eMedicine Specialties > Infectious Diseases > HEENT Infections
Sinusitis, Chronic: Treatment & Medication
Updated: Jun 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Medical therapy is often considered an adjunct to surgical treatment and is directed toward controlling predisposing factors, treating concomitant infections, reducing edema of sinus tissues, and facilitating the drainage of sinus secretions. The role of bacteria in the pathogenesis of chronic sinusitis remains debatable; however, an early diagnosis and intensive treatment with oral antibiotics, topical nasal steroids, decongestants, and saline nasal sprays results in symptom relief in a significant number of patients, many of whom can be cured. When medical therapy is unsuccessful, refer the patient for surgical evaluation.
- Control of predisposing factors: Because chronic sinusitis has many risk factors and potential etiologies, apply a combined approach to control or modify these factors in the management of chronic sinusitis.
- Viral upper respiratory tract infections: Reduce viral exposures by improved personal hygiene. The roles of zinc and vitamin C in the prevention of viral upper respiratory tract infection are controversial. On June 16, 2009, the US Food and Drug Administration (FDA) issued a public health advisory and notified consumers and health care providers to discontinue the use of intranasal zinc products.4 The intranasal zinc products (Zicam Nasal Gel/Nasal Swab; Matrixx Initiatives) are herbal cold remedies that claim to reduce the duration and severity of cold symptoms and are sold without a prescription. The FDA received more than 130 reports of anosmia (ie, an inability to detect odors) associated with intranasal zinc. Many of the reports described the loss of smell with the first dose.
- Environmental factors: Reduce exposure to dust, molds, cigarette smoke, and other environmental chemical irritants.
- Allergic rhinitis: Environmental control, antihistamines, cromolyn, topical steroids, or immunotherapy may be necessary.
- Patients with adult chronic sinusitis may benefit from control of GERD, which has increasingly been implicated in causing or exacerbating respiratory ailments such as asthma and chronic sinusitis. The exact relationships and mechanisms are presently a matter of speculation.
- Immunodeficiency states: Appropriate control of various congenital and acquired immunodeficiency states is necessary to cure chronic sinusitis.
- Symptomatic measures
- Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics. See the Medication section for further discussion.
- Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity.[#antimicrobials]
- The choice of antimicrobial therapy
- Oral antibiotic regimens are generally used to treat chronic sinusitis, since this condition is primarily treated in an outpatient setting. Antibiotic selection depends on several factors, including history of drug allergies, cost of therapy, and the likelihood of involvement by beta-lactamase–producing organisms and MRSA. In addition, if the patient has received antibiotics during the preceding 3 months, a different class of antibiotics should be used.
- Initial selection of the appropriate antimicrobial(s) is usually empiric. Sinus cultures are generally unnecessary for community-acquired infections unless empiric therapy fails to elicit a response. The agent(s) chosen should be effective against the most likely bacterial etiologies, including both aerobic and anaerobic pathogens. If MRSA is a possible pathogen, coverage for this should be included.
- Therapeutic regimens include the combination of a penicillin (eg, amoxicillin) plus a beta-lactamase inhibitor (eg, clavulanic acid), clindamycin, a combination of metronidazole plus a macrolide or a second- or third-generation cephalosporin, and the newer quinolones (eg, moxifloxacin). All of these agents (or similar ones) are available in oral and parenteral forms. Other effective antimicrobials are available only in parenteral form (eg, cefoxitin, cefotetan). If aerobic gram-negative organisms (eg, P aeruginosa) are involved, parenteral therapy with an aminoglycoside, a fourth-generation cephalosporin (cefepime or ceftazidime), or oral or parenteral treatment with a fluoroquinolone (only in postpubertal patients) is added. Parenteral therapy with a carbapenem (ie, imipenem, meropenem) is more expensive but provides coverage for most potential pathogens, both anaerobes and aerobes.
- Clindamycin as initial therapy provides coverage for MRSA and is effective against anaerobes. Alternatives include trimethoprim-sulfamethoxazole (TMP-SMX) or linezolid, which are added to other regimens that cover anaerobes. Parenteral antimicrobials effective against MRSA include vancomycin, linezolid, and daptomycin.
Surgical Care
Recent advances in endoscopic technology and a better understanding of the importance of the ostiomeatal complex in the pathophysiology of sinusitis have led to the establishment of functional endoscopic sinus surgery (FESS) as the surgical procedure of choice for the treatment of chronic sinusitis. FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by establishing patency of the ostiomeatal complex, and causes less damage to normal nasal functioning. FESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80-90% of patients. Supportive medical treatment is instituted preoperatively and postoperatively. In children, surgical management is not as well established and should be reserved for complicated cases.
- Fungal sinusitis: Fungal sinusitis can manifest in different ways.1
- Acute invasive fungal sinusitis is observed in patients who are immunosuppressed or who have diabetes and is usually caused by members of the genera Aspergillus, Mucor, and Rhizopus. This condition requires urgent workup and aggressive medical and surgical therapy. Mortality rates associated with acute invasive fungal sinusitis are very high.
- Chronic fungal sinusitis is usually observed in immunocompetent patients. Surgical debridement is the preferred treatment.
- Mycetomas or fungus balls may be asymptomatic or may manifest as chronic sinusitis. Surgical removal is the preferred treatment.
- Allergic fungal sinusitis usually manifests as nasal polyps and allergic sinusitis. Fungal elements in the sinuses are the inciting allergens. Treatment consists of systemic steroids and surgical removal of polyps and mucinous secretions.
Consultations
- Persistent or recurrent episodes of sinusitis despite appropriate medical therapy necessitate referral to an otolaryngologist. Examination, including nasal endoscopy and CT scanning, is mandatory to exclude surgically amenable conditions.
- Seek consultation with an ophthalmologist at the earliest suggestion of orbital involvement.
- Seek consultation with a dentist when an odontogenic infection is present or suspected.
Medication
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
Antibiotics
Many antibiotics have been used in the treatment of chronic sinusitis; the most common ones are presented below. Ideally, direct antibiotics against the organism obtained from endoscopic sampling and based on microbial sensitivity testing. If the patient is ill, empiric antimicrobial therapy may be indicated, which should be comprehensive and cover all likely pathogens in the context of the clinical setting. Duration of antibiotics is not well established. An initial 2- to 4-week trial of antibiotics may be reasonable. A longer duration (up to 12 mo) may be needed in some cases. After surgical management for uncomplicated chronic sinusitis is completed, antibiotics are of unclear benefit. Invasion of bone or deep structures may require a prolonged antibiotic course.
Vancomycin (Lyphocin, Vancocin, Vancoled)
Indicated for patients who have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment. Used in conjunction with gentamicin for prophylaxis in patients with penicillin allergy who are undergoing gastrointestinal or genitourinary procedures.
Adult
1 g or 15 mg/kg IV q12h
Pediatric
30-40 mg/kg/d IV in 2 doses
Erythema, histaminelike flushing, and anaphylactic reactions may occur following administration of anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Moxifloxacin (Avelox)
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
400 mg PO/IV qd
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia
Documented hypersensitivity; known QT prolongation; concurrent administration of drugs that cause QT prolongation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in CNS disorders and caused tendinitis or tendon rupture
Clindamycin (Cleocin)
Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Adult
150-450 mg PO q6h with full glass of water
Pediatric
Children <10 kg: 8-20 mg/kg/d PO; equally divided q6-8h; dosage administered depends on severity of the infection; oral dosage (clindamycin palmitate hydrochloride oral granules)
Children >10 kg: 37.5 mg PO tid should be considered the minimum dose
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except C difficile enterocolitis).
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose: 6 h following loading dose; infuse 7.5 mg/kg IV or 500 mg for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d
Pediatric
Administer as in adults based on body weight
May increase toxicity of anticoagulants, cyclosporine, lithium, phenytoin, tacrolimus, and carbamazepine; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol; coadministration increases amiodarone toxicity (QT prolongation); increases disulfiram toxicity (psychotic symptoms) with concurrent use; phenobarbital and rifampin may increase metabolism of metronidazole
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution with liver impairment; blood dyscrasias; CNS disease; reduce dosage in severe hepatic disease; monitor for seizures and development of peripheral neuropathy
Amoxicillin (Amoxil, Trimox, Biomox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
500 mg to 1 g PO q8h
Pediatric
40-45 mg/kg/d PO q8h divided
Reduces efficacy of oral contraceptives; increased amoxicillin levels with disulfiram and probenecid
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Skin rash in patients with infectious mononucleosis; potential superinfections with mycotic and bacterial pathogens; adjust dose in renal impairment
Amoxicillin and clavulanate (Augmentin)
Drug combination treats bacteria resistant to beta-lactam antibiotics.
Adult
500 mg PO q8h or 875 mg PO q12h
Pediatric
<3 months: 30 mg/kg/d PO q12h divided ; base dosing protocol on amoxicillin content
>3 months: 40-50 mg/kg/d PO divided q8-12h
Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity; history of amoxicillin/clavulanate-associated cholestatic jaundice/hepatic dysfunction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Skin rash in patients with infectious mononucleosis; potential superinfections with mycotic and bacterial pathogens; adjust dose in renal impairment; periodically monitor renal, hepatic, and hemopoietic functions during prolonged therapy
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
500 mg PO q12h
Pediatric
7.5 mg/kg PO q12h
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide, cisapride, and pimozide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration with cisapride or pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency; drug interactions and teratogenicity are important considerations; occasionally hepatotoxic; coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Cefuroxime (Ceftin)
Second-generation cephalosporin that maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.
Adult
500 mg PO bid
Pediatric
125-250 mg PO (tab) bid; alternatively, 20-30 mg/kg/d PO (susp) divided bid
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increases nephrotoxic potential; probenecid increases level of this group of drugs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer one half dose if CrCl is 10-30 mL/min and one quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy; 10% of patients who are allergic to penicillin may show cross-hypersensitivity
Cefixime (Suprax)
Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more of the penicillin-binding proteins.
Adult
400 mg/d PO or divided q12h
Pediatric
<12 years: 8 mg/kg/d PO or 4 mg/kg/d PO bid
>12 years or >50 kg: Administer as in adults
Coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects; carbamazepine levels may be increased
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Superinfections possible during prolonged therapy; adjust dose in renal insufficiency
Levofloxacin (Levaquin)
Inhibits bacterial topoisomeraseIV and DNA gyrase, which are required for bacterial DNA replication and transcription.
Adult
500 mg PO qd
Pediatric
Not recommended for children <18 y
Enhances effects of warfarin; increased levels of theophylline may occur; increased risk of CNS stimulation when used with NSAIDs
Documented hypersensitivity to fluoroquinolones
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid if allergic to other quinolones
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. One double-strength tab contains trimethoprim (TMP) 160 mg and sulfamethoxazole (SMX) 800 mg
Adult
1 DS tab PO q12h
Pediatric
8 mg/kg/d TMP and 40 mg/kg/d SMX PO q12h divided
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of MTX in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; term pregnancy; breastfeeding women and infants <2 mo because of possibility of development of kernicterus
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, patients with chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in individuals who are G-6-PD deficient; patients with AIDS may not tolerate or respond to TMP-SMX; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Decongestants, topical
These agents are alpha-adrenergic agonists that act by constricting dilated mucosal vessels. Topical preparations of oxymetazoline, naphazoline, tetrahydrozoline, and xylometazoline are available. Use all adrenergic topical preparations with caution in young patients and the elderly population. Topical agents can produce rebound vasodilation on discontinuation and rhinitis medicamentosa on prolonged use. Both of these adverse effects respond well to topical steroids.
Oxymetazoline (Afrin)
Applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.
Adult
Available in 0.05% nasal solution; 2-3 gtt each nostril q12h; generally, use for no longer than 5 d
Pediatric
<6 years: Not recommended
>6 years: 1-2 gtt q12h for 3-5 d
Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa may result in increased vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents such as ephedrine may be increased; guanethidine potentiates effects of epinephrine and inhibits effects of ephedrine; phenothiazines may reverse action of nasal decongestants such as oxymetazoline; TCAs potentiate vasopressor response and may result in dysrhythmias
Documented hypersensitivity; MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, patients who are hypertensive may experience change in blood pressure; do not use topical decongestants for longer than 3-5 d
Naphazoline (Privine)
Alpha-adrenergic effects on arterioles of conjunctiva and nasal mucosa produce vasoconstriction.
Adult
2 gtt of 0.05% nasal solution in each nostril q3-6h; generally, not to exceed 3-5 d
Pediatric
<6 years: Not recommended
6-12 years: Administer 1-2 gtt of 0.025% solution; do not use for more than 3-5 d
>12 years: Administer as in adults
Risk of hypertensive reactions increases when used concurrently with TCAs or MAOIs; toxicity increases when used concurrently with anesthetics
Documented hypersensitivity; narrow-angle glaucoma; do not use before a peripheral iridectomy is performed
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may cause rebound congestion; caution in patients with diabetes, hypertension, heart disease, cerebral arteriosclerosis, hyperthyroidism, and asthma
Tetrahydrozoline (Tyzine, Visine)
Alpha-adrenergic effects on nasal mucosa produce vasoconstriction.
Adult
2-4 gtt of 0.1% nasal solution in each nostril q4-6h; do not use longer than 3-5 d
Pediatric
<2 years: Not recommended
2-6 years: May administer 2-3 gtt of 0.05% nasal solution in each nostril q4-6h, not to exceed 3-5 d
>6 years: Administer as in adults
Risk of hypertensive reactions increases when used concurrently with TCAs or MAOIs
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may cause rebound congestion; caution in patients with diabetes, hypertension, heart disease, cerebral arteriosclerosis, hyperthyroidism, and asthma
Xylometazoline (Otrivin)
Applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction.
Adult
2-3 gtt of 0.1% nasal solution in each nostril q8-10h; generally, do not use for longer than 3-5 d
Pediatric
<2 years: Use only under direct supervision of physician
2-12 years: 2-3 gtt of 0.05% nasal solution q8-10h
>12 years: Administer as in adults; duration of treatment generally not to exceed 5 d
Risk of hypertensive reactions increases when used concurrently with TCAs or MAOIs; toxicity increases when used concurrently with anesthetics
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may cause rebound congestion; caution in patients with diabetes, hypertension, heart disease, cerebral arteriosclerosis, hyperthyroidism, and asthma
Corticosteroids, topical
These agents are particularly effective for chronic sinusitis associated with allergic rhinitis, nasal polyps, and rhinitis medicamentosa. Topical steroids along with systemic antibiotics are now the key components of the medical armamentarium in the management of chronic sinusitis.
Fluticasone propionate (Flonase)
Applied as nasal spray. Particularly effective in allergic and vasomotor rhinosinusitis and rhinosinusitis medicamentosa. Used as prophylaxis for nasal polyps. Plasma concentrations very low following intranasal administration in recommended doses.
Adult
50 mcg/spray; 2 sprays in each nostril qd or 1 spray in each nostril bid; not to exceed total dose of 200 mcg/d
Pediatric
<12 years: Not recommended
>12 years: 1 spray (50 mcg) in each nostril qd
None reported; concomitant use with other inhaled and/or systemically absorbed corticosteroids can increase risk of hypercorticism and/or suppression of HPA
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Epistaxis or sensations of nasal burnings may occur; local candidal infections of nasopharynx have been reported with topical steroid use; always consider potential risk of suppression of HPA when using large dose for prolonged periods; rare cases of cataract, glaucoma, and increased intraocular pressure have been reported following intranasal use of corticosteroids; concomitant use of intranasal corticosteroids and other inhaled and/or systemically absorbed corticosteroids may cause hypercorticism and/or HPA suppression; if exposed to measles or chickenpox, consider prophylactic therapy
Beclomethasone dipropionate (Beconase AQ)
Topical steroid nasal spray. Acts locally as anti-inflammatory and vasoconstrictor. Readily absorbed through nasopharyngeal mucosa and GI tract. Useful in allergic and vasomotor rhinosinusitis and sinusitis medicamentosa.
Adult
42 mcg/spray; 1 spray in each nostril bid/tid/qid
Pediatric
<6 years: Not recommended
6-12 years: 1 spray in each nostril tid
>12 years: Administer as in adults
None reported; concomitant use with other inhaled and/or systemically absorbed corticosteroids can increase risk of hypercorticism and/or suppression of HPA
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Always consider potential risk of suppression of HPA when using large dose for prolonged periods; rare cases of cataract, glaucoma, and increased intraocular pressure have been reported following intranasal use of corticosteroids; concomitant use of intranasal corticosteroids and other inhaled and/or systemically absorbed corticosteroids may cause hypercorticism and/or HPA suppression; if exposed to measles or chickenpox, consider prophylactic therapy
Nasal sprays
Nasal saline spray and steam inhalation help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. Symptomatic relief gained in some patients can be substantial; moreover, these are benign modalities of therapy.
Saline nasal spray (Ayr, Ocean)
Loosens mucous secretions to help remove mucus from nose and sinuses.
Adult
0.65% buffered isotonic sodium chloride nasal solution, 1-2 sprays or gtt in each nostril
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
None reported
Mast cell stabilizers
These agents may be helpful in chronic sinusitis associated with allergic rhinitis.
Cromolyn sodium (Nasalcrom)
Inhibits degranulation of sensitized mast cells following their exposure to specific antigens.
Adult
5.2 mg/spray; 1 spray in each nostril q4-6h; begin 1-2 wk before exposure to known allergen
Pediatric
<6 years: Not recommended
>6 years: 1 spray of 5.2 mg q6h
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment; symptoms may reoccur when withdrawing drug
Expectorants
Although no controlled studies on the efficacy of mucolytics in chronic sinusitis are available, guaifenesin (mucolytic agent) may be helpful in ameliorating some symptoms.
Guaifenesin (Humibid-LA)
Increases respiratory tract fluid secretions and helps to loosen phlegm and bronchial secretions. Indicated for patients with bronchiectasis complicated by tenacious mucous and/or mucous plugs.
Adult
600-mg sustained-release tab
1-2 tab PO q12h
Pediatric
<2 years: Not recommended
2-6 years: One-half tab PO q12h
6-12 years: 1 tab PO q12h
May increase renal clearance of urate and lower serum uric acid levels; may interfere with urine laboratory tests for 5-hydroxyindoleacetic acid and urine testing for catecholamines
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
When prescribing medication that may suppress cough, important to identify cause of cough so that suppression does not increase risk of clinical or physiologic complications
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| Differential Diagnoses & Workup: Sinusitis, Chronic |
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Further Reading
Keywords
chronic sinusitis, acute sinusitis, sinus infection, paranasal sinus, postnasal drip, facial pain, hyposmia, rhinitis, fungal sinusitis, cystic fibrosis, CF, asthma, nasal polyps, allergy, allergies, gastroesophageal reflux disease, GERD, brain abscess, meningitis, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Moraxella catarrhalis, M catarrhalis, functional endoscopic sinus surgery, FESS
