The medical-management-of-rhinosinusitis 1997-otolaryngology---head-and-neck-surgery


Published on

The medical-management-of-rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

The medical-management-of-rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

  1. 1. The medical management of rhinosinusitis MICHAELS. BENNINGER,MD,JACKANON, MD, and RICHARDL.MABRY,MD, Detroit, Michigan, Pittsburgh, Pennsylvania, and Dallas, Texas The management of rhinosinusitis depends on a number of variables related to the dura- tion and severity of symptoms in the individual patient. Furthermore acute rhinosinusitis is managed differently than chronic rhinosinusitis. Because a variety of conservative and pharmacologic interventions are available, the physician can find it difficult to develop a cohesive and logical approach to treatment. An understanding of the pathophysiology, microbiology, and natural history of rhinosinusitis is necessary to formulate the best treat- ment plan for the individual patient. (©tolaryngo[ Head Neck Surg ] 997;117:$41 -$49.) DEFINITIONS The Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery has established definitions and classified the various types of rhinosinusitis. 1 These classifications are criti- cal to understanding the possible treatments of rhinosi- nusitis in adults. In this discussion treatment recom- mendations are made for the specific diagnoses of acute rhinosinusitis, chronic rhinosinusitis, and acute exacer- bation of rhinosinusitis. Some or all of the treatments described may be recommended for individual patients based on a number of factors including the type of rhi- nosinusitis, concurrent medical conditions (e.g., aller- gic disease), severity of symptoms, and response to pre- vious treatment. Options for the treatment of rhinosinusi- tis based on clinical classification are listed in Table 1. PATHOPHYSIOLOGY The pathophysiology of rhinosinusitis is not perfect- ly clear and is likely to be multifactorial in most patients. Furthermore rhinosinusitis may be pathogeni- cally different in children than adults. Rhinosinusitis in children is usually the sequela of an acute upper respi- ratory tract infection.2 The incidence of upper respira- tory tract infections is higher in children tor a number of reasons, principally because lack of previous expo- From the Department of Otolaryngology-Head and Neck Surgery, (Dr. Benninger), Henry Ford Hospital, Detroit, University of Pittsburgh School of Medicine (Dr. Anon), Pittsburgh~ and Southwestern Medical Center (Dr. Mabry), Dallas. Reprint requests: Michael S. Benninger, MD, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202. Copyright © 1997 by the American Academy of O1olaryngology- Head and Neck Surgery Foundation, Inc. 0194-5998/97/$5.00 + 0 23/0/83515 sure makes them less immune to viruses that attack the upper respiratory tract and also because they are fre- quently in environments such as schools and day care centers in which close contact with other children facil- itates the transfer of infection. Upper respiratory tract infection leads to mucosa] swelling, which can obstruct sinus outflow, resulting in infection. In children the small size of the developing sinuses and the shorter distance between the mucosal surfaces of the ostia also seem to play a role in the development of rhinosinusitis after a viral upper respi- ratory tract infection. Because of the strong association of rhinosinusitis with this viral infection, several inves- tigators3,4 believe that, particularly in children, some episodes of rhinosinusitis may be self-limited and may not require aggressive medical management. A number of conditions can predispose an individual to have rhinosinusitis. Immunoglobulin deficiencies, whether transient or permanent, diminish the body's ability to combat infection. Because transient immunoglobulin deficiencies primarily occur in chil- dren, recurrent rhinosinusitis may require assessment in young patients. Disorders of mucociliary transport such as immotile cilia syndrome and cystic fibrosis are usu- ally identified in children after repeated episodes of pulmonary, sinus, or ear infections. Alterations in glan- dular secretions caused by cystic fibrosis can result in inspissated mucus that is difficult to clear.5 Stasis of such mucus may result in recurrent colonization and infection.6,7 In such cases it may be helpful to reduce mucus viscosity and improve mucus clearance. A role for allergies in the development of rhinosi- nusitis has been suggested but not proven. 8-m Antigen- antibody reactions result in the release of a number of mediators of inflammation, most prominently hista- mine. These mediators result in increased vascular per- meability, destabilized lysosomal membranes, and $4]
  2. 2. S42 BENNINGER,ANON, and MABRY Otolaryngology- Head and Neck Surgery September 1997 Table 1. Medical treatment options in rhinosinusitis General treatment Classification measures Antibiotics Acute adult rhinosinusitis + + Subacute adult rhinosinusitis + _+ Recurrent acute adult rhinosinusitis + + Chronic adult rhinosinusitis + __. Acute exacerbation of chronic adult + + rhinosinusitis Steroid Ipratropium nasal bromide Antihistamines spray nasal spray ± ± ± + + ± ± + ± + + ± + ± Systemic steroids Immunotherapy ± -- ± ± ± ± ± +, Beneficial; -, not beneficial; _+, beneficial in some cases. other reactions that produce inflammation and mucosal swelling. Such reactions can lead to obstruction of the sinus ostia, preventing mucus outflow. Ostial obstruc- tion results in a reduction in oxygen tension, changes in mucociliary transport, and a transudation of fluid into the sinuses.6,11Such an environment is suitable for bac- terial overgrowth. Prolonged obstruction results in mucus stasis with bacterial and occasionally fungal col- onization or infection. Anatomic factors occasionally play a significant, if not prominent, role in rhinosinusitis. Septal spurs or deviations, hypertrophic or paradoxic middle turbinates, and concha bullosa have been identified as anatomic abnormalities that can affect sinus ostia out- flow and result in rhinosinusitis.12,13 Sometimes anato- my is a cofactor in rhinosinusitis. In such cases the ostia are impinged upon but not permanently obstructed, so that minimal mucosal swelling or inflammation from an upper respiratory tract infection or an allergy intermit- tently obstructs the sinus and causes rhinosinusitis. Such cases may require surgical correction, but many can be treated medically in an effort to reduce the inflammatory or edematous component. Combined sur- gical and medical treatment may be necessary in some cases, or surgical correction of the anatomic abnormal- ity alone may be sufficient to prevent rhinosinusitis. MICROBIOLOGY Acute Rhinosinusitis The causative pathogens for acute rhinosinusitis have changed over the past 50 years. Whereas [3-hemolytic streptococci and pneumococci were the major organ- isms identified by aspiration of the maxillary sinuses in the 1940s, Streptococcus pneumoniae and Haemophilus influenzae are the predominant organisms currently found in patients with this infection. In 1981, Gwaltney et al) 4 reported the culture results for aspirates obtained in 113 patients with acute rhinosinusitis. Of 141 aspirates, 86 were positive, with S. pneumoniae present in 43% of aspirates and H. influenzae found in 31% of aspirates. Anaerobes were identified in 9% of the aspirates, Moraxella (Branhamella) catarrhalis was found in 5% of aspirates, and (z-hemolytic streptococci and S. aureus were each present in 3% of aspirates. The findings for 200 sinus aspirations performed in adults with acute rhinosinusitis were presented by Berg et al) 5in 1988. Pathogens were isolated in 87% of aspi- rates. Of these aspirates, 57% were positive for S. pneu- moniae, 22% for H. influenzae, 6% for [}-hemolytic streptococci, 7% for anaerobes, 2% for M. catarrhalis, and 2% for S. aureus. In 1988, Jousimies-Somer et al) 6 reported the cul- ture results for 339 sinus aspirates obtained in 238 young adult military personnel with acute maxillary rhinosinusitis. Cultures identified H. influenzae in 52% of aspirates, S. pneumoniae in 21% of aspirates, anaer- obes in 8% of aspirates, Streptococcus pyogenes in 6% of aspirates, and M. catarrhalis in 2% of aspirates. The authors noted that some of the sinus aspirates contained more than one pathogen. The efficacies of cefuroxime axetil and cefaclor in patients with acute rhinosinusitis were evaluated by Syndnor et al) 7 in 1989. The pathogens most common- ly isolated were H. influenzae and S. pneumoniae, which were found in, respectively, 38% and 37% of sinus aspirates. The percentages for the less common pathogens were similar to those reported in previous studies. Based on their 15-year experience and a review of the literature, Gwaltney et al) 8reported on 339 patients with acute rhinosinusitis in 1991. The bacterial recov- ery rate for sinus puncture and aspiration was 59%. Of the aspirate cultures, 41% were positive for S. pneumo- niae, 35% for H. influenzae, 7% for anaerobes, 7% for Streptococcus species, 4% for M. catarrhalis, and 3% for S. aureus. The authors noted that viruses were cul- tured from some of the sinuses. In a 1996 review of the literature, Brook19 reported that in acute sinus infections, cultures identified S.
  3. 3. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 BENNINGER,ANON, and MABRY $43 pneumoniae in 41% of aspirates, 14. influenzae in 35% of aspirates, anaerobes such as Peptostreptococcus species in 7% of aspirates, and M. catarrhalis in 4% of aspirates. In chronic rhinosinusitis 67% of aspirates contained anaerobes (i.e., pigmented Prevotella and Porphyromonas species, Fusobacterium species, and Peptostrep~ococcus species), 4% contained S. aureus, 2% contained S. pneumoniae, and 2% contained /4. influenzae. In summary, a 1996 compilation of the results of a number of studies by Gwaltney~° showed the preva- lence of infective organisms in acute rhinosinusitis to be as follows: S. pneumoniae, 31% (range, 20% to 35%), unencapsulated H. influenzae, 21% (range, 6% to 26%), anaerobes, 6% (range, 0% to 8%), S. aureus, 4% (range, 0% to 8%), S. pyogenes, 2% (range, 1% to 3%), and M. catarrhalis, 2% (range, 2% to 10%). Viruses were also found in the cultures, often in conjunction with bacteria. Subocute Rhinosinusitis The microbiology of early subacute rhinosinusitis is probably comparable to that of acute rhinosinusitis. As subacute rhinosinusitis approaches a more chronic phase, the bacteriologic findings tend to be more like those for chronic rhinosinusitis. Chronic Rhinosinusitis With the development of rigid endc,scopes, the increased use of computed tomographic (CT) scanning, and a reevaluation of the pathophysiolog~, of rhinosi- nusitis, attention was focused away from the maxillary sinus and toward the ethmoid sinuses. In 1991, Doyle and Wooham2~prospectively examined the microbiolo- gy of the ethmoid sinuses at the time of surgery. Antibiotic therapy had been discontinued in the patients enrolled in this study. Of the 94 biopsy specimens col- lected from 59 patients, 73% contained coagulase-neg- ative Staphylococcus species, 33% exhibited S. aureus, 19% had enteric gram-negative bacteria, 4% contained H. influenzae, and 2% showed & pneumoniae. No anaerobes or viruses were found in the specimens, and only one CUlturegrew a fungus. A review of previously published reports compared the bacteriology of chronic maxillary sinusitis and chronic ethmoid sinusitis. The following pathogens were more commonly cultured from the maxillary sinuses than from the ethmoid sinus- es: S. pneumoniae (6% vs 2%), H. influenzae (19% vs 4%), anaerobes (72% vs 0%), and Streptococcus viri- dans (32% vs 9%). In contrast, the pathogens more fre- quently found in ethmoid sinus cultures than in maxil- lary sinus cultures were as follows: S. aureus (33% vs 6%), coagulase-negative Staphylococcus species (71% vs 11%), and Enterobacteriaceae organisms (19% vs 2%). In 1992, Hoyt22 cultured mucosa removed from 197 patients at the time of surgery. The culture results showed coagulase-negative Staphylococcus species in 47% of specimens, S. aureus in 23% of specimens, S. pneumoniae in 7% of specimens, and H. influenzae in 3% of specimens. None of the anaerobic cultures was positive. In 28% of cultures more than one bacterial species was found. During office endoscopy in 47 patients with chronic rhinosinusitis, Bolger23 obtained swab cultures of pathologic secretions at the sinus ostia, within the eth- mold recesses, or in a postoperative cavity. Of the 98 cultures obtained, 14 showed no growth, 44 contained only one organism, and 34 grew more than one bacter- ial species. Coagulase-negative Staphylococcus species were present in 24% of positive cultures, S. aureus in 16% of cultures, Pseudornonas aeruginosa in 16% of cultures, other enteric gram-negative bacteria in 31% of cultures, and anaerobes in 4% of cultures. In this 1994 article the author theorized that the high incidence of gram-negative enteric organisms in these patients could be explained by their recent use of antibiotic therapy, their use of nasal steroids, and changes in tile local immunity of the area caused by previous bacterial infections. In 1994, Brook, et al.24 published a retrospective study of 68 patients who had undergone Caldwell-Luc procedures and had not received antibiotics before surgery. (z-hemolytic streptococci, S. aureus, M. catarrhalis, and Haemophilus species were the primary aerobic/facultative organisms isolated. Anaerobes were found in 82% of specimens. During endoscopic sinus surgery in 76 patients, Ramadan25 obtained tissue for cultures to study the microbiology of chronic rhinosinusitis. Although the patients had been receiving medical treatment includ- ing antibiotics, they were given no antibiotic therapy for the week before surgery. Of the positive cultures in this 1995 study, 80% grew coagulase-negative Staphy- lococcus species, 2I% grew S. aureus, 8% grew anaer- obes, and 4% grew S. pneumoniae. Miscellaneous organ- isms constituted the remainder of the pathogens that were isolated. In a 1996 study of 46 patients who underwent endo- scopic surgery, Rontal et al.26 reported that 31% of cul- tures grew coagulase-negative Staphylococcus species, 9% grew S. aureus, and 7% grew S. viridans. Other aer- obes were infrequent, but mixed organisms were seen in 17% of cultures. Only 4% of the cultures grew anaerobes. In summary, the major pathogens in chronic rhino- sinusitis appear to be as follows: coagulase-negative
  4. 4. $44 BENNINGER,ANON, and MABRY Otolaryngology- Head and NeckSurgery September 1997 Staphylococcus species, 51% (range, 24% to 80%), S. aureus, 20% (range, 9% to 33%), anaerobes, 3% (range, 0% to 8%, not including the work from Brook19), and S. pneumoniae, 4% (range, 0% to 7%). On average, multi- ple organisms are found in 16% of cultures. The microbiology of chronic maxillary sinusitis appears to be different from that of chronic ethmoid sinusitis. As several authors point out, a higher inci- dence of anaerobes in chronic maxillary sinusitis may reflect the greater degree of occlusion of this particular sinus and thus a more closed-offanaerobic environment compared with the more open ethmoid sinus. GENERAL TREATMENT MEASURES A number of general treatment measures are impor- tant in patients with rhinosinusitis. Many of these mea- sures are directed at establishing a more normal nasal environment through moisturization, humidification, and the reduction of swelling. Because mucociliary transport depends in part on the viscosity of mucus, efforts to reduce this viscosity have also been advocat- ed. Saline solution nasal sprays have been shown to reduce the symptoms of both allergic and nonallergic rhinitis,27 and they are likely to be beneficial in rhino- sinusitis as well. Saline solution moisturizes the nasal cavity, reduces dryness, and helps to clear inspissated or crusty mucus. Nasal irrigation with saline solution douches has also become important for clearing nasal crusts and thick mucus in patients with rhinosinusitis, particularly after surgery.28-3° Some investigators have advocated the addition of vinegar or acetic acid to reestablish a more normal pH or the addition of hydro- gen peroxide to help clean the nose and sinuses, although the value of these measures has not been clearly demonstrated. Because saline solution sprays or irrigations are inexpensive and have few to no adverse effects, it is reasonable to include them in the treatment of most patients with rhinosinusitis. Humidification may also be an important and simple measure to include in the treatment regimen for rhino- sinusitis. In dry environments mucociliary transport is slowed and mucus becomes thickened. In such envi- ronments humidification is likely to be valuable. However, in patients who have mold allergies or who live in more humid environments, excessive humidifi- cation may increase inflammation, precipitating or worsening rhinosinusitis. Controversy exists as to whether warm or cool humidification is preferable. Although the use of warm mist has been advocated for reducing the symptoms of upper airway and rhinovirus infections, controlled studies have not shown a positive benefit.31,32In most patients humidification can help to control symptoms, and it can be considered as an adjunct to other treatments. This measure has few to no adverse effects. However, to reduce fungal overgrowth it is important to keep the humidifier clean. Mucolytic agents have been advocated for the pre- vention and treatment of rhinosinusitis. Mucolytics such as guaifenesin, a component of many deconges- tants and expectorants, serve to thin mucus, which may reduce mucus stasis and promote clearing. This is par- ticularly important in disorders of mucociliary clear- ance and disorders in which there is a reduction or thickening of glandular secretion such as cystic fibro- sis.5 In experimentally induced sinusitis mucociliary clearance has been found to be reduced because of alterations in both mucus and cilia.6,H,33 Therefore mucolytics should be beneficial in most patients with rhinosinusitis. One double-blind, placebo-controlled study34 found that guaifenesin reduced nasal conges- tion and posterior nasal drainage in patients with human immunodeficiency virus infection who had either acute or chronic rhinosinusitis. DECONGESTANTS Systemic and topical decongestants act through stimulation of c~-adrenergic receptors in the mucosa of the upper airways. Stimulation of these receptors results in vasoconstriction of the mucosal capillaries with subsequent shrinking of swollen or edematous mucosa.35Decongestion would be expected to decrease nasal swelling and obstruction, to restore the patency of the ostia, and to improve ventilation. Consequently, decongestants are often advocated for the prevention or treatment of rhinosinusitis. Topical decongestants, particularly oxymetazoline hydrochloride, generally provide rapid and significant relief of nasal obstruction with minimal systemic effects. Whether the reduction in nasal swelling has a positive effect on rhinosinusitis is debatable. Based on experiments in a rabbit model, Bende et al.36 recently suggested that topical decongestants may actually have a negative effect.36 In this study histologic sections of rabbit sinuses obtained after the induction of sinusitis and treatment with nasal oxymetazoline were actually found to have a significantly greater degree of inflam- mation than sections from untreated sinuses on the opposite side. The authors postulated that decongestant nasal sprays may interfere with the normal defense mechanisms during bacterial-induced sinusitis, possi- bly by decreasing mucosal blood flow. Despite such reservations, topical decongestants will usually reduce symptoms and speed recovery in patients with rhinosi- nusitis. Given the significant rebound potential with long-term use, these agents are likely to be most effec-
  5. 5. Otolaryngo~ogy- Head and Neck Surgery Volume 117 Number 3 Part2 BENNINGER,ANON,and MABRY $45 tive in patients with acute rhinosinusitis, acute exacer- bation of chronic rhinosinusitis, or recurrent acute rhi- nosinusitis. Systemic decongestants are also used to treat many patients with rhinosinusitis. Because rhinosinusitis involves inflammation of the nose and the sinuses, nasal obstruction and drainage are common symptoms. Systemic decongestants help to alleviate these bother- some symptoms. Furthermore, unlike many antihista- mines, systemic decongestants have minimal drying side effects and thus are less likely to impede mucus transport. The addition of a mucolytic can aid mucus clearance by thinning the mucus. Oral decongestants should be used with caution in patients with medical conditions such as hypertension, ischemic heart disease, hyperthyroidism, and diabetes mellitus and in patients who are taking monoamine oxi- dase inhibitors. Whether oral decongestants speed the resolution of rhinosinusitis is debatable. Nonetheless, given the low risk, controllable side effects, relatively low cost, and benefits in symptom reduction, the use of decongestants seems to be warranted in some, if not many, patients with rhinosinusitis. ANTIHISTAMINES For many years physicians have intuitively used antihistamines to manage chronic rhinosinusitis in patients with coexisting allergy.37-4°However, no stud- ies clearly show a positive effect for antihistamines in this situation.41 Although numerous clinical trials have supported the efficacy of antihistamines in reducing the sneezing and rhinorrhea associated with allergic rhinitis, the mechanism by which these agents produce symptom relief is still incompletely understood. The classic explanation, based on in vitro studies, is competitive antagonism of histamine binding to H1 receptors on nerve endings, smooth muscle cells, and glandular cells. In addition, antihistamines have been shown to exhibit other mechanisms of action. Virtually all first- generation compounds have anticholinergic (antimus- carinic) action. Some also have sedative, local anes- thetic, and antiserotonin effects. Specific :in vivo studies of a number of individual antihistamine preparations have demonstrated their individual unique properties beyond and sometimes instead of "antihistamine" activity.42Azatadine maleate has been shown to have leukotriene-inhibiting proper- ties in vitro but only at concentrations that would be difficult to obtain with oral administration.43 In vivo studies have demonstrated leukotriene inhibition by azelastine44 and cetirizine45 without a significant effect on histamine and prostaglandin D2 generation. In a study measuring the effects of various agents on hista- mine release, leukotriene generation, and hyperrespon- siveness to methacholine, Naclerio and Baroody42 found differing mechanisms of action for azelastine, cetirizine, ketotifen, levocabastine, loratadine, and ter- fenadine. Because it now appears that antiallergy and antiinflammatory effects are produced in different fash- ions by various antihistamines, these drugs may not be simply antiallergy medications. More studies are required to determine whether these effects are relevant in the treatment of chronic sinusitis. In particular, antihistamines appear to be useful for preventing or treating acute allergic flares in patients with both allergy and chronic rhinosinusitis. Because the allergic reaction results in hypersecretion and local edema, which may, in turn, lead to stasis within the sinuses, prevention of this situation may avoid setting up favorable circumstances for the development of a secondary infection within the diseased sinuses.46This scenario can be prevented with antihistamines and other medications. One factor to be considered in administering antihis- tamines to patients with sinusitis is whether the anti- cholinergic effects of these drugs, especially the first- generation compounds, might result in the excessive drying of nasal and sinus secretions, leading to crust formation and stagnation within the sinuses. Because the newer second-generation antihistamines typically are free of undesirable anticholinergic effects, these agents can be used to relieve symptoms in patients with both allergy and rhinosinusitis.47 TOPICAL NASAL STEROIDS Topical nasal steroids are beneficial in a variety of acute and chronic nasal conditions including allergic and nonallergic rhinitis and chronic rhinosinusitis. It appears that these agents reduce the sensitivity of cholinergic receptors (thereby decreasing the secretory response), reduce the number of basophils in nasal epithelium and eosinophils in mucosa, and inhibit the late-phase reaction after exposure to allergenY ,48,49 Beclomethasone dipropionate, budesonide, flu- nisolide, fluticasone dipropionate, and triamcinolone acetonide do not have significant systemic effects when properly dosed. The multiple preparations and delivery systems that are now available allow the physician and patient great flexibility in nasal steroid treatment. When used as an adjunct to antibiotic therapy, nasal steroids have been shown to improve symptoms, to decrease the volume of inflammatory cells, and to aid in the regression of radiographic abnormalities. 5° Nasal steroid sprays are recommended before surgical intervention.
  6. 6. S46 BENNINGER,ANON, and MABRY Otolaryngology- Head and NeckSurgery September 1997 Nasal sprays containing ipratropium bromide have a different mechanism of action than those containing steroids. Ipratropium bromide, a topical anticholinergic agent that blocks glandular cholinergic receptors, has been found to reduce glandular hypersecretion and sneezing in patients with allergic rhinitis, nonallergic rhinitis, and the common cold.51-53Because this agent does not dramatically decrease nasal airway resistance, it should be used primarily for reducing the symptoms of nasal drainage in patients with rhinosinusitis. Ipratropium bromide may theoretically increase the vis- cosity of mucus, which may be counterproductive in some patients with rhinosinusitis, particularly those with acute rhinosinusitis. This effect appears to be min- imal compared with the effects that antihistamines have on mucus viscosity. Although ipratropium bromide has been shown to be beneficial in reducing the symptoms of the common cold, no studies have been done to val- idate its efficacy in rhinosinusitis. Nonetheless, ipra- tropium bromide nasal spray may be a useful adjunct in the treatment of rhinosinusitis. Cromolyn sodium acts to stabilize mast cells, pre- venting degranulation and the release of inflammatory mediators. Because this medication has no effect on the inflammatory process once it has occurred, it is best used before antigen exposure. Cromolyn sodium appears to have only minimal efficacy in patients with rhinosinusitis. This agent may, however, be useful in allergic patients with continued antigen exposure dur- ing an episode of rhinosinusitis. It may also help to pre- vent ostial occlusion, which could result in the devel- opment of rhinosinusitis. SYSTEM CORTICOSTEROIDS Oral corticosteroids have been very effective in managing the effects of a variety of inflammatory con- ditions including allergic rhinitis. By keeping capillary permeability from increasing, steroids prevent or reduce tissue edema. They deplete circulating eosinophils and T lymphocytes by redistribution of these into other compartments. They also serve to inhibit the production of many mediators of inflamma- tion including prostaglandins, lymphokines, leukotrienes, bradykinins, serotonin, and interferon.54 Lysosomal membranes are also stabilized.54'55 Steroids have been shown to be effective in treating allergic rhinitis, reduc- ing nasal polyposis, and treating allergic fungal dis- ease.54They are of great benefit in allergic patients with chronic rhinosinusitis and in patients with chronic rhi- nosinusitis and nasal polyposis. By reducing tissue edema and preventing the release of inflammatory mediators, systemic steroids are also likely to benefit patients with acute rhinosinusitis. However, given the relatively rapid response of patients with uncomplicat- ed acute rhinosinusitis to other less risky medications, the routine use of systemic corticosteroids for acute rhi- nosinusitis should be avoided. The predominant disadvantage of systemic corticos- teroids is that they suppress the hypothalamic-pituitary- adrenal axis. Long-term use of these agents has been associated with adrenal suppression. Furthermore the sudden discontinuation of steroids after long-term use results in adrenal insufficiency, which can be life- threatening. Even without a tapering dose the risk of such side effects is minimal with the short-term sys- temic corticosteroid therapy typically recommended for patients who have rhinosinusitis. When steroid therapy is used for more than 1 or 2 weeks, tapering doses are recommended. Note, however, that specific recommen- dations concerning the duration of steroid use that requires tapering doses vary among authors and studies. The more common side effects of short:term sys- temic corticosteroid therapy include mucosal itching, superficial gastric ulcerations, changes in affect or tem- perament, sleep disturbances, and, occasionally, prema- ture ventricular contractions.54 Because systemic corti- costeroids may alter insulin requirements, they should be used cautiously in patients with diabetes mellitus. With longer use these agents have more significant side effects including osteoporosis, myopathy, peptic ulcer disease, hypertension, ocular effects, and weight gain.54 Susceptibility to infection, which is known to increase with long-term steroid therapy, probably has only theo- retic implications in short-term therapy, but it should be considered, particularly in patients with acute rhinosi- nusitis. ANTIBIOTICS Although direct aspiration for culture is not needed routinely in patients with acute rhinosinusitis, cultures should be performed in all immunocompromised patients. Culture specimens obtained from the middle meatus under endoscopic guidance may provide useful information. The persistence of symptoms or an increase in symptoms during therapy implies treatment failure. In such cases further diagnostic studies includ- ing culture would be appropriate. As mentioned earlier, the causative organisms in rhi- nosinusitis have changed over the years. Furthermore the resistance patterns of the bacteria found in acute and chronic rhinosinusitis have led to changes in the antibi- otics chosen to combat these illnesses. ACUTE RHINOSINUSITIS Because up to 70% of acute rhinosinusitis cases are caused by either S. pneumoniae or H. influenzae, antibiotic therapy should be directed at these organ- isms. Because of the increased incidence of ~-lacta-
  7. 7. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 BENNINGER,ANON, and MABRY 547 mase-producing pathogens and drug-resistant S. pneu- moniae strains in acute rhinosinusitis, careful consider- ation should be used when selecting the most appropri- ate antibiotic. The duration of therapy should between 10 and 14 days. The Food and Drug Administration -as of January 1997- has approved amoxicillin-clavulonate, clar- ithromycin, cefprozil, cefuroxime axelil, loracarbef, and levofloxacin for the treatment of rhinosinusitis. Members of the Academy's Rhinosinusitis Task Force use a variety of oral antibiotics for treating rhinosinusitis. Antibiotics that are considered to be effective for the empiric treatment of acute rhinosinusitis include amoxi- cillin, amoxicillin-clavulanate, azithromycin, cefpo- doxime proxetil, cefprozil, cefuroxime axetil, clar- ithromycin, levofloxacin, loracarbef, and trimetho- prim/sulfamethoxazole. The choice of a specific antibi- otic should be based on factors that include previous antibiotic therapy, information about the resistance pat- terns of the pathogenic organisms within the physi- cian's community, dosing schedules, side effects, and the patient's drug allergy history. Penicillin, ery- thromycin, cephalexin, and tetracycline should not be used, because these drugs do not cover the major organ- isms that cause acute rhinosinusitis. CHRONIC RHINOSINUSITIS Antibiotic therapy for chronic rhinosi~usitis should be directed toward coagulase-positive and coagulase- negative Staphylococcus species and Streptococcus species. The necessity for anaerobic coverage is contro- versial. The currently recommended duration of antibi- otic therapy for chronic disease is 4 to 6 weeks, but studies are in progress to determine the optimal length of treatment. Members of the Task Force use a similar antibiotic selection as for acute rhinosinusitis. It is rea- sonable to consider the use of clindamycm or metro- nidazole alone or in combination with other antibiotics. IMMUNOTHERAPY Based on experience, immunotherapy is also viewed as being important in controlling allergies to prevent the recurrence of chronic rhinosinusitis after surgery. Unfortunately, as with antihistamines, no studies exist to support the benefits of immunotherapy. Nishioka et al.56 did show that allergic patients wl~o received immunotherapy had a better long-term omcome after endoscopic sinus Surgery than patients with untreated allergies. Although allergy has not been fully shown to be a contributing factor in chronic rhinosinusitis, most physicians believe that allergy does play a role in this infection. Some studies have found a higher, incidence of allergy in patients with sinus disease than in the gen- eral population. In a study in Finland, Savolainen57 reported allergy to be present in 25% to 32% of patients with verified acute maxillary sinusitis but in only 7% of control subjects. In another European study, however, Iwens and Clement58 found no difference in the inci- dence of sinusitis, as determined by CT scanning, in allergic and nonallergic children (61% and 64%, respectively) and adults (58.0% and 57.5%, respective- ly). Rachel&sky et al.59 found a 50% incidence of posi- tive skin tests to inhalant allergens in a large group of children with chronic sinusitis compared with a 15% to 30% incidence of allergy in the general population. Other studies and reviews of existing reports support this concordance of allergy and sinus diseases.6°'62 Allergy is generally considered to affect the sinuses through a combination of hypersecretion and obstruc- tion of the ostiomeatal complex caused by mucosal edema. The result is stasis within the sinuses) Studies using single-photon emission CT scanning have shown that pollens do not actually enter the sinuses.62Phillips and Platts-Mills63 believe that the mucosal thickening noted on CT scans in patients with allergic rhinosinusi- tis represents immunologically active tissue. The mechanism by which immunotherapy produces its effects remains a matter of debate and conjecture. The immunologic responses associated with allergen immunotherapy have been reported to be an increase in allergen-specific immunoglobulin G-blocking antibod- ies, an initial rise and then a drop in allergen-specific immunoglobulin E antibodies, a decrease in the release of basophil histamine in response to an allergen chal- lenge, an increase in allergen-specific suppressor T cells, and a decrease in the lymphocyte-cytokine response to an allergen challenge. 64 Whether immunotherapy has any direct effect on sinus mucosa has not been studied. However, the effectiveness of immunotherapy in ameliorating allergic symptoms per se has been demonstrated.65 Although no studies support the use of immunother- apy in the treatment of allergy coexisting with chronic sinus disease, the interrelationship of these entities is generally accepted. Therefore, when administered under the care of an appropriately trained physician, immunotherapy for inhalant allergens should be con- sidered a suitable measure in the overall management of chronic rhinosinusitis. REFERENCES 1. Lanza DC, Kennedy-DW. Task Force on Rhinosinusitis Research.Adultrhinosinasitisdefined.OtolaryngolHeadNeck Surg.1997;117:S1-$7. 2. GiebinkGS.Criteriaforevaluationof antimicrobialagentsand currenttherapiesfor acutesinusitisin children.CtinInfectDis 1992;14(Suppl2):$212-5.(gradeB)
  8. 8. $48 BENNINGER,ANON,and MABRY Otolaryngology- Head and Neck Surgery September 1997 3. Otten HW, Antvelilnk JB, Rayter de Wildt H, et al. Is antibiotic treatment of chronic sinusitis effective in children? Clin Otolaryngol 1994;19:215-7. (grade A) 4. Dohlman AW, Hemstreet MP, Odrezin GT, et al. Subacute sinusitis: are antimicrobials necessary? J Allergy Clin Immunol 1993;91:1015-23. (grade A) 5. Davidson TM, Murphy C, Mitchell M, et al. Management of chronic sinusitis in cystic fibrosis. Laryngoscope 1995;105:354- 8. (grade C) 6. Benninger MS, Schmidt JL, Creasman JD, et al. Mucociliary function after sinus mucosal regeneration. Otol Head Neck Surg 1991;105:641-8. (grade A) 7, Scadding GK, Lund VJ, Darby YC. The effect of long-term antibiotic therapy upon ciliary beat frequency in chronic rhino- sinusitis. J Laryngol Otol 1995;109:24-6. (grade A) 8. BenningerMS. Rhinitis, sinusitis and their relationships to aller- gies. Am J Rhinol 1992;6:37-43. (grade B) 9. Slavin R. Sinusitis in adults and its relation to allergic rhinitis, asthma and nasal polyps. J Allergy Clin Immunol 1985;82:950- 5. (grade B) 10. Druce HM, Cislunar MA. Allergic rhinitis. JAMA 1988;259:260-3: (grade C) 11. Hinni ML, McCaffrey TV, Kasperbower JL. Early mucosal changes in experimental sinusitis. Otolaryngol Head Neck Surg 1992;107:537-48. (grade A) 12. Kennedy DW, Zinreich SJ, Rosenbaum AE, et al. Functional endoscopic sinus surgery: theory and diagnostic evaluation. Arch Otolaryngol 1985;111:576-82. (grade C) 13. Stammberger H. Endoscopic endonasal surgery--concepts in treatment in recurring rhinosinusitis.Part I: Anatomic and patho- physiologic considerations. Otolaryngol Head Neck Surg 1986;94:143-7. (grade C) 14. Gwalmey JM, Sydnor A, Sande MA. Etiology and antimicrobial treatment of acute sinusitis. Ann Otol Rhinol Laryngol 1981;90:68-71. (grade A) 15. Berg O, Carenfelt C, Kronvall G. Bacteriology of maxillary sinusitis in relation to character of inflammation and prior treat- ment, Scand J Infect Dis 1988;20:511-6. (grade A) 16. Jousimies-Somer HR, Savolainen S, Ylikoski IS. Bacteriological findings of acute maxillary sinusitis in young adults. J Clin Microbiol 1988;26:1919-25. (grade A) 17. Sydnor A, Gwaltney JM, Cocchetto DM, et al. Comparative evaluation of cefuroxime axetil and cefaclor for treatment of acute bacterial maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1989;115:1430-3. (grade A) 18. Gwalmey JM, Scheld WM, Sande MA, et al. The microbial eti- ology and antimicrobial therapy of adults with acute communi- ty-acquired sinusitis: a fifteen-year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992;90:457-62. (grade A) 19. Brook I. Microbiology and management of sinusitis. J Otol 1996;25:249-56, (grade C) 20. Gwaltney JM. Acute community-acquired sinusitis. Clin Infect Dis 1996;23:1209-25. (grade C) 21. Doyle PW, Wooham JD. Evaluation of the microbiology of chronic ethmoid sinusitis. J Clin Microbiol 1991;29:2396-400. (grade A) 22. Hoyt WH. Bacterial patterns found in surgery patients with chronic sinusitis. J Am Osteopath Assoc 1992;92:205-12. (grade A) 23. Bolger WE. Gram negative sinusitis: an emerging clinical enti- ty? Am J Rhinol 1994;8:279-84. (grade B) 24. Brook I, Thompson DH, Frazier EH. Microbiology and manage- ment of chronic maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1994;120:1317-20. (grade B) 25. Ramadan ttH. What is the bacteriology of chronic sinusitis in adults? Am J Otolaryngol 1995;16:303-6. (grade A) 26. Rontal M, Bernstein J, Rontal E, Anon J. Bacteriologic findings from the nose and bloodstream during endoscopic sinus surgery. Presented at the Cottle InternationalRhinology Centennial, June 5-8, 1997, Philadelphia, Pa. (grade A) 27. Nuutinen J, Holopainen E, Haaketela T, et al. Balanced physio- logic saline in the treatment of chronic sinusitis. Rhinology 1986;24:265-9. (grade B) 28. Pigret D, Jankowski R. Management of post-ethmoidectomy crust formation: randomized single-blind clinical trial compar- ing pressurized seawater versus antiseptic/mucolytic saline. Rhinology 1996;34:38-40. (grade A) 29. Ryan RM, Whittet HB, Norval C, et al. Minimal follow-up after functional endoscopic sinus surgery. Does it affect outcome? Rhinology 1996;34:44-5. (grade B) 30. Benninger MS, Mickelson SA, Yaremchuk K. Functional endo- scopic sinus surgery; morbidity and early results. Henry Ford Hospital Med J 1990;38:5-8. (grade B) 31. Hendley It, Abbott RD, Beasley PP, et al. Effect of inhalation of hot, humidified air on experimental rhinovims infection. /AMA 1994;271:1112-3. (grade A) 32. Forstall GJ, Macknin ML, Yen-Lieberman BR, et al, Effect of inhaled heated vapor on symptoms of the common cold. JAMA 1994;271:1109-11. (grade A) 33. Benninger MS, Kaczor J, Stone C. Natural ostiotomy vs inferior antrostomy in the management of sinusitis. An animal model. Otolaryngol Head Neck Surg 1993;109:1034-42. (grade A) 34. Wawrose SF, Tami TA, Amoils CR The role of guaifenesinin the treatment of sinonasal disease in patients infected with the human immunodeficiency virus (HIV). Laryngoscope 1992;102:1225-8. (grade A) 35. DelaFuente JC, Davis TA, Davis JA. Pharmacotherapy of aller- gic rhinitis. Clin pharmacol Ther 1989;8:474-85. (grade C) 36. Bende M, Fukami M, Arfars KE, et al. Tile effect of oxymetazo- line nose drops on acute sinusitis in the rabbit. Ann Otol Rhinol Laryngol 1996;105:222-5. (grade A) 37. Calhoun K. Diagnosis and management of sinusitis in the allergic patient. Otolaryngol Head Neck Surg 1992;107:850-4. (grade C) 38. Friedman WH, Katsantonis GR Bumpous GM. Staging of chronic hyperplastic rhinosinusitis: treatment strategies. Otolaryngol Head Neck Surg 1995;112:210-4. (grade C) 39, Druce HM. Adjuncts to medical management of sinusitis. Otolaryngol Head Neck Surg 1990;103:880-3. (grade C) 40. Mabry RL. Therapeutic agents in the medical management of sinusitis. Otolaryngol Clin North Am 1993;26:561-70. (grade C) 41. Zeiger RS. Prospects for ancillary treatment of sinusitis in the 1990's. J Allergy Clin Immunol 1992;90:478-95. (grade B) 42. Naclerio RM, Baroody FM. H1receptor antagonists: antiallergic effects in humans. In: Simons FER, editor. Histamine and H1- receptor antagonists in allergic disease. New York: Marcel Dekker, Inc, 1996:145-74. (grade C) 43. LichtensteinLM, Gillespie E. The effects of the H1and H2 anti- histamines on "allergic" histamine release and its inhibition by histamine. J Pharmacol Exp Ther 1975;192:441-50. (grade A) 44. Shin M-H, Baroody F, Proud D, et al. The effect of azelastine on the early allergic response. Clin Exp Allergy 1992;22:289-95. (grade B) 45. Naclerio RM, Proud D, Kagey-Sobotka A, et al. The effect of cetirizine on early allergic response. Laryngoscope 1989;99:596-9. (grade B) 46. Mabry RL. Interface of allergy and sinus disease. Dallas Med J 1991;77:352-4. (grade C) 47. Simons FER. Evolution of H1 receptor antagonist treatment. Ann Allergy 1993;71:282-7. (grade B) 48. Pipkorn U, Proud D, Lichtenstein LM, et al. Inhibition of medi- ator release in allergic rhinitis by pretreatment with topical glu- cocorticosteroids. N Engl J Med 1987;316:1506-10. (grade A) 49. Paurvels R. Mode of action of corticosteroids in asthma and rhinitis. Clin Allergy 1986;16:281-8. (grade C) 50. Meltzer El?,Orgel HA, Backhans JW, et al. Intranasal flunisolide spray as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol 1993;92:812-23. (grade A)
  9. 9. Otolaryngology- Head and Neck Surgery Volume 117 Nucnber 3 Part 2 BENNINGER,ANON, and MABRY $49 51. Hayden FG, Diamond L, Wood PB, et al. Effectiveness and safe- ty of intranasal ipratropium bromide in common colds. A ran- domized double-blind, placebo-controlled trial. Ann Intern Med 1996;125:89-97. (grade A) 52. Georgites JW, Banov C, Boggs PB, et al. Ipratropium bromide nasal spray in non-allergic rhinitis: efficacy, nasal cytological response and patient evaluation on quality of life. Clin Exp Allergy 1994;24:1049-55. (grade A) 53. Kaiser HB, Findlay SR, Georgitis JW, et al. Long-term treatment of perennial allergic rhinitis with ipratropium bromide nasal spray 0.06%. J Allergy Clin Immunol 1995;95:1128-32. (grade A) 54. Nadol DM. The use of systemic steroids in otolaryngology. Ear Nose Throat J 1996;75:502-16. (grade C) 55. Melby JC. Systemic corticosteroid therapy: pharmacology and endocrinologic considerations. Ann Intern Med 1974;81:505-12. (grade C) 56. Nishioka GJ, Cook PR, McKinsey JR Immunotherapy in patients undergoing functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 1994;110:406-12. (grade B) 57. Savolainen S. Allergy in patients with acute maxillary sinusitis. Allergy 1989;44:116-22. (grade B) 58. Iwens R Clement PA. Sinusitis in allergic patients. Rhinology 1994;32:65-7. (grade B) 59. Rachelefsky G, Siegel SC, Katz RM, et al. Chronic sinusitis in children [Abstract]. J Allergy Clin ImmunoI 1991;87:219. (grade C) 60. Shapiro GG, Virant FS, Furukawa CT, et al. Immunologic defects in patients with refractory sinusitis. Pediatrics 1991;87:311-6. (grade B) 61. Furukawa CT. The role of allergy in sinusitis in children. J Allergy Clin Immunol 1992;90:5 t5-7. (grade B) 62. Spector SL. The role of allergy in sinusitis in adults. J Allergy Clin Immunol 1992;90:518-20. (grade B) 63. Phillips CD, Platts-Mills TA. Chronic sinusitis: relationship between CT findings and clinical history of asthma, allergy, eosinophilia, and infection. Am J Roentgenol 1995;164:185-7. (grade B) 64. Fireman R Allergic rhinitis. In: Fireman P, Slavin RG, editors. Atlas of allergies. 2nd ed. St Louis: Mosby-Wolfe, 1996:141-59. (grade C) 65. Gordon BR. Allergy skin tests and immunotherapy: comparison of methods in common Use. Ear Nose Throat J 1990;69:47-62, (grade C)