Now, what about therapy?
It’s really difficult to
study therapy in sinusitis
because many patients who have bacterial
sinusitis resolve spontaneously,
they get better on their own.
After all, if you think
about what’s going on,
if they have pus in their sinuses
and that pus will drain,
symptoms should resolve
and that they may resolve
without any antibiotics at all.
There was a meta-analysis looking
at placebo versus antibiotics.
And in that analysis they found
that antibiotics reduced
the clinical symptoms by just
a relatively small percent.
So that the take home message
is that antibiotics have
only a modest effect
and here are the data
from that study.
In the antibiotic group,
there was a cure or
improvement in 64%
and in the placebo group there was
a cure or improvement in 32%.
So I think you can see that the
effect of antibiotics is --
it’s real, but it’s very modest.
So what are our targets
for antibiotics if we
do think a patient has
They are Streptococcus pneumoniae
Haemophilus influenzae pleomorphic
So Moraxella is the third target and these
are organisms that are Gram-negative cocci.
They actually kind of look
like Neisseria on Gram stain.
And while I’m talking
about the Gram stain,
there is one trick that I
have used in the treatment of
in my patients.
Believe it or not, I have
had them blow their nose,
blow these purulent secretions
into a cellophane wrap.
Not into a Kleenex, but
into a cellophane wrap
so I can actually
trap the secretions.
Then taking a little bit of the
purulent secretions and doing a --
making a smear on a slide
and doing a Gram stain,
you can actually sometimes
tell exactly what organism
is causing bacterial sinusitis.
But I admit to being rather compulsive,
but for example if you are in a situation,
say, you’re doing missionary work
or you’re working in a developing country,
you could use a Gram stain
to direct your antibiotics,
you may be able to pick up
that Streptococcus pneumoniae
or Haemophilus influenzae.
So generally, we’re going to use
amoxicillin plus or minus clavulanate
and the clavulanate is a
So the more concerned you are
about a resistant organism
or the possibility of anaerobes,
you would use amox/clav,
but amoxicillin alone
We generally give it in a higher
dose in kids who are in daycare
or in people aged under two or
more than 65 years of age because
resistant organisms are a little
more common in those individuals.
Now if somebody has significant
we generally use one of the
cephalosporins, the oral cephalosporins,
or a respiratory quinolone, but we do not
give respiratory quinolones to children
because of the possible adverse effects
on connective tissue and tendons.
And prolonged quinolone therapy is also a
concern in adults for the same reason.
The duration of therapy
is widely variable
and it’s difficult to do studies
on duration of therapy.
Indeed, in many infectious diseases,
we’re not certain how long to treat.
If it’s ten days recommended,
would you believe eleven
or would you believe nine?
Would nine work as well as ten?
You can see obviously how difficult
it is to determine such a thing.
We may need to consider sinus surgery in
patients who have serious complications
as shown in this young lad.
He most likely has preseptal
And this is a crucial examination
if somebody presents like this.
You need to examine the
If the extraocular muscles are intact,
if movement is perfectly normal,
that’s an indication of preseptal and
less serious orbital cellulitis.
But if the eyes don’t move,
the infection is deep
within the orbit
and that’s an important
physical examination technique.
So normally, this would occur with a severe
acute infection refractory to antibiotics
and the ENT surgeons
would need to go in
and open up the sinuses
to allow them to drain.
A lot of people use corticosteroids
because systemic steroids have
been shown to have modest benefit.
But the studies do not permit
us to recommend steroids
and we know that topical steroids
are of no benefit at all.
What about antihistamines?
Antihistamines are not of benefit
in absolutely normal individuals
without a history of
only in those patients would
we use antihistamines
because antihistamines can actually
dry up the nasal secretions
and may cause blockage of the ostia of the
sinuses, which you’re trying to avoid.
Decongestants, like alpha-adrenergics,
also are of modest benefit.
And if you decide to use those,
you should be aware of the side
effects, like increased blood pressure,
CNS stimulation, insomnia,
and the problem with these
is after 24 to 48 hours,
these agents may actually
aggravate nasal congestion.
So if you’re going to recommend
those for your patients,
they should be used for a short
time only and not in children.
One thing that is somewhat useful
is that of saline irrigations.
And there are saline
and just gentle irrigation can loosen
up some of the thick secretions.
They are better than the saline sprays
that are commercially available.
However, you can imagine how difficult
they are to study in children,
so we don’t have good data
about them in children.
Bottom line, topical steroids have not
shown any benefit in treating sinusitis.
So despite how often they are given to
patients, they’re really not indicated.
And that concludes my discussion
with you today of sinusitis.