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October 2009

Treatment Options for Chronic Sinusitis

Andrew H. Murr, M.D.
Otolaryngologist
Vice Chair of Otolaryngology – Head and Neck Surgery

Sinusitis is the most common chronic condition for which patients seek treatment, with an annual treatment cost of $3 billion. It also can be difficult to accurately diagnose due to the ubiquitous nature of the condition's symptoms that replicate those of many others, including asthma, nasal polyps, the common cold, tooth abscess and pregnancy.

Sinusitis — both acute and chronic — is typically diagnosed based on a physical exam and symptoms. Although this does not confirm a diagnosis and whether the infection is bacterial, antibiotics are commonly prescribed.

About 60 to 70 percent of patients, however, recover from an acute sinus infection without antibiotics. For chronic sinusitis, patients are typically prescribed a minimum of three weeks of antibiotics, which costs around $300.

Diagnosis

Considering the cost and risks associated with the repetitive use of antibiotics, it is recommended that if after the first empiric therapy, no improvement is seen or the patient's condition worsens, a definitive diagnostic evaluation using one of the following techniques is conducted before further antibiotics are prescribed:

  • Limited CT scan of the paranasal sinuses with a specific algorithm that is not conducted with contrast
  • Endoscopic exam, using fiber-optic equipment of the nasal cavity and sinuses

It is important to note that the cost of a CT scan of the paranasal sinuses costs an average of $300 — the same as a standard course of antibiotics — and has the added benefit of offering a definitive diagnosis without incurring any risk to the patient.

Treatment

Acute rhinosinusitis treament may include decongestants and the following:
  • Antibiotics — While 60 to 70 percent of patients recover from acute infection without antiobiotics, the treatment can shorten the duration of the infection and reduce its severity. Many strains of bacteria causing acute rhinosinusitis are resistant to amoxicillin.

  • Topical and Oral Corticosteroids — We now know that the pathophysiology of sinusitis closely resembles that of asthma, being more inflammatory than infectious in nature. Sinusitis is associated with sinus membrane edema that may compromise drainage from the sinus ostia.

    Oral corticosteroids may be beneficial by helping to restore the ostia. However, there is little information on the use of oral corticosteroids in acute rhinosinusitis; some experts do not recommend its use for fear that it may prolong an acute infection.

    Topical corticosteroids may be prescribed as an adjunctive treatment to help reduce nasal membrane swelling.

Chronic rhinosinusitis treatment may include decongestants and the following:

  • Antibiotics — Amoxicillin/clavulanate, clarithromycin, fluoroquinolones and various cephalosporins are commonly used. There is no consensus as to which drug is most effective. Most experts advocate treatment with antibiotics for a minimum of three weeks.

  • Antihistamines — Antihistamines are recommended if there is an underlying allergy or symptoms consistent with allergy.

  • Oral Corticosteroids — Prednisone is most commonly used as an adjunctive treatment to antibiotics. It is typically prescribed for seven to ten days at the start of a three to four week course of antibiotics. In many cases, prednisone has been shown to have superior and longer lasting benefits compared to antibiotics for treating chronic infection.

  • Intranasal topical steroids — Topical steroids are highly recommended as part of a comprehensive medical treatment plan. Two studies have demonstrated significant clinical benefit from combination treatment that includes oral antibiotics, intranasal corticosteroids, decongestant nasal sprays, nasal saline irrigations, and in some cases a short course of oral steroids.

Surgery

Functional endoscopic sinus surgery appears to be effective in carefully selected patients who have failed maximal medical therapy. Patients with the following may consider surgical evaluation:

  • More than four acute sinusitis episodes a year that are refractory to therapy
  • Symptoms refractory to medical therapy for more than three months without success
  • Polyps, other masses or tumors that have not responded to treatment

UCSF Sinus Center

The UCSF Sinus Center diagnoses and treats diseases of the sinuses, nose and related structures. This includes the most common conditions, such as sinus infection and allergies, to more complex disorders such as nasal obstruction and tumors of the nose and sinuses. We specialize in minimally invasive endoscopic techniques for diagnosing and treating nose and sinus disorders.

Other Resources

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (888) 689-UCSF or (888) 689-8273
Email referral.center@ucsfmedctr.org