eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases
Sinusitis, Chronic, Medical Treatment: Treatment & Medication
Updated: Nov 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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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.
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
Risk of bleeding increases when coadministered with warfarin or heparin, possibly because of additive effects
Documented hypersensitivity to Augmentin or penicillin.
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.
Adult
250-500 mg PO bid 10 d minimum
Pediatric
Suspension: 20-30 mg/kg/d PO bid 10 d minimum
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
Documented hypersensitivity to product
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.
Adult
250-500 mg PO bid 10 d minimum
Pediatric
15 mg/kg/d PO divided bid 10 d minimum
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)
Documented hypersensitivity; patients taking 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
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.
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
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
Documented hypersensitivity; patients taking pimozide
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.
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)
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
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
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.
Adult
250-500 mg PO tid 10 d minimum
Pediatric
20-40 mg/kg/d PO divided tid 10 d minimum
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
Documented hypersensitivity
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.
Adult
100-400 mg PO bid
Pediatric
10/mg/kg PO divided bid
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
Documented hypersensitivity
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.
Adult
250-500 mg PO qd or divided bid
Pediatric
Not established
Probenecid increases effect; coadministration with furosemide and aminoglycosides increases nephrotoxic effects
Documented hypersensitivity
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.
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
Propranolol, MAOIs and sympathomimetic agents may increase toxicity; methyldopa and reserpine may reduce effects
Documented hypersensitivity; methyldopa and reserpine may reduce effects; coadministration with MAOIs may increase blood pressure
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.
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
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
Documented hypersensitivity, MAOI therapy
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.
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
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
Documented hypersensitivity, severe hypertension, ventricular tachycardia
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
More on Sinusitis, Chronic, Medical Treatment |
| Overview: Sinusitis, Chronic, Medical Treatment |
| Differential Diagnoses & Workup: Sinusitis, Chronic, Medical Treatment |
 Treatment & Medication: Sinusitis, Chronic, Medical Treatment |
| Follow-up: Sinusitis, Chronic, Medical Treatment |
| Multimedia: Sinusitis, Chronic, Medical Treatment |
| References |
| Further Reading |
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References
Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg. Sep 2007;137(3):365-77. [Medline].
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Benninger MS, Payne SC, Ferguson BJ, et al. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg. Jan 2006;134(1):3-9. [Medline].
Ponikau JU, Sherris DA, Weaver A, et al. Treatment of chronic rhinosinusitis with intranasal amphotericin B: a randomized, placebo-controlled, double-blind pilot trial. J Allergy Clin Immunol. Jan 2005;115(1):125-31. [Medline].
Bhattacharyya N. Radiographic stage fails to predict symptom outcomes after endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. Jan 2006;116(1):18-22. [Medline].
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Lund VJ. Maximal medical therapy for chronic rhinosinusitis. Otolaryngol Clin North Am. Dec 2005;38(6):1301-10, x. [Medline].
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Witsell DL, Stewart MG, Monsell EM, et al. The Cooperative Outcomes Group for ENT: a multicenter prospective cohort study on the effectiveness of medical and surgical treatment for patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg. Feb 2005;132(2):171-9. [Medline].
Further Reading
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.
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
