Health care providers are a little bit like that annoying family member who tells the same story from years before at every family function. When a health care provider sees an interesting case, it is often repeated to other professionals, patients and even their own family. Back in 2007, I had a very interesting case when a gentleman presented to the office with a swollen face. It was red and tender and seemed to start without an obvious cause. I started treatment with antibiotics for cellulitis, or a skin infection, of the face. I asked to see him back in 24 hours, because I was worried that it might get worse before it got better. When he returned, the swelling and inflammation in the face was much worse, which prompted me to get a CT scan. This test showed that he had an extensive sinus infection that had actually developed into an abscess. The abscess was moving from the sinus into the eye cavity. He required surgery and recovered without complication.

This case illustrates a complication of sinusitis, or infection of the sinuses. It is fascinating only in that it is very rare. I will likely never see this again, nor will most health care providers. In fact, sinusitis, while annoying, is a generally benign illness that has likely been over managed in the health care industry for years. In 2012, the Infectious Disease Society of America (IDSA) released new guidelines to provide a framework for the treatment of sinusitis. This framework contradicts what was often common practice in the medical community and deserves review so that patients understand how medical practice is evolving.

First off, it is of benefit to look at the sinus anatomy. Humans have eight sinuses in the face. The sinuses are actually cavities, or holes, filled with air and lined with a membrane that makes mucus. In normal day-to-day life, this mucus is made and drained into the nasal passage, where it ends up being swallowed without us even being aware it is happening. This process is part of the filtering capacity of the nasopharyngeal system. Symptoms develop when this normal function is disrupted because of inflammation. The sinuses may become filled with the mucus they normally drain, which is the source of the classic discomfort of a sinus infection.

Health care providers are encouraged to call these situations rhinosinusitis rather than sinusitis. This reflects that it is not just a change in the sinus cavity but also in the tissue of the nose itself. The most common cause of rhinosinusitis is not a bacterial infection, but instead it is the common cold virus. Bacterial infections are felt to be the cause in only 0.5-2.0 percent of cases. This means that although a patient might be diagnosed with rhinosinusitis, the prescribing of antibiotics should not be a foregone conclusion. It is difficult to distinguish which cases are caused by a virus and which are bacterial. The signs of rhinosinusitis are the same whether bacterial or viral. They include nasal congestion, nasal drainage (either clear or discolored), discomfort in the top teeth, and facial pain that worsens when bending forward. To distinguish between a viral and bacterial cause, health care providers are being taught to focus on persistence of symptoms and severity of symptoms. Rhinosinusitis that has been present for greater than 10 days without evidence of improvement may benefit from the addition of antibiotics. In the viral cases, the symptoms might be present for longer than 10 days, but there should be a gradual improvement by the 10-day mark. In terms of severity, health care providers are looking for fever of 102 or greater and severe pain, thick discharge with pain that presents very quickly in the illness.

As always, the reason for making this change in treatment is the avoidance of unnecessary antibiotics. It is the use of unnecessary antibiotics that can lead to severe bacterial infections unresponsive to traditional therapies. A patient should try many home remedies for what they believe to be a sinus infection, if severe symptoms are not present, before consulting their health care provider. Both Tylenol and Ibuprofen products can be of benefit for the discomfort of rhinosinusitis. Nasal irrigation can also help clear thickened mucus and allow the sinuses to drain appropriately. Now that there are options for steroid nasal sprays that are over the counter, those can also be used. The steroid sprays may decrease the inflammation in the nasal passage, also allowing appropriate function.

Whether we are the patient or the health care provider, the goals of treatment of rhinosinusitis should be relief of symptoms and antibiotics only when absolutely necessary. Hopefully, this information will help patients understand the disease process and the best way to assist its resolution.

Questions and or comments regarding this weeks health column please contact Kathleen Harder-Brouwer, MD at Ravalli Family Medicine 411 West Main Street, Hamilton, MT 59840. Working together to build a healthier community!

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Health care workers taking a new approach to treating sinus infections