Sinus infections: To treat or not to treat

By Dr. Kenneth A. Kaplan, M.D.

The paranasal sinuses are air spaces within the facial bones that communicate with the nasal passages through narrow channels.They are lined by respiratory-type cells that both produce mucus and move it along through the motion of cilia, tiny hair-like projections on the surface of these cells.

Sinus infections, or sinusitis, occur when the lining of the sinuses becomes inflamed and swollen, effectively blocking off these air spaces from the nasal passages.This can result in mucus accumulation in the sinus cavities. Symptoms of sinusitis include nasal congestion, nasal discharge that may be discolored, postnasal drainage, cough, fatigue, and pressure or pain in the face, forehead or around the eyes. Most frequently, sinusitis is due to a viral cause, especially within the first seven to nine days of symptoms.These usually begin as typical head colds. Treatment may include oral decongestants, expectorants, analgesics, saline nasal mist or irrigations, and possibly up to 3 days of a topical decongestant spray like Afrin. Antibiotics are not indicated in the treatment of viral sinusitis. In other words, patients with relatively persistent but manageable cold-symptoms that are not worsening after the third or fourth day should delay seeking medical attention (with the intention of being prescribed an antibiotic) for at least seven to 10 days. As long as symptoms are improving day to day, antibiotic use should be avoided.

Bacterial sinusitis occurs when the trapped secretions within the sinuses become super-infected by bacteria. Symptoms are usually somewhat similar to viral sinusitis, with generally more facial pain or discomfort, and a greater tendency toward low grade fevers.The nasal discharge and postnasal drainage tend to be yellow, green or even brown in color.The hallmark, however, is the duration and pattern of symptom severity — once the upper respiratory symptoms have lasted more than eight or nine days with no improvement or there is a worsening of symptoms after a few days of initial improvement, the likelihood of bacterial sinusitis becomes much greater. Treatment of acute bacterial sinusitis generally consists of a 10-day course of a suitable antibiotic, along with oral decongestants, expectorants, and a nasal steroid spray. Choice of antibiotic will depend on several factors. In general, amoxicillin, amoxicillin/ clavulanate (Augmentin) or a cephalosporin such a cefdinir or cefuroxime are the ideal first-line antibiotics in non-allergic patients. For patients who have penicillin allergies, trimethoprim-sulfamethoxazole (Bactrim), azithromycin (five days), clarithromycin, or a quinolone drug (levofloxacin or moxifloxacin) can be used. Cultures taken from the nose prior to initiating antibiotic therapy can be very helpful in directing therapy in case of a treatment failure. In the opinion of the author, levofloxacin (Levaquin) and moxifloxacin (Avelox) should be used as second-line therapy or when directed by a culture result only.These drugs are very broad spectrum and can have side effects such as weakening tendons as well as causing central nervous system side effects. Brief courses of oral steroids (prednisone) may be used in combination with antibiotics for more severe bouts of sinusitis. Curing sinusitis involves restoring normal drainage and ventilation to the sinuses in addition to killing the offending microorganism.

In conclusion, the vast majority of upper respiratory infections are viral in nature.As long as symptoms are not severe or worsening, supportive care with rest, good hydration, analgesics, decongestants, saline nasal mist and expectorants (for thick secretions) is the recommended course of action for the first seven to 10 days of illness. Antibiotics should be reserved for longer infections that are not improving, or infections that produce a clear worsening of symptoms after a brief period of improvement.

Dr. Kaplan practices at Advanced Otolaryngology Associates in East Brunswick. For more information, call 732-613-0600 or visit