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The Pharmaceutical Journal 599
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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
Reflect
RHINITIS (inflammation of the
mucous membranes of the nose)
and sinusitis (inflammation of the
mucous membranes of the
sinuses in the face) usually coexist 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 significant
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.
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.
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Symptoms and diagnosis
The most common symptoms of
rhinosinusitis are:
congestion, blockage or
• Nasal
stuffiness
discharge or postnasal
• Nasal
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 defined
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 fluctuate — a
patient can have a low level of
long-term disease and experience
acute flare ups.
PANEL 1: THE SINUSES
The paranasal sinuses consist of a group of four paired, air-filled bony
cavities within the facial bones. They are lined with mucous membrane
and connect to the nasal cavity via small openings (ostia).
All sinuses contain a sensory nerve supply. They are most sensitive
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
by cilia in a spiral fashion towards the ostia.
The sinuses are named from the bones within which they are formed.
The maxillary and ethmoidal sinuses lie beside the lateral walls of the
nose (ethmoidal at the top), the frontal sinuses are above the eyes,
within the frontal bones of the forehead, and the sphenoidal sinuses are
located at the centre of the skull base, under the pituitary gland.
For most patients rhinosinusitis
is diagnosed on the basis of
symptoms alone. There are,
however, a range of tests available
to validate the clinical symptoms
and signs, the most common
being nasal endoscopy, nasal
cytology, biopsy and bacteriology.
Causes and risk factors
Acute rhinosinusitis is usually
diagnosed and managed in
primary care. Studies report a
prevalence of 6 to 10 per cent. It
is principally viral but up to 2 per
cent of patients will develop a
secondary bacterial infection.
Prevalence varies with season
(higher in the winter months) and
climate. It increases in damp
environments and in the presence
of high levels of air pollution.
There is strong evidence to
support the hypothesis that
cigarette smoking predisposes
patients to rhinosinusitis, possibly
via changes to ciliary motility and
function.
The role of allergy in
rhinosinusitis is still under debate
but it is postulated that atopy
predisposes people to chronic
rhinosinusitis. Both conditions
share a trend in increasing
incidence and frequently co-exist.
It is believed that chronic swelling
of the nasal mucosa in patients
with allergies may obstruct the
ostia, leading to decreased
ventilation of the sinus, mucus
retention and development of
infection.
Studies have also shown that
there is a strong association — as
much as 50 per cent — between
patients with chronic
rhinosinusitus and asthma.
Cytokine patterns in sinus tissue
of chronic rhinosinusitus sufferers
are similar to those in bronchial
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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
suffering with sinus problems. In
fact, a large proportion of patients
who suffer 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 suffer from more than two
acute episodes in a year should be
offered further investigation.
Chronic bacterial sinusitis rarely
causes pain.
The authors will be
available to answer
questions on this topic
until 10 December 2012
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meningitis, encephalitis and
thrombosis of the superior sagittal
or cavernous sinuses. These
conditions may present with nonspecific symptoms and health
care professionals should be
highly suspicious of them for
timely diagnosis.
Osteomyelitis can result from
sinus infection spreading to the
facial skeleton. Symptoms can
include bone pain, fever and
swelling.
PANEL 2: NASAL POLYPS
Nasal polyps are fleshy, pedunculated
masses that arise from the mucous
membranes of the nose or paranasal
sinuses. There are two main
classifications: ethmoidal and
antrochoanal.
Ethmoidal polyps are most
common. They arise from the
ethmoid sinuses and are often
multiple and bilateral.
Antrochoanal polyps arise from
the maxillary sinuses and are more
likely to be unilateral.
Each types causes similar symptoms,
namely nasal congestion, chronic rhinosinusitis and loss of smell
(anosmia).
A general ear, nose and throat rule is that a unilateral polyp should be
assumed to be neoplastic until proven otherwise, even though a
retrospective study of polyp histology found that only 1 per cent of
removed polyps were malignant. It should be noted that nasal polyps
are distinct from gastrointestinal polyps, which are often premalignant.
Treatment
Cause Nasal polyps are a by-product of ongoing inflammation. The
cause is not well understood, and probably multifactorial — a result of
allergy and infection together with mechanical abnormalities. Analysis
of polyps shows oedematous submucosal tissue with a high infiltration
of plasma cells, lymphocytes, macrophages and eosinophils. Polyps
also contain high levels of histamine, presumably from mast cell
degranulation.
Nasal polyps can occur at any age but are less common in children.
They are more prevalent in men than in women (approximately 3:1)
except in people with asthma, where the prevalence in males and
females is equal. Samter’s triad is a recognised clinical syndrome of
aspirin sensitivity, asthma and nasal polyposis and has an estimated
prevalence of 1 per cent in the general population and 10 per cent
among people with asthma. Polyps are also common in people with
cystic fibrosis.
Management Nasal polyposis should be viewed as a chronic condition
with a need for ongoing treatment. Topical intranasal steroids are
effective at reducing the size and symptoms of most polyps but delivery
to the required site can prove problematic. In some cases, short-term
oral steroids may be used initially, to shrink large polyps. We often use
Flixonase nasules (400g) for an initial two weeks before changing to
Flixonase spray (50g) as a maintenance medication. Surgical removal
of polyps is considered for patients with no improvement following
pharmacological therapy. Regardless of treatment most nasal polyps
will recur. Patients who require surgery will require repeat procedures
on average every seven years.
Serious complications of acute
rhinosinusitis are rare but are
potentially serious. They may be
classified as orbital, intracranial or
osseous.
Orbital complications include
preseptal cellulitis (affects the
eyelid and periorbital soft tissue),
orbital cellulitis (behind the
orbital septum) and subperiostial
and intraorbital abscesses. Any
swelling or redness around the
eyes, severe unilateral headache
or visual disturbance needs to be
investigated urgently.
Intracranial complications
include epidural or subdural
abscesses, brain abscess,
A Cochrane report
showed benefit
when using saline
irrigation for
treatment
IMAGE: DR P. MARAZZI/SCIENCE PHOTO LIBRARY
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
identified as sources of sinus
infection.
Chronic rhinosinusitis is
common in people with cystic
fibrosis. 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 airflow
through the nose, leading to
insufficient ventilation of the
sinuses.
The management of acute
rhinosinusitis in primary care is
summarised in Figure 1.
For symptoms lasting fewer
than five days, over-the-counter
symptom relief can be offered.
For example, paracetamol,
ibuprofen or aspirin may be used
to relieve any headache, high
temperature and any facial pain.
A Cochrane report showed
benefit when using saline
irrigation for treatment.1 Nasal
douching (see Panel 3) appears to
be more effective than the use of
nasal sprays and the addition of
xylitol or hypochlorite to the
irrigation solution appears to
result in greater improvement in
symptoms over the use of saline
alone. Simple drops and low
volume nasal sprays have poor
distribution and should be
considered a nasal cavity
treatment only. The best
distribution is currently found
from high volume devices such as
squeeze bottles that allow positive
pressure irrigation, resulting in
more thorough rinsing of the
nasal passage and sinus openings.
Decongestant nasal sprays or
drops may help relieve a blocked
nose but should not be used for
more than a week at a time.
However, it should be noted that
there is no evidence for the use of
nasal decongestants,
antihistamines, mucolytics and
expectorants, herbal medicines
and probiotics in the treatment of
acute or chronic rhinosinusitis.
Steam inhalation is not
recommended because of the
danger of burns.
Corticosteroids
Corticosteroids bind to and
activate intracellular
glucocorticoid receptors, resulting
in increased expression of antiinflammatory and inhibition of
pro-inflammatory gene
transcription. These changes
directly decrease the viability and
activation of eosinophils and also
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How to manage acute rhinosinusitis
Ask if the person has two of the following symptoms:
obstruction or discoloured discharge, or both
• Nasal
±
Frontal
pain, headache
• ± Smell disturbance
• ± Cough (especially children)*
•
Symptoms for fewer than
five days or improving
Refer the following immediately:
or redness around an eye
• Swelling
disturbance, a bulging eyeball
• Visual
frontal headache or swelling
• Severe
of meningitis (eg, fever, non• Signs
blanching rash, photophobia)
signs (eg, difficult to
• Neurological
rouse, confusion, seizure)
Symptoms for over 10 days or
worsening after five days*
Moderate (ie, post viral)
Offer symptom relief
suitable for a common
cold (eg, analgesics,
nasal saline irrigation,
decongestants)
Severe (includes
bacterial infection)
Use topical steroids
No relief
after 14
days of
treatment
Consider referral to a
specialist
Use topical steroids,
consider antibiotics
Effect
in 48
hours
Continue
treatment
for seven
to 14 days
No
effect
in 48
hours
Refer to a
specialist
Figure 1: Acute rhinosinusitis management scheme for primary care (Adapted from Fokkens WJ, Lund VJ, Bachert C et al. European position paper
on rhinosinusitis and nasal polyps 2012. Rhinology 2012;50:S23)
corticosteroids
• Intranasal
improve symptoms and patient
•
reported outcomes
Delivery of intranasal
corticosteroids directly to
•
•
sinuses brings about a greater
effect
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
effects
The reported side effects of
intranasal corticosteroids are
epistaxis, nasal burning and
irritation, and a dry nose. These
are usually well tolerated and the
benefit 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 effects 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.
Nasal douching means sniffing
a solution (we advise one
teaspoon sugar, one teaspoon
salt and one teaspoon
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 —
four sniffs should be enough.
Nasal douching should
be done two to three times
a day.
Sprays such as Sterimar and
products such as NeilMed
Sinus Rinse are alternatives.
Patients using nose drops
should use them after
douching rather than before.
Available online until
27 December 2012
* 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
benefit outweighs the risk of frequent antibacterial prescriptions remains to be clarified. Nasal irrigation,
antihistamines, decongestants and mucolytics have not been shown to be helpful.
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 five
days. There is some weak
evidence that a short course of
oral corticosteroids in patients
suffering 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:
PANEL 3: NASAL
DOUCHING
PANEL 4: SURGERY
Sinus surgery is normally
effective in aiding symptomatic
relief in patients with genuine
rhinosinusitis unresponsive to
medical therapy. It involves the
removal of polypoid tissue and
enlarging the ostia to facilitate
drainage.
In an analysis of 1,713
patients 91 per cent
experienced symptom
improvement following
surgery. Surgery is indicated
when medical management of
chronic rhinosinusitis fails but
can be avoided in many cases
by improving compliance and
correcting spray use.
Adenoidectomy can improve
symptoms of chronic
rhinosinusitis in 50 per cent of
children, but is only indicated if
the adenoid is enlarged and
symptoms are not responding
to correct management.
Check your
learning
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The surgical state of the sinus
cavity, types of delivery device,
fluid dynamics and delivery
technique all play a role in
achieving effective topical
treatment with intranasal steroid
sprays. Delivery of topical steroid
to the sinus mucosa in patients
who have not had sinus surgery
(see later) is thought to be less
than 2 per cent of the total
irrigated volume. (Surgery to
open the sinus ostia increases
distribution to the sinuses; see
panel 4.)
Panel 5 (p602) explains how
pharmacists can help patients
with rhinosinusitis get the most
out of intranasal steroids by
making sure products are used
correctly.
There is a lack of evidence for
the use of oral corticosteroids to
treat chronic rhinosinusitis. The
few studies that have been
performed have shown a small
additional benefit from treatment
with oral corticosteroids together
with intranasal corticosteroids but
the long-term nature of this
condition together with the side
effects of long-term oral
corticosteroid administration
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Further reading
PANEL 5: HOW TO ENSURE GOOD DELIVERY
mean that the risk-benefit profile
is not likely to be favourable.
In children, intranasal
corticosteroids may be useful
adjuncts to antibiotic therapy in
acute rhinosinusitis.
In chronic rhinosinusitis, use of
corticosteroids beyond seven to
14 days may be required, under
the care of an ENT specialist.
There is a theoretical risk of
growth retardation that has not
been proved but the BNF
recommends that the height of
children is monitored. There is a
higher risk of systemic effects
with drops compared with sprays.
There are no randomised
controlled trials for use of
intranasal corticosteroids in
children with chronic
rhinosinusitis, but their proven
efficacy in adults and their
safety record from use in allergic
rhinitis in children makes them
first-line therapy, albeit
unlicensed. Note that different
products have different
recommended ages for rhinitis
(eg, over four years for Flixonase
spray, six years for budesonide
spray, no age range for
betamethasone drops).
Budesonide spray and
Flixonase Nasules are licensed to
treat nasal polyps in children over
12 and 16 years, respectively.
24 November 2012 (Vol 289)
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WJ, Lund VJ, Mullol J et
• Fokkens
al. European position paper on
THINGAMAJIGGS | DREAMSTIME.COM
Patients need detailed
counselling on the correct use
of nasal sprays in order to get
the correct dose of steroid to
the lateral nasal wall. Often,
patients will report no effect
with nasal steroid sprays as a
consequence of incorrect use.
Commonly patients will spray
the device into the nostril facing
upward while taking a sharp
breath in.
Correct dosing is best
achieved by asking the patient
to stand and look at his or her
feet when using the spray. The
spray is inserted into the nostril, pointing it directly in towards the ear
on that side. This is best achieved by reminding the patient to spray the
opposite nostril to the hand they are using to hold the spray (ie, left
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
too sharply, bypassing the nose and inhaling the steroid.
The premise of correct nasal drop administration is the same: to allow
maximal dosage to the lateral nasal wall. A common method of
instruction is to lie on your back with your head over the edge of the bed
and turned 45 degrees to the nostril you are administering the drops.
The drops should be instilled and the patient should wait for as long as
stated by the manufacturer. Different manufacturers give different
administration methods, but we find these methods more memorable
and universally effective.
•
•
rhinosinusitis and nasal polyps
2012. Rhinology Official Journal
of the European and
International Societies 2012;50
(S23).
Kanoh s, Rubin BK. Mechanisms
of action and clinical application
of macrolides as
immunomodulatory medications.
Clinical Microbiology Reviews
2010;23: 590–615.
Kale SU, Mohite U, Rowlands D,
Drake-Lee AB. Clinical and
histopathological correlation of
nasal polyps: are there any
surprises? Clinical
Otolaryngology and Allied
Sciences 2001;26(4):321–3.
Prescribers preference and
experience tends to govern what
is used.
Antibiotics
It has been proven that acute
rhinosinusitis resolves without
antibiotics in most cases.
Antibiotics should be reserved for
patients who present with high
fever or severe unilateral facial
pain. Most patients with acute
bacterial rhinosinusitis will
respond well to a short course of
antibiotics (eg, penicillin V or
amoxicillin for seven to 14 days).
Common causative pathogens are
Streptococcus pneumoniae and
Haemophyllis influenza and, less
commonly, Staphylococcus aureus
and Moraxella catarrhalis. Coamoxiclav or cephalosporins
should be considered for acute
cases not resolved by one course
of antibiotics.
Chronic infections are more
likely to be caused by
staphylococci or anaerobes.
There is little evidence to
support the short-term use of
antibiotics for chronic
rhinosinusitis. There is, however,
increasing interest in the use of
long-term antibiotics in chronic
rhinosinusitis following the
publication of a study of longterm, low-dose erythromycin use
PRACTICE POINTS
Reading is only one way to
undertake CPD and the
regulator will expect to see
various approaches in a
pharmacist’s CPD portfolio.
1. Ensure all patients
collecting prescriptions for
intranasal steroid
preparations know how to
use them correctly (see
Panel 5).
2. Educate counter staff on the
effectiveness of saline
nasal douches in
management of
rhinosinusitis.
3. Ensure all staff are aware
which patients presenting
with possible sinusitis
should be referred.
Consider making this activity
one of your nine CPD entries
this year.
KEY POINTS
symptoms of
• Common
rhinosinusitis are nasal
•
•
congestion, nasal discharge,
and loss of smell. Symptoms
can be chronic.
Evidence-based treatments
for rhinosinusitis include
nasal irrigation, intranasal
corticosteroids, antibiotics
and sinus surgery. Over-thecounter analgesics and
decongestants may be
offered for symptoms lasting
for fewer than five days.
Patients need detailed
counselling on the correct
use of nasal sprays in order
to achieve good outcomes.
in patients with diffuse
panbronchiolitis.2 This showed an
increase in 10-year survival from
25 to 90 per cent and
simultaneous clearing of the
rhinosinusitis. An effect has been
noted when erythromycin is used
at a lower dose than that used to
treat infection and in the presence
of non-sensitive pathogens. This
has led to speculation that the
drug may have an
immunomodulatory effect as well
as antibacterial properties.
Nevertheless, there are concerns
over long-term antibiotic use,
particularly in low doses which
fail to reach minimum inhibitory
concentrations, and the
emergence of resistant bacterial
strains. Side effects, including
gastrointestinal upset, skin rash
and elevation of liver enzymes,
and interaction with other
medicines may also be a problem.
Patients with chronic
rhinosinusitis will often have tried
multiple courses of antibiotics
and have more resistant
organisms. Exacerbations are best
treated with co-amoxiclav or a
cephalosporin. Long-term
antibiotic therapy is only
implicated in those for whom
topical corticosteroids and nasal
irrigation have failed to reduce
symptoms to an acceptable level.
Current recommendations are
that a trial of a macrolide for 12
weeks should be considered.
Recent studies indicate that
doxycycline may be of some
benefit.
There is no evidence to support
the use of topical antibiotics in
either acute or chronic
rhinosinusitis.
References available online.