eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Chronic, Medical Treatment

Seth M Brown, MD, MBA, Assistant Clinical Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut School of Medicine; Director, The Connecticut Sinus Institute
Marvin P Fried, MD, FACS, Professor and University Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine; Babak Sadoughi, MD, Resident Physician, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine; Osama A Abdel Razek, MB, BCh, MSc, Research Fellow, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard University Medical School; Dennis Poe, MD, Clinical Assistant Professor, Departments of Otology and Laryngology, Harvard University Medical Center, Boston University School of Medicine

Updated: Nov 17, 2009

Introduction

Background

Chronic sinusitis is an inflammatory process that involves the paranasal sinuses and persists for 12 weeks or longer. Recently, literature has supported that chronic sinusitis is almost always accompanied by concurrent nasal airway inflammation and is often preceded by rhinitis symptoms; thus, the term chronic rhinosinusitis (CRS) has evolved to more accurately describe this condition. The latest executive summary published in Otolaryngology - Head and Neck Surgery on adult sinusitis (2007) has altered the definition for chronic rhinosinusitis (CRS) to read: 12 weeks or longer of two or more of the following symptoms:

• Anterior or posterior mucopurulent drainage
• Nasal obstruction
• Facial-pain-pressure-fullness
• Decreased sense of smell

In addition, inflammation must be documented by demonstrating either:

• Purulent mucus or edema in the middle meatus or ethmoid region
• Polyps in the nasal cavity or middle meatus
• Imaging showing inflammation of the paranasal sinuses

This is in contrast to recurrent acute sinusitis, which is present when 4 or more episodes per year of acute bacterial rhinosinusitis without signs and symptoms of rhinosinusitis between episodes.¹

Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.

Pathophysiology

The pathophysiology of this disorder is poorly defined. Current thinking supports that chronic rhinosinusitis (CRS) is predominantly an inflammatory disease. Confounding factors that may contribute to inflammation include the following:

• Persistent infection (including biofilms and osteitis)
• Allergy and other immunologic disorders
• Intrinsic factors of the upper airway
• Superantigens
• Colonizing fungi that induce and sustain eosinophilic inflammation
• Metabolic abnormalities such as aspirin sensitivity

All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary function, or the quality of secretions leads to stagnation of secretions, decreased pH levels, and lowered oxygen tension within the sinus. These changes create a favorable environment for bacterial growth that, in turn, further contribute to increased mucosal inflammation.

Frequency

United States

The overall prevalence of chronic rhinosinusitis (CRS) in the United States is 146 per 1000 population. This involves nearly 30 million US adults yearly, making chronic rhinosinusitis (CRS) more common than any other chronic condition. For unknown reasons, the incidence of this disease appears to be increasing yearly. This results in a conservative estimate of 18-22 million physician visits in the United States each year and a direct treatment cost of $3.4-5 billion annually.

Mortality/Morbidity

Chronic sinusitis is rarely life-threatening, although serious complications can occur because of the proximity to the orbit and cranial cavity.

• Approximately 75% of all orbital infections are directly related to sinusitis.
• Intracranial complications remain comparatively rare, with 3.7-10% of intracranial infections related to sinusitis.

Age

Rhinosinusitis is more common in the pediatric population because this term includes both acute and chronic infection and both viral and bacterial disease. This is likely secondary to an increased frequency of exposure to upper respiratory tract infections in the pediatric population.

Clinical

History

Patient history is extremely important in chronic rhinosinusitis (CRS) because of the broad overlap between sinus symptoms and other disease processes, as well as poor correlation between symptoms and endoscopic and radiographic findings. Consequently, a number of key factors in the patient's history should be discerned. They are as follows:

• The presence of major symptoms (including purulent anterior nasal drainage, purulent-discolored posterior nasal drainage, nasal obstruction or blockage, facial congestion or fullness, facial pain or pressure, and hyposmia or anosmia)
• The presence of minor symptoms (including headache, ear pain or fullness, halitosis, dental pain, cough, fever, fatigue)
• Duration of symptoms
• Exacerbating and relieving factors
• History of previous nasal or paranasal sinus surgery
• Current medications
• Previous treatments and their duration
• Other confounding health problems (including asthma, allergy, and immunocompromising disorders)
• Active or passive tobacco smoke

Physical

The physical examination should include a complete head and neck examination to confirm the diagnosis and to rule out more serious disorders.

• Anterior rhinoscopy, with the use of a nasal speculum, to evaluate the condition of the nasal mucosa and to look for purulent drainage or evidence of polyps or other nasal masses (Other contributing factors to CRS that can be evaluated are nasal septal deviation and turbinate hypertrophy. The nasal examination should be carried out both before and after the use of a topical decongestant. If available, this portion of the examination can be supplemented with the use of nasal endoscopy.)
• Ear examination for the presence of middle ear fluid that may be the sign of a mass in the nasopharynx
• Neck examination for lymphadenopathy
• Cranial nerve examination for underlying sinus malignancy or neurological disorder
• Oral cavity and oropharynx examination to evaluate the integrity of the palate, the condition of dentition, and to look for evidence of postnasal drip
• Sinus palpation for evaluation of tenderness or swelling
• Ocular examination for spread of disease to the orbit and function of ocular musculature
• Laryngeal examination to look for other confounding upper airway pathology including laryngeal-pharyngeal reflux (LPR)
• Lung examination to determine if co-existing lower airway disease is present

Causes

A number of factors often contribute to the inflammatory process that causes chronic rhinosinusitis (CRS). Please see Pathophysiology for a discussion on etiology.

• Any disease process or toxin that affects cilia has a negative effect on chronic rhinosinusitis (CRS).
• The bacteria presumed to be involved in chronic rhinosinusitis (CRS) differ from those in acute rhinosinusitis. Those most commonly isolated in chronic rhinosinusitis (CRS) include Staphylococcus aureus, coagulase-negative Staphylococcus, anaerobic bacteria, and gram-negative bacteria.
• The reflux of gastric contents may play a contributing role in some cases of chronic rhinosinusitis (CRS). This relationship still needs to be better defined.

Differential Diagnoses

Other Problems to Be Considered

Nasal polyposis
Antral-choanal polyp
Inverting papilloma
Dental abscess
Aspirin/nonsteroidal anti-inflammatory drug sensitivity
Chronic headache of other etiology

Workup

Laboratory Studies

• Nasal swab and culture may help in selecting the proper antibiotic.
• Radioallergosorbent assay test (RAST) or skin testing for allergens may play an important role in treating patients with chronic rhinosinusitis (CRS) and confounding allergies.
• A sweat test for cystic fibrosis should be considered in all children with nasal polyposis and chronic rhinosinusitis (CRS).
• Evaluation of cilia function with a brush biopsy or turbinate biopsy can be considered in cases of presumed cilia dysfunction.
• Total immunoglobulin E (IgE) levels as well as the degree of staining of IgE in sinus epithelium and subepithelium can be tested and may be helpful to evaluate for allergic fungal sinusitis.²

Imaging Studies

• Plain radiographs do not have a role in chronic rhinosinusitis (CRS). Today, the clinical role of plain films is limited to documentation of acute maxillary or frontal sinusitis.
• A noncontrast, dedicated sinus CT scan is the current criterion standard to identify and evaluate the details of sinus anatomy and pathology. This modality provides 2.5- to 3-mm cuts or smaller through the paranasal sinuses in both the axial and coronal planes.
• Contrast can be added to a sinus CT scan in the case of acute infection with presumed spread beyond the paranasal sinuses (to the orbit or brain).
• For patients with a history of previous sinus surgery, a CT scan with an image-guided protocol may assist the surgeon intraoperatively if the patient requires further surgical intervention.
• An MRI is generally reserved for cases of paranasal sinus tumors or cases with orbital and cranial base involvement.
• Ultrasonography provides variable results and is not recommended.

Other Tests

• Transillumination lacks sensitivity but may have value in experienced hands.
• Nasal endoscopy is recommended in most cases prior to obtaining imaging because it demonstrates the condition of the nasal mucosa and evaluates for purulent drainage.

Procedures

• Traditionally, maxillary sinus tap via inferior meatal puncture was performed for sinus culture.
• Many otolaryngologists have moved away from maxillary sinus tap because of the discomfort of the procedure and the understanding that a culture of an organism from the middle meatus may be more accurate to determine the bacteria involved in the disease process.
• Recent literature has supported the use of endoscopically directed culture of the middle meatus (the primary drainage system of the anterior ethmoid, maxillary, and frontal sinuses) with the use of either a suction trap or a swab.
• Endoscopically directed middle meatal cultures have a sensitivity of 80.9% and specificity of 90.5% in a recent meta-analysis.³
• Calcium-alginate tipped applicators are a readily available device that can be used to obtain a culture.

Histologic Findings

Biopsy samples from the maxillary sinus mucosa of patients with chronic sinusitis show basement membrane thickening, atypical gland formation, goblet cell hyperplasia, mononuclear cell infiltration, and subepithelial edema. The mononuclear cell infiltrate often predominantly demonstrates neutrophils in acute disease and eosinophils in chronic disease. Rarely, squamous cell metaplasia may be seen.

Staging

Various staging systems have been proposed; however, no one system is accepted as the standard for use in chronic rhinosinusitis (CRS). Many studies use the Lund-Mackay scale to evaluate radiographic images. This scale grades the right and left sides independently, looking at the maxillary, anterior ethmoids, posterior ethmoids, sphenoid, and frontal sinuses, as well as the ostiomeatal complex. Each sinus is scored a 0 (no abnormality), 1 (partial opacification), or 2 (total opacification), while the ostiomeatal complex is scored either a 0 or 2 (for presence or absence of disease). Scores range from 0-24.

Treatment

Medical Care

No one treatment regimen exists in chronic rhinosinusitis (CRS). However, the principles involved in the treatment of chronic rhinosinusitis (CRS) consist of identifying and treating the underlying causes and confounding variables.

• An adequate antibiotic trial in chronic rhinosinusitis (CRS) usually consists of a minimum of 3-4 weeks of treatment, preferably culture directed.
• Other therapeutic entities used include intranasal corticosteroids, saline irrigations, short courses of oral steroids, decongestants, topical vasoconstrictors, and mucolytics.
• For patients with confounding nasal allergy, other antiallergy therapies, including either oral or topical antihistamines and immunotherapy, may play an important role.
• Especially for patients with co-existing asthma, leukotriene inhibitors may play a role.
• Some literature has suggested that topical antifungals may have a role in the treatment of chronic rhinosinusitis (CRS);⁴ however, this treatment remains controversial, and recent studies have not supported this treatment.
• 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.
• For resistant cases there may be a role for intravenous antibiotic therapy.

Surgical Care

• Surgical care should be used as an adjunct to medical treatment in most 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.⁵
• 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.

Consultations

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 with co-existing morbidities that are exacerbated by the sinus disease.

Diet

• 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.

Medication

The goals of pharmacotherapy are to reduce morbidity, improve symptoms, and to prevent complications.

Antibiotics

Management of sinusitis usually includes an oral antibiotic. Criteria of antibiotic selection include (1) culture-directed when possible; (2) knowledge of changing antimicrobial resistance in a community; (3) history of medication allergy, especially the sulfa drugs and penicillins; (4) adverse effect profile of the medication; (5) cost of the medication and the economic status of the patient; and (6) other factors that affect compliance, such as dosing and formulation.

Currently, first-line antibiotics for patients with chronic sinusitis include amoxicillin-clavulanate, second-generation cephalosporins, and erythromycin-sulfasoxazole. Beta-lactamase–mediated resistance to the early second-generation cephalosporins is high among strains of Haemophilus influenzae and Moraxella catarrhalis. Cefixime, a third-generation cephalosporin, may be selected for infections caused by H influenzae or M catarrhalis, but it has a poor spectrum of activity against Streptococcus pneumoniae. The newer-generation macrolides, clarithromycin and azithromycin, achieve excellent mucosal levels and should be considered in patients with penicillin allergies. Some recent studies suggest that macrolides may also have some anti-inflammatory effects. Clindamycin should be reserved for resistant S pneumoniae.

Amoxicillin clavulanate (Augmentin)

Extends the antibiotic spectrum of penicillin to include bacteria normally resistant to beta-lactam antibiotics; available in tabs, chewables, and susp. A newer extended-release product is available as amoxicillin 1000 mg and clavulanate 62.5 mg.

Dosing

Adult

875 mg PO bid 10 d minimum for regular product

Pediatric

45 mg/kg/d PO divided bid or 40 mg/kg/d divided tid 10 d minimum

Interactions

Risk of bleeding increases when coadministered with warfarin or heparin, possibly because of additive effects

Contraindications

Documented hypersensitivity to Augmentin or penicillin.

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform bacteriologic studies to determine causative organisms and susceptibility so that appropriate therapy is administered; use therapy for 3-4 wk in cases of real chronic sinusitis

Cefuroxime (Ceftin)

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; 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.

Dosing

Adult

250-500 mg PO bid 10 d minimum

Pediatric

Suspension: 20-30 mg/kg/d PO bid 10 d minimum

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h of administration; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity to product

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if CrCl 10-30 mL/min and quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Clarithromycin (Biaxin)

Reversibly binds to P site of 50S ribosomal subunit of susceptible organisms; may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl t-RNA from ribosomes.

Dosing

Adult

250-500 mg PO bid 10 d minimum

Pediatric

15 mg/kg/d PO divided bid 10 d minimum

Interactions

Coadministration with fluconazole may significantly increase levels; similarly, coadministration with pimozide may result in toxic levels and possibly death; conversely, antimicrobial effects may be decreased when taken concurrently with rifabutin or rifampin, while the frequency of adverse GI effects may be increased
Monitor anticoagulant function in patients receiving anticoagulants concurrently with any macrolide antibiotic
Adverse cardiovascular effects (eg, torsade de pointes, other ventricular effects) leading to cardiac arrest and reportedly death may occur when taken concurrently with astemizole
Plasma levels of certain benzodiazepines may increase, prolonging CNS depressant effects; carbamazepine concentrations may increase when taken concurrently
Serum digoxin concentrations may increase as a result of effects of antibiotic on gut flora that metabolize digoxin in more than 10% of patients; disopyramide plasma levels may increase when taken concurrently, causing arrhythmias and increasing QT intervals
Monitor patients receiving ergot alkaloids and any macrolide antibiotic; acute ergot toxicity characterized by severe peripheral vasospasm and dysesthesia may occur when taken concurrently
Risk of severe myopathy or rhabdomyolysis associated with HMG-CoA reductase inhibitors may be increased when taken concurrently
Coadministration with omeprazole may increase plasma levels of both drugs
Concurrent use of tacrolimus may be associated with elevated serum tacrolimus levels, increasing the risk of adverse effects (eg, nephrotoxicity)

Contraindications

Documented hypersensitivity; patients taking pimozide

Precautions

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

Clarithromycin in combination with ranitidine bismuth citrate therapy is not recommended in patients with CrCl <25 mL/min; patients with severe renal impairment (CrCl <30 mL/min) with or without coexisting hepatic impairment should receive half dose, but dosing interval may be doubled under these circumstances; consider the possibility of pseudomembranous colitis in patients who present with diarrhea subsequent to the administration of clarithromycin; risk of secondary infections present with prolonged or repeated antimicrobial therapy because it may result in bacterial or fungal overgrowth of nonsusceptible organisms; appropriate measures should be taken if superinfection occurs

Azithromycin (Zithromax)

Advanced-generation macrolide; works similarly to clarithromycin but with shorter dosage time.

Dosing

Adult

500 mg PO initially, then 250 mg PO for 4 d

Pediatric

<16 years: Not established; suggested dose is 10 mg/kg initially, followed by 5 mg/kg PO for 4 d

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; patients taking pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzyme levels and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Clindamycin (Cleocin)

Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, thus causing inhibition of bacterial growth.

Dosing

Adult

150-450 mg PO qid with a full glass of water 10 d minimum

Pediatric

Children 8-20 mg/kg/d PO divided tid/qid; dosage administered depends on severity of infection; oral dosage (clindamycin palmitate hydrochloride oral granules)

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity, regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Dose adjustment may be necessary in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; use has been associated with severe and possibly fatal colitis

Cefaclor (Ceclor)

Indicated for management of infections caused by susceptible mixed aerobic-anaerobic microorganisms.

Dosing

Adult

250-500 mg PO tid 10 d minimum

Pediatric

20-40 mg/kg/d PO divided tid 10 d minimum

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h of administration; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Give half dose if CrCl 10-30 mL/min and quarter dose if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Cefpodoxime (Vantin)

Indicated for management of infections caused by susceptible mixed aerobic-anaerobic microorganisms.

Dosing

Adult

100-400 mg PO bid

Pediatric

10/mg/kg PO divided bid

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h of administration; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Give half dose if CrCl 10-30 mL/min and quarter dose if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Cefprozil (Cefzil)

Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.

Dosing

Adult

250-500 mg PO qd or divided bid

Pediatric

Not established

Interactions

Probenecid increases effect; coadministration with furosemide and aminoglycosides increases nephrotoxic effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dosage in renal impairment

Decongestants

Goals include reduction of tissue edema, facilitation of drainage, and maintenance of patency of sinus ostia. In short, decongestants are necessary to meet the management goals for chronic sinusitis. Decongestants are available in 2 forms, topical and oral. Each agent differs slightly in its method of action.

Topical agents are locally active vasoconstrictor agents such as phenylephrine HCl 0.5% and oxymetazoline HCl 0.5% that provide almost immediate symptomatic relief by shrinking the inflamed and swollen nasal mucosa. Topical nasal formulations should not be used for longer than 3-5 consecutive days because of the risk of development of tolerance, rhinitis medicamentosa, and rebound after drug withdrawal.

Oral systemic agents are used when decongestion is necessary for longer than 3 days. An oral systemic agent, such as phenylpropanolamine (recalled from US market) or pseudoephedrine, is preferred. Oral decongestants are alpha-adrenergic agonists that reduce nasal blood flow. Theoretically, these oral systemic agents have the potential to act on tissues deep in the ostiomeatal complex, where topical agents may not penetrate effectively.

Pseudoephedrine (Sudafed)

Stimulates vasoconstriction by directly activating the alpha-adrenergic receptors of the respiratory mucosa; induces bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors; available in tabs, chewables, solution, extended-release tabs, and infant drops.

Dosing

Adult

60 mg PO q4-6h; 120-mg SR q12h; not to exceed 240 mg/d

Pediatric

3-12 months: 3 gtt/kg PO q4-6h; not to exceed 4 doses/d
1-2 years: 7 gtt (0.2 mL)/kg PO q4-6h; not to exceed 4 doses/d
2-5 years: 15 mg PO q4-6h; not to exceed 60 mg/d
>5 years: 30 mg PO q4-6h; not to exceed 120 mg/d

Interactions

Propranolol, MAOIs and sympathomimetic agents may increase toxicity; methyldopa and reserpine may reduce effects

Contraindications

Documented hypersensitivity; methyldopa and reserpine may reduce effects; coadministration with MAOIs may increase blood pressure

Precautions

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

Exercise caution in cardiovascular disease, diabetes mellitus, prostatic hypertrophy, and increased intraocular pressure

Oxymetazoline HCl 0.5% (Afrin)

Stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Also induces bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors. Provides almost immediate symptomatic relief by shrinking inflamed and swollen nasal mucosa.

Dosing

Adult

2-3 sprays or 2-3 gtt each nostril bid

Pediatric

<6 years: 2-3 gtt of 0.025% solution each nostril bid
>6 years: Administer as in adults

Interactions

Hypotensive action of guanethidine may be reversed; coadministration with methyldopa may increase vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents (eg, ephedrine) may be increased; guanethidine potentiates effects of epinephrine and inhibits effects of ephedrine; phenothiazines may reverse action of nasal decongestants (eg, oxymetazoline); TCAs potentiate vasopressor response and may result in dysrhythmias

Contraindications

Documented hypersensitivity, MAOI therapy

Precautions

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

Exercise caution in patients with hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, hypertensive patients may experience a change in blood pressure; do not use topical decongestants for longer than 3-5 d

Phenylephrine HCl (Neo-Synephrine)

Synthetic sympathomimetic amine.

Dosing

Adult

Apply 2-3 gtt or sprays of 0.25-0.5% solution each nostril or small quantity of 0.5% nasal jelly applied into each nostril q4h prn; 1% solution may be used in adults with severe congestion

Pediatric

Infants > 6 months: 1-2 gtt 0.125% solution each nostril q4h
<6 years: 2-3 gtt or puffs 0.125% solution each nostril q4h prn
6-12 years: 2-3 gtt 0.25% solution each nostril q4h prn
>12 years: Administer as in adults

Interactions

Bretylium may potentiate action of vasopressors on adrenergic receptors, possibly resulting in arrhythmias; MAOIs may significantly enhance adrenergic effects, and its pressor response may be increased 2-3 times; guanethidine may increase pressor response of direct-acting vasopressors, possibly resulting in severe hypertension

Contraindications

Documented hypersensitivity, severe hypertension, ventricular tachycardia

Precautions

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 elderly patients and those with hyperthyroidism, myocardial disease, bradycardia, partial heart block, or severe arteriosclerosis

Follow-up

Further Inpatient Care

• Generally, chronic rhinosinusitis (CRS) can be treated on an outpatient basis. If intracranial or orbital complications are suggested, the patient should be admitted and properly investigated.

Further Outpatient Care

• 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.

Transfer

• Ophthalmology or neurosurgery consultation should be sought in those cases in which sinusitis has spread beyond the paranasal sinuses.
• Neurology consultation should be considered in cases of sinus symptoms without positive findings on CT to evaluate for migraine or other neurological causes for the patient's symptom.

Complications

• 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.
• Other complications include osteomyelitis or mucocele formation.

Patient Education

• Patients should be educated on the importance of smoking cessation because tobacco use has negative effects on sinus function as well as other negative health effects.
• For excellent patient education resources, see the eMedicine's patient article Sinus Infection.

Miscellaneous

Medicolegal Pitfalls

• Failure to identify and treat sinusitis in cases that progress to more serious infections beyond the paranasal sinuses
• Failure to consider malignancy, particularly in cases that are unilateral in nature or that demonstrate a nasal mass on examination or imaging

Special Concerns

• Rhinitis of pregnancy is an entity that should be entertained in women who present with sinus symptoms for the first time during pregnancy.
• Pediatric patients with chronic rhinosinusitis (CRS) and particularly with nasal polyps should be assessed for immunodeficiency, especially cystic fibrosis.

Multimedia

Media file 1: Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.

References

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Keywords

sinusitis, chronic sinusitis, chronic rhinosinusitis, recurrent sinusitis, chronic rhinitis, recurrent rhinitis, runny nose, sinus congestion, chronic congestion, chronic sinus congestion, recurrent sinus congestion, chronic cold, recurrent cold

Contributor Information and Disclosures

Author

Seth M Brown, MD, MBA, Assistant Clinical Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut School of Medicine; Director, The Connecticut Sinus Institute
Seth M Brown, MD, MBA is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic Society, and North American Skull Base Society
Disclosure: Nothing to disclose.

Coauthor(s)

Marvin P Fried, MD, FACS, Professor and University Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine
Marvin P Fried, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, American Society of Plastic and Reconstructive Surgery, Massachusetts Medical Society, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Entrigue Consulting fee Board membership

Babak Sadoughi, MD, Resident Physician, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine
Babak Sadoughi, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Osama A Abdel Razek, MB, BCh, MSc, Research Fellow, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard University Medical School
Disclosure: Nothing to disclose.

Dennis Poe, MD, Clinical Assistant Professor, Departments of Otology and Laryngology, Harvard University Medical Center, Boston University School of Medicine
Dennis Poe, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Otological Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons
Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

Clinical guidelines

Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC 3rd, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007 Sep;137(3 Suppl):S1-31. ¹

University of Michigan Health System. Acute rhinosinusitis in adults. Ann Arbor (MI): University of Michigan Health System; 2007 Mar. 8 p.

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