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Rhinosinusitis and its treatment
About two thirds of those who get sinusitis do not need to see a doctor and many will
seek advice from their pharmacist. This article discusses this common condition
WILL METCALFE MPHARM, MBBCH, CORE TRAINEE 2 DOCTOR, AND TOBY MOORHOUSE MBBCH, DOHNS, SPECIALIST REGISTRAR, OTORHINOLOGY,
SINGLETON HOSPITAL, SWANSEA
RHINITIS (inammation of the
mucous membranes of the nose)
and sinusitis (inammation of the
mucous membranes of the
sinuses in the face) usually co-
exist so the term rhinosinusitis
has been adopted. Panel 1
describes the sinuses.
Rhinosinusitis is a common
condition that has a high impact
on quality of life. It has also been
shown to have a signicant
economic impact. For example,
studies in the US have estimated
that chronic rhinosinusitis alone
costs the economy $5.78bn per
year. Most patients (85 per cent)
are between the ages of 16 and 65
years, so are likely to be absent
from work. Patients with chronic
rhinosinusitis make 43 per cent
more outpatient appointments
and have 43 per cent more
prescriptions dispensed than
others.
Symptoms and diagnosis
The most common symptoms of
rhinosinusitis are:
Nasal congestion, blockage or
stuness
Nasal discharge or postnasal
drip (often mucopurulent)
There may also be reduction or
loss of smell, and facial pain or
pressure and headache.
These symptoms may be
accompanied by pharyngeal,
laryngeal and tracheal irritation
causing sore throat, hoarse voice
(dysphonia) and cough,
drowsiness, malaise and fever.
Acute rhinosinusitis is dened as
lasting less than 12 weeks, with
complete resolution of symptoms.
When symptoms last longer, the
rhinosinusitis is classed as
chronic. Although the symptoms
of acute and chronic forms of the
condition are similar, acute
disease may have more distinct
and often more severe symptoms,
including facial pain. Chronic
rhinosinusitis can uctuate a
patient can have a low level of
long-term disease and experience
acute are ups.
Reflect
Evaluate Plan
Act
REFLECT
1 How long can acute
rhinosinusitis last?
2 What are nasal polyps?
3 What are the current evidence
based treatments for
rhinosinusitis?
Before reading on, think about
how this article may help you to
do your job better.
3D4MEDICAL.COM/SCIENCE PHOTO LIBRARY
PANEL 1: THE SINUSES Prevalence varies with season
(higher in the winter months) and
The paranasal sinuses consist of a group of four paired, air-filled bony climate. It increases in damp
cavities within the facial bones. They are lined with mucous membrane environments and in the presence
of high levels of air pollution.
and connect to the nasal cavity via small openings (ostia).
All sinuses contain a sensory nerve supply. They are most sensitive There is strong evidence to
around the ostia, the main body of the sinus lacking sensation. Glands
within the lining of the sinuses produce a mucous film that is propelled
support the hypothesis that
cigarette smoking predisposes
by cilia in a spiral fashion towards the ostia. patients to rhinosinusitis, possibly
The sinuses are named from the bones within which they are formed. via changes to ciliary motility and
The maxillary and ethmoidal sinuses lie beside the lateral walls of the function.
nose (ethmoidal at the top), the frontal sinuses are above the eyes, The role of allergy in
within the frontal bones of the forehead, and the sphenoidal sinuses are rhinosinusitis is still under debate
located at the centre of the skull base, under the pituitary gland. but it is postulated that atopy
predisposes people to chronic
rhinosinusitis. Both conditions
For most patients rhinosinusitis share a trend in increasing
is diagnosed on the basis of incidence and frequently co-exist.
symptoms alone. There are, It is believed that chronic swelling
however, a range of tests available of the nasal mucosa in patients
to validate the clinical symptoms with allergies may obstruct the
and signs, the most common ostia, leading to decreased
being nasal endoscopy, nasal ventilation of the sinus, mucus
cytology, biopsy and bacteriology. retention and development of
infection.
Causes and risk factors Studies have also shown that
Acute rhinosinusitis is usually there is a strong association as
diagnosed and managed in much as 50 per cent between
primary care. Studies report a patients with chronic
prevalence of 6 to 10 per cent. It rhinosinusitus and asthma.
is principally viral but up to 2 per Cytokine patterns in sinus tissue
cent of patients will develop a of chronic rhinosinusitus suerers
secondary bacterial infection. are similar to those in bronchial
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tissue of asthmatic patients, and
increased numbers of eosinophils
are found in both conditions.
Dental infections have been
reported to cause acute maxillary
sinusitis. Gum disease, a tooth
root projecting into the sinus or
dental abscesses have all been
identied as sources of sinus
infection.
Chronic rhinosinusitis is
common in people with cystic
brosis.The primary mechanism
is thought to be impaired ciliary
clearance of the thickened mucus
within the sinus, leading to
bacterial infection.
Chronic rhinosinusitus is often
also associated with nasal polyps
(see Panel 2).
Hypertrophy of the adenoid
(tonsillar tissue) is thought to
contribute to a large number of
cases of paediatric chronic
rhinosinusitis by blocking airow
through the nose, leading to
insucient ventilation of the
sinuses.
When to refer
Rhinosinusitis rarely causes
headache or facial pain, except
when there is an acute bacterial
infection with blockage of the
sinus.This is usually preceded by
a viral upper respiratory tract
infection and results in severe
unilateral pain, pyrexia and
unilateral nasal obstruction. (So
rhinosinusitis is not the problem
for most patients who present to
primary care with facial pain and
headaches, despite these patients
frequently labelling themselves as
suering with sinus problems. In
fact, a large proportion of patients
who suer from symmetrical
frontal or temporal headaches
have tension type headache.
Unilateral episodic headaches are
often vascular.)
Most patients with acute
bacterial rhinosinusitis respond to
antibiotics (see later). Patients
who suer from more than two
acute episodes in a year should be
oered further investigation.
Chronic bacterial sinusitis rarely
causes pain.
The authors will be
available to answer
questions on this topic
until 10 December 2012
Ask the
expert
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24 November 2012 (Vol 289)
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meningitis, encephalitis and
PANEL 2: NASAL POLYPS thrombosis of the superior sagittal
Nasal polyps are eshy, pedunculated or cavernous sinuses.These
masses that arise from the mucous conditions may present with non-
membranes of the nose or paranasal specic symptoms and health
sinuses. There are two main care professionals should be
classications: ethmoidal and highly suspicious of them for
antrochoanal. timely diagnosis.
Ethmoidal polyps are most Osteomyelitis can result from
common. They arise from the sinus infection spreading to the
ethmoid sinuses and are often facial skeleton. Symptoms can
multiple and bilateral. include bone pain, fever and
Antrochoanal polyps arise from swelling.
the maxillary sinuses and are more
likely to be unilateral. Treatment
Each types causes similar symptoms, The management of acute
namely nasal congestion, chronic rhinosinusitis and loss of smell rhinosinusitis in primary care is
(anosmia). summarised in Figure 1.
A general ear, nose and throat rule is that a unilateral polyp should be For symptoms lasting fewer
assumed to be neoplastic until proven otherwise, even though a than ve days, over-the-counter
retrospective study of polyp histology found that only 1 per cent of symptom relief can be oered.
removed polyps were malignant. It should be noted that nasal polyps For example, paracetamol,
are distinct from gastrointestinal polyps, which are often premalignant. ibuprofen or aspirin may be used
to relieve any headache, high
Cause Nasal polyps are a by-product of ongoing inammation. The temperature and any facial pain.
cause is not well understood, and probably multifactorial a result of A Cochrane report showed
allergy and infection together with mechanical abnormalities. Analysis benet when using saline
of polyps shows oedematous submucosal tissue with a high inltration irrigation for treatment.1 Nasal
of plasma cells, lymphocytes, macrophages and eosinophils. Polyps douching (see Panel 3) appears to
also contain high levels of histamine, presumably from mast cell be more eective than the use of
degranulation. nasal sprays and the addition of
Nasal polyps can occur at any age but are less common in children. xylitol or hypochlorite to the
They are more prevalent in men than in women (approximately 3:1) irrigation solution appears to
except in people with asthma, where the prevalence in males and result in greater improvement in
females is equal. Samters triad is a recognised clinical syndrome of symptoms over the use of saline
aspirin sensitivity, asthma and nasal polyposis and has an estimated alone. Simple drops and low
prevalence of 1 per cent in the general population and 10 per cent volume nasal sprays have poor
among people with asthma. Polyps are also common in people with distribution and should be
cystic brosis. considered a nasal cavity
treatment only.The best
Management Nasal polyposis should be viewed as a chronic condition distribution is currently found
IMAGE: DR P. MARAZZI/SCIENCE PHOTO LIBRARY
with a need for ongoing treatment. Topical intranasal steroids are from high volume devices such as
eective at reducing the size and symptoms of most polyps but delivery squeeze bottles that allow positive
to the required site can prove problematic. In some cases, short-term pressure irrigation, resulting in
oral steroids may be used initially, to shrink large polyps. We often use more thorough rinsing of the
Flixonase nasules (400g) for an initial two weeks before changing to nasal passage and sinus openings.
Flixonase spray (50g) as a maintenance medication. Surgical removal Decongestant nasal sprays or
of polyps is considered for patients with no improvement following drops may help relieve a blocked
pharmacological therapy. Regardless of treatment most nasal polyps nose but should not be used for
will recur. Patients who require surgery will require repeat procedures more than a week at a time.
on average every seven years. However, it should be noted that
there is no evidence for the use of
nasal decongestants,
Serious complications of acute antihistamines, mucolytics and
rhinosinusitis are rare but are expectorants, herbal medicines
potentially serious.They may be and probiotics in the treatment of
classied as orbital, intracranial or acute or chronic rhinosinusitis.
osseous. Steam inhalation is not
Orbital complications include recommended because of the
preseptal cellulitis (aects the danger of burns.
eyelid and periorbital soft tissue),
orbital cellulitis (behind the Corticosteroids
orbital septum) and subperiostial Corticosteroids bind to and
and intraorbital abscesses. Any activate intracellular
swelling or redness around the A Cochrane report glucocorticoid receptors, resulting
in increased expression of anti-
eyes, severe unilateral headache
or visual disturbance needs to be showed benet inammatory and inhibition of
investigated urgently. when using saline pro-inammatory gene
Intracranial complications transcription. These changes
irrigation for
include epidural or subdural
abscesses, brain abscess, treatment
directly decrease the viability and
activation of eosinophils and also

How to manage acute rhinosinusitis
Ask if the person has two of the following symptoms:
Nasal obstruction or discoloured discharge, or both
Frontal pain, headache
Cough
Smell disturbance
(especially children)*
Symptoms for fewer than
ve days or improving
Oer symptom relief
suitable for a common
cold (eg, analgesics,
nasal saline irrigation,
decongestants)
* In children bacterial infection should be considered when symptoms are not self-limiting and extend beyond
seven to 10 days. In these situations treatment with antibiotics seems to accelerate resolution. Whether this
benet outweighs the risk of frequent antibacterial prescriptions remains to be claried. Nasal irrigation,
antihistamines, decongestants and mucolytics have not been shown to be helpful.
Figure 1: Acute rhinosinusitis management scheme for primarycare (Adapted from FokkensWJ,LundVJ,Bachert C et al. European position paper
on rhinosinusitis and nasal polyps 2012. Rhinology 2012;50:S23)
cause an indirect reduction
in the secretion of chemotactic
cytokines from respiratory
mucosa (and from polyp
endothelial cells), further
reducing eosinophil activation.
Topical corticosteroids
(eg, nasal sprays) may be used in
acute rhinosinusitis that lasts for
longer than 10 days or if
symptoms are worse after ve
days.There is some weak
evidence that a short course of
oral corticosteroids in patients
suering from acute
rhinosinusitis may help to
resolve symptoms more quickly
but this is not generally
recommended.
In the treatment of chronic
rhinosinusitis, the evidence-based
recommendations for
corticosteroids are as follows:
Intranasal corticosteroids
improve symptoms and patient
reported outcomes
Delivery of intranasal
corticosteroids directly to
Refer the following immediately:
Swelling or redness around an eye
Visual disturbance, a bulging eyeball
Severe frontal headache or swelling
Signs of meningitis (eg, fever, non-
blanching rash, photophobia)
Neurological
rouse, confusion, seizure)
Symptoms for over 10 days or
worsening after ve days*
Moderate (ie, post viral)
Use topical steroids
No relief
after 14
days of
treatment
Consider referral to a
specialist
sinuses brings about a greater
eect
Patients who have had sinus
surgery (see later) have a better
response to intranasal
corticosteroids than those who
have not
Intranasal corticosteroids are
associated with only minor side
eects
The reported side eects of
intranasal corticosteroids are
epistaxis, nasal burning and
irritation, and a dry nose. These
are usually well tolerated and the
benet of treatment clearly
outweighs the associated risks. In
chronic sinusitis, especially in
patients with nasal polyps,
intranasal corticosteroids may be
used lifelong. The small doses and
topical application mean that
systemic eects are negligible.
The use of intranasal
corticosteroids during active
infection has not been shown to
worsen outcomes or to increase
the risk of serious complications.
The Pharmaceutical Journal 601
cpd
PANEL 3: NASAL
DOUCHING
Nasal douching means sning
a solution (we advise one
teaspoon sugar, one teaspoon
salt and one teaspoon
signs (eg, dicult to
bicarbonate of soda in a pint of
water that has been boiled and
cooled to room temperature)
into each nostril, from a
cupped hand, allowing it to go
down the back of the nose and
spitting it out. Not all the
mixture needs to be used
Severe (includes four snis should be enough.
bacterial infection) Nasal douching should
be done two to three times
a day.
Sprays such as Sterimar and
Use topical steroids, products such as NeilMed
consider antibiotics Sinus Rinse are alternatives.
Patients using nose drops
should use them after
Eect No
in 48 eect douching rather than before.
hours in 48
hours
Continue
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for seven
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to 14 days
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The surgical state of the sinus
cavity, types of delivery device,
uid dynamics and delivery
technique all play a role in
PANEL 4: SURGERY achieving eective topical
treatment with intranasal steroid
Sinus surgery is normally
sprays. Delivery of topical steroid
to the sinus mucosa in patients
eective in aiding symptomatic who have not had sinus surgery
relief in patients with genuine (see later) is thought to be less
rhinosinusitis unresponsive to than 2 per cent of the total
medical therapy. It involves the
removal of polypoid tissue and
irrigated volume. (Surgery to
open the sinus ostia increases
enlarging the ostia to facilitate distribution to the sinuses; see
drainage. panel 4.)
In an analysis of 1,713 Panel 5 (p602) explains how
patients 91 per cent pharmacists can help patients
experienced symptom with rhinosinusitis get the most
improvement following out of intranasal steroids by
surgery. Surgery is indicated making sure products are used
when medical management of correctly.
chronic rhinosinusitis fails but There is a lack of evidence for
can be avoided in many the use of oral corticosteroids to
cases by improving treat chronic rhinosinusitis.The
compliance and correcting few studies that have been
spray use. performed have shown a small
Adenoidectomy can improve additional benet from treatment
symptoms of chronic with oral corticosteroids together
rhinosinusitis in 50 per cent of
children, but is only indicated if
with intranasal corticosteroids but
the long-term nature of this
the adenoid is enlarged and condition together with the side
symptoms are not responding
to correct management.
eects of long-term oral
corticosteroid administration
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Further reading
PANEL 5: HOW TO ENSURE GOOD DELIVERY KEY POINTS
Fokkens WJ, Lund VJ, Mullol J et
Patients need detailed
counselling on the correct use
al. European position paper on
rhinosinusitis and nasal polyps Common symptoms of
rhinosinusitis are nasal
of nasal sprays in order to get 2012. Rhinology Ocial Journal congestion, nasal discharge,
the correct dose of steroid to of the European and and loss of smell. Symptoms
the lateral nasal wall. Often, International Societies 2012;50 can be chronic.
(S23).
patients will report no eect
Evidence-based treatments
with nasal steroid sprays as a
Kanoh s, Rubin BK. Mechanisms for rhinosinusitis include

THINGAMAJIGGS | DREAMSTIME.COM
consequence of incorrect use. of action and clinical application nasal irrigation, intranasal
Commonly patients will spray of macrolides as corticosteroids, antibiotics
the device into the nostril facing immunomodulatory medications. and sinus surgery. Over-the-
upward while taking a sharp Clinical Microbiology Reviews counter analgesics and
breath in. 2010;23: 590615. decongestants may be
Correct dosing is best
achieved by asking the patient
Kale SU, Mohite U, Rowlands D,
Drake-Lee AB. Clinical and
oered for symptoms lasting
for fewer than ve days.
histopathological correlation of
to stand and look at his or her
feet when using the spray. The nasal polyps: are there any Patients need detailed
counselling on the correct
spray is inserted into the nostril, pointing it directly in towards the ear surprises? Clinical use of nasal sprays in order
on that side. This is best achieved by reminding the patient to spray the Otolaryngology and Allied to achieve good outcomes.
opposite nostril to the hand they are using to hold the spray (ie, left Sciences 2001;26(4):3213.
hand for right nostril and vice versa). Patients should spray during a
quiet breath in. If they taste the spray straight away, they are breathing in patients with diuse
too sharply, bypassing the nose and inhaling the steroid. panbronchiolitis.2 This showed an
The premise of correct nasal drop administration is the same: to allow increase in 10-year survival from
maximal dosage to the lateral nasal wall. A common method of 25 to 90 per cent and
instruction is to lie on your back with your head over the edge of the bed simultaneous clearing of the
and turned 45 degrees to the nostril you are administering the drops. rhinosinusitis. An eect has been
The drops should be instilled and the patient should wait for as long as noted when erythromycin is used
stated by the manufacturer. Dierent manufacturers give dierent at a lower dose than that used to
administration methods, but we nd these methods more memorable treat infection and in the presence
and universally eective. of non-sensitive pathogens.This
has led to speculation that the
drug may have an
mean that the risk-benet prole Prescribers preference and immunomodulatory eect as well
is not likely to be favourable. experience tends to govern what as antibacterial properties.
In children, intranasal is used. Nevertheless, there are concerns
corticosteroids may be useful over long-term antibiotic use,
adjuncts to antibiotic therapy in Antibiotics particularly in low doses which
acute rhinosinusitis. It has been proven that acute fail to reach minimum inhibitory
In chronic rhinosinusitis, use of rhinosinusitis resolves without concentrations, and the
corticosteroids beyond seven to antibiotics in most cases. emergence of resistant bacterial
14 days may be required, under Antibiotics should be reserved for strains. Side eects, including
the care of an ENT specialist. patients who present with high PRACTICE POINTS gastrointestinal upset, skin rash
There is a theoretical risk of fever or severe unilateral facial and elevation of liver enzymes,
growth retardation that has not pain. Most patients with acute Reading is only one way to and interaction with other
been proved but the BNF bacterial rhinosinusitis will undertake CPD and the medicines may also be a problem.
recommends that the height of respond well to a short course of regulator will expect to see Patients with chronic
children is monitored.There is a antibiotics (eg, penicillin V or various approaches in a rhinosinusitis will often have tried
higher risk of systemic eects amoxicillin for seven to 14 days). pharmacists CPD portfolio. multiple courses of antibiotics
with drops compared with sprays. Common causative pathogens are and have more resistant
There are no randomised Streptococcus pneumoniae and 1. Ensure all patients organisms. Exacerbations are best
controlled trials for use of Haemophyllis influenza and, less collecting prescriptions for treated with co-amoxiclav or a
intranasal corticosteroids in commonly, Staphylococcus aureus intranasal steroid cephalosporin. Long-term
children with chronic and Moraxella catarrhalis. Co- preparations know how to antibiotic therapy is only
rhinosinusitis, but their proven amoxiclav or cephalosporins use them correctly (see implicated in those for whom
ecacy in adults and their should be considered for acute Panel 5). topical corticosteroids and nasal
safety record from use in allergic cases not resolved by one course 2. Educate counter sta on the irrigation have failed to reduce
rhinitis in children makes them of antibiotics. eectiveness of saline symptoms to an acceptable level.
rst-line therapy, albeit Chronic infections are more nasal douches in Current recommendations are
unlicensed. Note that dierent likely to be caused by management of that a trial of a macrolide for 12
products have dierent staphylococci or anaerobes. rhinosinusitis. weeks should be considered.
recommended ages for rhinitis There is little evidence to 3. Ensure all sta are aware Recent studies indicate that
(eg, over four years for Flixonase support the short-term use of which patients presenting doxycycline may be of some
spray, six years for budesonide antibiotics for chronic with possible sinusitis benet.
spray, no age range for rhinosinusitis.There is, however, should be referred. There is no evidence to support
betamethasone drops). increasing interest in the use of the use of topical antibiotics in
Budesonide spray and long-term antibiotics in chronic Consider making this activity either acute or chronic
Flixonase Nasules are licensed to rhinosinusitis following the one of your nine CPD entries rhinosinusitis.
treat nasal polyps in children over publication of a study of long- this year.
12 and 16 years, respectively. term, low-dose erythromycin use References available online.

24 November 2012 (Vol 289)

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