New York Eye and Ear Infirmary
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Antibacterials

Content provided by Steven Schaefer, M.D.
Department of Otolaryngology/Head and Neck Surgery
The New York Eye and Ear Infirmary of Mount Sinai

Antimicrobial agents are frequently prescribed for both acute and chronic sinusitis. In many individuals, acute sinusitis is a self-limiting disease which spontaneously resolves without antibiotic treatments. Other individuals seek medical care from their primary care physicians for acute sinusitis, and are typically treated for seven to ten days with derivatives of penicillin, macrolides or erythromycin.

These antibiotics are moderately effective against non-hospital acquired Streptococcus pneumoniae and Haemonphilus influenzae bacteria, which are common disease causing agents in acute sinusitis. Such treatment may be complimented by oral decongestants, mucolytic agents (mucus thinning drugs), and decongestant nose sprays. The medical treatment of chronic sinusitis is more problematic. Such individuals have an underlying sinus disorder which is exacerbated by episodes of acute infection. In these individuals, we believe that treatment must be more than two weeks and include broad-spectrum antibiotics. This group of antibiotics includes the cephalosporins, quinolones and clarithromycins. 

Our treatment practice reflects the following: 1) the pathogenic (disease causing) bacteria are often different than those in acute infections, including Staphylococcus aureus and anaerobic bacteria. These microbials are often resistant to antibiotics which are effective for acute sinusitis, 2) the combination of mechanical obstruction of the communication of the sinuses to the nose and/or foci of longstanding infection within the sinuses impairs the efficacy of treatment, 3) the inflamed mucous membrane within infected sinuses can have an impaired blood supply and in such case, less antibiotic would reach the site of infection, and 4) patients with prior surgery should be assumed to have compromised blood flow to the operated sinus.

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Antifungals

Four different types of antimicrobial therapies, with and without surgery, are now employed for fungi-induced disease of the sinuses. Invasive fungal sinusitis is a life threatening infection, and appears more frequently in chronically ill patients, such as insulin-dependent diabetics. 

Treatment consists of intravenous antifungal medications, such as amphotericin B and surgical debridment of infected tissue (Gillespie,1998). In contrast, allergic fungal sinusitis (AFS) is a non-life threatening, often indolent, non-invasive colonization of the nose and sinuses, which occurs in healthy individuals. 

Treatment is directed towards surgical removal of the fungus and inflammatory polyps with restoration of drainage of involved sinuses, and oral steroids to reduce the inflammatory response of the mucous membrane to the fungi (Manning, 1993). Oral antifungals, or lavage of the sinuses with such agents, may be empirically useful but relatively few reports support such therapy. At a minimum, daily lavage of the nose with normal saline is helpful.

Intra-operative photograph of allergic fungal sinusitis debris within sphenoid sinus.

Intra-operative photograph of allergic fungal sinusitis debris within sphenoid sinus.

Intra-operative photograph of the maxillary sinus in another patient with AFS.

Intra-operative photograph of the maxillary sinus in another patient with AFS. The edematous or swollen mucous membrane (mm) is typical of the inflammatory response to the fungus (fungus).

Axial CT scan of patient with allergic fungal sinusitis.

Axial CT scan of patient with allergic fungal sinusitis. The image has been electronically manipulated on the right to better show the contrast between the fungi and mucus membrane. The areas of increased density (appearing more white) within the maxillary sinuses are sequestered fungi. As the fungus proliferates within the sinuses the protein content of the mucous produced in response to the fungus increases. This inflammatory reaction leads to pockets of increased density typical of AFS.

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Most recently, the presence of an inflammatory response (as evidenced by an intense eosinophilic infiltration into the nose and sinus mucus membrane) to fungi, which normally colonize the nose and sinuses leading to chronic sinusitis (or chronic rhinosinusitis [CRS]) has been postulated by the Mayo Clinic (Ponikau, 2002, 2003). 

In theory, diminution of this allergic response should lead to cessation of infected mucous drainage and/or other inflammatory reactions to the fungi. Recommended treatment now consists of a three-month or greater trial of amphotericin B nasal lavage twice daily or voriconazole nose spray once a day. 

This therapy is often supplemented by nasal lavage with Wilson’s solution (gentamycin in saline) twice daily, followed by the application of one of the above antifungal agents. If after three months the patient is positively responding to the protocol, antifungal treatment is continued indefinitely to diminish re-colonization of the nose with fungi. Wilson’s solution is selectively discontinued after six months. 

Illustration of the role of fungi in chronic rhinosinusitis

Role of fungi in chronic rhinosinusitis (Ponikau, 2002, 2003). Fungi (1) elicit an inflammatory response by lymphocytes (2). The lymphocytes then trigger the release of major basic protein (MBP, 4) by eosinophils (3). The MBP is normally synthesized to destroy foreign agents, such as viruses or parasites. In this case, the MBP causes ulcer in the mucous membrane (5) of the nose and sinuses, giving rise to bacterial sinusitis (6).

The fourth form of fungus sinusitis is mycetoma (myceto = fungus + oma = mass; fungus ball). This is a non-life threatening sequestration or fungus ball, that forms within most typically the maxillary sinus. Treatment is primarily surgical, and consists of removing the fungus ball from the involved sinus. We recommend chronic saline irrigation of the nose after surgery to reduce the likelihood of re-colonization of the sinus with fungus. 

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Nasal Steroids

The ideal nasal steroid should be: 

  1. Easily administered or directed into the nose, most often in the form of a spray
  2. Physiologic or not harmful to the nasal mucous membrane
  3. Compatible with the normal nasal functions of regulation of humidification and cleansing air en route to the lungs
  4. Not absorbed into the general circulation to avoid the adverse effects of systemic steroids
  5. Relatively slow acting to permit once or twice daily usage in most patients, and
  6. Effective in minimizing inflammation within the nose. 

Nasal steroid sprays have evolved from meeting few of the above requirements to now being both safe and effective in most patients. To meet these requirements, these sprays must be used daily and will often require weeks before their benefits are apparent to the patient. They should be sprayed towards the inner margin of the eye, which directs them towards the point of drainage of most of the sinuses. However, these drugs can cause nasal bleeding due to atrophy or erosion of the nasal mucous membrane, and require supervision by an ophthalmologist in those patients with glaucoma or cataracts. 

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Saline Nasal Lavage

Saline lavage, or washing of the nose is highly effective in reducing colonization of the nose by bacteria and fungi, cleaning dried mucous from the nose, and pre and post-operative sinus surgery hygiene. In some individuals, saline lavage works well to control chronic nasal drainage. We believe that such lavage works well because of the combination of mechanical cleaning with large volumes of saline, use of sufficient saline to reach the primary drainage site of the sinus (known as the middle meatus or osteomeatal complex) and the physiologic effect of using normal saline as the irrigation solution. 

Although commercial products are available for this purpose, we recommend the following:

Mix 1 level teaspoon (5 grams) of non-iodized salt in 2 cups (16 ounces or 480 milliliters) of clean water, which yields a 0.94% saline solution. The salt content of human blood, or also known as normal saline, is 0.9%. 

This solution can be applied to the nose using a nasal irrigation or bulb syringe (as would be used for cleaning the nose or irrigating the external ear), a clean turkey baster or a Water Pik nasal irrigation attachment (such as the Grossan Nasal Irrigator®, [HydroMed]). In using any of these methods, the saline should be used daily; the device should be placed within the nostril without occluding the nose and directed towards the inner margin of the eye; the head leaned over a sink to permit the irrigant to passively drain from the nose or mouth; and, no pain should occur if the nose is irrigated properly.

Minutes to hours following nasal lavage, the saline solution will often drain from the nose during movement of the head. This may be minimized by moving one’s head downward or from side to side to permit this irrigant to drain out of the nose and sinuses. This planned maneuver allows the patient to clear their nose of saline, rather than during a socially embarrassing moment. 

Although numerous commercial nasal irrigants are available, in our opinion the saline is active or essential ingredient, and the patient is served well by this simple therapy. 

Person demonstrating nasal irrigation

Nasal irrigation with saline, or other therapeutic solutions, is directed towards the medial canthus (inner margin of the eye [arrow]). This aims the irrigant towards the site of drainage of the frontal, ethmoid and maxillary sinuses into the nose. 

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References

Gillespie MB, O'Malley BW Jr, Francis HW. An approach to fulminant invasive fungal rhinosinusitis in the immunocompromised host.Arch Otolaryngol Head Neck Surg. 1998;124:520-6.

Malani PN, Kauffman CA. Invasive and Allergic Fungal Sinusitis. Curr Infect Dis Rep. 2002;4:225-232

Manning SC, Mabry RL, Schaefer SD.Evidence of IgE-mediated hypersensitivity in allergic fungal sinusitis. Laryngoscope. 1993;103:717-21.

Ponikau JU, Sherris DA, , Kita H, Kern EB. Intranasal antifungal treatment in 51 patients with chronic rhinosinusitis. J Allergy Clin Immunol. 2002;110:862-866. 

Ponikau JU, Sherris DA, Kephart GM, Kern EB, Gaffey TA, Tarara JE, Kita H..Features of airway remodeling and eosinophilic inflammation in chronic rhinosinusitis: is the histopathology similar to asthma? J Allergy Clin Immunol. 2003;112:877-82.

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Learn More About Rhinology & the Sinuses

General Description of Sinusitis

What is Sinusitis?

Medical Treatment of Sinusitis

Antibacterials, antifungals, and nasal steroids

Surgical Treatment of Sinusitis:

 

Definition

 

What to Expect When Undergoing Sinus Surgery

 

Ethmoidectomy & Antrostomy

 

Sphenoidotomy

 

Frontal Sinusotomy

 

Caldwell Luc

 

Orbital & Optic Nerve Decompression

 

CSF Rhinorrhea

 

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