Mercy Family Practice SC
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Sinus infection is probably one of the most common ailments that we see in private practice. I once had a professor tell me, "behind every dam there is mud." What he meant by that is if you have an orifice that is plugged, fluid and debris accumulates in the space preceding it. In the case of the sinuses, the opening to the outside world is plugged. Bacteria that is trapped there will start to multiply. The accumulation causes pressure, pain, and extension into the surrounding tissues. In the case of sinusitis, this amounts to pain and pressure under the eye sockets, behind the maxillary arch on each side, stuffiness in the nose, pressure in the Eustacian tubes, causing referred pain in the ears and sometimes extension into the lacrimal glands, which may result in yellow or green drainage in the eyes. A common feeling is that you want to drill a hole in your cheek bones to remove the pressure and drain out the junk. Timeframe is important. It takes approximately 10 days to get a sinus infection.
If you call the office, we will go though a quick checklist. It goes something like this:
Symptoms for 2-3 days.
Symptoms for over 10 days.
Sinusitis: It takes a while for a sinus infection to occur. At this point, you have reached the point of "no return" so to speak. If you were going to recover, you would have done so by now. The cause is multifactorial. Some people have structural abnormalities that interfere with the bodies abilities to drain the sinuses. A small amount of edema can prevent drainage of the sinuses. Sometimes people have allergies that cause the sinus opening to swell, preventing proper drainage. For whatever reason, if the sinus cavities do not drain properly, then they become infected. Likewise, if it takes a long time for the sinuses to become infected, it often takes a long time for them to resolve. Often it takes from 2-4 weeks of antibiotics to clear a sinus infection. In addition to antibiotics, we often use other medications such as decongestants, antihistamines, and expectorants. The most common decongestant is pseudoephedrine (PSE); common non-sedating antihistamines include clemastine (Tavist), cetirizine (Zyrtec) and fexofenadine (Allegra). Often we recommend a normal saline sinus rinse. Often Ocean Spray nasal or a Netty Pot is often used for the latter. Although there is no study that supports the use of adjunct therapy for sinusitis, it often makes patients feel better and able to tolerate the symptoms until they fully recover from the infection.
Figure 1, Schematic of the sinuses, coronal view
Figure 2, X-ray of the sinuses, coronal view
The asterisk '*' marks the ethmoids, the M the middle turbinates, the 'I'
A recent article has looked at an evidence-based approach to the diagnosis and management of acute sinus infection. As the devil's advocate, you may ask, "Why not just treat everyone with suspected sinusitis with antibiotics?" For years, this has been the approach. For the past quarter century, physicians have overtreated patients with antibiotics. The down side has been drug resistance. Now there are several forms of bacteria that cannot be treated with standard antibiotics. The cost of treating indiscriminately has been the emergence of resistant strains of bacteria. There may come a day where there are no new antibiotics that will work. That day is approaching quickly.
Therefore, a new conservative approach has emerged to balance the need for antibiotic treatment against the likelihood when it will do the most good. Figure 3 illustrates and algorithm which is the summary of current thinking:
Figure 3, Algorithm for the management of acute sinusitis
The diagnosis of sinusitis, even among otorhinolaryngologists, can be difficult to make. Specialists are often only able to make a correct diagnosis in 60% of cases. This makes the diagnosis elusive. Often we rely on the types of symptoms, the onset of the illness in days (at least 10), clinical impression, and sometimes a CT scan of the sinuses.
Table 1, Common Symptoms of Sinusitis
Predictors of Infection
The best predictors of an acute sinusitis come from a study by Hanset et al in which symptoms were correlated with positive sinus cultures. The two most common bacteria are Streptococcus pneumoniae and Hemophilus influenzae.
Table 2, Predictive Value of Clinical Findings
A value of 1.00 means that you are no more likely to have an infection.
Figure 4, Natural History of the Course of Sinusitis
The mainstay of treatment in the US has been antibiotics. This still remains the main modality. In Europe, myringotomy (aspiration of fluid by piercing the ear drum) has been shown to be equally effective. For children and adults, the antibiotic with the highest effectiveness is amoxicillin-clavulanic acid (Augmentin). There are many second line agents that work as well. Often treatment has to be given up to a month for clearing of the infection (the range is 10-36 days).
There has been an ongoing debate regarding the overuse of antibiotics for approximately 15 years. Many feel we are entering a new era in which antibiotics will no longer work. The reason for this is that due to overuse, many bacteria have been able to produce enzymes that counteract the antibiotics mechanism. A recent article suggests that antibiotics only help in 2-10% of the upper respiratory illnesses, and the 90-98% are due to viruses. The author suggests using the following red flags to note when antibiotics may be helpful: "symptoms persisting at least 10 days without improvement, or signs of a worsening infection, such as a fever of 102-plus degrees, increased nasal discharge and facial pain lasting at least three days."
Table 3, Antibiotics for Sinusitis in Children
Table 4, Antibiotics for Sinusitis in Adults
1. Chow,Anthony W. et al, IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults, Clinical Infectious Diseases, March 20, 2012 (full article)
2. Huff, Charlotte, 'Unlearning' How to Prescribe Antibiotics, American College of Physicians, Sept 2012, 32(8), p 1-16 (full article)
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