Sinus Infections: Helping Patients Cope

Pharmacists can make a significant difference in the treatment of patients with sinusitis.

Sinusitis, more commonly known as a sinus infection, is an inflammation of the sinuses and nasal passages.¹ This condition is common in the United States, with almost 30 million cases annually.² The vast majority of these infections are viral, with only 2% to 10% of patients presenting with a bacterial infection.³ An opportunistic fungal infection, mucormycosis, can also occur, but usually presents in immunocompromised patients and patients with diabetes.⁴

Sinus infections can be classified into several categories, either chronologically or according to the sinus cavity affected (Table 1).⁵ Acute infections are new infections that last up to 4 weeks. Subacute infections typically last between 4 and 12 weeks. Chronic infections last for more than 12 weeks.

Causes of Sinusitis

Sinusitis can be caused by viruses, bacteria, fungi, allergens, pollutants (smoke and other airborne chemicals or irritants), periapical or periodontal infections, structural problems with the Eustachian tube or the nasal cavity (eg, deviated nasal septum, nasal bone spur, or nasal polyps), and a weak immune system.^1,4 Risk factors that may contribute to the occurrence of sinusitis include smoking, cystic fibrosis, attending day care, large adenoids, diseases that prevent nasal cilia from working properly, and changes in altitude (eg, flying, scuba diving).⁶

Signs and Symptoms of Sinusitis

Pain and pressure in the face and head, as well as a stuffy or runny nose, are the chief complaints among patients experiencing sinusitis. The location of this pain or pressure usually depends on which sinuses are affected (Table 1), and head movement or leaning forward typically increases both the pain and pressure. Other symptoms may include postnasal drip, cough, sore throat, fever, fatigue, tooth pain, bad breath, and reduced sense of taste or smell.^1,6,7 A yellow or green discharge from the nose or throat is also common. If an infection lasts more than 10 days without evidence of improvement, is accompanied by a fever with severe symptoms, or exhibits “doublesickening” (improves, then worsens), it is most likely bacterial and will require antibiotics.3,8

Complications

Decreased or total loss of sense of smell may occur with sinusitis, and can be temporary or permanent. Temporary loss can result from nasal obstruction, which will likely improve once the sinuses are open. Permanent decrease or total loss of smell is usually a result of nerve damage in the olfactory nerve caused by chronic inflammation.⁸

Drainage of mucus from the sinuses may also be obstructed, causing a mucocele. If a mucocele becomes infected, causing a mucopyocele, this may further infect surrounding structures. Diagnosis usually requires the use of magnetic resonance imaging or computed tomography. Symptoms may show initial improvement if treated with antibiotics, but surgery is ordinarily required to drain and unblock the sinuses.⁸ Other rare complications can include abscess, osteomyelitis, orbital cellulitis, and meningitis.^8,9

Treatment

Palliative treatment is recommended for both viral and bacterial infections. Advise patients to drink plenty of fluids to thin mucus and keep sinuses from becoming congested, and to get plenty of rest. Applying heat to the affected areas of the face for 5 to 10 minutes at a time, several times a day, may help thin mucus and reduce pain. Breathing warm, moist air (eg, steam from a hot shower, bath, or bowl of water) is also helpful in this regard. Humidifiers and saline nasal spray are good for keeping the nasal passages moist, and nasal irrigation (eg, neti pot) aids in removing mucus and bacteria. Patients also benefit by avoiding smoking, secondhand smoke, and other pollutants, such as allergens and airborne chemicals.¹⁰

Nonprescription products that help overcome symptoms of sinusitis are listed in Online Table 2.^10,11 Some sources advise against the use of decongestants and antihistamines, as they are not helpful and may, in fact, worsen symptoms.¹² Before recommending any OTC products, the pharmacist should evaluate the patient’s symptoms and their duration, screen the patient’s medical and allergy history for interactions and contraindications, and advise patients to read all labeling instructions and adhere to recommended dosages, administration, and duration of use. While making these recommendations, pharmacists should stress the importance of an annual flu vaccine, and query patients of appropriate age about the pneumococcal vaccine.

TABLE 2: NONPRESCRIPTION TREATMENTS FOR SINUSITIS

Examples

Use

Potential Adverse Effects

Comments

Analgesics

Acetaminophen, ibuprofen, naproxen

Relieve pain; reduce inflammation and fever

Acetaminophen:

nausea, rash

Ibuprofen:

upset stomach, nausea, vomiting, diarrhea, constipation, dizziness, drowsiness

Naproxen:

same as ibuprofen, plus heartburn

Use with caution in patients with renal or hepatic impairment. Advise patients not to take additional products that contain acetaminophen-.

Corticosteroids

Triamcinolone acetonide

Fluticasone propionate

Reduce nasal inflammation

Temporary nasal burning, stinging, irritation

Remind patients to clean nasal applicator according to package directions.

Mucolytic

guaifenesin

Thin mucus

Nausea, vomiting, upset stomach

No known drug interactions

^{Adapted from references 10 and 11.}

A corticosteroid nasal spray may be used to reduce inflammation and swelling of nasal passages.¹¹ Patients should be advised to prime the sprayer before using it to make sure they are receiving the correct amount of medication. Blowing the nose before use will help to clear out nostrils. As the spray enters the nose, patients should sniff gently as opposed to snorting; this will help reduce the amount of medication that sticks to the back of the throat. Patients should avoid blowing their nose for 10 minutes after use and should try not to sneeze. The sprayer should be cleaned once a week according to package labeling.¹³

Bacterial infections will most likely require antibiotics for complete recovery. Empiric antimicrobial therapy with amoxicillin-clavulanate or doxycycline is recommended as first-line therapy. Resistance issues have been seen with macrolides, such as clarithromycin and azithromycin, as well as trimethoprimsulfamethoxazole and second- and thirdgeneration cephalosporins. Combination therapy, using a third-generation cephalosporin added to clindamycin, may be employed in patients with non—type-1 penicillin allergy or in geographical areas with high endemic rates of penicillinresistant Streptococcus pneumoniae. Levofloxacin may be used in patients with type-1 penicillin allergy.³

Refer patients to an otolaryngologist if they experience chronic or recurring sinusitis. Surgery should only be considered for patients who fail to benefit from medications.

Prevention

To prevent sinusitis, as well as other communicable diseases, advise patients to wash their hands frequently; never touch their mouth, nose, or eyes unless their hands have been washed; avoid sharing food/drinks; cover their nose and mouth when coughing or sneezing; and get enough rest and proper nutrition. Another technique to keep family members healthy is to disinfect germ hotspots in the home, such as doorknobs, remote controls, light switches, faucets, phones, computer keyboards, handheld devices, and toys.

Conclusion

Pharmacists can make a significant difference in how patients with sinusitis treat their symptoms. Most sinus infections are viral, so it’s important for pharmacists to let patients know when to seek medical attention. Also, the plethora of remedies on the shelves of pharmacies can often overwhelm patients. Pharmacists can help by recommending cost-effective, convenient products to help patients cope with sinusitis.

Dr. Kenny earned her doctorate from the University of Colorado Health Sciences Center. She has 20-plus years of experience as a community pharmacist and is a clinical medical writer based out of Colorado Springs, Colorado.

References

• Sinus infection (sinusitis). Centers for Disease Control and Prevention website. www.cdc.gov/getsmart/antibiotic-use/URI/sinus-infection.html. Accessed February 26, 2015.
• Anon JB. Upper respiratory infections. Am J Med. 2010;123:16-25.
• Diagnosing and Treating Rhinosinusitis: New Guidelines. Medscape website. www.medscape.com/viewarticle/761374. Accessed January 26, 2015.
• People at risk for mucormycosis. Centers for Disease Control and Prevention website. www.cdc.gov/fungal/diseases/mucormycosis/risk-prevention.html. Accessed February 27, 2015.
• Sinus cavities. Healthline website. www.healthline.com/human-body-maps/sinus-cavities. Accessed February 26, 2015.
• Sinusitis. The University of Maryland Medical Center website. http://umm.edu/health/medical/ency/articles/sinusitis. Accessed February 26, 2015.
• Sinusitis: symptoms. WebMD website. www.webmd.com/allergies/tc/sinusitis-symptoms. Accessed February 26, 2015.
• Complications of sinusitis. American Rhinologic Society website. http://care.american-rhinologic.org/complications_sinusitis. Accessed February 26, 2015.
• Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Lanryngoscope. 1970;80:1414-1428.
• Symptom relief. Centers for Disease Control and Prevention website. www.cdc.gov/getsmart/antibiotic-use/symptom-relief.html. Accessed February 26, 2015.
• Sinusitis: symptoms. WebMD website. www.webmd.com/allergies/tc/sinusitis-treatment-overview. Accessed February 26, 2015.
• Corticosteroid nasal sprays. WebMD website. www.webmd.com/allergies/corticosteroid-nasal-sprays. Accessed February 26, 2015.
• Most sinus infections don't require antibiotics. Infectious Diseases Society of America website. www.idsociety.org/2012_Rhinosinusitis_Guidelines. Accessed February 26, 2015.