• Antibiotics
  Antibiotics may play a significant part in the treatment of sinus patients.

Choose the remedy with ingredients best suited to combat your own symptoms. If the label does not clearly state the ingredients and their functions, ask the pharmacist to explain them. Some novel treatments such as zinc, megadose vitamin C, echinacea pills, and nasal gel (Zicam®) have been introduced, but they still lack scientific proof of effectiveness.

Numerous combinations of antihistamines with decongestants are available; for example:

• Actifed®
• Allegra-D®
• Chlor-Trimeton D®
• Claritin D®
• Contac®
• Co-Pyronil 2®
• Deconamine®
• Demazin®
• Dimetapp®
• Drixoral®
• Isoclor®
• Nolamine®
• Novafed A®
• Ornade®
• Sudafed Plus®
• Tavist D®
• Triaminic®
• Trinalin®

A patient may find one product quite helpful for several months or years, but may need to switch to another one when the first loses its effectiveness. Since no one reacts exactly the same as another to the side effects of these drugs, patients may wish to try their own ideas on adjusting the dosages. You might take the antihistamine only at night and take the decongestant alone in the daytime, or take them together, increasing the dosage of antihistamine at night (while decreasing the decongestant dose) and then doing the opposite for daytime use. For example, take Chlor-Trimeton,®* 4mg, one tablet three times daily and two tablets at bedtime.

• Antihistamines
  Antihistamines are administered to alleviate “allergy” symptoms, but too much use may magnify a more underlying sinus ailment.

• Decongestants
  Decongestants cause constriction or tightening of the blood vessels in the membranes of the nose and air passages, which forces much of the blood out of the membranes so that they shrink.

Typically we place patients on the maximally tolerated dose of Guifenesin. This is the active ingredient in Mucinex and Humabid. There are some extended release formulations available; however, we generally strive to give patients 2400 mg per day of guifenesin. We prescribe this as Humabid LA or Mucinex 1200 mg PO BID or Mucinex 600 mg PO QID.

Adequate hydration cannot be overstressed. Avoiding dehydrating fluids such as soft drinks or coffee and trying to drink as much water as the person can stand can be incredibly helpful for the sinus patient. The primary limiting symptom for high dose mucolytics seems to be nausea.

If cultures can be obtained, they are. Studies have shown good correlation between endoscopically obtained cultures with those obtained in surgery. Augmentin, Cleocin, Cefuroxime, Clarithromycin, or a Quinolone are all good choices for empiric treatment. When using a quinolone I will generally use the higher dose, such as Ciprofloxacin 750 mg 2 times per day.

Macrolides

I tend to like the macrolides, especially Clarithromycin (Biaxin), as it is well tolerated and seems to have some other immunomodulatory (anti-inflammatory) activities. Often I will start with 500 mg 2 times a day for 2-3 weeks and then go to 250 mg once or twice a day for another 2-3 weeks. Patients often notice a metallic taste while on it. No matter what I always treat 7 – 10 days past the complete resolution of symptoms. I counsel my patients on the importance of this and try to get absolute compliance. Another Macrolide is Azithromycin and can be given at 250 mg ever other day or 2-3 times per week.

A former medical student of mine, and now a fellowship trained rhinologist at the Cleveland clinic, likes Doxycycline 100 mg 2 times a day. I would continue this out past 1 month. Bactrim DS 1 tab po bid for a month is another option.

Intravenous antibiotics rarely have a role. They are typically administered via central line access for 4-6 weeks. Having a central access line certainly brings with it risks.

Of note, patients with MRSA sinusitis are not contagious.

Topical

All of the the nasal steroid sprays are about equal in effectiveness, but some patients prefer one over the other for various reasons such as fragrance, taste, or delivery system. We typically have patients administer the sprays one to two times a day after a nasal saline rinse. Compliance is critical as the dose given several days ago is the one that is helping you today. You cannot take these medications on an as-needed basis.The same is true of oral-inhaled steroids. If you use a nasal steroid spray such as Flonase, Vancenase, Beconase or Nasacort, always use the salt-water mixture first, then use your nasal steroid spray. The steroid reaches deeper into the nose and sinuses when it is sprayed onto clean, decongested nasal tissues. Always aim your steroids up and out, actually pointing them towards the top of the same side ear.

Systemic

Typical doses of systemic steroids range from a Medrol dose pack to a three to four-week Prednisone taper. Some patients find Methylprednisolone more tolerable than Prednisone. We generally have patients take the majority of the dose in the morning since that parallels our own corticosteroid production , and sleep cycles are less disrupted.

Direct injection of steroids has been helpful to many of our patients as well. We will often inject up to 80 mg of Kenalog into the inferior nasal turbinates. We also use this method to reduce tip edema after rhinoplasty .

• mental status changes
• sleep deprivation
• blood sugar elevation in diabetics
• blood pressure elevation in hypertensives
• hyperacidity in patients with peptic ulcer disease
• myopathy
• impaired wound healing
• bone loss
• ocular complications

In regards to the wound healing complications, high-dose Vitamin A may be helpful. Pre-treatment bone densitometry, calcium, vitamin D, and bisphosphonates can help limit orthopedic concerns. And, a pre-treatment ophthalmologic evaluation to look at the likelihood of developing posterior subcapsular cataracts and open angle glaucoma may be appropriate.

The delivery method can help limit these adverse side effects.

Because corticosteroids are something our bodies make anyway, replacing too much for too long can cause a body to quit producing it. Adrenals typically produce the equivalent of 5 mg of prednisone per day. You can generally take any amount of steroids up to three weeks without having to worry about such changes.

• Flonase®
• Rhinocort®
• Nasarel
• Nasonex®
• Nasocort®

Common systemic steroids include:

• Medrol
• Prednisone

• Common Brands Several prescription brands of topical and systemic steroids are available.

• Side Effects Steroids can have numerous significant side effects.