In addition to antibiotics, other therapies have been utilized in the management of bacterial sinusitis. These include topical and systemic decongestants, corticosteroids, antiinflammatory agents, mucolytic agents, humidification, antihistamines, nasal lavage or saline nasal spray, spicy food, and hot dry air.
Medical management of acute and chronic bacterial sinusitis | ||
Acute | Chronic | |
Antibiotics | 5–14 days | 3–6 weeks |
Decongestants | ||
Topical | < 5 days | < 5 days when needed |
Systemic | when needed | when needed |
Nasal corticosteroids | no* | yes |
Nasal lavage or saline spray | yes | yes |
Humidification (cool mist or steam) | yes | yes |
Hydration | yes | yes |
Mucolytic agents | when needed | yes |
Antihistamines | in allergy | in allergy |
* Yes in allergy. | ||
Decongestants
• Induce rapid vasoconstriction.
• Improve ostial potency.
• Reduce swelling and congestion of the turbinates.
• Decrease inflammation at the OMC, thus facilitating sinus drainage.
• The use of decongestants improves access into the congested nasal cavity for other therapeutic agents, such as corticosteroids, used in allergic sinusitis.
• Extended use of topical decongestants for more than 5 days can cause rebound vasodilatation and congestion (also called rhinitis medicamentosa).
• Oral decongestants (such as pseudoephedrine hydrochloride) can be used when the congestion lasts longer.
• In chronic sinusitis when therapy is required for a period longer than 5 days, systemic decongestants are used.
Reduction in the viscosity and improvement in the quality of mucus can assist in resolution of the infection. Several methods achieve this goal, including nasal saline spray or irrigation, air humidification, adequate hydration, and mucolytic agents.
Nasal Saline Irrigation/Spray
• Nasal saline irrigation or spray is a simple and effective method, available in the form of a nasal spray of sterile saline solution.
• It can also be made by dissolving half a teaspoonful of salt (about 3 g) in warm water (260 ml), with or without baking soda (about 0.5 g). The solution can be placed in a spray bottle or a syringe for nasal lavage.
• Sprays of saline (2–4 puffs at a time) are inhaled three times a day, and when necessary, the nasal secretions can be washed out with syringe rinsing and aspiration.
• Its use is recommended in both acute and chronic bacterial sinusitis.
Humidification
Inspired cool or hot humidified air and intake of adequate amounts of fluid are helpful in preventing and clearing thick secretions.
Mucolytic Agents
Many mucolytic and mucoregulatory agents, as well as expectorants, are used to treat sinusitis. The most common is guaifenesin, which liquefies thick secretions effectively. It is available in liquid or tablet form, alone or in combination with oral decongestants and/or antihistamines.
Antihistamines
• Antihistamines are generally not used to treat bacterial sinusitis, because they can thicken and dry the secretions, which leads to crusting and further blocks the OMC.
• They can be useful, however, if the underlying cause is allergic.
• Two classes of antihistamines are available:
a) the first generation (i.e., diphenhydramine, hydroxyzine, promethazine, meclizine, chlorpheniramine, and tripelennamine)
b) the newer second generation, which cause less dryness and are nonsedating (i.e., cetirizine, fexofenadine, and loratadine)
Corticosteroids
• Topical nasal corticosteroids are rarely used in acute bacterial sinusitis.
• They are, however, useful in the treatment of recurrent acute or chronic bacterial sinusitis and in allergic rhinitis.
• Use is based on the corticosteroid’s powerful antiinflammatory activity, and on its inhibition of cellular influx and all the phases of allergic reaction.
• Steroids have a delayed onset of action, and clinical improvement may take 7 to 10 days.
• Corticosteroids are always used in conjunction with antimicrobial therapy.
• The topical agents include fluticasone, budesonide, flunisolide, and triamcinolone acetonide, and can be administered for prolonged periods (in contrast to the limitations with topical decongestants).
• Topical agents can be delivered as an aerosol or aqueous solution. With prolonged use, topical side effects may occur (more so with the aerosol form than the aqueous form), and include irritation, sneezing, drying, burning sensation, crusting, bleeding, and (rarely) septal perforation.
• Systemic corticosteroids are rarely necessary in the treatment of allergic rhinitis, because of the generally good efficacy of topical corticosteroids. They are saved for the more severe cases for which immunotherapy may be effective.
Cromolyn Sodium
• Cromolyn sodium is available as a topical spray and helps to prevent perennial as well as seasonal allergic rhinitis.
• It works best when administered prior to exposure to an allergen.
• It is administered with a spray pump, in doses of one spray in each nostril every 4 hours during waking time.
• Relief is achieved between 4 and 7 days, whereupon the dose is reduced to an individual maintenance level. Side effects are infrequent, but include irritation and sneezing.
• Cromolyn sodium is effective in the treatment of allergic rhinitis, but does not help prevent the development of postviral sinus symptoms and nonallergic bacterial sinusitis.
• It is not recommended for use in sinusitis, except to alleviate a concomitant allergic rhinitis.
SURGICAL THERAPY
Surgical drainage may be needed in cases that fail medical therapy especially when complications occur. Surgical drainage is the mainstay of treatment for chronic sinusitis, especially in patients that have not responded to medical therapy. The goals of surgery are to prevent persistence, recurrence, progression and complications of chronic sinusitis. This is accomplished by removal of diseased tissue, preservation of normal tissue, promotion of drainage (or obliteration if this is not possible) and consideration of the cosmetic outcome. Functional endoscopic sinus surgery (FESS) has become the main surgical technique used. Radical procedures are reserved primarily for acute or chronic sinusitis complicated by orbital or intracranial involvement. Endoscopic surgery can achieves up to 80–90% success in both adults and children.
