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with Rod Moser, PA, PhD

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Friday, March 2, 2012

Sinusitis: Antibiotics or No?

By Rod Moser, PA, PhD

Sinus Infection

As I’ve said before, medical providers in the United States are using too many antibiotics. Antibiotics may be necessary in the management of some bacterial infections, but not all infections are bacterial. To randomly prescribe antibiotics for all illnesses, regardless of the pathogen, is not appropriate. We often refer to this method as “shotgun treatment”.

The most common use of antibiotics in the U.S. is for the management of otitis media (middle ear infections) in children. Recent and past studies have shown that antibiotics are usually NOT needed for otitis media, that given sufficient time, the body’s immune system will manage the vast majority of cases (over 90%).  So, why are clinicians still routinely prescribing antibiotics? Old habits are hard to break.

Another common reason for using antibiotics in adults is for the management of sinusitis. One in five antibiotic prescriptions given to adults in the U.S. are for sinusitis, but a newly published study seems to prove that antibiotics are not usually needed. Patients treated with a course of amoxicillin did not get better any faster than a group taking a placebo (a fake medication). Why? Most infections in the sinuses are viral, and viruses never respond to antibiotics.

So, why do medical providers continue to prescribe them? Not to repeat myself, but old habits are hard to break and adults can be very assertive. Since they may have a history of sinusitis in the past that seemed to respond to antibiotics, they are going to want them again.

Each person should be treated individually, and there are some moderate to severe sinus infections that definitely need antibiotic intervention. I used to have the “ten-day rule.” If a person has sinusitis for over ten days and is getting worse, then I tend to intervene. Sinusitis can last months if not appropriately managed. I once had to stay on antibiotics for several weeks (under the care of my own ENT) to get a handle on a sinus infection that just wouldn’t go away on its own.

Some medical providers just assume, since you made an office visit, that you are expecting antibiotics. If your philosophy is, indeed, conservative when it comes to using antibiotics, share this with your medical provider. If your doctor recommends antibiotics, it is really okay to ask for their clinical justification. Of course, if your sinusitis has all the clinical hallmarks of a moderate to severe infection or it is becoming increasingly worse, then antibiotics are probably going to be used.

Sinusitis is not as easy to accurately diagnose, as many assume. Symptoms such as sinus pressure, green/yellow mucous, postnasal drainage, headaches, fever, sore throats, severely congested nose, and even dental pain is reported. Medical examinations range from pounding on the sinus area to check for pain to transillumination.

I have always been a fan of transillumination of the sinuses. Using the bright halogen light of the otoscope or a special transillumination light, I will shine the light into the frontal sinuses (located above the eyes), and the maxillary sinuses (located below the eyes in the cheeks). A sinus that is filled with air and open will glow like a Christmas bulb, assuming the exam room is completely dark. One that is filled with dark mucous is not likely to glow at all, and often corresponds to an area that is more painful. For some reason, very few clinicians do this anymore since the Gold Standard for making a diagnosis is a CT scan of the sinuses. While transillumination may not be as accurate, it is relatively free. A CT scan costs big bucks. I do order CT scans when there is failure to respond to treatment.

Treatment is not easy either. In children, most cases of sinusitis are clearly viral. As a matter of fact, the sinuses are not truly formed to adult size until the teenage years. The bigger the sinus cavity, the more likely they can get infected, so in this case, these tiny sinuses rarely cause adult symptoms. The kids are terribly stuffy, yes, and they do get headaches that may be sinus related. Kids are also famous for their copious amounts of green snot. Since parents have been erroneously taught that green equals bacteria, not prescribing antibiotics can be a heated, exam room negotiation at times.

It is a different story with those larger adult sinuses. They can become secondarily infected with bacteria and do need antibiotics on occasion. Unfortunately, since the blood supply to the bony sinuses are poor, and the blood is really the only transport system for antibiotics, clinicians need to take this in consideration. If it is clinically determined that a person has a true, bacterial sinusitis; one that is persistent and worsening, then it should be more aggressively treated. Those ten-day courses of antibiotics at a dose I would treat a toddler with an ear infection are not likely to be successful. Most cases of treatment failure are really related to these sub-clinical dosages and improper antibiotic choices. Of course, if the sinusitis is viral and not bacterial, then no antibiotic will work.

I deal with sick people, so I get exposed to many pathogens. Unfortunately, I am prone to sinusitis. I tend to ignore it for a while and treat myself very conservatively: warm compresses, hot showers, some ibuprofen, or perhaps a decongestant during the day. I did not use the neti pot since I can’t stand water in my nose. If the sinusitis remains like an unwanted visiting relative, I will consider taking antibiotics. Many years ago, I had a persistent sinusitis that worried me. It was not responding to any treatments, from nasal steroids to potent antibiotics, so I did what I often recommend to people on WebMD’s Ear, Nose, and Throat Community: Saw an ENT.

The ENT ordered a CT to confirm my nasty sinusitis and recommended antibiotics: 12 weeks of antibiotics! I had never prescribed nor have I taken antibiotics for this prolonged a period of time in my life, but I also didn’t want to head for the operating room, so I agreed to try it. It worked. Not only did the sinusitis finally resolve, but I did not get another one for over two years – a personal record.

So, the answer is not “no antibiotics,” but really “antibiotics only if absolutely needed.” In this age of bacterial resistance, we should not, as clinicians, reach for the prescription pad so easily, nor demand antibiotics as patients when there may be other treatment options.

Photo: Pixland

Posted by: Rod Moser, PA, PhD at 12:36 pm

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