The Treatment of Sinusitis

Introduction
Sinusitis is one of the most common chronic illnesses in the United States. However, many cases of chronic sinusitis will improve with appropriate medical therapy. Following is some advice on how to minimize your risk of getting a sinus infection, as well as a description of the various medications that are commonly used in treating acute and chronic sinus infections. Since some of these medications may interact with other drugs, be sure to bring a list and/or inform your doctor of all the medications you are currently taking at each visit.

HOW IS SINUSITIS TREATED?

Prevention
The best treatment of any of these various conditions is to avoid the precipitating factor whenever possible. If you smoke cigarettes, you should quit promptly. If you recognize a substance you are allergic to, you should avoid it as much as possible and establish allergy treatment. If you have any underlying medical condition or illness, you should be under the care of an appropriate physician. Your general state of health and nutrition affects every part of your body, including your sinuses. For this reason, we advocate maintaining a healthy diet, including taking vitamin supplements, and getting regular exercise.

The influenza immunization plays an important role in medical therapy. This is especially true for groups at high risk for influenza-related complications. This includes persons greater than 65 years old, residents of nursing homes or long-term care facilities, people with chronic disorders of the pulmonary or cardiovascular system, and patients with chronic metabolic diseases, renal dysfunction, hemoglobinopathies or immunosuppression. The best time to have the flu shot is October to mid-November before the start of the influenza season.

Medical Treatment
Recurrent infection is often treated successfully with medication alone. Several medications may be used in combination with an antibiotic to decrease swelling and help the nose drain properly. The medications used may include: antibiotics, oral steroids, nasal steroid sprays, antihistamines, decongestants, mucolytic expectorants and nasal irrigations. **Please be sure to read the information that is in this brochure pertaining to each medication you are prescribed.**

ANTIBIOTICS

Introduction: Antibiotics are medicines designed to treat bacterial infections. Since sinusitis is a condition where the sinuses may be infected, antibiotics are an important component of your therapy. Your doctor’s choice of antibiotic may be based on the bacteria that can be identified from a sample of pus taken from your nose or sinuses (i.e., a culture). However, it is often not necessary, or possible, to obtain an adequate culture. In many cases, therefore, your physician may prescribe an antibiotic for you based on what bacteria are most likely to be causing the infection. All antibiotics do not penetrate into the bone very well. Because the penetration of the antibiotic inside the sinuses can be limited, an extended treatment is often necessary.

Dosing: You should always take your antibiotic exactly as prescribed unless you are experiencing an adverse reaction to the medication. Otherwise always complete the entire course of antibiotic, even if you start feeling better before you are due to finish. By failing to complete the entire course of your treatment, you may be increasing the number of resistant bacteria. This could make further antibiotic therapy ineffective.

Antibiotics are prescribed to be taken by mouth the great majority of the time. Occasionally, for a more resistant or serious infection such as when bone is infected, or if resistant bacteria are causing the infection, intravenous antibiotics may be needed.

Adverse effects: As with any medication, antibiotics can cause side-effects. Any antibiotic can cause an allergic reaction, ranging from a rash on the skin, with or without itching, to a swollen mouth or tongue, wheezing, and/or trouble breathing. In all cases of an allergic reaction, you should stop taking the drug immediately and call your physician.

Perhaps the most common adverse effect of antibiotics is the gastrointestinal symptoms they produce. These can include stomach pain, nausea, vomiting, and diarrhea. If these symptoms are mild and tolerable they are probably not of concern, but if they are severe, you should stop the antibiotic and inform your physician. In rare cases, antibiotics can cause a severe diarrhea known as “pseudomembranous colitis.” Patients with this disorder have severe watery diarrhea. In this case you should stop the antibiotic and notify your doctor or your family physician immediately. Do not try to treat yourself with an anti-diarrheal medication or hope that a severe diarrhea problem will subside. Because antibiotics alter the normal bacteria in the body, as well as the disease-causing bacteria, they can cause other side effects. A yeast infection, most commonly in the mouth or vagina, is one such complication.

To minimize the risk of both diarrhea and yeast from antibiotics, we recommend daily ingestion of a PROBIOTIC Lactobacillus acidophilus, popularly known as acidophilus. This can be important because with chronic sinusitis you may need to be on antibiotics for an extended period of time. Acidophilus can be found in two forms; yogurt with active cultures, and capsule preparations.
Be sure to inform your doctor if any of the following apply to you: impaired kidney function, rash when previously given an antibiotic, ulcerative colitis, mononucleosis (mono), anemia, abnormal liver function, myasthenia gravis, pregnancy, breast feeding, other medications, mitral valve prolapse or prosthetic devices. If you are using an oral contraception while on antibiotics a back up method is highly recommended.

Antibiotic Preparations:
Penicillins (penicillin/Pen-Vee K®, amoxicillin/Amoxil®, ampicillin/Omnipen®, amoxicillin+clavulanate/Augmentin®): skin rash and gastrointestinal disturbances (nausea, diarrhea) are the most common adverse effects.

Cephalosporins (cefadroxil/Duricef®, cefprozil/Cefzil®, cephalexin/Keflex®, and cefuroxime/Ceftin®): distant cousins to the penicillin’s, with similar adverse effects; not recommended for patients with a history of immediate or severe penicillin reaction.

Sulfonamides (sulfamethoxazole+trimethoprim/Bactrim®, Septra®): may interact with other drugs, such as oral hypoglycemics, anticoagulants, anti-seizure medications, and thiazide diuretics; avoid if you have G6PD deficiency; stop at first sign of skin rash; may cause sensitivity to sunlight. Not to be taken if you are allergic to sulfa.

Quinolones (ciprofloxacin/Cipro®, ofloxacin/Floxin®, levofloxacin/Levaquin®, moxifloxacin/Avelox®), anticoagulants (may elevate coumadin blood levels), non-sedating antihistamines (such as Seldane®, Hismanal®); see “Antihistamines” below) or probenecid; patients on theophylline may need to decrease their dosage; may increase effects of caffeine; patients should avoid sun while taking; may cause dizziness or light-headedness, so avoid driving or operating machinery until you know how you will react to this drug. This drug class has been associated with rotator-cuff tear, Achilles tendon rupture and joint stiffness. You should avoid strenuous activities or heavy lifting while taking this medication. If you are taking vitamins, antacids, or yogurt you should take them two hours before or four hours after. THIS MEDICATIONS ARE THE ONLY ORAL THERAPY FOR Pseudomonas especies a very common a persistent bacteria associated to sinusitis.

Tetracyclines (doxycycline/Vibramycin®, minocycline/Minocin®): skin requires protection from sunlight while on these drugs; should not be taken antacids, oral contraceptives, barbiturates, phenytoin or carbamazepine; do not take milk products at the same time as tetracyclines, iron and vitamin supplements. Recommend taking on empty stomach with at least 8 oz. of water (except Vibramycin®, which must be taken with food). If you are taking vitamins, antacids, or yogurt you should take them two hours before or four hours after. Monitor INR levels if on an anticoagulants.

Macrolides (Erythromycin/PCE®, clarithromycin/Biaxin, and azithromycin/Zithromax®): nausea and stomach upset occurs most commonly; may interact with digoxin, carbamazepine, some non-sedating antihistamines (such as Seldane® and Hismanal®), warfarin, and cisapride (Propulsid®). Theophylline dosage may need to be reduced. With Biaxin® use alternative or stop taking statins (Lipitor®) during treatment

Monobactams: should be avoided in patients with a history of cephalosporin-allergy.

Miscellaneous:

Metronidazole Flagyl®: it is important to avoid alcoholic beverages and alcohol-containing medications (such as cough syrups) for at least 24 hours after taking this medication; may interact with anticoagulants, anticonvulsants, lithium and cimetidine; may cause dark urine. Drug should be stopped should you develop numbness, tingling, weakness in hands or feet.

Clindamycin /Cleocin®: diarrhea is the most common adverse reaction and can be severe; should not be taken with neuromuscular blocking agents.

STEROIDS

Steroids are anti-inflammatory medications, which are used in the treatment of sinusitis in both a topical (nasal irrigation) and systemic (pill) form. Steroids help prevent and decrease swelling of the lining of the nose and sinuses. They also help to decrease the size of polyps and may prevent them from recurring once they have been removed. Because steroids can also decrease the immune response, there are certain risks associated with their use. The risks associated with topical nasal steroids are very limited because they do not have the same widespread effects in the body that may occur with systemic steroids. However, adverse reactions may still occur and are described below.

Topical nasal steroid sprays
Introduction: Nasal steroid sprays (Flonase®, Nasocort®, Rhinocort AQ, Nasonex®, etc) deliver a high concentration of steroid dose to the lining of the nose. Because this dose effects the lining of the nose without being completely absorbed by the body, the adverse effects on your body are minimized. For this reason, topical nasal steroids are safe and effective medications for the treatment of nasal swelling and congestion in patients with and without allergies. Studies from Europe indicate that steroid sprays are very safe even after many years of continued use. However, they should not be abused by taking more than the recommended dose.

Dosing: Topical nasal steroids do not produce the immediate relief of nasal congestion achieved through topical nasal decongestants. Occasionally they require weeks of regular use before any therapeutic effect is noticeable, and a month of regular use before their maximum effect is realized. These nasal sprays will not work if they are used sporadically. Because of this, you should develop a routine that ensures that you will use the sprays as prescribed by your physician.

Adverse reactions: Nasal steroids may have some local effects on the lining of the nose such as nasal drying, crusting, and bleeding. More extensive local effects such as nasal septal perforations are rare but may occur if the preparations are used more frequently than recommended. Nasal steroids may also produce irritation of the throat. We also recommend an annual ophthalmologic examination if you are on nasal steroids for prolonged periods, as there is a theoretical risk of cataract formation or unmasking your tendency towards glaucoma.

Steroid irrigations
Introduction: The steroid Budesonide is FDA approved to use in the nose in a form of a spray (Rhinocort®) or to use in the lungs as an inhaler (Pulmicort®). The use of Budesonide as an irrigation is not yet approved by the Federal Drug Administration (FDA). However, research studies and years of clinical experience attest to the safeness of this medication when use to irrigate the nose.

Dosing: Steroid irrigations with Budesonide provide a more efficient delivery mechanism of medication to sinus cavities. In absolute terms they provide less amount of steroids to the nose and this molecule has an even lower rate of systemic absorption making it even safer for the patient. These irrigations are generally used twice a day with Lanza’s pirouette irrigation technique. (VIDEO OF IRRIGATION TECHNIQUE)

Adverse reactions: Adverse effects are similar to risks associated with nasal steroid sprays but less frequent as the total dose concentration which remains in the nose is less.

Oral Steroids
Introduction and Dosing: Systemic steroids (prednisone or Medrol®) are sometimes necessary for the treatment of nasal polyps or swelling of the nasal lining. Steroids are normally produced by our bodies and are an essential part of our daily functioning. When oral steroids are taken, the body’s natural production of steroids can decrease. If oral steroids are discontinued suddenly, the body may not have sufficient time to respond and increase its natural steroid production back up to the normal rate. Therefore, your steroid prescription is written so that you will slowly decrease your daily steroid dose (i.e. tapering) prior to stopping completely. It is recommended that you take you steroids on a full stomach after breakfast in the morning. This will help to prevent possible side effects such as stomach irritation and insomnia.

It is not infrequent to have some increased appetite or to retain some fluid when you are on oral steroid therapy. You should therefore watch your diet. An initial high dose may also make you feel hyperactive, and you may feel somewhat down as the dose is decreased. However, with appropriate management of the steroid dosage, these effects can usually be minimized.

Individuals at risk for osteoporosis, especially women who have undergone menopause, should have a bone density study performed every 1-2 years if they are on long term steroids. An annual ophthalmologic examination is also recommended. In general, systemic steroids should be avoided during pregnancy or if you have a history of a bleeding abnormality, tuberculosis (TB), glaucoma, significant clinical depression, or an immune deficiency. If you have a history of a duodenal ulcer, you should inform your doctor and he will prescribe some medication to protect your stomach. It is recommended that you take 1500mg of calcium and 400 IU of vitamin D to aid in the prevention of osteoporosis.

Adverse Effects: Cataracts, glaucoma, high-blood pressure, high blood sugar (as with diabetes), mood changes, stomach irritation or ulcer disease, bone-thinning (osteoporosis) and menstrual irregularities may occur with oral steroid use. Thus, if you have a history of any of these problems, be sure to inform your doctor.

A serious but very rare adverse reaction to oral steroids (avascular necrosis) can result in permanent damage to an affected joint. Fortunately, this is very uncommon. However, you should inform your physician if you develop significant joint pains while taking oral steroids.

ANTIFUNGAL AGENTS

Introduction: Antifungal agents are used to treat fungal infections. They include oral agents (itraconozole/Sporonox®, terbinafine/Lamisil®, and fluconozole/Diflucan®), and agents used in irrigation solutions (nystatin, amphotericin).

Dosing: Oral antifungal medications are typically used short-term (generally a 6-12 week course). If they are to be used long-term, liver enzymes may become elevated. Liver function tests (LFT’s) are recommended every 6-8 weeks. Those agents used in irrigation solutions are not meant to be absorbed systemically so should not have the same effect.

Adverse Reactions: There are several drug interactions to be aware of if you are taking itraconozole/Sporonox®. Cardiac effects may occur if used with terfenadine/Seldane® or cisapride/Propulsid®. May potentate diazepam/Valium®, digoxin, methylprednisolone/ Medrol®, and anticoagulants. May cause severe hypoglycemia if used with oral hypoglycemic agents. Cholesterol lowering drugs such as Lipitor® should be stopped while on treatment with oral antifungals.

ANTIHISTAMINES

Introduction: Antihistamines are designed to oppose the effects of histamine, the main chemical released by the body in allergic reactions. Some chronic sinusitis sufferers have allergies, which may contribute to swelling in the nose and sinuses. Antihistamines do not truly alter your allergic susceptibility but can lessen the uncomfortable symptoms of an allergic reaction.

Dosing: Antihistamines are most effective when taken before an anticipated allergic reaction. If taken after an allergic reaction is already in progress, the helpful effects may be delayed. Therefore, in patients with multiple allergies, the medication is typically taken on a regular basis.

Adverse effects: Most antihistamines have a sedating effect, and the drowsiness they produce is usually the most undesired side-effect. The more recently developed non-sedating antihistamines such as fexofenadine /Allegra®, loratadine/Claritin®, and desloratadine/Clarinex® are exceptions to this rule; there is usually less sedation and dryness. Cetirizine/Zyrtec® may cause drowsiness and should be taken at bedtime. These should not be taken if you have abnormal liver function or hypokalemia (low potassium).

Common side-effects of antihistamines includes dry mouth, blurry vision, and difficulty urinating. You should inform your doctor if you have glaucoma, prostate trouble, kidney or liver disease. Because of possible drug interactions, inform your physician if you take sedatives, monoamine oxidase inhibitors (MAOI’s – a type of anti-depressant medication) or consume large amounts of alcoholic beverages.

Topical Antihistamine Spray: Topical nasal antihistamine spray such as Astelin® may be prescribed. It is an antihistamine that does not get absorbed significantly into in the bloodstream but stays locally in the nose. It can be used with patients that are unable to tolerate or take oral antihistamines. It does have a bitter taste.

LEUKOTRIENE INHIBITORS

Introduction: Leukotriene inhibitors are used to control chronic asthma. Leukotrienes play a role in the inflammatory process in the nose. Montelukast (Singulair®) blocks the activation of leukotriene by interfering with its synthesis pathway.

Dosing: Montelukast should be taken once every day, not just with acute attacks.

Adverse reactions: Singulair® can potentiate drugs metabolized by certain isoenzymes (including coumadin, Dilantin®, calcium channel blockers, and cyclosporine).

DECONGESTANTS

Topical Nasal Decongestants: Topical nasal decongestants (Afrin®) in the form of drops or sprays can be very effective in immediately shrinking the swelling of the lining of the nose. However, these sprays should be used no longer than 2 or 3 consecutive days, for prolonged usage may result in “rebound” swelling of the nose. Rebound swelling (known as “rhinitis medicamentosa”) can be extremely difficult to treat because the nose may no longer respond normally to treatment.

Oral Decongestants: If more prolonged decongestant therapy is required, systemic decongestants may be used. These agents have the same effect in decreasing the swelling of the lining of the nose and promoting drainage of the sinuses. However, since higher concentrations are present in the bloodstream, systemic decongestants are more likely to produce side-effects. These include high blood pressure, anxiety and sleeplessness, and the “jitters.” Decongestants can also cause blurry vision (in patients who suffer from glaucoma) and difficulty urinating in patients with prostrate problems. You should let your doctor know if you are currently taking any medications for depression (such as MAOIs – monoamine oxidase inhibitors, or tricyclic antidepressants), since these medications can have serious adverse effects when they interact with either topical or systemic decongestants.

MUCOLYTICS

Mucolytic agents (guaifenesin/ Humibid®/Duratuss-G®) are drugs that thin mucus and secretions, so they can drain out of the sinuses more easily. They may be helpful for people suffering from a thick post-nasal drip. Often, they are found in combination preparations with decongestants and/or antihistamines. Most are well tolerated and have few side effects such as headache, rash, or nausea.

ANTI-REFLUX MEDICATIONS

Introduction: Anti-reflux medications are used in conjunction with diet therapy to treat GERD. They include acid pump inhibitors (omeprazole/Prilosec®, lansoprazole/Prevacid®, esomeprazole/Nexium®) and H2 antagonists (ranitidine/Zantac®, famotidine/Pepcid AC®, cimetidine/Tagamet®, nizatidine/Axid®).

Dosing: Dosing is dependent on the severity of disease. If you will be continuing these medications on a daily basis, you should be followed by a gastroenterologist. We will work with his/her recommendations for further treatment.

Adverse Effects: Proton pump inhibitors (Prilosec®, Prevacid®, and Nexium®) may alter absorption of pH dependent drugs such as ketoconozole/Nizoral® and itraconozole/Sporonox®. Common side effects are diarrhea and headache.There is an association between PPIs and increased risk of myocardial infarction (heart attack). Long term use of PPIs can reduced Calcium and Vitamin D absorption precipitating osteopenia or osteoporosis.

NASAL IRRIGATIONS

The nasal and sinus cavities are normally able to clear mucus on their own through “mucociliary transport.” Up to one quart of mucus is produced daily and is swallowed. Sometimes swelling of the nose from either allergy, irritation, or infection can prevent this self-cleaning. In these cases, irrigations (nasal flushing or washing) are used to assist in mucociliary transport.

Irrigation solutions: A variety of solutions can be used, depending on the nature and degree of material that needs to be cleared out of the nose. Irrigation solutions can be homemade or prescribed.

Prescription: Medications can be added to the irrigation solution. In this case, the solution would be prepared by your pharmacist. Added medications can include antibiotics or antifungal agents to inhibit bacterial or fungal growth. If gentamicin, ceftazidime, or amphotericin irrigations are prescribed for you it is best filled by a compounding pharmacy near your home.

Other Helpful Ideas:

• Vaporizers and humidifiers are helpful when treating sinusitis. Bedside humidifiers and vaporizers help to thin the mucous secretions. Dryness inside the nose is seen as an irritant and may cause the nose to swell. Patients with allergies should keep the humidity in the home less than 50% to prevent dust and mold from growing. Strict attention should be maintained to keeping these devices clean.
• Hepa Air Filter Purifiers help to lower allergens and pollutant in the air your breath.
• Proper diet and exercise is essential to your health and disease prevention.
• DRINK WATER- you should drink a minimum of eight glasses of water a day. This helps to keep the body and mucous membranes well hydrated.
• AVOID ALCOHOL- alcohol may worsen sinusitis because it dehydrates the body and may interfere with the effective absorption of some medications.
• AVOID SMOKING.