Overview of the Treatment and Management of Rhinosinusitis
The goals of therapy for both acute and chronic rhinosinusitis are to control infection, reduce tissue edema, facilitate drainage, maintain patency of the sinus ostia, and break the pathologic cycle that leads to CRS. Acute viral rhinosinusitis is a self-limiting condition. Since no pharmacotherapeutic interventions are proven to reduce the duration of illness, the goals of medical management are to relieve the symptoms of nasal obstruction and rhinorrhea.
Treatment of ABRS may include antibiotics to eliminate the infection, but, as stated before, the majority of bacterial infections will clear spontaneously. Since ABRS cannot generally be differentiated from its viral counterpart in the first 10 days, antibiotic therapy should be reserved for patients with severe symptoms for at least 3 to 4 consecutive days, signs of double sickening, and illness persisting for longer than 10 days without evidence of clinical improvement.
Patients with facial swelling, edema around the eyes, abnormal vision, or mental status alterations may be experiencing intracranial or intraorbital extension of sinusitis, and should be referred immediately for urgent medical attention.
Supportive therapy for AVRS should be tailored to an individual's symptom profile. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are recommended for the pain and discomfort associated with mucosal swelling. Oral and topical decongestants reduce symptoms of rhinosinusitis by constricting the blood vessels of the nasal mucosa, thereby reducing edema and inflammation. Topical decongestants, such as oxymetazoline, can provide more relief than systemic decongestants due to their increased potency and local administration, but they should be used for no more than 3 days to avoid rebound congestion. Systemic decongestants should be used with caution in patients with cardiovascular disease or uncontrolled hypertension.
Intranasal corticosteroids reduce edema and inflammation and have been shown to reduce symptoms of acute rhinosinusitis (Table 1). In clinical trials, intranasal mometasone furoate has been shown to effectively reduce symptoms of congestion associated with rhinosinusitis both as monotherapy and in combination with amoxicillin-clavulanate. Similar results have been achieved with intranasal fluticasone, flunisolide, and budesonide. Intranasal corticosteroids are unlikely to cause systemic adverse effects because of low systemic bioavailability. The bioavailability of fluticasone propionate is <1%, and the bioavailability of mometasone furoate is ≤0.1%. Systemic therapy with corticosteroids should be avoided in most patients due to limited evidence and an increased risk of adverse events. Potential effects of short-term systemic corticosteroid use include hyperglycemia, hypertension, increased appetite, and insomnia.
Antihistamines are often prescribed for symptom relief due to their drying effect, but there is no evidence to support their use in infectious rhinosinusitis. Overdrying the mucous membrane can impair mucus clearance and cause additional discomfort. Antihistamines should only be recommended to patients with symptoms suggesting a significant allergic component.
Saline nasal rinses are used to soften viscous secretions and improve mucous clearance. A 2010 Cochrane literature review found three small trials showing limited evidence to support the use of sinus rinses in acute rhinosinusitis. In one study, 389 medium-risk patients using daily nasal saline irrigation saw a decrease in antibiotic use (relative effect 0.44, 95% confidence interval [CI], 0.18–1.09) and time away from work or school (relative effect 0.29, 95% CI, 0.16–0.53). Better evidence exists to support the role of sinus rinses in treating recurrent rhinosinusitis. As saline rinse product have few medication-related side effects and drug interactions, pharmacists can feel comfortable recommending their use to patients in the community setting.
Zinc has frequently been used to reduce the severity and duration of colds and sinus infections, but recent reports of long-term or permanent anosmia associated with zinc use has led the FDA to advise against the use of zinc-containing products.
The symptoms of bacterial and viral rhinosinusitis are almost indistinguishable within the first 10 days. As such, patients presenting with fewer than 10 days of nonsevere symptoms, including mild pain and fever ≤101° F (38.3° C), should be managed symptomatically as previously discussed. Antibiotics should be initiated when signs and symptoms of acute rhinosinusitis do not improve within 10 days, in patients who experience a secondary worsening after initial improvement of symptoms (double sickening), or in patients with severe symptoms lasting for 3 to 4 days.
Initial antibiotic choice should be based on a number of factors including safety, cost, and efficacy against microorganisms likely to cause ABRS. A review of aspiration studies in adult ABRS shows that the most commonly isolated organisms include S pneumoniae (20%-43%), H influenzae (22%-35%), and M catarrhalis (2%-10%). To prevent bacterial resistance, antibiotics with a narrow spectrum of activity are preferred. The 2012 IDSA guidelines for the treatment of ABRS suggest amoxicillin-clavulanate as first-line therapy for patients requiring antibiotics. Previously, amoxicillin alone had been recommended for initial therapy. For patients with a penicillin allergy, doxycycline or a respiratory fluoroquinolone (levofloxacin, moxifloxacin) should be used. Macrolide antibiotics (erythromycin, azithromycin) are no longer recommended for the treatment of ABRS.
The recommended duration of therapy is 5 to 7 days for adults and 10 to 14 days for pediatric patients, based on the typical therapy used in randomized, controlled trials of antibiotics in ABRS; however, no significant differences in cure rates are obtained with a shorter, 3- to 4-day course of therapy.
Some other factors may dictate the use of alternative therapy. A history of antibiotic use in the previous 4 to 6 weeks increases the risk of antibiotic-resistant microorganisms. Guidelines suggest a fluoroquinolone or high-dose amoxicillin-clavulanate (2,000 mg/125 mg by mouth twice a day) for such patients.
Treatment failure is defined as progression of symptoms during antibiotic therapy or no improvement after 7 days of therapy. These patients should be reevaluated for a nonbacterial cause or infection with drug-resistant bacteria. If treatment with narrow-spectrum antibiotics is insufficient, a more broad-spectrum fluoroquinolone or high-dose amoxicillin-clavulanate should be considered. Refractory cases should be referred to an otolaryngologist, who may obtain endoscopic cultures to guide therapy.
The symptoms of CRS, regardless of origin, can be managed similarly to those of acute rhinosinusitis. Better evidence for the use of daily nasal saline rinse exists for CRS sufferers. One randomized, controlled trial of 76 subjects, mostly in the family practice setting, found that CRS sufferers using once-daily saline nasal rinses for 6 months used less nasal spray, required fewer antibiotics, and experienced fewer 2-week periods with sinus-related symptoms.
As previously discussed, patients with symptoms of rhinosinusitis lasting more than 12 weeks require medical management, including imaging studies, endoscopy, and potentially surgery. Therefore, these patients should be referred to a physician.
Treatment
The goals of therapy for both acute and chronic rhinosinusitis are to control infection, reduce tissue edema, facilitate drainage, maintain patency of the sinus ostia, and break the pathologic cycle that leads to CRS. Acute viral rhinosinusitis is a self-limiting condition. Since no pharmacotherapeutic interventions are proven to reduce the duration of illness, the goals of medical management are to relieve the symptoms of nasal obstruction and rhinorrhea.
Treatment of ABRS may include antibiotics to eliminate the infection, but, as stated before, the majority of bacterial infections will clear spontaneously. Since ABRS cannot generally be differentiated from its viral counterpart in the first 10 days, antibiotic therapy should be reserved for patients with severe symptoms for at least 3 to 4 consecutive days, signs of double sickening, and illness persisting for longer than 10 days without evidence of clinical improvement.
Patients with facial swelling, edema around the eyes, abnormal vision, or mental status alterations may be experiencing intracranial or intraorbital extension of sinusitis, and should be referred immediately for urgent medical attention.
Acute Viral Rhinosinusitis
Supportive therapy for AVRS should be tailored to an individual's symptom profile. Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are recommended for the pain and discomfort associated with mucosal swelling. Oral and topical decongestants reduce symptoms of rhinosinusitis by constricting the blood vessels of the nasal mucosa, thereby reducing edema and inflammation. Topical decongestants, such as oxymetazoline, can provide more relief than systemic decongestants due to their increased potency and local administration, but they should be used for no more than 3 days to avoid rebound congestion. Systemic decongestants should be used with caution in patients with cardiovascular disease or uncontrolled hypertension.
Intranasal corticosteroids reduce edema and inflammation and have been shown to reduce symptoms of acute rhinosinusitis (Table 1). In clinical trials, intranasal mometasone furoate has been shown to effectively reduce symptoms of congestion associated with rhinosinusitis both as monotherapy and in combination with amoxicillin-clavulanate. Similar results have been achieved with intranasal fluticasone, flunisolide, and budesonide. Intranasal corticosteroids are unlikely to cause systemic adverse effects because of low systemic bioavailability. The bioavailability of fluticasone propionate is <1%, and the bioavailability of mometasone furoate is ≤0.1%. Systemic therapy with corticosteroids should be avoided in most patients due to limited evidence and an increased risk of adverse events. Potential effects of short-term systemic corticosteroid use include hyperglycemia, hypertension, increased appetite, and insomnia.
Antihistamines are often prescribed for symptom relief due to their drying effect, but there is no evidence to support their use in infectious rhinosinusitis. Overdrying the mucous membrane can impair mucus clearance and cause additional discomfort. Antihistamines should only be recommended to patients with symptoms suggesting a significant allergic component.
Saline nasal rinses are used to soften viscous secretions and improve mucous clearance. A 2010 Cochrane literature review found three small trials showing limited evidence to support the use of sinus rinses in acute rhinosinusitis. In one study, 389 medium-risk patients using daily nasal saline irrigation saw a decrease in antibiotic use (relative effect 0.44, 95% confidence interval [CI], 0.18–1.09) and time away from work or school (relative effect 0.29, 95% CI, 0.16–0.53). Better evidence exists to support the role of sinus rinses in treating recurrent rhinosinusitis. As saline rinse product have few medication-related side effects and drug interactions, pharmacists can feel comfortable recommending their use to patients in the community setting.
Zinc has frequently been used to reduce the severity and duration of colds and sinus infections, but recent reports of long-term or permanent anosmia associated with zinc use has led the FDA to advise against the use of zinc-containing products.
Acute Bacterial Rhinosinusitis
The symptoms of bacterial and viral rhinosinusitis are almost indistinguishable within the first 10 days. As such, patients presenting with fewer than 10 days of nonsevere symptoms, including mild pain and fever ≤101° F (38.3° C), should be managed symptomatically as previously discussed. Antibiotics should be initiated when signs and symptoms of acute rhinosinusitis do not improve within 10 days, in patients who experience a secondary worsening after initial improvement of symptoms (double sickening), or in patients with severe symptoms lasting for 3 to 4 days.
Initial antibiotic choice should be based on a number of factors including safety, cost, and efficacy against microorganisms likely to cause ABRS. A review of aspiration studies in adult ABRS shows that the most commonly isolated organisms include S pneumoniae (20%-43%), H influenzae (22%-35%), and M catarrhalis (2%-10%). To prevent bacterial resistance, antibiotics with a narrow spectrum of activity are preferred. The 2012 IDSA guidelines for the treatment of ABRS suggest amoxicillin-clavulanate as first-line therapy for patients requiring antibiotics. Previously, amoxicillin alone had been recommended for initial therapy. For patients with a penicillin allergy, doxycycline or a respiratory fluoroquinolone (levofloxacin, moxifloxacin) should be used. Macrolide antibiotics (erythromycin, azithromycin) are no longer recommended for the treatment of ABRS.
The recommended duration of therapy is 5 to 7 days for adults and 10 to 14 days for pediatric patients, based on the typical therapy used in randomized, controlled trials of antibiotics in ABRS; however, no significant differences in cure rates are obtained with a shorter, 3- to 4-day course of therapy.
Some other factors may dictate the use of alternative therapy. A history of antibiotic use in the previous 4 to 6 weeks increases the risk of antibiotic-resistant microorganisms. Guidelines suggest a fluoroquinolone or high-dose amoxicillin-clavulanate (2,000 mg/125 mg by mouth twice a day) for such patients.
Treatment failure is defined as progression of symptoms during antibiotic therapy or no improvement after 7 days of therapy. These patients should be reevaluated for a nonbacterial cause or infection with drug-resistant bacteria. If treatment with narrow-spectrum antibiotics is insufficient, a more broad-spectrum fluoroquinolone or high-dose amoxicillin-clavulanate should be considered. Refractory cases should be referred to an otolaryngologist, who may obtain endoscopic cultures to guide therapy.
Chronic Rhinosinusitis
The symptoms of CRS, regardless of origin, can be managed similarly to those of acute rhinosinusitis. Better evidence for the use of daily nasal saline rinse exists for CRS sufferers. One randomized, controlled trial of 76 subjects, mostly in the family practice setting, found that CRS sufferers using once-daily saline nasal rinses for 6 months used less nasal spray, required fewer antibiotics, and experienced fewer 2-week periods with sinus-related symptoms.
As previously discussed, patients with symptoms of rhinosinusitis lasting more than 12 weeks require medical management, including imaging studies, endoscopy, and potentially surgery. Therefore, these patients should be referred to a physician.
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