Medical Management

PICC line in positionThe conventional medical treatment involves the use of broad spectrum anitbiotics, antihistamines with or without decongestants, and mucolytic agents in patients with uncomplicated sinusitis. The choice of medications is based on the patient's medical condition and there are times when the choice may be severely restricted, due to another medical condition that patient may be experiencing.

In treating adult Sinusitis, the antibiotics are usually chosen based on culture results or prudent medical judgement. The choice would also vary with the immunological status of the patient. In patients with cystic fibrosis, immotile cilia syndrome, severe allergic diathesis, antibiotic resistance from previous medical or surgical treatments, or the severely immunosuppressed, patients may require careful evaluation in the choice of antibiotics. This may vary depending on the extent of the disease and the general medical condition of the patient. Streptococcus Pneumonia, Hemophilus Influenza and Moraxella Catarhalis are the most commonly encountered organisms at the present time and the antibiotics are chosen accordingly. Community acquired Sinusitis with Beta Lactamase producing organisms require a careful selection of antibiotics. This includes the use of Augmentin™ (containing Potassium Clavulunate), Aminoquinolones which include Levaquin™, Tequin™ and Avelox™. In patients where the response to oral antibiotics are poor, intravenous antibiotics are recommended, based on culture results. A practical introduction to the usage of intravenous antibiotics is suggested by the author.

What Type of Doctor Is Best Suited to Treat Sinusitis?

An otolaryngologist - or ear, nose and throat (ENT) specialist - is the best type of physician to treat sinusitis as they are the medical specialists that routinely treat nose and sinus conditions. An otolaryngologist can provide a full range of treatment options - from medication to surgery. On rare occasions sinus infections can spread to the eye or brain. This complication is considered a medical emergency and requires immediate surgical intervention by an ENT specialist. Some otolaryngologists - like Vijay K. Anand, MD have chosen to further specialize in rhinology and focus their ENT practices on diseases of the nose and paranasal sinuses.

After an advanced rhinologic evaluation by an otolaryngologist - which includes a nasal endoscopy - it may be apparent that the nasal and sinus mucosa have an allergic appearance. If indeed the allergic cause is established, desensitization may be necessary and this involves injections in a graduated manner which might be addressed by an allergist.

Primary care, family practice, pulmonologists, allergists and internists will send their most severe sinusitis patients - including themselves - to an ENT specialist for advanced treatment.

What follows is an algorithm for antibiotic therapy for chronic Sinusitis, visualized for the viewer:

Effective Utilization of IV Antibiotic Therapy for Chronic Sinusitis

Evaluations

1. If pre-operative evaluation (+) for: Signs &/or Symptoms c/w chronic sinusitis, should be confirmed by nasal endoscopy

Chronic Rhinologic Conditions:
- Cystic Fibrosis
- Immotile Cilia Disorder
- Sampter's Triad
Patient w/high risk co-morbid factors:
- Immune Deficiency
- Diabetic Endarteritis
Culture positive for oral antibiotic resistant organisms
Mucopyocele
CT shows unequivocal hyperostosis
Fungal sinusitis (IV Abx wanted as adjunctive therapy)

Pre-operatively: To start 2 weeks prior to surgery to continue post-operatively for 4 weeks

2. If intra-operative evaluation (+) for:

Culture positive for oral antibiotic resistant organism
Mucopyocele
Unequivocal hyperostosis
Fungal sinusitis (IV Abx wanted as adjunctive therapy)

and

No signs of anatomic obstruction

Pre-operatively: To start as soons as all arrangements are made to continue for 4 - 6 weeks

3. If post-operative evaluation (+) for:

Persistant signs &/or symptoms c/w chronic sinusitis
Recurrent signs &/or symptoms c/w chronic sinusitis
Culture positive for oral antibiotic resistant organism
CT shows unequivocal hyperostosis

and

No signs of anatomic obstruction

Pre-operatively: To start as soons as all arrangements are made to continue for 4 - 6 weeks

4. If (+) for any medical contraindications for surgery

Medical contraindications for surgery:

Timing of IV Antibiotics:
- Arrangement made for PICC line Position confirmed with CXR
- Choice of Antibiotics: Culture specific, or if culture are negative, Polymicrobial therapy including anaerobes

Pre-operatively: To start as soon as all arrangements are made to continue for 4-6 weeks

Follow-up Visits

Timing: To begin 2 weeks after initiation of IV Abx
Perform: History & Physical exam including nasal endoscopy
Evaluation:
- If complete resolution (symptoms and exam), continue IV Abx for additional 2 weeks to complete therapy; then, remove PICC
- If partial resolution (symptoms and exam), recommend additional 2 weeks of IV Abx.
  Re-evaluation after a total of 4 weeks therapy
  If complete resolution, remove PICC line
  If partial resolution, see below
- If no improvement (symptoms and exam),
  culture or re-culture
  consider anti-fungal therapy
  consider changing and/or adding other Abx
  Re-evaluation after another 2 weeks of therapy
  - If complete resolution (symptoms and exam), continue IV Abx for additional 2 weeks to complete therapy; then, remove PICC
  - If still with partial or no improvement,
    re-culture sinuses after discontinuing all Abx for 1 week
    Infectious disease consultation
    Re-evaluation by allergist
    Re-evaluation by immunologist
At each follow-up visit:
Patient fills SF-36 (quality of life) form, and SNOT-21 (chronic sinusitis) form
- For the first year after therapy, follow-up evaluations every 3 months and on as needed basis
- After first year of follow-up, Follow-up yearly, and on as needed basis