Treatment for Acute Sinusitis

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. Less than half of patients reporting symptoms of sinusitis need aggressive treatment. Home remedies can be very useful.

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 to 4 times a day is also very 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.

Medications for Mild Pain and Fever Reduction

Many people take medications to reduce mild pain and fever. Adults most often choose aspirin, ibuprofen (Advil), or acetaminophen (Tylenol).

The following are recommendations for children:

• Acetaminophen (Tylenol) or ibuprofen (usually Advil or Motrin) is the pain-reliever of choice in children. Most pediatricians advise such medications for children who run fevers over 101 degrees F.
• Aspirin and aspirin-containing products are virtually never recommended for children or adolescents. Reye's Syndrome, a very serious condition, has been associated with aspirin use in children who have flu symptoms or chicken pox.

Some studies suggest that these anti-fever drugs may actually reduce the body's immune response against cold and flu viruses and prolong symptoms. A 2000 study, for example, reported a longer flu duration in people who took aspirin or acetaminophen (although people still felt better). Nevertheless, most doctors strongly recommend lowering fevers in children, since high fevers can sometimes cause seizures.

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.) The nasal wash should be performed 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 the remaining solution out
• 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

Decongestants

Decongestants are drugs that help reduce nasal congestion. They are available in a pill or nasal form. However, decongestants will not cure sinusitis. Nasal decongestants can actually worsen sinusitis by increasing sinus inflammation. Due to the lack of evidence for nasal decongestants’ benefits for sinusitis, the FDA has ruled that manufacturers of over-the-counter (OTC) nasal decongestant products remove from their labeling all references to sinusitis.

Your doctor may still recommend that you take either an OTC or prescription nasal decongestant to help relieve blockage symptoms associated with sinusitis. If you think you have sinusitis, it is important that you check with your doctor before taking a decongestant. Do not try to treat sinusitis by yourself.

Nasal Decongestants. Nasal decongestants come in long-acting or short-acting forms. The effects of short-acting decongestants last about 4 hours; long-acting decongestants last 6 to 12 hours. The active ingredients in nasal decongestants include oxymetazoline, xylometazoline, and phenylephrine.

Tips for Use. The following precautions are important for people taking nasal decongestants:

• When using a nasal spray, spray each nostril once. Wait a minute to allow absorption into the mucosal tissues, and then spray again.
• Do not share droppers and inhalators with other people.
• Discard sprayers, inhalators, or other decongestant delivery devices when the medication is no longer needed. Over time, these devices can become reservoirs for bacteria.
• Discard the medicine if it becomes cloudy or unclear.

Decongestants Taken by Mouth. Pseudoephedrine is the only decongestant taken by mouth that is currently available over-the-counter (OTC) in the United States. It decreases the volume of mucous in the nose, as well as within the Eustachian tubes. Many brands of OTC oral decongestants are available. A common brand is Sudafed. Oral decongestants such as Sudafed can also be helpful for relieving cough associated with postnasal drip.

Warning: Anyone with old forms of any decongestant should check the labels and discard them if they contain phenylpropanolamine. In November 2000, the U.S. Food and Drug Administration (FDA) banned products, including decongestants, which contained phenylpropanolamine (PPA). This action was in response to a few reports of an increased risk of stroke. (Stroke tended to occur in people who took diet suppressants containing PPA rather than decongestants. In any case, serious events were still very rare.) All major brands that previously contained PPA have now substituted other active ingredients (usually pseudoephedrine) and are safe to use.

Side Effects of Decongestants. Decongestants have certain adverse effects, which are more apt to occur in oral than nasal decongestants and include:

• Agitation and nervousness
• Drowsiness (particularly with decongestants taken by mouth and in combination with alcohol)
• Changes in heart rate and blood pressure
• Avoid combinations of oral decongestants with alcohol or certain drugs, including monoamine oxidase inhibitors (MAOI) and sedatives

Individuals at Risk for Complications from Decongestants. People who may be at higher risk for complications are those with certain medical conditions, including disorders that make blood vessels highly susceptible to contraction. Such conditions include:

• Heart disease
• High blood pressure
• Thyroid disease
• Diabetes
• Prostate problems that cause urinary difficulties
• Migraines
• Raynaud's phenomenon
• High sensitivity to cold
• Emphysema or chronic bronchitis. (Such individuals should particularly avoid high-potency short-acting nasal decongestant.)
• People taking medications that increase serotonin levels, such as certain antidepressants, anti-migraine agents, diet pills, St. John's wort, and methamphetamine. The combinations can cause blood vessels in the brain to narrow suddenly, causing severe headaches and even stroke.

Anyone with these conditions should not use either oral or nasal decongestants without a doctor's guidance. Other groups who should not use these drugs without first consulting a doctor include:

• Pregnant women.
• Children. The American College of Chest Physicians advises against the use of over-the-counter decongestants and other cold medications in children ages 14 years or younger. Children are at particular risk for side effects that depress the central nervous system. Such symptoms cause changes in blood pressure, drowsiness, deep sleep, and, rarely, coma.

Antihistamines

Older antihistamines such as diphenhydramine (Benadryl) are helpful in relieving cough when used alone or in combination with a decongestant.

Expectorants

Expectorants are drugs that cause mucus to be coughed up from the lungs. The most common type used is guaifenesin, which is found in many over-the-counter (OTC) cough syrups as well as prescription products. Expectorants used to be recommended for treatment of sinusitis-associated cough, but some recent guidelines advise against their use. According to the American College of Chest Physicians (ACCP), expectorants and cough suppressants do not help treat cough. The ACCP recommends that adults instead take a decongestant or antihistamine to relieve cough. The ACCP also recommends against OTC cold and cough medicine for children ages 14 years and younger. Parents should talk with their child’s pediatrician for advice on treating cough.

Antibiotics for Acute 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.

• A major analysis reported that antibiotics helped only 1 child out of 8 who had persistent nasal discharge for at least 20 days. Even when they were helpful, benefits were modest in reducing duration of the infection. No long-term benefits have been reported. This study backed up a number of small studies that have found no significant benefit from antibiotics for most children. In a 2001 study, for example, 87% of children improved regardless of their treatment.
• Although antibiotics may prevent complications and reduce the risk of recurrent or chronic sinusitis, few well-conducted studies have been performed to confirm or refute their benefits in most cases for which they are prescribed.

The intense and widespread use of antibiotics--not only for sinusitis but also for other upper respiratory tract infections--is leading to a serious global problem, which is bacterial resistance to common antibiotics. For example, according to reports in 2002 and 2001, in Canada 15% of S. pneumoniae strains are resistant to penicillin; in the U.S. 30 - 40% are resistant; in Hong Kong 70 - 80% of strains no longer respond to penicillin. Furthermore, in the U.S. about 23% of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions with the highest rate of resistance are those in which antibiotics are the most heavily prescribed. Encouraging studies are now reporting that inappropriate antibiotic prescriptions are on the decline.

When to Use Antibiotics. Because the majority of sinusitis cases resolve on their own, doctors generally wait 10-14 days before prescribing antibiotics. However, antibiotics may be prescribed sooner if severe symptoms develop. These symptoms include:

• Fever
• Facial pain or tenderness
• Swelling around the eyes

Antibiotic Regimens

• The standard first-line antibiotic treatment for acute bacterial sinusitis is a 10-14 day course of amoxicillin. Trimethoprim-sulfamethoxazole is an alternative choice.
• If no change occurs within 3-5 days, 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, broad-spectrum antibiotics such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime may be used. 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.

Intranasal Nebulized Antibiotics

In 2003, research by scientists at Stanford University suggested that delivering medications directly to the sinus passages (instead of the bloodstream, like a pill might) significantly increases the amount of time chronic sinusitis patients remain infection free. The treatment, called nebulized antibiotic therapy, requires that patients inhale antibiotics in mist form to topically treat their sinusitis. The study, published in the journal of Otolaryngology - Head and Neck Surgery showed that nebulization therapy increased the infection free period for some patients by almost 300% when compared to other treatments.

Emergency Treatment

Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull require 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 oxygen administered at high pressure (hyperbaric oxygen) is showing promise as additional therapy for potentially deadly fungal infections.