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Mucolytics

Mucolytics are medications designed to make the nasal secretions more watery. That is to make that thick, tenacious, or viscous mucous thinner and more serous so it drains easier. Everyone makes a liter of “snot” or nasal secretions per day, so drainage is the norm; however, it seems to be more noticeable and problematic when those secretions are thicker. Those secretions are necessary to warm, filter, and humidify the air you breathe, so we do not want to disrupt the normal functions of the nose.

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.

Antibiotics

Although there has been a lot of excitement about the role fungi may play in chronic sinusitis, there is still far more evidence to support a larger role for bacteria. When dealing with the “problem” or chronic sinus patient the bacteriology is different and anaerobes are more common. I typically treat a minimum of 3 weeks, and 4-6 weeks of antibiotics along with systemic steroids is not unusual.

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.

Using Steroids

The benefits of steroids clearly outweigh the side effects. We like to try a trial of steroids in allergy patients, because we are more optimistic about the success of immunotherapy in patients who get good relief from steroids. Immunotherapy typically provides the benefits of steroids without the ominous side effects.

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 .

Side Effects

Potential side effects of steroids include:

• 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.

Common Brands

Common topical steroids (nasal sprays) include:

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

Common systemic steroids include:

• Medrol
• Prednisone