patients, medical therapy
fails to provide relief of their symptoms. These patients may be considered for
surgery (See "What is Endoscopic Sinus
Often the treatment of chronic sinusitis involves combining a number of
medications. Each class of drugs is summarized below.
STEROID NASAL SPRAYS This class of medications works to diminish the
nasal lining's inflammatory response, resulting in less swelling and better
mucus transport. These sprays form the first in the treatment of a number of
inflammatory conditions within the nose. They are typically sprayed into both
sides of the nose and work directly on the lining they come into contact with.
Their onset of action is relatively slow and patients may not feel their effect
for days or weeks. For this reason, often patients give up on this method
of treatment too soon.
Steroid nasal sprays are generally well tolerated. Side effects from these
medications include irritation within the nose and nasal bleeding. This bleeding
can be avoided by pointing the spray bottle away from the nasal septum (the bone
and cartilage that runs down the middle of the nasal cavity). Because the sprays
are minimally absorbed throughout the rest of the body, side effects seen with
taking steroid pills (see below) are extremely rare.
ANTIBIOTICS The vast majority of cases of chronic sinusitis are due to
bacteria. For this reason, antibiotics are another mainstay of treatment. Most
patients who see a specialist regarding their sinuses have previously been on
many courses of numerous antibiotics. In many cases, these courses are for only
seven to ten days, usually insufficient to stamp out the bacteria in a chronic
infection. Most experts now believe that antibiotics for chronic sinus
infections should be maintained for a minimum of three to four weeks. Ideally,
the antibiotic should be chosen based on the results of a culture, where a
sample of the bacteria is sent to the laboratory for identification and other
testing. Because the openings of the sinuses cannot be seen without an endoscope
(See "How is sinusitis
diagnosed?"), blind sampling of the nasal cavity using conventional
equipment is nearly useless. Nevertheless, endoscopically directed cultures have
proven quite useful and specific.
Antibiotics have a number of side effects, many of which are specific to each
different type of drug. Nevertheless, some are common including rash and
diarrhea. If these occur, the drug should be discontinued and the symptoms
immediately reported to your physician. While most reactions are mild, some can
be serious and may require additional medical attention.
ANTIHISTAMINES Antihistamines combat the allergic response within the
nose. Many patients with chronic sinusitis have symptoms of allergies including
itchy nose or eyes, sneezing, watery eyes, and nasal congestion. Patients with
chronic allergies may not experience the typical itching and sneezing symptoms,
but may have chronic congestion, runny nose, and fatigue. The allergic response
to an irritant (commonly dust mites, pet fur, or pollen) results in inflammation
within the nose, precipitating or worsening the sinus condition. Blocking this
response can improve sinus function and reduce symptoms of sinusitis.
One problem with many older antihistamines is the fact that they can cause
sedation as well as drying and thickening of nasal secretions. Many new
antihistamines have little or no sedative side effects and don't cause problems
with secretions. Some are also combined with a decongestant to further reduce
swelling within the nose and sinuses. While most antihistamines come in the form
of pills taken once or twice a day, others can be sprayed into the nose or come
as eye drops to control specific symptoms.
DECONGESTANTS Decongestants act specifically to decrease swelling
within the nose. They work directly on the blood vessels within the nose that
control the thickness of the lining. They may also affect blood vessels
throughout the body and should be used with caution (if at all) in individuals
with certain disorders, particularly difficult to control hypertension or high
blood pressure. Most decongestants are available "over the counter" and they are
often combined with antihistamines. They can cause jitteriness or difficulty
sleeping for some patients and should not be used in men with prostate problems.
Decongestant nasal sprays merit a special word of caution. They are particularly
useful in diminishing swelling within the nose for a short period of time.
If used for more than three days in a row, they can lead to a "rebound effect"
and actually worsen nasal swelling. Often patients will then increase the dosage
or the frequency with which they use the sprays in order to diminish the rebound
swelling. This leads to a vicious cycle of decongestion followed by rebound
swelling, a condition known as "rhinitis medicamentosa"
MUCOLYTICS These drugs, also known as expectorants, are common
ingredients in cough syrups to loosen and thin mucus. Because mucus often
becomes thick and stagnant in chronic sinusitis, many physicians believe these
medications may be helpful in this condition as well. The mucolytics are usually
well tolerated with almost no side effects. In higher doses they can cause
nausea and, because these drugs act to thin mucus, they can increase fertility
NASAL SALINE SPRAY Like mucolytics, nasal saline (salt water) has been
theorized to improve mucus transport. While there are no good studies to support
this claim, saline sprays are relatively innocuous and inexpensive. They appear
to be helpful in some patients, especially those with dryness or crusting as a
major symptom. Other sprays, which have various herbal additives, have given
some patients relief as well.
IRRIGATIONS Some physicians advocate rinsing the nose with saline or
other solutions. The fluid can be delivered using a rubber bulb or with an
attachment to a Water Pik machine. Irrigations can assist in removing thick or
dried mucus. Antibiotics are sometimes added to the solution to decrease
infection as well. If irrigations are used within the nose, great care should be
taken to keep all items as clean as possible. This will prevent introducing new
bacteria from the irrigation system into the nose, which can perpetuate an
ORAL STEROIDS In severe cases of chronic sinusitis, oral steroids
(steroid pills taken by mouth) may be used. These drugs augment the action of
the nasal steroid sprays in decreasing the inflammatory response within the nose
and sinuses. While they are quite effective, because these drugs are taken in
pill form the medication spreads throughout the body and may have significant
side effects. These include osteoporosis, liver abnormalities, cataracts,
glaucoma, weight gain, emotional changes, and joint problems. With the exception
of emotional changes and weight gain, most of the side effects are rarely seen
unless the drug is used for a prolonged period of time. Oral steroids are often
given to patients with nasal polyps or asthma in preparation for surgery. They
may be continued for a few weeks following the procedure to diminish the
inflammatory response during healing.
Go to next page: "What is Endoscopic Sinus