Treating Sinusitis

Updated on 10/14/09

The primary goal in treating sinusitis is to decrease the inflammation in the nose and the sinus openings so that your sinuses are able to go back to draining mucus normally. This may include a combination of medical treatments.

The majority of episodes of sinusitis are successfully treated without the use of antibiotics by simply treating the thick mucus and nasal swelling. Even if bacterial infection is involved, sinusitis often goes away without antibiotics. Inappropriate use of antibiotics can lead to bacterial resistance and side effects; thus these medications must be used carefully and thoughtfully. However, if you have a bacterial infection in your sinuses, your healthcare provider will most likely prescribe antibiotics.

Many people can control their sinusitis with nasal washing and steroid nasal spray. Read more about nasal wash in the managing section. Decongestants, antihistamines, and steroids help many people. Some people with chronic sinusitis may benefit from surgery.

This section includes information on:

• Antibiotics
• Steroid nasal spray
• Decongestants
• Antihistamines
• Systemic steroids
• Functional endoscopic sinus surgery (FESS)
• Risks of FESS

Antibiotics

In some cases of sinusitis, but certainly not all, the underlying cause will be a bacterial infection. Such an infection can be difficult to treat because the bacteria thrive in the warm, moist, dark sinus cavities. These infections usually respond to antibiotic treatment, but you may need to continue treatment for one to three weeks or longer.

The choice of antibiotic depends on several factors, such as drug allergies, what antibiotics you have used in the past, and your symptoms. If antibiotics aren't working, your healthcare provider may collect mucus from your nose and send it to the laboratory for culture to confirm the presence of bacteria. This test can also help in the selection of the proper antibiotic to fight the infection.

If you are given antibiotics to treat a bacterial infection, it is very important to finish taking all of your medicine as prescribed, even if you feel better before your medicine runs out. This is because stopping your antibiotics before they're finished can lead to the development of drug-resistant bacteria, or "superbugs". Drug-resistant bacteria are very difficult to treat.

Steroid nasal spray

A prescription steroid nasal spray can decrease nasal inflammation and mucus production. This will relieve symptoms of nasal congestion and improve sinus drainage. A steroid nasal spray does not provide immediate relief of symptoms and may require several weeks of routine use to be effective. If you have chronic sinusitis, you may benefit from continued daily use of this medication. If you have occasional sinusitis episodes, you may only require periodic use. The combination of nasal wash and nasal steroid sprays can be highly effective for many patients with nasal and sinus problems.

Several steroid nasal sprays are available and include:

• Beconase AQ, Vancenase DS AQ (beclomethasone)
• Flonase (fluticasone)
• Nasacort AQ, Nasacort® (triamcinolone)
• Nasarel (flunisolide)
• Nasonex (mometasone)
• Rhinocort (budesonide)
• Omnaris (ciclesonide)
• Veramyst (fluticasone furoate)

When used properly, steroid nasal sprays are safe and effective. However, nasal dryness and bleeding are possible side effects.

Decongestants

These medicines, available as tablet, syrup, or nasal spray, help unblock the openings of the sinuses and temporarily reduce symptoms of nasal congestion. Common over the counter decongestants include Sudafed® and Dimetapp® (pseudoephedrine). Decongestants containing pseudoephedrine must now be kept behind the pharmacy counter in the United States, but they are still available without a prescription. There is debate over whether ingredients that some manufacturers are substituting for pseudoephedrine work as well.

Combination decongestant/antihistamine medicines are available over the counter. Read the label to see what is in the over-the-counter medicine you are buying and discuss the medicine with your healthcare provider.

Topical nasal decongestants (sprays) can be highly effective in the immediate shrinking of swollen nasal tissue. However these sprays must be used for no more than three consecutive days because more prolonged use can cause rebound nasal congestion with increased symptoms.

Systemic decongestants (taken by mouth) have the same effect of decreasing the swelling of the lining of the nose and promoting drainage of the sinuses. However, since higher concentrations are present in the bloodstream, systemic decongestants are more likely to cause side effects than are sprays. These may include high blood pressure, anxiety, sleeplessness, prostate problems in men, and the "jitters". You should always discuss the use of these medications with your physician.

Antihistamines

Antihistamines are medicines designed to counter the actions of histamine, the main chemical produced in the body in allergic reactions. Antihistamines in tablet or syrup form may help reduce the allergic symptoms of sneezing and itchy eyes and nose, and may reduce mucus production. Your healthcare provider may elect to add this type of medicine to your treatment, particularly if allergies are present.

Common over-the-counter antihistamines include:

• Claritin (loratadine)
• Chlor-Trimeton (chlorpheniramine)
• Benadryl (diphenhydramine)

Newer classes of prescription antihistamines do not cause drowsiness (the same is true of Claritin, now over the counter). They include:

• Clarinex (desloratadine)
• Allegra (fexofenadine)
• Zyrtec (cetirizine)

Topical antihistamine sprays are now available by prescription and may provide additional relief.  They include:

• Astelin (azelastine)
• Patanase (olopatadine)

Systemic steroids

Systemic corticosteroids are sometimes required to treat severe nasal and sinus inflammation. They may also shrink nasal polyps. Steroids are powerful medicines that are very good at reducing inflammation and mucus production in the airways. Corticosteroids are not the same as anabolic steroids, used illegally by some athletes for bodybuilding, and do not affect the liver or cause sterility. Corticosteroids are similar to cortisol, a hormone produced by the adrenal glands in the body.

These medicines can be in pill or syrup form or can be injected into a muscle or vein.

Many side effects are possible, and include: cataract formation, high blood pressure, high blood sugar, mood changes, stomach irritation, bone loss (osteoporosis), vision change, and menstrual irregularities. These side effects are always possible when using systemic steroids but become more of a concern with long-term use.

If you have been taking steroids long term, do not stop your steroids abruptly. When a person takes high doses of steroids over a long time, the brain may decrease or stop cortisol production. As the control of your disease improves, or if serious side effects develop, your healthcare provider may decrease your steroid dose by tapering it to prevent "breakthrough" symptoms and to allow the adrenal glands to gradually take over cortisol production again. It's important to follow your doctor's instructions.

As your body adjusts to a lower steroid dose, you may notice some withdrawal side effects. These may include fatigue, weakness, depression, and muscle and joint pain. If any of the above symptoms are severe, notify your healthcare provider. The symptoms usually disappear within a few weeks or months.

If your steroid dose has recently been decreased or stopped and you have a serious illness, need surgery, or have been injured, you may require a short steroid burst. During this time, your adrenal glands may not be functioning at full capacity and cannot handle stress to the body. Inform all of your healthcare providers that you have been on steroid treatment.

Functional endoscopic sinus surgery (FESS)

The majority of patients with sinusitis do not require surgery. However, in some patients with chronic sinusitis, the symptoms continue despite prolonged medical treatment. Surgery should only be considered when medicines have failed to improve the patient's symptoms and quality of life. The most common indications for surgery include chronic bacterial infection, nasal obstruction or blockage, and nasal polyps.

Functional endoscopic sinus surgery (FESS) has become the standard technique for sinus surgery. In carefully chosen patients, research has found FESS to be 70 to 90 percent successful in improving symptoms of sinusitis and related nasal and sinus problems. During the operation, the surgeon will enlarge the openings of the sinuses, allowing them to drain more easily. The surgeon may also remove diseased tissue and nasal polyps.

While older sinus surgery techniques included making incisions in the face, FESS is a minimally-invasive approach in which the surgeon uses an endoscope to view the important structures of the nose and sinuses. The endoscope is inserted through the nose, as are the tiny surgical instruments the surgeon uses to perform the surgery. The view with the endoscope allows for better identification of the underlying disease, which in turn allows the surgeon to be precise, careful, and thorough with minimal damage to normal surrounding tissue. FESS allows for less tissue removal, more rapid tissue healing, and shorter recovery periods. The surgery is often performed on an outpatient basis. It may be performed with general anesthesia or local anesthesia with sedation. Newer technologies are being introduced to help make sinus surgery safer and easier for the patient.  New instruments include balloon catheters for dilation of the sinus openings and new tools to efficiently remove disease tissue.

As with any surgical procedure, FESS has associated risks. Although the chance of a complication occurring is small, it is important that you understand the potential complications and ask your surgeon about any concerns you may have.

Although FESS is the most commonly performed surgery for sinusitis, in some cases other surgical procedures may also be necessary, such as surgery to remove the adenoids or open surgery on the forehead to reach the pair of sinuses located above the eyes.

Risks of FESS

Most sinus surgery involves some degree of blood loss, which is generally not a problem for the patient. However, on occasion, significant bleeding may require stopping the procedure. A few patients will require a small nasal pack, a small piece of material placed in the nose to stop bleeding, removed one to three days after surgery.

Other possible complications include:

Recurrence of disease: Although FESS gives the vast majority of patients significant relief from their symptoms, surgery is not a cure for most forms of sinusitis. Therefore, you can expect to continue with your sinus medications even after successful sinus surgery, although you probably won't need to use as much medication as you used to. In some instances, additional "touch-up" surgery may be necessary to optimize your surgical outcome. This may be necessary in 5 to 10 percent of cases.

Spinal fluid leak: Because the sinuses are located in close proximity to the brain, there is a rare chance of creating a leak of spinal fluid (the fluid surrounding the brain) or injuring the brain. This happens in less than 1 percent of cases. If a leak were to occur, it might require more surgery and extend your hospitalization. Symptoms would include profuse clear watery discharge from the nose, but a spinal fluid leak can be quite difficult to detect. The surgeon should identify and fix the problem at the time of surgery.

Visual problems: There have been a few reports of visual loss after sinus surgery. The eye or orbit can be injured during surgery, causing injury to the muscles or optic nerve. The potential for recovery in such cases is not good. In addition, eye injury resulting in double vision, blurring vision, or excessive tearing from the eye are additional potential complications. Such complications have been reported in less than 1 percent of cases.

Other uncommon risks of surgery include alteration of sense of smell or taste; persistence and/or worsening of sinus symptoms and facial pain; and swelling or bruising of the area around the eye.