Introduction
Chronic rhinosinusitis (CRS) is a very common disorder globally as well as in India. More than 1 in 5 antibiotics prescribed in adults are for sinusitis, making it fifth most common diagnosis for which antibiotic is prescribed.1 Despite the high prevalence and economic impact of sinusitis, considerable practice variations exists across and within the multiple disciplines involved in managing this condition.1 This variation is mainly because of the fact that the disease exists in many forms and may be due to numerous causes and associated factors such as asthma, allergic rhinitis, bacterial infections, bio-films, nasal polyps, aspirin sensitivity, fungus, osteitis, super antigens, etc. The management is also variable for specific groups of patients. One such example is the management of rhinosinusitis in children, which is quite controversial. The recommended treatment for pediatric CRS ranges from functional endoscopic sinus surgery (FESS) to minimal or no intervention. During the past decade FESS has been widely used and advocated as the treatment of choice in CRS refractory to medical management in children. However, recent concern regarding interference with facial skeletal growth and risk of complications following FESS has led to the exploration of other treatment options.2
No single treatment exists for the management of CRS because of its heterogeneity. The treatment has to be tailored to the specific type of disease and patient related factors with an aim to reduce mucosal edema re-establish sinus ventilation and eradicate infective pathogens. To achieve these goals multiple medical therapies are available in the armamentarium for management of CRS including antibiotics, saline irrigations, topical and systemic glucocorticoids, anti-leukotrienes, antifungal agents, etc. the salient aspects of which are discussed in this chapter.3
Role of Antibiotics
As antibiotics are the most commonly prescribed drugs for CRS, the selection of an appropriate antibiotic and its proper mode of administration are important.
Selection of Antibiotic
Several authors have identified increasing prevalence for gram negative organisms in CRS in native and surgically treated cases.4,5 Studies by Brook et al6 and Erkan et al7 have established the potential importance of anaerobic species in chronic sinusitis and so the need for broad spectrum antibiotic coverage for an extended period of time has been recommended by the American Academy of Otolaryngology—Head and Neck Surgery Task Force on Rhinosinusitis. Most authors recommend treating chronic sinusitis with a broad spectrum antibiotic for 3–4 weeks that may be extended up to 8–10 weeks in refractory cases. However, other investigators feel that broad spectrum antibiotics may be the key step in promotion of bacterial resistance and recommend culture directed therapy as the ideal approach.8
Amoxicillin is appropriate for the initial treatment of acute, uncomplicated, mild sinusitis. Antimicrobial agents with a wider spectrum activity may be indicated as initial therapy for patients who have more severe infection, presence of co-morbidities, risk factors for bacterial resistance, or lack of response to amoxicillin therapy. These agents include amoxicillin and clavulanic acid, the newer quinolones (e.g., levofloxacin, gatifloxacin, moxifloxacin), and some second and third generation cephalosporins (cefdinir, cefuroxime axetil and cefpodoxime proxetil). Patients who are allergic to penicillin may be treated with a macrolide, trimethoprim sulfamethoxazole, tetracycline, or clindamycin.9
In chronic sinusitis the therapy is more effective if targeted against both aerobic, anaerobic and β-lactamase producing bacilli. These agents include a combination of penicillin and β-lactamase inhibitor (e.g., amoxicillin and clavulanic acid), clindamycin, combination of metronidazole and macrolide, or the newer quinolines (e.g., levofloxacin, gatifloxacin moxifloxacin). Most of these are available in oral as well as parenteral forms.
If aerobic gram negative organisms such as Pseudomonas aeruginosa are involved, an aminoglycoside (amikacin, gentamicin), a fourth generation cephalosporin (cefepime or ceftazidime), or a fluroquinoline is added. Parenteral therapy with a carbapenem (i.e., imipeneim, meropenem) is more expensive but provides coverage for most potential pathogens including both anaerobes and aerobes. Therapy is given for at least 21 days and may be extended up to 10 weeks.10,11
Culture directed therapy requires significant co-operation on part of patient, is more expensive, and hence may not be feasible all the time. However, it is strongly recommended for all patients after endoscopic sinus surgery and for non-surgical patients after the failure of first line of antimicrobials.12
A snapshot view of various antibiotics used for the treatment of this condition is compiled in Table 1.
Table 1 Antibiotics Recommended for Medical Treatment of Chronic Rhinosinusitis* | ||
| Antibiotic | Minor factors | Pediatric dosage |
| First line therapy | ||
| Amoxicillin | 45mg/kg/day or 90mg/kg/day divided | 500mg BID |
| Second line therapy | ||
| Amoxicillin/potassium calvulanate | 22.5–45mg/kg/day divided (dose based on amoxicillin component) | 500–875mg BID |
| Azithromycin | 10mg/kg/day on 1, then 5mg/kg/day on days 2–5 | 500mg QID on day 1, then 250mg QID on days 2–5 |
| Cefdinir | 14mg/kg/day | 300mg BID |
| Cefpodoxime | 10mg/kg/QID | 200mg BID |
| Cefprozil | 15mg/kg/BID | 250–500mg BID |
| Cefuroxime | 15mg/kg/BID | 250mg BID |
| Ciprofloxacin | 500mg BID | |
| Clarithromycin | 7.5mg/kg/BID | 500mg BID |
| Clindamycin | 8–20mg/kg/day divided QID | 150–450mg BID |
| Doxycycline | 100–200mg QID | |
| Garifloxacin | 400mg QID | |
| Levofloxacin | 500mg QID | |
| Sulfamethoxazole/trimethoprim | 6–12mg/kg/daydivided (based on trimethoprim) | 800/160mg BID |
*Duration of treatment with a broad spectrum antibiotic is usually 3–4 weeks that may extend up to 8–10 weeks. | ||
Role of Long-term Macrolide Therapy
Apart from its antibiotic effect the macrolides have some immunomodulatory properties also. Recent studies have shown that long-term, low dose macrolide therapy is effective for treating chronic airway inflammation and CRS.13 The efficacy of macrolide treatment in CRS is variable for each individual patient. Table 2 summarizes the points in favor and those against antibiotic therapy with macrolides.
Table 2 Conditions in which Macrolide Therapy is Considered or Avoided in Chronic Rhinosinusitis | |
| Macrolide therapy considered | Macrolide therapy avoided |
Where indicated, studies recommend treatment for 10–12 weeks and if response is good, treatment should be prolonged for another 3–9 months.
The macrolides commonly used in most studies include erythromycin, roxithromycin, and clarithromycin. For better compliance a once daily dosing of 250mg in case of clarithromycin or 150mg of roxithromycin can be used.
Role of Intravenous Antibiotics
Although success rates for endoscopic sinus surgery have been reported as >80%, there continues to be a population of patients who fail surgical cure. Recent literature supports osteitis as the source of persistent infection in a subset of patients, refractory to endoscopic sinus surgery.14
Friedmand et al15 studied the effectiveness of intravenous (IV) antibiotics in a group of patients with recurrent or persistent sinusitis after endoscopic sinus surgery who failed oral antibiotics. The authors found >80% of patients had improved symptoms and 32% of them had complete resolution.
Don et al2 conducted a study in pediatric group of patients to check the effectiveness of IV antibiotics as an alternative to endoscopic surgery in patients who failed oral antibiotics. In this study it was found that 89% of the children improved clinically and did not require subsequent endoscopic surgery.
Culture guided IV antibiotics can definitely be considered as a modality of treatment before surgical intervention in children, in people who are very reluctant to opt for surgery, and in a few cases of chronic sinusitis with resistant organisms. However, when considering IV antibiotics the clinician should not ignore the potential complication of thrombophlebitis associated with any IV therapy.
Role of Steroids
Steroids, both in topical and systemic forms, have been used widely in the treatment of CRS. In a recent survey, 99% of ear, nose, and throat surgeons in UK stated that they used topical steroids and 34% used oral steroids quite frequently in such cases.16 Steroid therapy has a role in many facets of sinonasal disease, including allergic rhinitis, nasal polyposis and the reduction of postoperative reactive edema.17
Topical Steroids
A number of studies have demonstrated the efficacy of intranasal glucocorticoids in management of CRS.18,19 Topical intranasal corticosteroids constitute the first line of therapy in almost all patients with CRS with or without nasal polyposis because they provide many of the benefits of systemic corticosteroids without the side-effects.
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