1. Nasal medicaments include decongestants, mucolytic agents, topical decongestants, antihistamines, nasal and systemic steroids and p.o. garlic e.g. chicken soup. The following list these by generic names:
   1. Decongestants

      psuedoephedrine

      propylphenylalamine

   2. Mucolytic agents

      water p.o.

      quaifenesin

      iodine

      nasal saline drops

      nasal saline irrigation

   3. Topical decongestants

      neosynephrine

      oxymetazoline

   4. Antihistamines

      Non specific:

      Benadryl

      Others

      H1 specific

   5. Steroids

      topical nasal steroids

   There is little science and much individual opinion about the treatment of the common cold. We recommend nasal saline, p.o. garlic, horseradish and lots of water. Chicken soup is recommended as a treatment for the common cold. Its efficacy is probably related to the garlic. It is therefore an excellent treatment for it contains fluids, salts and the garlic which stimulates rhinorrhea. Antihistamines concentrate and increase the viscosity of nasal mucus and impair mucociliary clearance. They are therefore counterproductive. They may provide benefit for individuals with allergic rhinitis. Topical decongestants are addictive, but many physicians recommend their judicious use. Oral decongestants remain efficacious. Systemic steroids suppress immunity and are not normally prescribed. Topical nasal steriods are indicated for the treatment of allergic rhinitis. Their benefit for infection and anatomic abnormaltities has not been investigated.

2. Amoxicillin 250 mg p.o. tid is the drug of choice for acute sinusitis. It is the author's experience that this low dose works. Many experienced physicians use higher doses such as 500 mg bid or 875 mg bid. If the patient fails to respond or relapses the addition (NOT SUBSTITUTION) of Augmentin 250 mg provides amoxicillin 500 mg + clavulonate. The amount of clavulonate in Augmentin 250 and 500 is the same. The Augmentin supplement is only taken while the patient is ill, usually 3–7 days. The patient completes the antibiotic course with amoxicillin 250 tid. Which is cost–effective and minimizes the occurrence of side effects such as intestinal disturbance and yeast or fungal infection.
   
   
3. If the Penicillin allergic patient fails Erythromycin or Septra treatment, the two can be combined or the patient administered a macrolide or a second generation cephalosporin effective against H.flu and M. catarrhalis.
   
   
4. Ciprofloxacin is given when the patient persists or relapses after beta lactam resistant antibiotic treatment. It is effective against Pseudomonas and secondarily methicillin resistant Staphylococcus. While ciprofloxacin was the first available quinoone, others are available. Ciprofloxacin remains the most effective against Pseudomonas.
   
   
5. These are low dose, low side effect, long–term antibiotic treatments. These prescriptions are continued until the patient is well and then half again as long. They can be administered for 6,12,18 or more weeks. The long-term toxicity and risk of low dose antibiotics is less than even the shortest of general anesthetics.
   
   
6. Complications include periorbital infection and brain abscess. Frontal and sphenoid sinusitis also require prompt aggressive treatment and early referral because of their propensity to cause meningitis and brain abscess.
   
   
7. Diagnosis is a clinical one. Sinus CT without contrast is used to determine operative strategy. Sinus X–rays have limited utility in the diagnosis of acute sinusitis and are of no value in the evaluation of chronic sinusitis.

   The diagnosis of sinusitis is made from the clinical history. The reason the primary care physician (PCP) orders the CT is to save the cost of a specialist visit. The CT is a road map for the endoscopic surgery. If your Utilization Review Committee requires an abnormal CT, order the CT when the patient is ill. If they do not require an abnormal CT, order the sinus CT when the patient is well for this will show the baseline disease. A normal sinus CT is found in up to 20-30% of patients with chronic sinusitis.

   If you believe the patient does not have sinus disease, but rather sinus headaches, order the CT when the patient is at their worst, for when they see that the X-ray is normal they will realize they do not need antibiotics and do need stress reduction.

   

Overview of Sinusitis

Acute sinusitis is extremely common. Most upper respiratory tract viral infections develop a muco–purulent rhinorrhea. Virtually, all of these involve the sinuses. The average American suffers acute viral rhinosinusitis twice annually.

Fortunately, most of these resolve and as the underlying mucosa regains its integrity, the bacterial infection resolves.

Acute bacterial sinusitis is caused by mucociliary transport obstruction at the sinus ostia. This may be inflammation in the anterior ethmoids with secondary obstruction of the maxillary and/or frontal sinus drainage systems or it can be swelling and obstruction of the ostia directly, all of the above are compounded by anatomic narrowing and by previous inflammation with resultant cicatricial scarring.

The two must, common causes of acute osteal obstruction are the common cold and allergic rhinitis. In these situations the ostia are narrowed and the muco–ciliary transport systems of the sinuses are impaired. Secretions stagnate and are infected by the ever present upper respiratory tract bacteria including: streptococcus, H. influenza, M.catarrhalis and occasionally Staphylococcus and Pseudomonas.

The treatment for acute bacterial sinusitis is antibiotics. The ancillary nasal medicaments are the art of medicine, and while they may improve patient comfort, have no proven benefit for outcome.

Most patients respond to antibiotics within 36–48 hours. If within this period they fail to respond or continue to worsen, one assumes the bacteria are resistent to the antibiotic and second generation antibiotics are recommended.

Acute isolated frontal and sphenoid sinusitis is uncommon, but when it occurs, is concerning; because of its immediate proximity to the brain and potential to cause meningitis and brain abscess. If frontal or sphenoid sinusitis fails to respond within the 24 hours, it requires aggressive treatment, including IV antibiotics. If it does not respond to the intravenous antibiotics, surgical drainage is indicated. Emergent frontal sinusitis presents with acute onset isolated frontal sinus pain. The patient is sick and has fever. The white count is elevated with a left shift. The sinus is tender to percussion. Emergency sinus CT scan is indicated. If abnormal, the patient is admitted for IV antibiotic therapy. Failure to improve within 24 hours is indication for emergency surgery.

The same paradigm is true for sphenoid sinusitis and ethmoid sinusitis with periorbital cellulitis.

Recurrent sinusitis is the diagnosis for those who clear the sinus infection, but very shortly after discontinuing antibiotic therapy, develop a new infection. This can be from a narrowed, scared, or otherwise damaged sinus drainage, or it can result from ongoing allergic or other inflammatory rhinitis. Low dose prophylactic antibiotics are indicated, but if, after 6–12 weeks of antibiotics the patient again recurs, the prognosis without surgical drainage is poor.

Chronic sinusitis is an entirely different illness. To understand chronic sinusitis one must understand the mucociliary transport system.

The nose and paranasal sinuses are lined with upper respiratory tract epithelium. This is an epithelium with cilia covered by a mucus blanket floating on a layer of saline. Bacteria, irritants and other particulate matter are trapped in the mucus layer and then carried along by the ciliary motion out of the sinuses to the back of the nose, and into the pharynx. If the mucociliary transport system is impaired, the sinuses will be chronically infected. Aerobes and anaerobes are easily grown. Culture and sensitivity and stronger and stronger antibiotics provide little benefit. Attention must be directed towards the cause of the mucociliary transport system impairment. This may be anatomic or it may be scarring from too many infections. Very often it is caused or worsened by allergy and very often it is worsened by the irritants present in today's polluted air. If the cause cannot be identified and corrected, the patient is chronically infected, congested, obstructed and ill with sinus symptoms such as pain, postnasal drip and cough.

If a patient with sinusitis continues to have symptoms after three months of appropriate antibiotic and nasal steroid therapy, ENT referral is indicated.

With the advent of nasal endoscopy and sinus CT, we have come to learn that plain sinus radiographs are incorrect so much of the time, that they are of no benefit. Even maxillary and frontal sinusitis presence or absence is often misinterpreted on plain radiographs. Plain sinus radiographs are virtually never requested.

The diagnosis of sinusitis is made by the patient's history and physical examination. Sinus CT is ordered primarily as a Òroad mapÓ for the operating surgeon. It can be ordered, however, to document presence and extent of disease.

If a patient is being referred for an ENT consultation, one may first order a sinus CT if one is certain that the patient has chronic sinusitis which will require surgery.

MR is a poor imaging examination for sinus disease and would never be ordered in lieu of sinus CT. If diffuse sinusitis is present on MR, a sinus CT will be indicated.

Lastly, sinus CT is not the end all for evaluating sinus disease. Approximately, 25 percent of individuals with sinus symptoms and normal sinus CT will be found at surgery to have chronically inflamed sinus mucosa. This group does benefit from sinus surgery despite negative imaging studies.

Endoscopic sinus surgery has become the surgery of choice for sinus disease. Conversely, the old surgical procedures including: Caldwell Luc, nasal antral windows, external ethmoidectomy, etc., are rarely recommended.

Endoscopic sinus surgery evolved from the understanding of the mucociliary transport system and that the best way to obtain normal healthy sinuses was to enlarge the natural sinus ostia.

Once an improved drainage system is established, the diseased sinus mucosa reverts to normal. The surgery is relatively safe and is performed as an outpatient. Discomfort is minimal, convalescence is short and complications are few. Overall success rates are around 90%.

There are certain conditions in which the prognosis is less than 90%. Individuals with the ASA triad namely: asthma, aspirin sensitivity, and nasal polyps do poorly with all treatments. They can be improved with sinus surgery. We do not speak of cure, we speak of control and for many it has improved control significantly.

Nasal polyps are felt to be a result of inflammation, present in those with infection, allergy and other sources of irritation. Patients with nasal polyps do benefit from endoscopic sinus surgery, but the cure is only as good as the subsequent control of the underlying inflammatory rhinitis.

Many patients with asthma have allergic rhinitis and chronic sinusitis. Endoscopic sinus surgery will improve the sinus disease. Those individuals, whose asthma flares secondary to flare ups of their nasal and sinus illness, will have marked benefit in their nose and their lungs following sinus surgery. Carefully selected groups will have very high cure rates; poorly selected groups will have limited benefit.

Many HIV infected patients will develop sinonasal disease as their HIV illness progresses. These patients will benefit greatly from endoscopic sinus surgery followed by twice daily nasal irrigations. Many children and young adults with cystic fibrosis will have sinonasal disease; many will have nasal polyps. These people also benefit from early endoscopic sinus surgery followed by aggressive nasal irrigations.