CHRONIC SINUSITIS

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. A recent multidisciplinary consensus statement on CRS supported that the definition of CRS requires 2 or more of the following symptoms: anterior or posterior mucopurulent drainage, nasal obstruction, or facial-pain-pressure-fullness. The definition of CRS also requires both endoscopy, to document the presence of inflammation, and evidence of rhinosinusitis on imaging.
Medical Care: No one treatment regimen exists in CRS. However, the principles involved in the treatment of CRS consist of identifying and treating the underlying causes and confounding variables.
• An adequate antibiotic trial in 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 antihistamines and immunotherapy, may play an important role.
• For patients with co-existing asthma, leukotriene inhibitors may play a role.
• Recent literature has suggested that topical antifungals may have a role in the treatment of CRS; however, this treatment remains controversial.
• 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.
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.
• 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.
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.
Drug Category: 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 pne
Drug Category: 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 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
Further Inpatient Care:
• Generally, 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 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.
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.