US Pharm. 2014;39(4):8-11.
Sinus infections are common and painful. Patients may
attempt self-care without seeing a physician. Pharmacists must impress
upon patients with suspected sinus infections that it is imperative to
visit a physician for a differential diagnosis and an antibiotic
prescription if the cause is bacterial.
Definition and Prevalence of Sinusitis
Sinusitis is a general term for inflammation of the paranasal passages.1 The CDC considers the term to be synonymous with “sinus infection.”2 About 30 million Americans develop sinusitis in a typical year.1-3
Epidemiology of Sinusitis
Some people are more prone to sinusitis. They include
those with the following medical conditions or risk factors: allergic
rhinitis (e.g., hay fever); structural problems in the nasal cavity that
block the sinus openings (e.g., deviated nasal septum, nasal bone spur,
nasal polyps); a compromised immune system (perhaps due to HIV or
chemotherapy); any disease that prevents sinus cilia from functioning as
they should; large adenoids; cystic fibrosis; history of smoking;
exposure to airborne chemicals or irritants; and attendance at day care.4 Those living in southern states are at greater risk.2
Acute sinusitis is generally due to viral invaders, but, rarely, bacteria are the causal agent.5 Both cause a nasal inflammation that can be so intense that the sinus openings, known as ostia, are completely obstructed.1
When this occurs, the sinuses cannot self-cleanse, and sinus secretions
are retained. Impacted mucus in the sinuses decreases oxygenation, and
trapped air and mucus induce pressure changes in the sinus cavities. In
the case of the common cold (as well as allergies), the patient may
overproduce mucus in the sinus cavities, thereby worsening an already
unhealthy situation. All of these morbid changes promote sinus infection
due to inoculation of pathogens into the secretions and mucus.4
Acute bacterial sinusitis and acute viral sinusitis both
last 4 weeks or less and occur fewer than three times in any 12-month
period (viral) or fewer than four times yearly (bacterial).5
A sinus infection is considered subacute when the duration exceeds 4 weeks but lasts 12 weeks or less.2,5 It is considered chronic when the duration exceeds 12 weeks and infection occurs more than four times yearly.5
A wide variety of problems can induce a chronic sinus infection,
including nasal polyps, tumors, allergies, and respiratory infections of
viral, bacterial, or fungal origin. Symptoms of chronic sinusitis are
generally milder than the acute from of sinus infection.4
Manifestations of Sinus Infection
Sinus infections cause numerous problems for patients.
These include pain or tenderness in several places. The specific
locations of the pain and/or tenderness help identify which sinuses are
infected.6 If the frontal sinuses are infected, the pain location is the forehead. Maxillary sinus infection produces pain in the upper jaw and teeth; the cheeks may also be tender to touch. Ethmoid
sinus infection causes pain between the eyes, perhaps with inflammation
of the eyelids and periorbital region, accompanied by tenderness when
the patient touches the sides of the nose. Finally, infection of the sphenoid sinuses causes pain in the neck, earaches, and deep pain at the top of the head.
In addition to pain and/or tenderness, patients with sinus
infection also complain of rhinorrhea or nasal congestion. Nasal
secretions are abnormally thick due to having spent a longer time in the
sinuses prior to expulsion, which decreases their water content. Nasal
discharge is often discolored to white, yellow, or green, and it may be
blood-tinged. Other symptoms of sinusitis include loss of smell,
postnasal drip (mucus from the nose dripping down into the throat), sore
throat, fever, cough (often worse at night), fatigue, general malaise,
Physician Diagnosis of Sinusitis
Physicians can conduct several tests to confirm a diagnosis of sinusitis.5 They may use transillumination, in which a light is placed against the sinus to see signs of infection. They may employ nasal endoscopy or rhinoscopy,
in which a fiberoptic scope is used to directly visualize the sinus
cavities. CT scanning of the sinuses allows the physician to view the
bones and tissues of the sinuses, and an MRI can visualize tumors or
fungal infections. The physician may also simply tap the area overlying
the sinuses to locate sites of infection.
Several conditions mimic sinus infection, including the
common cold, influenza, nasal polyposis, sarcoidosis, neoplasia,
acquired and congenital immuno-deficiency, allergic and nonallergic
rhinitis, Wegener’s granulomatosis, and fungal infection.1 To
identify these, physicians might check the nostrils for nasal polyps
and recommend such examinations as allergy testing, blood tests for HIV
and/or immune status, sweat chloride analysis or blood work for cystic
fibrosis, nasal ciliary function tests, nasal cytology, and nasal
Complications of Untreated Acute Bacterial Sinusitis
If bacterial sinus infection is not promptly and
appropriately treated, the patient can develop infection of the
ophthalmic orbit (orbital cellulitis), meningitis, bone infection
(osteomyelitis), and/or abscess.1,4 Patients may lose their sight permanently.
The nonprescription product market has numerous sinus
products for consumers. Virtually all oral and topical products contain a
nasal decongestant. The FDA, in an amendment to its monograph on nasal
decongestant products, discussed this use of decongestants.1
The agency pointed out that prospective studies up to that date (2004)
concerning the efficacy of nasal decongestants did not exist, and,
further, that existing research attempting to confirm the efficacy of
decongestants as adjunctive treatment of sinusitis was limited and also
controversial. The FDA was aware that many physicians, in the context of
a physician-patient relationship, recommend or prescribe nasal
decongestants as adjunctive therapy for sinusitis. The agency voiced
concern that some would take that practice as evidence that consumers
can self-diagnose and self-manage sinusitis with OTC products. The FDA
also pointed out that preclinical evidence demonstrates that topical
nasal decongestants may actually prolong sinusitis, by increasing
inflammation of the sinuses.
In its 2004 amendment, the FDA explained that the labeling
then used by manufacturers on both oral and topical nasal decongestant
products could give consumers the mistaken idea that medical advice is
not needed for treatment of sinusitis. Consumers misled by this labeling
would miss an opportunity to obtain a medical evaluation that would
rule out conditions mimicking sinus infection. Delaying treatment of a
bacterial sinus infection could result in serious complications.
A further issue for the FDA was the fact that sinusitis and asthma are common comorbidities.1
Perhaps 40% to 70% of those with asthma have sinusitis. If these
persons were to delay a medical appointment, either or both conditions
For the above reasons, the FDA proposed in 2004 to
disallow any labeling on topical and oral nasal decongestants that
included the word “sinusitis,” or the wording “symptoms associated with
sinusitis.” The decision was finalized in 2005.6
Nonprescription internal analgesics can help alleviate the pain of sinus infection.2
Possible choices are acetaminophen (e.g., Tylenol), ibuprofen (e.g.,
Advil, Motrin IB), and naproxen (e.g,, Aleve). Patients must be urged
not to use them as a substitute for medical care, since treating the
pain without addressing the infection would be counterproductive.
Other Treatment Options
Antibiotics/antibacterials are critical for a bacterial
sinus infection. Physicians may also recommend or prescribe intranasal
corticosteroid sprays (e.g., Flonase, Nasonex, Nasacort Allergy 24 HR),
oral corticosteroids, saline nasal sprays, or saline washes.2
Surgery is a last resort for chronic rhinosinusitis. The objectives of
surgical procedures are twofold: improve drainage from the sinuses and
reduce nasal blockage. To this end, surgery may be performed to enlarge
the sinus ostia, remove nasal polyps, and/or correct intranasal sinus
obstructions. Some pediatric patients benefit from adenoidectomy when
adenoidal tissues cause nasal obstruction.
Antihistamines are irrelevant for sinus infection, as
histamine does not play a role in sinus congestion, although they may
help treat underlying allergy symptoms. Further, no homeopathic, herbal,
or dietary supplement has been shown to be either safe or effective for
Optimizing Indoor Humidity
The National Institutes of Health (NIH) suggests that patients inhale steam two to four times daily to reduce sinus congestion.4
The agency gives the example of sitting in the bathroom with the shower
running. However, hot water from the shower may not reach the
temperature that creates appreciable steam in the bathroom. This
well-meaning advice can be modified by the pharmacist to increase its
efficacy. Rather than a hot shower, the patient can be directed to any
of several brands of steam vaporizers. When used as directed, these
devices create a steady flow of steam into the room. The vaporizer
should be placed at least 4 feet from the user before it is plugged in.
The patient should follow all directions, such as
periodically cleaning the electrodes of certain steam vaporizers. If
water used to fill the vaporizer does not have sufficient electrolyte
content, the patient will be directed to add either sodium bicarbonate
or salt. It is best to advise patients to closely follow the directions
on the pamphlet inside the box.
Prevention of sinus infections is preferable to treating
an infection. Several federal websites address prevention through use of
a humidifier.2,4,5 Humidifiers employ various technologies
to increase the indoor relative humidity. Impeller and ultrasonic
humidifiers are both efficient and inexpensive. If they are run
constantly during the dry seasons of the year (e.g., winter), the added
moisture in the air may facilitate the activity of the cilia in the
respiratory tract and the sinuses. However, indoor humidity should be
monitored, as overhumidification can lead to the growth of mold and
mildew in the house, either of which could cause allergies.
What Are Sinuses?
Your sinuses are four pairs of air pockets in the skull.
They have tiny holes that allow air to freely flow through them. When
the sinuses are healthy, they are free of bacteria and other organisms.
They have cells that make mucus to help the nose remain moist during
breathing and to help trap materials that are inhaled. They self-cleanse
because they also contain small hairs (cilia) that move the mucus out
of them, carrying the unwanted materials with it. Thus, normal sinus
drainage is a protective mechanism of the body to prevent infection.
Where Are My Sinuses?
Your frontal sinuses are above your eyes, in the area of
the brows, and the maxillary sinuses are inside each cheekbone. The
ethmoid sinuses are between your eyes, just behind the bridge of the
nose. The sphenoid sinuses are behind the ethmoids, in the upper area of
the nose and behind the eyes.
Preventing Sinus Infections
The most reliable way to prevent sinus infections is to
prevent the common cold and flu, and to treat any other contributing
problem (e.g., allergies) promptly. Eat a balanced diet with an
abundance of fruits and vegetables. These foods are full of antioxidants
and other nutrients that may help boost your immune system to prevent
infection. Get vaccinated for the flu annually.
Nonprescription products may be helpful, if you read and
follow all label directions. For instance, take decongestants such as
pseudoephedrine (e.g., Sudafed) or use an oxymetazoline-containing
nasal spray such as Afrin if you have an upper respiratory infection.
Treat allergies with antihistamines (e.g., Allegra, Claritin, Zyrtec).
Wash your hands frequently, especially after shaking hands, and keep
your fingers away from your mouth, eyes, and nose. Reduce life stresses
and avoid smoke and other pollutants. Keep well-hydrated to optimize
body moisture and use a humidifier in the house and workplace.
Symptoms of Sinus Infection
Sinusitis usually begins after a cold or flu. You should
suspect sinusitis if the cold does not get better or worsens after 5 to 7
days. Acute sinusitis is caused by bacteria growing in the sinuses and
is present for a period up to 4 weeks. Symptoms include bad breath, loss
of smell, cough (which may be worse at night), fatigue, a general
feeling of illness, fever, headache, pressure-like pain behind the eyes,
toothache, facial tenderness, nasal congestion, nasal runniness, sore
throat, and/or postnasal drip.
You may have chronic sinusitis if the symptoms last for
longer than 3 months. This is usually due to bacteria or fungi in the
sinuses. Symptoms are the same as in acute sinusitis, but are usually
milder. They include those above, but with a high fever and darkened
nasal discharge that lasts for at least 3 days, and a nasal discharge
(with or without cough) that is present for more than 10 days and is not
You must see a physician to determine if your infection is
bacterial, in which case an antibiotic is required. Nonprescription
products (e.g., analgesics, antihistamines, decongestants, nasal sprays)
may provide slight relief of symptoms, but will not kill bacterial or
fungal sinus invaders.
Remember, if you have questions, Consult Your Pharmacist.
1. Cold, cough, allergy, bronchodilator, and antiasthmatic
drug products for over-the-counter human use; proposed amendment of
final monograph for over-the-counter nasal decongestant drug products. Fed Regist. 2004;69(147):46119-46122.
2. Sinusitis. National Institute of Allergy and Infectious
Diseases. January 2012.
February 24, 2014.
3. Chronic sinusitis. CDC FastStats. www.cdc.gov/nchs/fastats/sinuses.htm. Accessed February 24, 2014.
4. Sinusitis. PubMed Health. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001670/. Accessed February 24, 2014.
5. Sinus infection (sinusitis). CDC. www.cdc.gov/getsmart/antibiotic-use/URI/sinus-infection.html. Accessed February 24, 2014.
6. Cold, cough, allergy, bronchodilator, and antiasthmatic
drug products for over-the-counter human use; amendment of final
monograph for over-the-counter nasal decongestant drug products. Fed Regist. 2005;70(195):58974-58977.
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