Sinusitis Solutions - Vijay K. Anand, M.D. Vijay K. Anand, M.D.
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Medical Management

The 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 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

and

  • 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)
Post-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

Post-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:

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

Timing of IV Antibiotics

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

 

Follow-up Visits

  1. Timing: To begin 2 weeks after initiation of IV Abx
  2. Perform: History & Physical exam including nasal endoscopy
  3. 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

  4. 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