Treating sinusitis

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For negative-pressure sinus headaches, an oral decongestant may be all that is required to relieve the headache. If an underlying hay fever is present, then it will need treatment. This may require the addition of a nasal steroid spray.

It is important to treat a sinus infection as soon as it starts. Treatment involves controlling the source of sinus infection, re-establishing proper nasal drainage, and relieving pain.

Home remedies include: 

The following home treatments may get sinuses draining normally again:

Drink extra fluids to thin mucus. Drink at least 8 glasses (15 to 20 ideally) of water per day. Some sinusitis medications may make you thirsty. 

Breathe moist air from a humidifier, hot shower, or sink filled with hot water. Increase home humidity, especially in the bedrooms. (If you are allergic, keep humidity under 50% to prevent mould and dust mite growth.)

Use oral decongestants, or mucus-thinning agents. Decongestant nasal sprays may offer temporary relief. However, try not to use this treatment unless it's essential, and then do not use for longer than 3 days as this often results in “rebound” – a situation where the nasal obstruction is worse when the decongestant nasal spray's effect starts wearing off. Avoid products containing antihistamines. 

Take aspirin, acetaminophen (paracetamol) or ibuprofen for headaches. 

Check the back of your throat for postnasal drip. If streaks of mucus appear, gargle with warm water to prevent a sore throat. 

Elevate your head at night. 

Buffered saline (salt-water + bicarbonate of soda) irrigation helps wash mucus and bacteria out of the nasal passages. Use a bulb syringe to gently squirt the solution into your nose – one nostril at a time, with your head bent forward to encourage the solution to go into the roof of your nose. Sniff it through and then spit it out. Blow your nose gently afterwards. Repeat 2 to 4 times a day.

Try to keep your nose clear so you can breathe through it. Air exchange into the sinuses occurs twice as rapidly with nasal breathing as with mouth breathing. Air exchange reduces the likelihood of bacteria growing in the sinuses. 

Avoid alcohol; it functions as a diuretic, i.e. it may cause dehydration, leading to drying and thickening of mucus. This may in turn cause blockage of the ostia and worsen infection. Allergies or intolerances to red wine, yeast, sulphites or other components of alcohol may compound the problem by causing allergic swelling of the nose. 

Breathing in eucalyptus oils may help open the nose in some cases. 

Some people report that breathing in garlic fumes helps. 

Several non-traditional treatments have been used in the treatment of sinusitis. Acupuncture has been claimed to help the condition, but there are no studies that confirm this. 

Non-drug treatments should be used together with prescription medication to avoid serious complications.


Over-the-counter medication

Again, for negative-pressure sinus headaches, an oral decongestant may be all that is required to relieve the headache. Acute sinusitis is usually treated with antibiotic therapy aimed at fighting the most common bacteria known to cause sinusitis, since it is usually not possible to get a reliable culture without aspirating the sinuses.

Commonly used antibiotics such as penicillin, erythromycin and tetracycline may not work if the bacteria have become resistant. Antibiotics such as amoxicillin and sulfa drugs may be used as first-line treatment for uncomplicated acute sinus infections, but commonly do not work in people who have had infections for more than a short period or who have been on multiple antibiotics previously.

It may then be necessary to use one of the newer antibiotics. Because antibiotics penetrate poorly into the sinuses, extended treatment is often necessary. Sometimes several different antibiotics are used until the correct one is found. In some cases multiple antibiotics are used. If the situation doesn't improve after five days of treatment with amoxicillin, your doctor may decide to switch to another antibiotic.

Generally an antibiotic must be continued for at least 10 to 14 days. It is, however, not unusual to have to continue treatment for sinusitis for up to 6 to 8 weeks. Fungal infections of the sinus are common and a specific treatment for this may be required.

Although antibiotics are important in sinus infection treatment, mucus must be allowed to drain adequately. This is done by using nasal sprays containing small amounts of cortisone to reduce inflammation inside the nose and around the ostia.

Oral decongestants (pseudoephedrine) and mucolytics (guaifenesin) used according to directions for 3 to 7 days, may help with sinus drainage. Nasal decongestant spray should be avoided or used sparingly. Take care to prevent worsening of symptoms or addiction to these sprays.

Rarely, antihistamines are used, but only if allergies play a prominent part in symptoms. Antihistamines can be drying, and should be avoided in sinusitis treatment, if possible. Mucus may dry out and become plastered against the sinus wall, trapping bacteria. 

People feel better initially while fluid volume in the sinuses is reduced, but eventually symptoms return. A topical nasal steroid spray should reduce swelling in the allergic individual without the antihistamine drying effect. However, it is important to note that it takes about four to six weeks for topical nasal steroids to become effective, so do not expect an immediate effect.

Treatment of chronic sinusitis requires longer courses of drugs, and may require a sinus drainage procedure. Approximately two-thirds of people with sinus infections have side effects from medications, including dizziness, difficulty concentrating, jitteriness, rapid heartbeat, difficulty sleeping, nausea, bloating, rectal itching, burning on urination, and fatigue.

Several of these symptoms can also be due to sinusitis.  It is important to schedule follow-up visits to ensure treatment has been adequate. The most common reason why people develop future problems with sinus infections is that they stop medications too soon. If you are allergic and have chronic or recurrent sinusitis, it may help to get desensitisation allergy injections. Allergy injections are required for 36 months and can start working within six to 24 months, and must be used together with other treatment, including control of exposure to environmental allergy-causing agents.

You may need surgery

A small percentage of chronic sinusitis sufferers will not improve, even with good medical treatment. In such cases, surgery may be a viable option. The surgery, called functional endoscopic sinus surgery, may be done under local or general anaesthesia. The operation takes approximately 2 to 3 hours. During this time, the surgeon may perform procedures such as straightening the septum, removing tissue from inside the nose, making an opening into the sinus (es) on either side of the nose to improve drainage, and removing some of the inflamed sinus lining. 

The number of sinuses opened up depends on the nature of your problem. The surgeon inserts a rigid tube (endoscope) into the nose. The entire operation is done through the nose.

Generally, you will stay in hospital for the day of the operation, or sometimes overnight. You will probably miss 1 to 2 weeks of work. Full recovery may take 6 weeks, although for 6 months to a year you may be more sensitive to infection.  If you aren't better at that point, you may have allergies, immune problems, fungal infection of the sinuses, scarring from the original surgery, or sinusitis involving sinuses other than those originally operated on.

The surgeon will typically remove crusting from the nose to prevent scarring. For a short period while healing occurs, there will be limitations on lifting, blowing the nose, and flying. Most people don't have a much pain, but if you do, ask your doctor for pain medication. Having surgery does not necessarily mean you won't get sinusitis again, but it often becomes easier to treat. Once the sinuses are surgically opened, it is possible to wash them out, and as a result, sometimes oral antibiotics become unnecessary.

After surgery, it often becomes easier to perform endoscopy and find out exactly where the cause of the problem is. Treatment of polyps involves steroids, treatment of sinusitis, and treating any allergies. They may sometimes need to be removed surgically, but may come back. They are usually not pre-cancerous.

When to see a doctor

Although rare, serious complications can result from sinus infections. These include direct extension of infection to the brain and eyes, and blockage of vessels in the head. Erosion of bone can occur if infection eats through the sinuses. Untreated sinusitis can lead to acute bronchitis, ear infection and pneumonia. In certain cases, medical attention is needed.

Call your doctor if:

•Cold symptoms last longer than 10 to 14 days or worsen over time.

•You have a severe headache that is not relieved by acetaminophen, aspirin, or ibuprofen or a decongestant.

•There is increased facial swelling, or changes in vision.

•Nasal discharge changes from clear to yellow or green after five to seven days of a cold, and other symptoms (such as sinus pain or fever) are worsening. If nasal discharge is coloured from the start of a cold, call if it lasts longer than 7 to 10 days.

•Facial pain, especially in one sinus area or along the ridge between the nose and lower eyelid, persists after 2 to 4 days of home treatment. If you also have a fever and coloured nasal discharge, call in 1 to 2 days.

•Sinusitis symptoms persist after a full course of antibiotics.

Read more:
Preventing sinusitis

Reviewed by Dr Harris Steinman MBChB. (UCT), D.CH (SA), FAAAAI, D.Av.Med.(SAMS), Private specialist at FACTS (Food & Allergy Consulting & Testing Services), February 2015. (Previously updated by Dr H Steinman, June 2007)

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