Advising Patients About Sinus Infections

US Pharm. 2014;39(4):8-11.

Sinus infections are common and painful. Patients may attempt self-care without seeing a physician. Pharmacists must impress upon patients with suspected sinus infections that it is imperative to visit a physician for a differential diagnosis and an antibiotic prescription if the cause is bacterial.

Definition and Prevalence of Sinusitis

Sinusitis is a general term for inflammation of the paranasal passages.¹ The CDC considers the term to be synonymous with “sinus infection.”² About 30 million Americans develop sinusitis in a typical year.^1-3

Epidemiology of Sinusitis

Some people are more prone to sinusitis. They include those with the following medical conditions or risk factors: allergic rhinitis (e.g., hay fever); structural problems in the nasal cavity that block the sinus openings (e.g., deviated nasal septum, nasal bone spur, nasal polyps); a compromised immune system (perhaps due to HIV or chemotherapy); any disease that prevents sinus cilia from functioning as they should; large adenoids; cystic fibrosis; history of smoking; exposure to airborne chemicals or irritants; and attendance at day care.⁴ Those living in southern states are at greater risk.²

Acute Sinusitis

Acute sinusitis is generally due to viral invaders, but, rarely, bacteria are the causal agent.⁵ Both cause a nasal inflammation that can be so intense that the sinus openings, known as ostia, are completely obstructed.¹ When this occurs, the sinuses cannot self-cleanse, and sinus secretions are retained. Impacted mucus in the sinuses decreases oxygenation, and trapped air and mucus induce pressure changes in the sinus cavities. In the case of the common cold (as well as allergies), the patient may overproduce mucus in the sinus cavities, thereby worsening an already unhealthy situation. All of these morbid changes promote sinus infection due to inoculation of pathogens into the secretions and mucus.⁴

Acute bacterial sinusitis and acute viral sinusitis both last 4 weeks or less and occur fewer than three times in any 12-month period (viral) or fewer than four times yearly (bacterial).⁵

Chronic Sinusitis

A sinus infection is considered subacute when the duration exceeds 4 weeks but lasts 12 weeks or less.^2,5 It is considered chronic when the duration exceeds 12 weeks and infection occurs more than four times yearly.⁵ A wide variety of problems can induce a chronic sinus infection, including nasal polyps, tumors, allergies, and respiratory infections of viral, bacterial, or fungal origin. Symptoms of chronic sinusitis are generally milder than the acute from of sinus infection.⁴

Manifestations of Sinus Infection

Sinus infections cause numerous problems for patients. These include pain or tenderness in several places. The specific locations of the pain and/or tenderness help identify which sinuses are infected.⁶ If the frontal sinuses are infected, the pain location is the forehead. Maxillary sinus infection produces pain in the upper jaw and teeth; the cheeks may also be tender to touch. Ethmoid sinus infection causes pain between the eyes, perhaps with inflammation of the eyelids and periorbital region, accompanied by tenderness when the patient touches the sides of the nose. Finally, infection of the sphenoid sinuses causes pain in the neck, earaches, and deep pain at the top of the head.

In addition to pain and/or tenderness, patients with sinus infection also complain of rhinorrhea or nasal congestion. Nasal secretions are abnormally thick due to having spent a longer time in the sinuses prior to expulsion, which decreases their water content. Nasal discharge is often discolored to white, yellow, or green, and it may be blood-tinged. Other symptoms of sinusitis include loss of smell, postnasal drip (mucus from the nose dripping down into the throat), sore throat, fever, cough (often worse at night), fatigue, general malaise, and/or halitosis.^4,5

Physician Diagnosis of Sinusitis

Physicians can conduct several tests to confirm a diagnosis of sinusitis.⁵ They may use transillumination, in which a light is placed against the sinus to see signs of infection. They may employ nasal endoscopy or rhinoscopy, in which a fiberoptic scope is used to directly visualize the sinus cavities. CT scanning of the sinuses allows the physician to view the bones and tissues of the sinuses, and an MRI can visualize tumors or fungal infections. The physician may also simply tap the area overlying the sinuses to locate sites of infection.

Several conditions mimic sinus infection, including the common cold, influenza, nasal polyposis, sarcoidosis, neoplasia, acquired and congenital immuno-deficiency, allergic and nonallergic rhinitis, Wegener’s granulomatosis, and fungal infection.¹ To identify these, physicians might check the nostrils for nasal polyps and recommend such examinations as allergy testing, blood tests for HIV and/or immune status, sweat chloride analysis or blood work for cystic fibrosis, nasal ciliary function tests, nasal cytology, and nasal culture.^2,4

Complications of Untreated Acute Bacterial Sinusitis

If bacterial sinus infection is not promptly and appropriately treated, the patient can develop infection of the ophthalmic orbit (orbital cellulitis), meningitis, bone infection (osteomyelitis), and/or abscess.^1,4 Patients may lose their sight permanently.

Nonprescription Decongestants

The nonprescription product market has numerous sinus products for consumers. Virtually all oral and topical products contain a nasal decongestant. The FDA, in an amendment to its monograph on nasal decongestant products, discussed this use of decongestants.¹ The agency pointed out that prospective studies up to that date (2004) concerning the efficacy of nasal decongestants did not exist, and, further, that existing research attempting to confirm the efficacy of decongestants as adjunctive treatment of sinusitis was limited and also controversial. The FDA was aware that many physicians, in the context of a physician-patient relationship, recommend or prescribe nasal decongestants as adjunctive therapy for sinusitis. The agency voiced concern that some would take that practice as evidence that consumers can self-diagnose and self-manage sinusitis with OTC products. The FDA also pointed out that preclinical evidence demonstrates that topical nasal decongestants may actually prolong sinusitis, by increasing inflammation of the sinuses.

In its 2004 amendment, the FDA explained that the labeling then used by manufacturers on both oral and topical nasal decongestant products could give consumers the mistaken idea that medical advice is not needed for treatment of sinusitis. Consumers misled by this labeling would miss an opportunity to obtain a medical evaluation that would rule out conditions mimicking sinus infection. Delaying treatment of a bacterial sinus infection could result in serious complications.

A further issue for the FDA was the fact that sinusitis and asthma are common comorbidities.¹ Perhaps 40% to 70% of those with asthma have sinusitis. If these persons were to delay a medical appointment, either or both conditions could worsen.

For the above reasons, the FDA proposed in 2004 to disallow any labeling on topical and oral nasal decongestants that included the word “sinusitis,” or the wording “symptoms associated with sinusitis.” The decision was finalized in 2005.⁶

Internal Analgesics

Nonprescription internal analgesics can help alleviate the pain of sinus infection.² Possible choices are acetaminophen (e.g., Tylenol), ibuprofen (e.g., Advil, Motrin IB), and naproxen (e.g,, Aleve). Patients must be urged not to use them as a substitute for medical care, since treating the pain without addressing the infection would be counterproductive.

Other Treatment Options

Antibiotics/antibacterials are critical for a bacterial sinus infection. Physicians may also recommend or prescribe intranasal corticosteroid sprays (e.g., Flonase, Nasonex, Nasacort Allergy 24 HR), oral corticosteroids, saline nasal sprays, or saline washes.² Surgery is a last resort for chronic rhinosinusitis. The objectives of surgical procedures are twofold: improve drainage from the sinuses and reduce nasal blockage. To this end, surgery may be performed to enlarge the sinus ostia, remove nasal polyps, and/or correct intranasal sinus obstructions. Some pediatric patients benefit from adenoidectomy when adenoidal tissues cause nasal obstruction.

Antihistamines are irrelevant for sinus infection, as histamine does not play a role in sinus congestion, although they may help treat underlying allergy symptoms. Further, no homeopathic, herbal, or dietary supplement has been shown to be either safe or effective for sinus infection.

Optimizing Indoor Humidity

The National Institutes of Health (NIH) suggests that patients inhale steam two to four times daily to reduce sinus congestion.⁴ The agency gives the example of sitting in the bathroom with the shower running. However, hot water from the shower may not reach the temperature that creates appreciable steam in the bathroom. This well-meaning advice can be modified by the pharmacist to increase its efficacy. Rather than a hot shower, the patient can be directed to any of several brands of steam vaporizers. When used as directed, these devices create a steady flow of steam into the room. The vaporizer should be placed at least 4 feet from the user before it is plugged in.

The patient should follow all directions, such as periodically cleaning the electrodes of certain steam vaporizers. If water used to fill the vaporizer does not have sufficient electrolyte content, the patient will be directed to add either sodium bicarbonate or salt. It is best to advise patients to closely follow the directions on the pamphlet inside the box.

Prevention of sinus infections is preferable to treating an infection. Several federal websites address prevention through use of a humidifier.^2,4,5 Humidifiers employ various technologies to increase the indoor relative humidity. Impeller and ultrasonic humidifiers are both efficient and inexpensive. If they are run constantly during the dry seasons of the year (e.g., winter), the added moisture in the air may facilitate the activity of the cilia in the respiratory tract and the sinuses. However, indoor humidity should be monitored, as overhumidification can lead to the growth of mold and mildew in the house, either of which could cause allergies.

PATIENT INFORMATION

What Are Sinuses?

Your sinuses are four pairs of air pockets in the skull. They have tiny holes that allow air to freely flow through them. When the sinuses are healthy, they are free of bacteria and other organisms. They have cells that make mucus to help the nose remain moist during breathing and to help trap materials that are inhaled. They self-cleanse because they also contain small hairs (cilia) that move the mucus out of them, carrying the unwanted materials with it. Thus, normal sinus drainage is a protective mechanism of the body to prevent infection.

Where Are My Sinuses?

Your frontal sinuses are above your eyes, in the area of the brows, and the maxillary sinuses are inside each cheekbone. The ethmoid sinuses are between your eyes, just behind the bridge of the nose. The sphenoid sinuses are behind the ethmoids, in the upper area of the nose and behind the eyes.

Preventing Sinus Infections

The most reliable way to prevent sinus infections is to prevent the common cold and flu, and to treat any other contributing problem (e.g., allergies) promptly. Eat a balanced diet with an abundance of fruits and vegetables. These foods are full of antioxidants and other nutrients that may help boost your immune system to prevent infection. Get vaccinated for the flu annually.

Nonprescription products may be helpful, if you read and follow all label directions. For instance, take decongestants such as pseudoephedrine (e.g., Sudafed) or use an oxymetazoline-containing nasal spray such as Afrin if you have an upper respiratory infection. Treat allergies with antihistamines (e.g., Allegra, Claritin, Zyrtec). Wash your hands frequently, especially after shaking hands, and keep your fingers away from your mouth, eyes, and nose. Reduce life stresses and avoid smoke and other pollutants. Keep well-hydrated to optimize body moisture and use a humidifier in the house and workplace.

Symptoms of Sinus Infection

Sinusitis usually begins after a cold or flu. You should suspect sinusitis if the cold does not get better or worsens after 5 to 7 days. Acute sinusitis is caused by bacteria growing in the sinuses and is present for a period up to 4 weeks. Symptoms include bad breath, loss of smell, cough (which may be worse at night), fatigue, a general feeling of illness, fever, headache, pressure-like pain behind the eyes, toothache, facial tenderness, nasal congestion, nasal runniness, sore throat, and/or postnasal drip.

You may have chronic sinusitis if the symptoms last for longer than 3 months. This is usually due to bacteria or fungi in the sinuses. Symptoms are the same as in acute sinusitis, but are usually milder. They include those above, but with a high fever and darkened nasal discharge that lasts for at least 3 days, and a nasal discharge (with or without cough) that is present for more than 10 days and is not improving.

Treatment Options

You must see a physician to determine if your infection is bacterial, in which case an antibiotic is required. Nonprescription products (e.g., analgesics, antihistamines, decongestants, nasal sprays) may provide slight relief of symptoms, but will not kill bacterial or fungal sinus invaders.

Remember, if you have questions, Consult Your Pharmacist.

REFERENCES

1. Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; proposed amendment of final monograph for over-the-counter nasal decongestant drug products. Fed Regist. 2004;69(147):46119-46122.
2. Sinusitis. National Institute of Allergy and Infectious Diseases. January 2012. www.niaid.nih.gov/topics/sinusitis/Documents/sinusitis.pdf. Accessed February 24, 2014. 
3. Chronic sinusitis. CDC FastStats. www.cdc.gov/nchs/fastats/sinuses.htm. Accessed February 24, 2014.
4. Sinusitis. PubMed Health. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001670/. Accessed February 24, 2014.
5. Sinus infection (sinusitis). CDC. www.cdc.gov/getsmart/antibiotic-use/URI/sinus-infection.html. Accessed February 24, 2014.
6. Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; amendment of final monograph for over-the-counter nasal decongestant drug products. Fed Regist. 2005;70(195):58974-58977.

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