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Sinusitis

Diagnosis and Conventional Treatment

Sinusitis is usually diagnosed based upon a physician’s assessment of a patient’s symptoms and medical history. In some cases, when a patient presents with a history of upper respiratory infection and symptoms lasting from 7 to 10 days, a bacterial culture may be obtained. Some other procedures can help aid diagnosis, but are typically not required in uncomplicated cases; these include radiography, computed tomography, endoscopic visualization of ostia secretions, and sinus puncture in cases that have failed other treatments (Fort 2012).

Conventional treatment recommendations for acute sinusitis are largely dependent upon the underlying cause of infection (Mayo Clinic 2012b). The majority of sinusitis cases are caused by viral infection, and antibiotics are generally not needed in these cases (AAFP 2011; Mayo Clinic 2012b; Smith 2012). Since the symptoms of viral sinusitis are mild-to-moderate and typically resolve on their own within 10 days or less, they can often be managed via self-care techniques and/or home remedies (Leung 2008; Mayo Clinic 2012b; Smith 2012; Puhakka 1998).

The following self-care strategies may provide relief from sinusitis symptoms:

  • Adequate rest to help the body fight infection and speed-up recovery (AAFP 2008; Mayo Clinic 2012b).
  • Elevate the head while sleeping by using an extra pillow to reduce congestion and keep the sinuses draining properly (AAFP 2008; Mayo Clinic 2012b).
  • Stay hydrated with water, as this helps to thin out mucus secretions and promote drainage (Mayo Clinic 2012b; NIH 2012). Sipping hot beverages may also help, since they can dilate blood vessels and promote drainage (AAFP 2008; Merck 2008).
  • Avoid alcohol and caffeine consumption, since they can cause dehydration and contribute to nasal and sinus swelling (AAFP 2008; Mayo Clinic 2012b).
  • Eat a healthy, well-balanced diet, which includes plenty of fruits and vegetables; a diet rich in antioxidants may boost immune function and help fight infection (NIH 2012).
  • Try steam inhalation 3-4 times daily to open sinus passages, which can reduce pain and help clear mucus (AAFP 2011). This can be done by draping a towel over the head and inhaling rising steam from a bowl of hot water (Mayo Clinic 2012b). Breathing in the warm, moist air of a hot shower or use of a humidifier may also be beneficial (AAFP 2011; Mayo Clinic 2012b; NIH 2012).
  • Apply a warm, damp towel to painful sinus areas several times a day (AAFP 2008; Mayo Clinic 2012b; NIH 2012).
  • Rinse out nasal passages with a saline nasal spray several times a day. This helps to reduce congestion by loosening mucus and cleaning out sinuses and nasal passages (AAFP 2008, 2011; Balkissoon 2010; Mayo Clinic 2012b; NIH 2012). This technique may also have a moisturizing effect, which can reduce the crusting of nasal secretions (Balkissoon 2010). Nasal irrigation with a sea salt solution appears to be as effective as saline nasal wash and topical nasal steroids for the management of chronic rhinosinusitis (Friedman 2006, 2012).

Treatment with one or more of the following medications may also help:

  • Decongestants – Also known as α-adrenergic agonists, decongestants cause blood vessel constriction, thereby reducing airway resistance by increasing the size of the airway lumen (Balkissoon 2010; DeMuri 2009; Corboz 2008). Oral decongestants such as pseudoephedrine (eg, Sudafed™) are less potent than topical nasal decongestant sprays such as oxymetazoline (eg, Afrin™) and phenylephrine (eg, Neo-Synephrine™) (Balkissoon 2010). Unlike topical nasal decongestants, oral decongestants are associated with systemic side effects, including increased blood pressure, restlessness, insomnia, and urinary retention (Balkissoon 2010; DeMuri 2009). Although topical nasal decongestants are preferred for these reasons, their use should be limited to no more than 3-5 consecutive days. This is because they quickly induce tolerance, which means that higher and higher doses will be needed to achieve the same effect (Balkissoon 2010). Furthermore, if a nasal decongestant spray is overused and then abruptly stopped, an extreme increase in nasal congestion (ie, rebound congestion) may be experienced (Mayo Clinic 2012b; Balkissoon 2010). Similarly, continued overuse of nasal decongestant sprays can cause a phenomenon known as rhinitis medicamentosa, in which congestion worsens despite continued or even increased medication use (Doshi 2009).

  • Mild analgesics – Over-the-counter pain relievers such as aspirin, acetaminophen (Tylenol™), or ibuprofen (Advil™ or Motrin™) may be helpful for temporarily relieving sinus pain and headache (Mayo Clinic 2012b; AAFP 2008). Refer to the Acetaminophen and NSAID Toxicity protocol especially when using acetaminophen over an extended period.

  • Intranasal corticosteroids – Although nasal steroids may decrease the inflammatory response associated with sinusitis, clinical trials have shown conflicting results (DeMuri 2009). The Food and Drug Administration (FDA) has not approved their use for the treatment of acute sinusitis (Leung 2008). However, nasal steroids may still be of benefit, since they are able to decrease swelling of the sinus passages associated with allergies and allow the sinuses to drain (NIAID 2012). As a result, nasal steroids may be of benefit to individuals whose nasal allergies (eg, hay fever) predispose them to developing sinusitis (DeMuri 2009).

  • Antibiotics – Although bacterial sinusitis is less common and more severe than viral sinusitis, it may resolve without the need for antibiotics (Mayo Clinic 2012b). As a result, sinusitis treatment guidelines do not recommend taking antibiotics within the first week of illness, unless the symptoms are particularly severe (eg, high fever or extreme pain). The cautious use of antibiotics for the treatment of sinusitis is warranted because they are not usually helpful, and are also associated with negative side effects, antibiotic resistance, and increased medical costs (Smith 2012). If deemed necessary,  antibiotics that  may be prescribed include amoxicillin, doxycycline, and trimethoprim-sulfamethoxazole (Mayo Clinic 2012b). A typical course of antibiotic treatment for severe bacterial sinusitis will last for 10-14 days, and should not be discontinued early just because the symptoms have resolved (Balkissoon 2010).

Surgical intervention is usually a last resort, and thus reserved for cases of chronic sinusitis that have not responded to drug therapy (DeMuri 2009; NIAID 2012). For example, allergic fungal sinusitis represents up to 9% of all sinusitis cases requiring surgery (Schubert 2009). The goal of surgery is to improve drainage by removing or reducing sinus obstruction (NIAID 2012). Most surgical procedures for sinusitis are aided by endoscopic visualization (DeMuri 2009). Surgery can be performed to enlarge sinus openings, remove nasal polyps, and correct anatomical abnormalities (eg, deviated septum) (DeMuri 2009; NIAID 2012; NIH 2012). For most patients, surgery results in lasting symptom improvement and an increased quality of life (DeMuri 2009; NIAID 2012); however, symptoms may reoccur (NIAID 2012).

Drug-free sinusitis relief with therapeutic ultrasound

Chronic sinusitis is notoriously difficult to treat and causes significant suffering for those it afflicts. Antibiotics and/or corticosteroid therapies may fail to provide relief in some cases, leaving surgery as a last resort (Leung 2008).

Therapeutic ultrasound, in which low-frequency ultrasound waves are applied to the sinuses, appears to be an effective drug-free treatment for chronic, as well as acute sinusitis, with little potential for side effects (Patel 2012).

In a 2010 study on 22 subjects with a history of chronic rhinosinusitis that had failed aggressive medical management, therapeutic ultrasound 3 days per week for 6 sessions lead to a 34% improvement on a standardized assessment of sinusitis symptoms (Young 2010). A 2012 study on 30 chronic rhinosinusitis patients who received therapeutic ultrasound 3 days per week for 10 sessions revealed a reduction of sinusitis symptoms of up to 65% (Ansari 2012). A 2010 case report showed that this same treatment regimen resolved sinusitis symptoms in a patient who had been suffering from chronic sinusitis for a year. After the treatment the patient only experienced mild nasal obstruction (Ansari 2010). In a larger 2010 trial involving 42 subjects with acute sinusitis, therapeutic ultrasound administered for 4 consecutive days provided as much relief from symptoms as the antibiotic amoxicillin (Hosoien 2010).

Therapeutic ultrasound has been shown to disrupt biofilms (Karosi 2012). A Biofilm is a layer of mucus-like film secreted by some pathogens that helps infectious organisms colonize a surface. Organisms embedded in a biofilm are very difficult to eradicate. In the sinus cavities, biofilms appear to contribute to persistent infection and are associated with sinusitis (Biel 2011; Bezerra 2009). Therapeutic ultrasound appears to disrupt biofilm, which may contribute to its efficacy in relieving sinusitis symptoms (Karosi 2012; Patel 2012; Young 2010).