Adjunctive Treatment

Adjunctive therapies are designed to promote ciliary function and decrease edema to improve drainage through the sinus ostia. Unfortunately, few randomized controlled trials have investigated the effectiveness of these approaches.

Sipping hot fluids, applying moist heat with a hot towel and inhaling steam may improve ciliary function and decrease congestion and facial pain. Salt water nasal rinses provide short-term relief of congestion by removing crusts and secretions. A normal saline solution can be made by adding one-fourth teaspoon of table salt to 8 oz of warm water to be delivered with a squeeze bottle or pump spray bottle.

Decongestants may provide temporary relief of nasal congestion. Nasal spray or drops act by constricting the sinusoids in the nasal mucosa. These sinusoids are regulated by

both alpha1 and alpha2 adrenoreceptors. The nasal mucosal blood flow is not significantly affected by the alpha1 agonists, but recent studies suggest that oxymetazoline, a selective alpha2 adrenoreceptor agonist, interferes with the healing of maxillary

sinusitis by decreasing nasal mucosal blood flow. As a result, alpha1 agonists, such as phenylephrine are the preferred topical mucosal decongestants. Because of the risk of rebound rhinitis (rhinitis medicamentosa), the use of topical decongestants should be restricted to three to four days or less.

Oral decongestants such as pseudoephedrine, taken in a dosage of 60 to 120 mg, will reduce nasal congestion within 30 minutes, and the effect persists for up to four hours. Side effects include nervousness, insomnia, tachycardia and hypertension. No clinical trials demonstrate the effectiveness of oral decongestants in treating acute sinusitis.

The mucolytic agent guaifenesin, which is usually given in decongestants is widely prescribed to thin secretions despite its lack of demonstrated effectiveness. The recommended dosage of 2,400 mg is just below the level that may cause emesis. A recent study comparing the effects of guaifenesin and placebo on nasal mucociliary clearance and ciliary beat frequency failed to show any measurable effect.

There is no rationale for using antihistamines in treating acute sinusitis, since histamine does not play a role in this condition and these agents dry the mucous membranes with crusts that block the osteomeatal complex. The newer, nonsedating, second-generation antihistamines do not cause excessive dryness and crusting; however, no evidence supports the use of these expensive agents.

Although widely prescribed for acute sinusitis, intranasal steroids are of questionable benefit. Given the limited role of allergic rhinitis in the etiology of acute sinusitis and the limited effectiveness of steroid agents in clinical trials, topical steroids should not routinely be used in the management of acute sinusitis.

Despite the use of antibiotics and selected adjunctive therapy, 10 to 25 percent of patients continue to have symptoms. The re-evaluation of these patients, two to three weeks after the first visit, should include a careful history and physical examination, and a single Waters view of the sinuses should be taken to confirm the diagnosis.

Empiric therapy may include a two-week course of a second-line antibiotic. Recurrent or chronic sinusitis often requires otolaryngology consultation and CT imaging of the osteomeatal complex. Surgical therapy may be required for the most serious cases, such as progressive disease with traversal of bone or invasion of the calvarium. Drainage may also be helpful in patients with frequent symptomatic recurrences or failure to achieve resolution with antimicrobials alone. Older procedures, such as Caldwell-Luc drainage of maxillary sinuses into the mouth, have now been replaced by functional endoscopic sinus surgery (FESS) FESS often successfully restores the physiology of sinus aeration and drainage. By enlarging the osteomeatal complex, the surgeon can assure that both the ethmoid and maxillary sinuses are drained.

Between 80 and 90 percent of FESS patients experience significant improvement of symptoms. This procedure can also be used to obtain a good specimen for microbial testing.