Treatment of Chronic Rhinosinusitis With Antibiotics

Abstract

Chronic rhinosinusitis is among the most common chronic diseases. It presents a major financial burden to the health care system [1], not to mention the burden of personal suffering and morbidity to the patient with debilitating chronic rhinosinusitis. Chronic rhinosinusitis is not a uniform entity, and its clinical presentations and etiologies may vary. Environmental factors predispose patients to chronic rhinosinusitis, but allergens for allergic patients or other environmental irritants may be ill defined. Chronic rhinosinusitis may present with nasal polyposis that sometimes occurs in conjunction with asthma and aspirin insensitivity. Traditionally, the disease is classified as chronic rhinosinusitis either with or without polyposis, a distinction that may reflect differences in the cytokines between the 2 conditions. However, the difference between these 2 may not always be clinically obvious because some patients present with polypoid thickening of the mucosa in the middle nasal meatus without obvious nasal polyps. Chronic rhinosinusitis may also occur with comorbidities other than allergy and asthma, such as immune deficiencies and disorders of the mucociliary clearance. Because of the variability of the etiology of chronic rhinosinusitis, it is challenging to define. The American Academy of Otolaryngology—Head and Neck Surgery published in 2007 a clinical practice guideline that defines chronic rhinosinusitis by clinical signs, symptoms, and objective findings [2]. According to the guideline, chronic rhinosinusitis is defined by having for 12 weeks or longer$2 of the following signs and symptoms: (1) mucopurulent drainage (anterior, posterior, or both); (2) nasal obstruction (congestion); (3) facial pain, pressure, or fullness; or (4) decreased sense of smell. In addition, objective findings of nasal inflammation are needed for the diagnosis. These are $1 of the following: (1) purulent (not clear) mucus or edema in the middle meatus or ethmoid region, (2) polyps in the nasal cavity or the middle meatus, or (3) radiographic imaging showing inflammation of the paranasal sinuses. In an office setting, the first 2 findings can be evaluated by nasal endoscopy. The preceding definition of chronic rhinosinusitis requires neither a microbiologic diagnosis nor the isolation of a pathogen in the nasal sinuses. For example, at present it is often unknown in a given patient whether nasal polyposis is actually triggered by a microbe, microbial superantigen, or an environmental agent, or whether there is any foreign triggering agent in the first place. Nevertheless, chronic rhinosinusitis may involve biofilm formation that is accompanied by acute exacerbations of sinus infection [3]. The cornerstones of treatment of chronic rhinosinusitis are relief of inflammation of the nasal mucosa, facilitation of drainage of secretions, and if possible, restoration of mucociliary clearance within the sinuses [4]. The rationale in relieving inflammation is to reduce swelling of the mucosa, which may then open obstructed sinus cavities and improve drainage. Topical corticosteroids are widely used for this purpose. Short courses of oral steroids are used to reduce the size of nasal polyps and in selected cases to relieve overt inflammation in the nasal mucosa. Saline nasal irrigation is also widely used in patients with chronic rhinosinusitis [5]. Self-administered saline irrigation helps to remove crusts, mucus, and irritants. Many patients report that saline irrigation improves their symptoms. It follows that an ideal treatment for a biofilm disease would be to remove the biofilm mechanically, which could at least to some extent be accomplished by saline irrigation. Endoscopic sinus surgery is reserved for patients who fail to benefit from medical therapy. Here again the aim is often to improve drainage from the nasal sinuses. A common reason for surgery is to remove nasal polyps that do not respond to medical therapy. Received 31 August 2011; accepted 6 September 2011; electronically published 22 November 2011. Correspondence: Petri Mattila, MD, PhD, Department of Otorhinolaryngology, Helsinki University Central Hospital, PO Box 220, FI-00029 HUS, Helsinki, Finland (petri.mattila@hus.fi). Clinical Infectious Diseases 2012;54(1):69–70 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/cid/cir757