The medical-management-of-rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

1. The medical management of rhinosinusitis
MICHAELS. BENNINGER,MD,JACKANON, MD, and RICHARDL.MABRY,MD, Detroit, Michigan,
Pittsburgh, Pennsylvania, and Dallas, Texas
The management of rhinosinusitis depends on a number of variables related to the dura-
tion and severity of symptoms in the individual patient. Furthermore acute rhinosinusitis is
managed differently than chronic rhinosinusitis. Because a variety of conservative and
pharmacologic interventions are available, the physician can find it difficult to develop a
cohesive and logical approach to treatment. An understanding of the pathophysiology,
microbiology, and natural history of rhinosinusitis is necessary to formulate the best treat-
ment plan for the individual patient. (©tolaryngo[ Head Neck Surg ] 997;117:$41 -$49.)
DEFINITIONS
The Task Force on Rhinosinusitis of the American
Academy of Otolaryngology-Head and Neck Surgery
has established definitions and classified the various
types of rhinosinusitis. 1 These classifications are criti-
cal to understanding the possible treatments of rhinosi-
nusitis in adults. In this discussion treatment recom-
mendations are made for the specific diagnoses of acute
rhinosinusitis, chronic rhinosinusitis, and acute exacer-
bation of rhinosinusitis. Some or all of the treatments
described may be recommended for individual patients
based on a number of factors including the type of rhi-
nosinusitis, concurrent medical conditions (e.g., aller-
gic disease), severity of symptoms, and response to pre-
vious treatment. Options for the treatment of rhinosinusi-
tis based on clinical classification are listed in Table 1.
PATHOPHYSIOLOGY
The pathophysiology of rhinosinusitis is not perfect-
ly clear and is likely to be multifactorial in most
patients. Furthermore rhinosinusitis may be pathogeni-
cally different in children than adults. Rhinosinusitis in
children is usually the sequela of an acute upper respi-
ratory tract infection.2 The incidence of upper respira-
tory tract infections is higher in children tor a number
of reasons, principally because lack of previous expo-
From the Department of Otolaryngology-Head and Neck Surgery,
(Dr. Benninger), Henry Ford Hospital, Detroit, University of
Pittsburgh School of Medicine (Dr. Anon), Pittsburgh~ and
Southwestern Medical Center (Dr. Mabry), Dallas.
Reprint requests: Michael S. Benninger, MD, Department of
Otolaryngology-Head and Neck Surgery, Henry Ford Hospital,
2799 W. Grand Blvd., Detroit, MI 48202.
Copyright © 1997 by the American Academy of O1olaryngology-
Head and Neck Surgery Foundation, Inc.
0194-5998/97/$5.00 + 0 23/0/83515
sure makes them less immune to viruses that attack the
upper respiratory tract and also because they are fre-
quently in environments such as schools and day care
centers in which close contact with other children facil-
itates the transfer of infection.
Upper respiratory tract infection leads to mucosa]
swelling, which can obstruct sinus outflow, resulting in
infection. In children the small size of the developing
sinuses and the shorter distance between the mucosal
surfaces of the ostia also seem to play a role in the
development of rhinosinusitis after a viral upper respi-
ratory tract infection. Because of the strong association
of rhinosinusitis with this viral infection, several inves-
tigators3,4 believe that, particularly in children, some
episodes of rhinosinusitis may be self-limited and may
not require aggressive medical management.
A number of conditions can predispose an individual
to have rhinosinusitis. Immunoglobulin deficiencies,
whether transient or permanent, diminish the body's
ability to combat infection. Because transient
immunoglobulin deficiencies primarily occur in chil-
dren, recurrent rhinosinusitis may require assessment in
young patients. Disorders of mucociliary transport such
as immotile cilia syndrome and cystic fibrosis are usu-
ally identified in children after repeated episodes of
pulmonary, sinus, or ear infections. Alterations in glan-
dular secretions caused by cystic fibrosis can result in
inspissated mucus that is difficult to clear.5 Stasis of
such mucus may result in recurrent colonization and
infection.6,7 In such cases it may be helpful to reduce
mucus viscosity and improve mucus clearance.
A role for allergies in the development of rhinosi-
nusitis has been suggested but not proven. 8-m Antigen-
antibody reactions result in the release of a number of
mediators of inflammation, most prominently hista-
mine. These mediators result in increased vascular per-
meability, destabilized lysosomal membranes, and
$4]

2. S42 BENNINGER,ANON, and MABRY
Otolaryngology-
Head and Neck Surgery
September 1997
Table 1. Medical treatment options in rhinosinusitis
General
treatment
Classification measures Antibiotics
Acute adult rhinosinusitis + +
Subacute adult rhinosinusitis + _+
Recurrent acute adult rhinosinusitis + +
Chronic adult rhinosinusitis + __.
Acute exacerbation of chronic adult + +
rhinosinusitis
Steroid Ipratropium
nasal bromide
Antihistamines spray nasal spray
± ±
± + +
± ± +
± + +
± + ±
Systemic
steroids Immunotherapy
±
-- ±
± ±
± ±
+, Beneficial; -, not beneficial; _+, beneficial in some cases.
other reactions that produce inflammation and mucosal
swelling. Such reactions can lead to obstruction of the
sinus ostia, preventing mucus outflow. Ostial obstruc-
tion results in a reduction in oxygen tension, changes in
mucociliary transport, and a transudation of fluid into
the sinuses.6,11Such an environment is suitable for bac-
terial overgrowth. Prolonged obstruction results in
mucus stasis with bacterial and occasionally fungal col-
onization or infection.
Anatomic factors occasionally play a significant, if
not prominent, role in rhinosinusitis. Septal spurs or
deviations, hypertrophic or paradoxic middle
turbinates, and concha bullosa have been identified as
anatomic abnormalities that can affect sinus ostia out-
flow and result in rhinosinusitis.12,13 Sometimes anato-
my is a cofactor in rhinosinusitis. In such cases the ostia
are impinged upon but not permanently obstructed, so
that minimal mucosal swelling or inflammation from an
upper respiratory tract infection or an allergy intermit-
tently obstructs the sinus and causes rhinosinusitis.
Such cases may require surgical correction, but many
can be treated medically in an effort to reduce the
inflammatory or edematous component. Combined sur-
gical and medical treatment may be necessary in some
cases, or surgical correction of the anatomic abnormal-
ity alone may be sufficient to prevent rhinosinusitis.
MICROBIOLOGY
Acute Rhinosinusitis
The causative pathogens for acute rhinosinusitis have
changed over the past 50 years. Whereas [3-hemolytic
streptococci and pneumococci were the major organ-
isms identified by aspiration of the maxillary sinuses in
the 1940s, Streptococcus pneumoniae and Haemophilus
influenzae are the predominant organisms currently
found in patients with this infection.
In 1981, Gwaltney et al) 4 reported the culture
results for aspirates obtained in 113 patients with acute
rhinosinusitis. Of 141 aspirates, 86 were positive, with
S. pneumoniae present in 43% of aspirates and H.
influenzae found in 31% of aspirates. Anaerobes were
identified in 9% of the aspirates, Moraxella
(Branhamella) catarrhalis was found in 5% of aspirates,
and (z-hemolytic streptococci and S. aureus were each
present in 3% of aspirates.
The findings for 200 sinus aspirations performed in
adults with acute rhinosinusitis were presented by Berg
et al) 5in 1988. Pathogens were isolated in 87% of aspi-
rates. Of these aspirates, 57% were positive for S. pneu-
moniae, 22% for H. influenzae, 6% for [}-hemolytic
streptococci, 7% for anaerobes, 2% for M. catarrhalis,
and 2% for S. aureus.
In 1988, Jousimies-Somer et al) 6 reported the cul-
ture results for 339 sinus aspirates obtained in 238
young adult military personnel with acute maxillary
rhinosinusitis. Cultures identified H. influenzae in 52%
of aspirates, S. pneumoniae in 21% of aspirates, anaer-
obes in 8% of aspirates, Streptococcus pyogenes in 6%
of aspirates, and M. catarrhalis in 2% of aspirates. The
authors noted that some of the sinus aspirates contained
more than one pathogen.
The efficacies of cefuroxime axetil and cefaclor in
patients with acute rhinosinusitis were evaluated by
Syndnor et al) 7 in 1989. The pathogens most common-
ly isolated were H. influenzae and S. pneumoniae,
which were found in, respectively, 38% and 37% of
sinus aspirates. The percentages for the less common
pathogens were similar to those reported in previous
studies.
Based on their 15-year experience and a review of
the literature, Gwaltney et al) 8reported on 339 patients
with acute rhinosinusitis in 1991. The bacterial recov-
ery rate for sinus puncture and aspiration was 59%. Of
the aspirate cultures, 41% were positive for S. pneumo-
niae, 35% for H. influenzae, 7% for anaerobes, 7% for
Streptococcus species, 4% for M. catarrhalis, and 3%
for S. aureus. The authors noted that viruses were cul-
tured from some of the sinuses.
In a 1996 review of the literature, Brook19 reported
that in acute sinus infections, cultures identified S.

3. Otolaryngology-
Head and Neck Surgery
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pneumoniae in 41% of aspirates, 14. influenzae in 35%
of aspirates, anaerobes such as Peptostreptococcus
species in 7% of aspirates, and M. catarrhalis in 4% of
aspirates. In chronic rhinosinusitis 67% of aspirates
contained anaerobes (i.e., pigmented Prevotella and
Porphyromonas species, Fusobacterium species, and
Peptostrep~ococcus species), 4% contained S. aureus,
2% contained S. pneumoniae, and 2% contained /4.
influenzae.
In summary, a 1996 compilation of the results of a
number of studies by Gwaltney~° showed the preva-
lence of infective organisms in acute rhinosinusitis to
be as follows: S. pneumoniae, 31% (range, 20% to
35%), unencapsulated H. influenzae, 21% (range, 6% to
26%), anaerobes, 6% (range, 0% to 8%), S. aureus, 4%
(range, 0% to 8%), S. pyogenes, 2% (range, 1% to 3%),
and M. catarrhalis, 2% (range, 2% to 10%). Viruses
were also found in the cultures, often in conjunction
with bacteria.
Subocute Rhinosinusitis
The microbiology of early subacute rhinosinusitis is
probably comparable to that of acute rhinosinusitis. As
subacute rhinosinusitis approaches a more chronic
phase, the bacteriologic findings tend to be more like
those for chronic rhinosinusitis.
Chronic Rhinosinusitis
With the development of rigid endc,scopes, the
increased use of computed tomographic (CT) scanning,
and a reevaluation of the pathophysiolog~, of rhinosi-
nusitis, attention was focused away from the maxillary
sinus and toward the ethmoid sinuses. In 1991, Doyle
and Wooham2~prospectively examined the microbiolo-
gy of the ethmoid sinuses at the time of surgery.
Antibiotic therapy had been discontinued in the patients
enrolled in this study. Of the 94 biopsy specimens col-
lected from 59 patients, 73% contained coagulase-neg-
ative Staphylococcus species, 33% exhibited S. aureus,
19% had enteric gram-negative bacteria, 4% contained
H. influenzae, and 2% showed & pneumoniae. No
anaerobes or viruses were found in the specimens, and
only one CUlturegrew a fungus. A review of previously
published reports compared the bacteriology of chronic
maxillary sinusitis and chronic ethmoid sinusitis. The
following pathogens were more commonly cultured
from the maxillary sinuses than from the ethmoid sinus-
es: S. pneumoniae (6% vs 2%), H. influenzae (19% vs
4%), anaerobes (72% vs 0%), and Streptococcus viri-
dans (32% vs 9%). In contrast, the pathogens more fre-
quently found in ethmoid sinus cultures than in maxil-
lary sinus cultures were as follows: S. aureus (33% vs
6%), coagulase-negative Staphylococcus species (71%
vs 11%), and Enterobacteriaceae organisms (19% vs
2%).
In 1992, Hoyt22 cultured mucosa removed from 197
patients at the time of surgery. The culture results
showed coagulase-negative Staphylococcus species in
47% of specimens, S. aureus in 23% of specimens, S.
pneumoniae in 7% of specimens, and H. influenzae in
3% of specimens. None of the anaerobic cultures was
positive. In 28% of cultures more than one bacterial
species was found.
During office endoscopy in 47 patients with chronic
rhinosinusitis, Bolger23 obtained swab cultures of
pathologic secretions at the sinus ostia, within the eth-
mold recesses, or in a postoperative cavity. Of the 98
cultures obtained, 14 showed no growth, 44 contained
only one organism, and 34 grew more than one bacter-
ial species. Coagulase-negative Staphylococcus species
were present in 24% of positive cultures, S. aureus in
16% of cultures, Pseudornonas aeruginosa in 16% of
cultures, other enteric gram-negative bacteria in 31% of
cultures, and anaerobes in 4% of cultures. In this 1994
article the author theorized that the high incidence of
gram-negative enteric organisms in these patients could
be explained by their recent use of antibiotic therapy,
their use of nasal steroids, and changes in tile local
immunity of the area caused by previous bacterial
infections.
In 1994, Brook, et al.24 published a retrospective
study of 68 patients who had undergone Caldwell-Luc
procedures and had not received antibiotics before
surgery. (z-hemolytic streptococci, S. aureus, M.
catarrhalis, and Haemophilus species were the primary
aerobic/facultative organisms isolated. Anaerobes were
found in 82% of specimens.
During endoscopic sinus surgery in 76 patients,
Ramadan25 obtained tissue for cultures to study the
microbiology of chronic rhinosinusitis. Although the
patients had been receiving medical treatment includ-
ing antibiotics, they were given no antibiotic therapy
for the week before surgery. Of the positive cultures in
this 1995 study, 80% grew coagulase-negative Staphy-
lococcus species, 2I% grew S. aureus, 8% grew anaer-
obes, and 4% grew S. pneumoniae. Miscellaneous organ-
isms constituted the remainder of the pathogens that
were isolated.
In a 1996 study of 46 patients who underwent endo-
scopic surgery, Rontal et al.26 reported that 31% of cul-
tures grew coagulase-negative Staphylococcus species,
9% grew S. aureus, and 7% grew S. viridans. Other aer-
obes were infrequent, but mixed organisms were seen in
17% of cultures. Only 4% of the cultures grew anaerobes.
In summary, the major pathogens in chronic rhino-
sinusitis appear to be as follows: coagulase-negative

4. $44 BENNINGER,ANON, and MABRY
Otolaryngology-
Head and NeckSurgery
September 1997
Staphylococcus species, 51% (range, 24% to 80%), S.
aureus, 20% (range, 9% to 33%), anaerobes, 3% (range,
0% to 8%, not including the work from Brook19), and S.
pneumoniae, 4% (range, 0% to 7%). On average, multi-
ple organisms are found in 16% of cultures.
The microbiology of chronic maxillary sinusitis
appears to be different from that of chronic ethmoid
sinusitis. As several authors point out, a higher inci-
dence of anaerobes in chronic maxillary sinusitis may
reflect the greater degree of occlusion of this particular
sinus and thus a more closed-offanaerobic environment
compared with the more open ethmoid sinus.
GENERAL TREATMENT MEASURES
A number of general treatment measures are impor-
tant in patients with rhinosinusitis. Many of these mea-
sures are directed at establishing a more normal nasal
environment through moisturization, humidification,
and the reduction of swelling. Because mucociliary
transport depends in part on the viscosity of mucus,
efforts to reduce this viscosity have also been advocat-
ed.
Saline solution nasal sprays have been shown to
reduce the symptoms of both allergic and nonallergic
rhinitis,27 and they are likely to be beneficial in rhino-
sinusitis as well. Saline solution moisturizes the nasal
cavity, reduces dryness, and helps to clear inspissated
or crusty mucus. Nasal irrigation with saline solution
douches has also become important for clearing nasal
crusts and thick mucus in patients with rhinosinusitis,
particularly after surgery.28-3° Some investigators have
advocated the addition of vinegar or acetic acid to
reestablish a more normal pH or the addition of hydro-
gen peroxide to help clean the nose and sinuses,
although the value of these measures has not been
clearly demonstrated. Because saline solution sprays or
irrigations are inexpensive and have few to no adverse
effects, it is reasonable to include them in the treatment
of most patients with rhinosinusitis.
Humidification may also be an important and simple
measure to include in the treatment regimen for rhino-
sinusitis. In dry environments mucociliary transport is
slowed and mucus becomes thickened. In such envi-
ronments humidification is likely to be valuable.
However, in patients who have mold allergies or who
live in more humid environments, excessive humidifi-
cation may increase inflammation, precipitating or
worsening rhinosinusitis. Controversy exists as to
whether warm or cool humidification is preferable.
Although the use of warm mist has been advocated for
reducing the symptoms of upper airway and rhinovirus
infections, controlled studies have not shown a positive
benefit.31,32In most patients humidification can help to
control symptoms, and it can be considered as an
adjunct to other treatments. This measure has few to no
adverse effects. However, to reduce fungal overgrowth
it is important to keep the humidifier clean.
Mucolytic agents have been advocated for the pre-
vention and treatment of rhinosinusitis. Mucolytics
such as guaifenesin, a component of many deconges-
tants and expectorants, serve to thin mucus, which may
reduce mucus stasis and promote clearing. This is par-
ticularly important in disorders of mucociliary clear-
ance and disorders in which there is a reduction or
thickening of glandular secretion such as cystic fibro-
sis.5 In experimentally induced sinusitis mucociliary
clearance has been found to be reduced because of
alterations in both mucus and cilia.6,H,33 Therefore
mucolytics should be beneficial in most patients with
rhinosinusitis. One double-blind, placebo-controlled
study34 found that guaifenesin reduced nasal conges-
tion and posterior nasal drainage in patients with human
immunodeficiency virus infection who had either acute
or chronic rhinosinusitis.
DECONGESTANTS
Systemic and topical decongestants act through
stimulation of c~-adrenergic receptors in the mucosa of
the upper airways. Stimulation of these receptors
results in vasoconstriction of the mucosal capillaries
with subsequent shrinking of swollen or edematous
mucosa.35Decongestion would be expected to decrease
nasal swelling and obstruction, to restore the patency of
the ostia, and to improve ventilation. Consequently,
decongestants are often advocated for the prevention or
treatment of rhinosinusitis.
Topical decongestants, particularly oxymetazoline
hydrochloride, generally provide rapid and significant
relief of nasal obstruction with minimal systemic
effects. Whether the reduction in nasal swelling has a
positive effect on rhinosinusitis is debatable. Based on
experiments in a rabbit model, Bende et al.36 recently
suggested that topical decongestants may actually have
a negative effect.36 In this study histologic sections of
rabbit sinuses obtained after the induction of sinusitis
and treatment with nasal oxymetazoline were actually
found to have a significantly greater degree of inflam-
mation than sections from untreated sinuses on the
opposite side. The authors postulated that decongestant
nasal sprays may interfere with the normal defense
mechanisms during bacterial-induced sinusitis, possi-
bly by decreasing mucosal blood flow. Despite such
reservations, topical decongestants will usually reduce
symptoms and speed recovery in patients with rhinosi-
nusitis. Given the significant rebound potential with
long-term use, these agents are likely to be most effec-

5. Otolaryngo~ogy-
Head and Neck Surgery
Volume 117 Number 3 Part2 BENNINGER,ANON,and MABRY $45
tive in patients with acute rhinosinusitis, acute exacer-
bation of chronic rhinosinusitis, or recurrent acute rhi-
nosinusitis.
Systemic decongestants are also used to treat many
patients with rhinosinusitis. Because rhinosinusitis
involves inflammation of the nose and the sinuses,
nasal obstruction and drainage are common symptoms.
Systemic decongestants help to alleviate these bother-
some symptoms. Furthermore, unlike many antihista-
mines, systemic decongestants have minimal drying
side effects and thus are less likely to impede mucus
transport. The addition of a mucolytic can aid mucus
clearance by thinning the mucus.
Oral decongestants should be used with caution in
patients with medical conditions such as hypertension,
ischemic heart disease, hyperthyroidism, and diabetes
mellitus and in patients who are taking monoamine oxi-
dase inhibitors. Whether oral decongestants speed the
resolution of rhinosinusitis is debatable. Nonetheless,
given the low risk, controllable side effects, relatively
low cost, and benefits in symptom reduction, the use of
decongestants seems to be warranted in some, if not
many, patients with rhinosinusitis.
ANTIHISTAMINES
For many years physicians have intuitively used
antihistamines to manage chronic rhinosinusitis in
patients with coexisting allergy.37-4°However, no stud-
ies clearly show a positive effect for antihistamines in
this situation.41
Although numerous clinical trials have supported
the efficacy of antihistamines in reducing the sneezing
and rhinorrhea associated with allergic rhinitis, the
mechanism by which these agents produce symptom
relief is still incompletely understood. The classic
explanation, based on in vitro studies, is competitive
antagonism of histamine binding to H1 receptors on
nerve endings, smooth muscle cells, and glandular
cells. In addition, antihistamines have been shown to
exhibit other mechanisms of action. Virtually all first-
generation compounds have anticholinergic (antimus-
carinic) action. Some also have sedative, local anes-
thetic, and antiserotonin effects.
Specific :in vivo studies of a number of individual
antihistamine preparations have demonstrated their
individual unique properties beyond and sometimes
instead of "antihistamine" activity.42Azatadine maleate
has been shown to have leukotriene-inhibiting proper-
ties in vitro but only at concentrations that would be
difficult to obtain with oral administration.43 In vivo
studies have demonstrated leukotriene inhibition by
azelastine44 and cetirizine45 without a significant effect
on histamine and prostaglandin D2 generation. In a
study measuring the effects of various agents on hista-
mine release, leukotriene generation, and hyperrespon-
siveness to methacholine, Naclerio and Baroody42
found differing mechanisms of action for azelastine,
cetirizine, ketotifen, levocabastine, loratadine, and ter-
fenadine. Because it now appears that antiallergy and
antiinflammatory effects are produced in different fash-
ions by various antihistamines, these drugs may not be
simply antiallergy medications. More studies are
required to determine whether these effects are relevant
in the treatment of chronic sinusitis.
In particular, antihistamines appear to be useful for
preventing or treating acute allergic flares in patients
with both allergy and chronic rhinosinusitis. Because
the allergic reaction results in hypersecretion and local
edema, which may, in turn, lead to stasis within the
sinuses, prevention of this situation may avoid setting
up favorable circumstances for the development of a
secondary infection within the diseased sinuses.46This
scenario can be prevented with antihistamines and
other medications.
One factor to be considered in administering antihis-
tamines to patients with sinusitis is whether the anti-
cholinergic effects of these drugs, especially the first-
generation compounds, might result in the excessive
drying of nasal and sinus secretions, leading to crust
formation and stagnation within the sinuses. Because
the newer second-generation antihistamines typically
are free of undesirable anticholinergic effects, these
agents can be used to relieve symptoms in patients with
both allergy and rhinosinusitis.47
TOPICAL NASAL STEROIDS
Topical nasal steroids are beneficial in a variety of
acute and chronic nasal conditions including allergic
and nonallergic rhinitis and chronic rhinosinusitis. It
appears that these agents reduce the sensitivity of
cholinergic receptors (thereby decreasing the secretory
response), reduce the number of basophils in nasal
epithelium and eosinophils in mucosa, and inhibit the
late-phase reaction after exposure to allergenY ,48,49
Beclomethasone dipropionate, budesonide, flu-
nisolide, fluticasone dipropionate, and triamcinolone
acetonide do not have significant systemic effects when
properly dosed. The multiple preparations and delivery
systems that are now available allow the physician and
patient great flexibility in nasal steroid treatment. When
used as an adjunct to antibiotic therapy, nasal steroids
have been shown to improve symptoms, to decrease the
volume of inflammatory cells, and to aid in the
regression of radiographic abnormalities. 5° Nasal
steroid sprays are recommended before surgical
intervention.

6. S46 BENNINGER,ANON, and MABRY
Otolaryngology-
Head and NeckSurgery
September 1997
Nasal sprays containing ipratropium bromide have a
different mechanism of action than those containing
steroids. Ipratropium bromide, a topical anticholinergic
agent that blocks glandular cholinergic receptors, has
been found to reduce glandular hypersecretion and
sneezing in patients with allergic rhinitis, nonallergic
rhinitis, and the common cold.51-53Because this agent
does not dramatically decrease nasal airway resistance,
it should be used primarily for reducing the symptoms
of nasal drainage in patients with rhinosinusitis.
Ipratropium bromide may theoretically increase the vis-
cosity of mucus, which may be counterproductive in
some patients with rhinosinusitis, particularly those
with acute rhinosinusitis. This effect appears to be min-
imal compared with the effects that antihistamines have
on mucus viscosity. Although ipratropium bromide has
been shown to be beneficial in reducing the symptoms
of the common cold, no studies have been done to val-
idate its efficacy in rhinosinusitis. Nonetheless, ipra-
tropium bromide nasal spray may be a useful adjunct in
the treatment of rhinosinusitis.
Cromolyn sodium acts to stabilize mast cells, pre-
venting degranulation and the release of inflammatory
mediators. Because this medication has no effect on the
inflammatory process once it has occurred, it is best
used before antigen exposure. Cromolyn sodium
appears to have only minimal efficacy in patients with
rhinosinusitis. This agent may, however, be useful in
allergic patients with continued antigen exposure dur-
ing an episode of rhinosinusitis. It may also help to pre-
vent ostial occlusion, which could result in the devel-
opment of rhinosinusitis.
SYSTEM CORTICOSTEROIDS
Oral corticosteroids have been very effective in
managing the effects of a variety of inflammatory con-
ditions including allergic rhinitis. By keeping capillary
permeability from increasing, steroids prevent or
reduce tissue edema. They deplete circulating
eosinophils and T lymphocytes by redistribution of
these into other compartments. They also serve to
inhibit the production of many mediators of inflamma-
tion including prostaglandins, lymphokines, leukotrienes,
bradykinins, serotonin, and interferon.54 Lysosomal
membranes are also stabilized.54'55 Steroids have been
shown to be effective in treating allergic rhinitis, reduc-
ing nasal polyposis, and treating allergic fungal dis-
ease.54They are of great benefit in allergic patients with
chronic rhinosinusitis and in patients with chronic rhi-
nosinusitis and nasal polyposis. By reducing tissue
edema and preventing the release of inflammatory
mediators, systemic steroids are also likely to benefit
patients with acute rhinosinusitis. However, given the
relatively rapid response of patients with uncomplicat-
ed acute rhinosinusitis to other less risky medications,
the routine use of systemic corticosteroids for acute rhi-
nosinusitis should be avoided.
The predominant disadvantage of systemic corticos-
teroids is that they suppress the hypothalamic-pituitary-
adrenal axis. Long-term use of these agents has been
associated with adrenal suppression. Furthermore the
sudden discontinuation of steroids after long-term use
results in adrenal insufficiency, which can be life-
threatening. Even without a tapering dose the risk of
such side effects is minimal with the short-term sys-
temic corticosteroid therapy typically recommended for
patients who have rhinosinusitis. When steroid therapy
is used for more than 1 or 2 weeks, tapering doses are
recommended. Note, however, that specific recommen-
dations concerning the duration of steroid use that
requires tapering doses vary among authors and studies.
The more common side effects of short:term sys-
temic corticosteroid therapy include mucosal itching,
superficial gastric ulcerations, changes in affect or tem-
perament, sleep disturbances, and, occasionally, prema-
ture ventricular contractions.54 Because systemic corti-
costeroids may alter insulin requirements, they should
be used cautiously in patients with diabetes mellitus.
With longer use these agents have more significant side
effects including osteoporosis, myopathy, peptic ulcer
disease, hypertension, ocular effects, and weight gain.54
Susceptibility to infection, which is known to increase
with long-term steroid therapy, probably has only theo-
retic implications in short-term therapy, but it should be
considered, particularly in patients with acute rhinosi-
nusitis.
ANTIBIOTICS
Although direct aspiration for culture is not needed
routinely in patients with acute rhinosinusitis, cultures
should be performed in all immunocompromised
patients. Culture specimens obtained from the middle
meatus under endoscopic guidance may provide useful
information. The persistence of symptoms or an
increase in symptoms during therapy implies treatment
failure. In such cases further diagnostic studies includ-
ing culture would be appropriate.
As mentioned earlier, the causative organisms in rhi-
nosinusitis have changed over the years. Furthermore
the resistance patterns of the bacteria found in acute and
chronic rhinosinusitis have led to changes in the antibi-
otics chosen to combat these illnesses.
ACUTE RHINOSINUSITIS
Because up to 70% of acute rhinosinusitis cases are
caused by either S. pneumoniae or H. influenzae,
antibiotic therapy should be directed at these organ-
isms. Because of the increased incidence of ~-lacta-

7. Otolaryngology-
Head and Neck Surgery
Volume 117 Number 3 Part 2 BENNINGER,ANON, and MABRY 547
mase-producing pathogens and drug-resistant S. pneu-
moniae strains in acute rhinosinusitis, careful consider-
ation should be used when selecting the most appropri-
ate antibiotic. The duration of therapy should between
10 and 14 days.
The Food and Drug Administration -as of January
1997- has approved amoxicillin-clavulonate, clar-
ithromycin, cefprozil, cefuroxime axelil, loracarbef,
and levofloxacin for the treatment of rhinosinusitis.
Members of the Academy's Rhinosinusitis Task Force
use a variety of oral antibiotics for treating rhinosinusitis.
Antibiotics that are considered to be effective for the
empiric treatment of acute rhinosinusitis include amoxi-
cillin, amoxicillin-clavulanate, azithromycin, cefpo-
doxime proxetil, cefprozil, cefuroxime axetil, clar-
ithromycin, levofloxacin, loracarbef, and trimetho-
prim/sulfamethoxazole. The choice of a specific antibi-
otic should be based on factors that include previous
antibiotic therapy, information about the resistance pat-
terns of the pathogenic organisms within the physi-
cian's community, dosing schedules, side effects, and
the patient's drug allergy history. Penicillin, ery-
thromycin, cephalexin, and tetracycline should not be
used, because these drugs do not cover the major organ-
isms that cause acute rhinosinusitis.
CHRONIC RHINOSINUSITIS
Antibiotic therapy for chronic rhinosi~usitis should
be directed toward coagulase-positive and coagulase-
negative Staphylococcus species and Streptococcus
species. The necessity for anaerobic coverage is contro-
versial. The currently recommended duration of antibi-
otic therapy for chronic disease is 4 to 6 weeks, but
studies are in progress to determine the optimal length
of treatment. Members of the Task Force use a similar
antibiotic selection as for acute rhinosinusitis. It is rea-
sonable to consider the use of clindamycm or metro-
nidazole alone or in combination with other antibiotics.
IMMUNOTHERAPY
Based on experience, immunotherapy is also viewed
as being important in controlling allergies to prevent
the recurrence of chronic rhinosinusitis after surgery.
Unfortunately, as with antihistamines, no studies exist
to support the benefits of immunotherapy. Nishioka et
al.56 did show that allergic patients wl~o received
immunotherapy had a better long-term omcome after
endoscopic sinus Surgery than patients with untreated
allergies.
Although allergy has not been fully shown to be a
contributing factor in chronic rhinosinusitis, most
physicians believe that allergy does play a role in this
infection. Some studies have found a higher, incidence
of allergy in patients with sinus disease than in the gen-
eral population. In a study in Finland, Savolainen57
reported allergy to be present in 25% to 32% of patients
with verified acute maxillary sinusitis but in only 7% of
control subjects. In another European study, however,
Iwens and Clement58 found no difference in the inci-
dence of sinusitis, as determined by CT scanning, in
allergic and nonallergic children (61% and 64%,
respectively) and adults (58.0% and 57.5%, respective-
ly).
Rachel&sky et al.59 found a 50% incidence of posi-
tive skin tests to inhalant allergens in a large group of
children with chronic sinusitis compared with a 15% to
30% incidence of allergy in the general population.
Other studies and reviews of existing reports support
this concordance of allergy and sinus diseases.6°'62
Allergy is generally considered to affect the sinuses
through a combination of hypersecretion and obstruc-
tion of the ostiomeatal complex caused by mucosal
edema. The result is stasis within the sinuses) Studies
using single-photon emission CT scanning have shown
that pollens do not actually enter the sinuses.62Phillips
and Platts-Mills63 believe that the mucosal thickening
noted on CT scans in patients with allergic rhinosinusi-
tis represents immunologically active tissue.
The mechanism by which immunotherapy produces
its effects remains a matter of debate and conjecture.
The immunologic responses associated with allergen
immunotherapy have been reported to be an increase in
allergen-specific immunoglobulin G-blocking antibod-
ies, an initial rise and then a drop in allergen-specific
immunoglobulin E antibodies, a decrease in the release
of basophil histamine in response to an allergen chal-
lenge, an increase in allergen-specific suppressor T
cells, and a decrease in the lymphocyte-cytokine
response to an allergen challenge. 64 Whether
immunotherapy has any direct effect on sinus mucosa
has not been studied. However, the effectiveness of
immunotherapy in ameliorating allergic symptoms per
se has been demonstrated.65
Although no studies support the use of immunother-
apy in the treatment of allergy coexisting with chronic
sinus disease, the interrelationship of these entities is
generally accepted. Therefore, when administered
under the care of an appropriately trained physician,
immunotherapy for inhalant allergens should be con-
sidered a suitable measure in the overall management
of chronic rhinosinusitis.
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