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Patience and antimicrobial stewardship are key to treating sinusitis.
The COVID-19 pandemic has upended the world of respiratory diseases. Every cough and sniffle raises red flags in a clinical area that already was a drain on health care resources. Roughly 12% of US adults have chronic sinusitis, and about 2.7 million physician and 234,000 emergency department visits are attributed to this diagnosis each year.1
Drawing the line between acute sinusitis and every other respiratory bug can be difficult, though. As with many other conditions driven by viral infection, there is little clinicians can really offer patients for sinusitis other than supportive care and calls for patience.
As COVID-19 transmissions are lessening, patients and clinicians are equally concerned about respiratory symptoms, but experts say the pandemic isn’t really changing the game plan for sinusitis.
“I think the biggest thing I try to explain to patients is the disease process,” says Jane Carnazzo, MD, of Children’s Hospital and Medical Center in Omaha, Nebraska.
Observations of mucus changes can help patients determine where they are in a bout with sinusitis, she explains, adding that green mucus is common for about a week after infection and doesn’t really signal a severe infection.
“When it comes to sinusitis, your acute sinusitis is really going to be someone who is sick for 10 to 14 days. You have to give a cold a good week to get better,” she adds.
A high fever or copious amounts of mucus right away is a different story, she says, but this level of infection isn’t common.
COVID-19 isn’t the only worry when it comes to respiratory symptoms, Carnazzo adds. Antibiotic resistance is a real problem and one she says she tries to educate her patients about. Prescribing antibiotics may give patients a peace of mind regarding their symptoms, but Carnazzo says 75% of her patients don’t return for a prescription after a bit of education about what to expect and what is normal in terms of symptoms and progression of sinusitis.
Besides education, she says offering patients an alternative for symptom management can help. People like to turn to over-the-counter (OTC) remedies that dry out mucus at the first sign of illness, but she says this is really the opposite of how you want to manage sinusitis.
“You want the nose to drain. When it comes to preventing a sinus infection, it’s the best you can do,” she says.
Saline rinses have become a popular choice among her patient population, Carnazzo adds, but lavage can sometimes make symptoms worse. Instead, things like promoting crying, exposure to cold weather, and anything else that can help make the nose run works well, she says.
The exception, she explains, is children who have issues such as anatomical problems that could increase mucus retention, immune deficiencies, and conditions including Down syndrome that may predispose a child to smaller sinus cavities. Even with these patients, though, Carnazzo says clinicians should use caution about jumping to antimicrobial treatments.
Time is an important tool in the clinician’s arsenal, and many patients will improve in about a week with little intervention. It’s also to be expected that some children will appear to have chronic sinus problems, but constant antibiotic therapy isn’t an option, she notes.
“Kids in day care have runny noses all the time but you can’t just keep them on antibiotics,” she says. “It’s just a matter of trying to sort it out. Give it some time and try to get them to clear their nasal passages. Don’t try to dry it up too much.”
Pushing OTC medications isn’t much help, she adds, and imaging studies like x-ray and computed tomography scans are not generally recommended for diagnosis.
The best thing pediatricians can do is to get a good history and description of how symptoms developed, what they feel like, and when they are worse.
“History, symptoms, and presentation are key,” Carnazzo says. “Chronic sinus issues may need imaging, but lab work and imaging are really not necessary. Just because the sinuses are plugged doesn’t mean they are infected.”
Purulent drainage is the key symptom in diagnosing an infection that needs more intervention, she says. Pediatricians especially also need to remember a less common differential diagnosis: foreign objects.
Foul or smelly drainage—especially on just 1 side of the nose—is a red flag for possibly finding things stuckin the nasal cavity, Carnazzo says.
Overall, the best practice for sinusitis, she adds, is to stress patience and exercising restraint when it comes to antibiotics and medications that dry mucus. Mucus is an annoying symptom, but drainage is what sinusitis needs, she says.
“We’re always looking for a quick and easy fix, even if there isn’t one,” she adds.
For symptom relief, Carnazzo says she tends to point parents to menthol products, hydration, and humidifiers rather than OTC medications. If antibiotics are needed, Carnazzo says amoxicillin is the first choice, while zithromax is not recommended because of resistance. The lowest-spectrum antibiotic is always best to use first, she adds.
“Just telling them it will take time and offering comfort is key,” she says.