Chronic Sinusitis Treatment & Management

The goals of medical therapy for CRS are to reduce mucosal edema, promote sinus drainage, and eradicate infections that may be present. This often requires a combination of topical or oral glucocorticoids, antibiotics, and nasal irrigation. If these measures fail, the patient should be referred to an otolaryngologist for consideration of sinus surgery. 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.

Inpatient treatment of chronic sinusitis is indicated for patients with orbital and intracranial complications. Immunosuppressed patients and pediatric patients with chronic sinusitis may need inpatient care, depending on the severity of the disease.

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.^[24] 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 and allergic factors

Environmental factors and/or allergic factors may predispose some individuals to chronic sinusitis. Reduce exposure to dust, molds, cigarette smoke, and other environmental chemical irritants. For patients with confounding nasal allergy, other antiallergy therapies, including either oral or topical antihistamines, cromolyn, topical steroids, and immunotherapy, may reduce recurrences and symptoms of allergic rhinitis.

Smoking cessation likely plays a large role in the success of both medical and surgical treatments because tobacco products act as an irritant to normal nasal mucosa and cilia function.

Gastroesophageal reflux disease

Patients with adult chronic sinusitis may benefit from control of gastroesophageal reflux disease (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

Appropriate control of various congenital and acquired immunodeficiency states is necessary to cure chronic sinusitis.

Asthma

Especially for patients with co-existing asthma, leukotriene inhibitors may play a role.

Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics.

Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity.

Initial oral steroid therapy followed by topical steroid therapy was found to be more effective than topical steroid therapy alone in decreasing polyp size and improving olfaction in patients with chronic rhinosinusitis (CRS) with at least moderate nasal polyposis.^[25]

Catalano et al evaluated balloon dilation for the treatment of chronic frontal sinusitis in 20 patients with advanced sinus disease in whom medical therapy had failed and therefore required operative intervention. Preoperative and postoperative CT scans were compared. There were no significant complications from balloon dilation, and there was significant improvement in patients with certain subsets of CRS.^[26]

To see complete information on Balloon Sinuplasty, please go to the main article by clicking here.

An adequate antibiotic trial in CRS usually consists of a minimum of 3-4 weeks of treatment, preferably culture directed. Oral antibiotic regimens are generally used to treat chronic sinusitis, since this condition is primarily treated in an outpatient setting. For resistant cases, there may be a role for intravenous antibiotic therapy.

Initial choice of the appropriate antimicrobial(s) is usually empiric. Sinus cultures are not generally obtained 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. The likelihood of involvement by beta-lactamase–producing organisms should be considered. If methicillin-resistant Staphylococcus aureus (MRSA) is a possible pathogen, coverage for this should be included. History of drug allergies (if any) and cost of therapy should be taken into account as well. In addition, if the patient has received antibiotics during the preceding 3 months, a different class of antibiotics should be used.

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, Pseudomonas 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 or linezolid, which are added to other regimens that cover anaerobes. Parenteral antimicrobials effective against MRSA include vancomycin, linezolid, and daptomycin.

Ferguson et al performed a prospective observational study of 125 adults with classic symptoms of chronic rhinosinusitis who underwent nasal endoscopy and sinus CT. Severe symptoms occurred more often in younger patients with normal CT scans of the sinus than in those with positive CT findings. Improvement in response to antibiotics was similar for patients with positive CT findings and those with normal CT scans. The authors concluded that most symptoms considered to be typical for chronic rhinosinusitis proved to be nonspecific, and they suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if a prolonged course of antibiotics is being considered.^[27]

Surgical care is used as an adjunct to medical treatment in some cases. Surgical care is usually reserved for cases that are refractory to medical treatment and for patients with anatomic obstruction. Recent studies suggest that preoperative CT findings prior to sinus surgery may be poor predictors of surgical outcomes.^[28]

The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining.

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.^[29]

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.

For more information, see the Medscape Reference article Functional Endoscopic Sinus Surgery.

Three main surgical options are available for chronic maxillary sinusitis:

• Endoscopic uncinectomy with or without maxillary antrostomy
• Caldwell-Luc procedure
• Inferior antrostomy (naso-antral window)

The preferred treatment for chronic fungal sinusitis is surgical debridement. Mycetomas or fungus balls are best treated by means of surgical removal. Allergic fungal sinusitis, which usually manifests as nasal polyps and allergic sinusitis, is treated by means of systemic steroids and surgical removal of polyps and mucinous secretions.

Some literature has suggested that topical antifungals may have a role in the treatment of CRS^[30] ; however, this treatment remains controversial, and other studies have not supported this approach. A recent assessment that included 6 studies (N = 380) showed no statistically significant benefit of topical or systemic antifungals over placebo for the treatment of CRS.^[31]

Garlic has an active ingredient (allyl thiosulfinate) that provides a short-term decongestant effect. Eating foods highly seasoned with garlic has been considered therapeutic. Chewing horseradish root is another home remedy reported by some patients as effective for clearing the sinuses, but no scientific data support this belief.

The most common complication of chronic sinusitis is superimposed acute sinusitis. In children, the presence of pus in the nasopharynx may cause adenoiditis, and a high percentage of such patients develop secondary serous or purulent otitis media. Dacryocystitis and laryngitis may also occur as complications of chronic sinusitis in children.

Orbital complications include preseptal cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, and cavernous sinus thrombosis. Intracranial complications include meningitis, epidural abscess, subdural abscess, and brain abscess.^[18]

Other complications include osteomyelitis and mucocele formation.

Some studies have suggested a higher incidence of complications associated with fungal sinusitis.^{[32, 33]} Untreated chronic sinusitis can lead to life-threatening complications, as in patients with cystic fibrosis.^[34]

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.

A consult with an otolaryngologist should be considered when one of the following occurs:

• The disease is refractory to maximal medical therapy.
• The disease has progressed beyond the paranasal sinuses.
• The disease is unilateral (patient should be evaluated for potential neoplasm).
• Patients have coexisting morbidities that are exacerbated by the sinus disease.

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.

Continued outpatient medical treatment with nasal decongestants and topical steroids is important even after surgical treatment.

Nasal douching may improve symptoms, particularly following surgical treatment. Steam inhalation may have a role to liquefy and soften crusts while moisturizing dry inflamed mucosa.

Nasal cavity irrigation using buffered normal saline may have a role in decreasing mucosal edema. Irrigation should be performed at least twice daily.

Patients with presumed allergic rhinitis in conjunction with chronic sinusitis may benefit from an evaluation by an otolaryngologist trained in otolaryngic allergy or an allergist/immunologist. In most instances, prick/puncture tests are performed to clarify the role of allergies.