Acute sinusitis - Treatment

The "gold standard" in the treatment of acute purulent sinusitis is still considered to be puncture treatment. In Western Europe and the United States, the prescription of systemic antibiotics is more common. This is primarily due to the trauma to the patient's psyche during repeated punctures. The absence of disposable puncture needles is also of no small importance, especially in the context of constant phobias of infection with blood-borne infections (HIV infection, hepatitis B).

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Non-drug treatment of acute sinusitis

Advantages of puncture treatment of acute sinusitis: the possibility of rapid and targeted evacuation of purulent discharge from the paranasal sinus cavity in accordance with the fundamental principles of purulent surgery. An important factor determining the positive value of puncture treatment is the possibility of local action of antibacterial, anti-inflammatory, antiseptic and enzymatic agents directly on the mucous membrane of the paranasal sinuses.

Puncture of the ethmoid labyrinth cells is considered inappropriate due to the variability of their anatomical structure, despite the available publications promoting this method. Trepanopunctures of the frontal sinus are performed much less frequently and only according to strict indications.

In the last quarter of the last century, many studies were devoted to the selection of special multi-component mixtures for introduction into the paranasal sinuses when they are inflamed. The disadvantages of this method are considered to be a very rapid spontaneous evacuation of medicinal substances through natural anastomoses, the impossibility of strict dosing of the administered substances, the lack of standardization of procedures in various medical institutions, the difficult to predict interaction of the components of complex mixtures, the lack of information on the consequences of the effect of the medicinal substance directly on the inflamed mucous membrane of the paranasal sinuses. Thus, the introduction of more than 100,000 U of benzylpenicillin into the maxillary sinus led to a violation of the transport function of the ciliated epithelium of the mucous membrane lining the sinus, and it is mucociliary transport that is considered one of the main mechanisms for the evacuation of pathological contents from the sinus.

The use of prolonged depot preparations based on lanolin, petroleum jelly and olive oil for administration into the paranasal sinuses is currently of only historical interest.

In order to reduce the number of repeated punctures, a method of permanent drainage was proposed. The basis of the method is the installation of a permanent drainage tube in the sinus cavity. The tube is necessary for multiple repeated sinus lavage, without additional punctures. The lack of a standard catheter for these purposes led to the creation of dozens of variations, ranging from a conventional polyvinyl chloride tube to the use of subclavian catheters.

Without denying a number of positive aspects of this method, I would like to note, however, that the drainage itself is a foreign body for the paranasal sinuses. Constant multi-day irritation of the inflamed mucous membrane by this foreign body can negate all the obvious advantages of the catheterization method,

The method of paranasal sinus dialysis was used to try to compensate for the shortcomings of the very rapid spontaneous evacuation of complex medicinal mixtures through natural anastomoses. The principle of the method was that medicinal mixtures were introduced into the sinuses by drip using standard systems for intravenous drip administration of medicinal substances connected to a puncture needle inserted into the sinus or to a catheter located in the sinus. The method had a number of advantages over the usual jet injection of medicinal mixtures. At the same time, it is fully characterized by all the above-mentioned shortcomings of introducing complex medicinal mixtures into the paranasal sinuses.

The method of aeration of the paranasal sinuses is based on the fact that anaerobic flora, which is poorly amenable to conventional antibiotic therapy, dies when pure oxygen is introduced into the sinuses. Oxygen is introduced using a pressure-reducing reducer directly through a puncture needle or through a permanent catheter. The disadvantage of the method is the risk of embolism of blood vessels.

Having analyzed all the advantages and disadvantages of the method of puncture therapy of acute sinusitis, we can draw certain conclusions. In the presence of mucopurulent discharge, puncture of the paranasal sinuses is considered a necessary mandatory method of treatment. Evacuation of mucopurulent discharge is a powerful means of pathogenetic treatment of acute sinusitis.

Puncture treatment should be used according to strict indications only in the presence of mucopurulent discharge in the sinus, which prevents complex pathogenetic therapy. In catarrhal sinusitis, accompanied only by edema (even significant) of the mucous membrane of the paranasal sinuses and a moderate amount of discharge in the sinuses, puncture is not indicated.

The possibilities of modern complex pathogenetic pharmacotherapy of acute sinusitis (general and local antibiotic therapy, general and local anti-inflammatory therapy, secretomotor and secretolytic therapy) allow to significantly reduce the number of punctures per course of treatment. When observing the conditions of complex pharmacotherapy, punctures are indicated no more than 3-4 times per course of treatment and only for the purpose of evacuating pathological purulent discharge.

The possibilities of modern pharmacotherapy allow us to abandon the practice of introducing complex medicinal mixtures directly into the sinuses. To wash the paranasal sinuses, it is sufficient to use antiseptic solutions. Antibiotic therapy and mucolytic therapy should be standardized on the basis of official systemic drugs or local drugs specially designed for endonasal administration.

Drug treatment of acute sinusitis

As has already been shown, the key link in the pathogenesis of acute sinusitis is the blockade of the paranasal sinus ostia due to mucosal edema. In this regard, one of the main directions of symptomatic (and in some sense pathogenetic) therapy of acute sinusitis is considered to be the restoration of the patency of these ostia, the so-called unloading therapy. Restoration of normal aeration of the sinuses will compensate for the unfavorable pathogenetic effect of hypoxia and ensure the drainage function of the paranasal sinuses through natural ostia.

Preparations that allow to sharply reduce the swelling of the mucous membrane filling the lumen of the paranasal sinus ostia, and thus restore their patency for some time, are vasoconstrictors (decongestants). To some extent, this effect can be achieved by using anti-inflammatory drugs of systemic (fenspiride) and especially local (fusafungine) action, as well as secretolytic agents (sinupret, myrtol).

Vasoconstrictors (decongestants) can be prescribed both locally, in the form of nasal drops, aerosol, gel or ointment, and orally. The first group includes ephedrine, naphazoline, oxymetazoline, xylometazoline, etc. Pseudoephedrine, phenylpropanolamine and phenylephrine are intended for oral administration, and they are almost always prescribed in combination with antihistamines: loratadine, cetirizine, chlorphenamine. According to the mechanism of action, all decongestants are alpha-adrenergic receptor agonists, and they can selectively act on a1- or alpha2-receptors or stimulate both.

Prescribing decongestants is absolutely necessary for acute sinusitis, as these drugs eliminate swelling of the nasal mucosa in the shortest possible time, restore nasal breathing and patency of the natural openings of the paranasal sinuses. However, all vasoconstrictors have their drawbacks and side effects. With prolonged local use, oxymetazoline, naphazoline, etc. cause "rebound syndrome" and the so-called drug-induced rhinitis, so the use of these drugs should be limited to 5-7 days. In this regard, phenylephrine compares favorably with the rest. Having a soft vasoconstrictor effect due to stimulation of alpha1-adrenergic receptors, it does not cause a decrease in blood flow in the mucous membrane of the nasal cavity and paranasal sinuses and, therefore, disrupts their functions to a lesser extent. The form of release of the drug is of great importance. Nasal drops, in the form of which the vast majority of decongestants are released, are almost impossible to dose, since most of the administered solution immediately flows down the bottom of the nasal cavity into the pharynx. In this case, it is not only difficult to achieve the necessary therapeutic effect, but there is also a risk of drug overdose. In this regard, the use of metered aerosols is considered much more advantageous.

Decongestants for oral administration do not cause the development of drug-induced rhinitis, but during the course of treatment with them, insomnia, tachycardia, and episodes of increased blood pressure may occur. Since these drugs have a psychostimulating effect, they are considered doping for athletes. For the same reason, they should be used with great caution in children and adolescents.

Antimicrobial drugs for local action on mucous membranes can be prescribed in combination with systemic drugs, and in some cases as an alternative method of treating acute sinusitis.

The issue of local antibiotic therapy for sinusitis is being actively discussed. The practice of introducing antibiotic solutions intended for intramuscular or intravenous administration into the paranasal sinuses should definitely be excluded. Their pharmacokinetics are not adapted for these purposes. In addition, the dosing regimen is extremely difficult. The main contraindication is considered to be a violation of mucociliary transport in the paranasal sinuses due to the adverse effect of large doses of antibiotics on the ciliated epithelium.

There are special forms of antibiotics intended for endonasal administration in the form of a spray. In the case of catarrhal sinusitis, they can penetrate through the anastomoses of the paranasal sinuses and directly affect the pathogen in the inflammation focus. When the sinuses are filled with mucous or mucopurulent exudate, such contact is impossible.

The composition of the nasal spray Isofra includes the aminoglycoside antibiotic framycetin, intended for local use in otolaryngology. The concentration of framycetin achieved with local use provides its bactericidal activity against both gram-positive and gram-negative microorganisms that cause the development of infectious processes in the upper respiratory tract.

Aminoglycoside antibiotics are known to have a spectrum of action aimed at destroying pathogenic microorganisms of the respiratory tract. In this regard, in pulmonology, this group of antibiotics is considered one of the leading ones in treatment regimens. In otolaryngology, aminoglycoside antibiotics are rarely used due to their potential ototoxicity. Indeed, with inflammatory pathology of the middle ear, the protective barrier decreases, and aminoglycoside antibiotics can accumulate in the inner ear, causing damage to the coccygeal vestibular receptors. In the case of using framycetin, there is a unique opportunity to use the entire antimicrobial potential of an aminoglycoside antibiotic directed against pathogenic microorganisms of the upper respiratory tract, and at the same time not to be afraid of its ototoxic effect, since the drug is administered not systemically, but exclusively locally. Low systemic absorption of framycin completely eliminates the ototoxic effect.

The composition of the nasal spray polydex includes antibiotics of different classes: neomycin and polymyxin, glucocorticoid drug dexamethasone and vasoconstrictor - phenylephrine. The therapeutic effect of the nasal spray is due to the anti-inflammatory effect of dexamethasone on the mucous membrane of the nasal cavity, the antimicrobial action of antibiotics of two different groups, covering in their spectrum of action all the main pathogens of diseases of the nasal cavity, nasopharynx and paranasal sinuses, as well as the vasoconstrictor effect of phenylephrine.

The inhalation preparation Bioparox contains a unique ingredient - fusafungine, an antibiotic of fungal origin, the only representative of its class. It has a well-adapted antibacterial spectrum from gram-positive cocci to more specific microorganisms - gram-negative cocci, gram-positive and gram-negative rods, anaerobic pathogens, mycoplasmas and even mold fungi. A persistent antibacterial effect is also provided by the activation of interleukin-2, which, in turn, increases the activity of natural killers. In addition to the antibacterial effect, fusafungine also has a local anti-inflammatory effect due to the limitation of free radical production and a decrease in the release of anti-inflammatory cytokines. Due to its strong local anti-inflammatory activity, fusafungine can be used not only at the stage of catarrhal sinusitis, but also in the case of an inflammatory block of anastomoses as an auxiliary anti-inflammatory local agent.

Most guidelines for the treatment of acute sinusitis classify systemic antibiotic therapy as first-line treatment for this condition. However, strong arguments against the routine use of empirically prescribed systemic antibiotics in acute sinusitis include the high prevalence of resistant strains of bacteria that cause sinusitis, the inability to accurately determine the etiology of sinusitis (bacterial or viral), the presence of allergic reactions, secondary immunodeficiency states, and zosinophilic fungal sinusitis.

The main goal of systemic antibiotic therapy in acute rhinosinusitis is to eliminate the infection and restore the sterility of the paranasal sinus. In most cases, the drug for acute processes is chosen empirically based on data on the prevalence of certain pathogens, their resistance in the region and taking into account the severity of the patient's condition.

The sensitivity of the main pathogens of acute sinusitis to antibiotics varies significantly in different regions. According to foreign researchers, a tendency towards increasing resistance of pneumococci to benzylpenicillin, macrolides, and Haemophilus influenzae to aminopenicillins is currently observed.

Streptococcus pneumoniae and Haemophilus influenzae isolated in acute sinusitis retain high sensitivity to aminopenicillins and cephalosporins: 97% of S. pneumoniae strains are sensitive to benzylpenicillin, 100% to ampicillin, amoxicillin, amoxicillin + clavulanic acid, cefuroxime, 100% of H. influenzae strains are sensitive to amoxicillin + clavulanic acid, 88.9% to ampicillin and cefuroxime. The main problem is considered to be high resistance of pneumococci and Haemophilus influenzae to co-tricmoxazole; moderate and high levels of resistance were noted in 40% of S. pneumoniae strains and 22% of H. influenzae.

To establish the specific pathogen and its sensitivity, a puncture of the affected paranasal sinus is necessary, followed by a microbiological study of the obtained material. However, in practice, patients do not always agree to a puncture of the sinuses, and a microbiological study is not a standard procedure in every case of uncomplicated acute sinusitis. In this regard, the drug is often prescribed empirically, based on data on the main pathogens and their sensitivity to antibiotics in the region.

The basic principles for choosing an antibiotic for the treatment of acute sinusitis are as follows:

• activity against S. pneumoniae and H. influenzae,
• the ability to overcome the resistance of pathogens to antibiotics;
• good penetration into the mucous membrane of the paranasal sinuses, achieving a concentration above the minimum inhibitory level for a given pathogen;
• maintaining serum concentrations above the minimum inhibitory level for 40-50% of the time between doses of the drug.

Taking into account typical pathogens and antibiotic resistance data, I consider amoxicillin, a semi-synthetic antibacterial drug from the aminopenicillin group, to be the drug of choice for acute sinusitis. The spectrum of antimicrobial action of amoxicillin and ampicillin is similar, but in clinical practice amoxicillin has significant advantages over ampicillin, which is primarily due to higher concentrations of the drug in the blood and middle ear fluids achieved with the use of the same doses. These properties of amoxicillin are due to its good absorption in the intestine: the bioavailability of ampicillin is 50% when taken on an empty stomach, amoxicillin in capsules - 70%, and the bioavailability of amoxicillin in the form of dispersible tablets reaches 93%, which ensures maximum effectiveness of the drug. At the same time, due to the minimal "residual" concentration of amoxicillin in the intestine (only 7% of the dose taken), the risk of developing adverse reactions from the gastrointestinal tract, including dysbiosis, is significantly reduced. Dispersible amoxicillin tablets can be taken regardless of food intake. The tablet can be swallowed whole, chewed or dissolved in water (you will get a pleasant-tasting suspension with an apricot smell), which makes the use of the drug most convenient for patients of any age. The recommended dose for children is 40-45 mg / kg per day, for adults 1.5-2 g per day, divided into 2-3 doses. If the presence of penicillin-resistant pneumococci is suspected, the dose of the drug can be increased to 80-90 mg / kg per day for children and 3-3.5 g per day for adults.

In case of insufficient clinical effect after 3 days, amoxicillin should be replaced with an antibiotic active against beta-lactamase-producing strains of Haemophilus influenzae and Moraxella - amoxicillin + clavulanic acid. It has a broad spectrum of antibacterial action and is active against both amoxicillin-sensitive strains and strains producing beta-lactamases. The irreversible beta-lactamase inhibitor included in the amoxicillin + clavulanic acid combination forms a stable inactivated complex with the specified enzymes and protects amoxicillin from the loss of antibacterial activity caused by the production of beta-lactamases by both pathogens and opportunistic microorganisms. It is this combination that ensures the high activity of this drug against the key pathogens of acute sinusitis. It is also possible to prescribe 2nd generation cephalosporins (cefuroxime orally). If the intramuscular route of administration is preferred, ceftriaxone is used (once a day for 3 days) or ampicillin + sulbactam (150 mg/kg per day in 3-4 doses, for adults 1.5-3 g per day).

In case of recurrent acute sinusitis, it is better to start treatment immediately with oral administration of amoxicillin + clavulanic acid. Its dose should be 40-45 mg/kg per day for children and 1.5-2 g per day for adults (in terms of amoxicillin). For small children, the drug is prescribed as a suspension or dispersible tablets.

Considering all of the above, the drug of choice for the treatment of acute sinusitis should be amoxicillin orally. Of all the available oral penicillins and cephalosporins, including second- and third-generation cephalosporins, amoxicillin is considered the most active against penicillin-resistant pneumococci.

Among oral cephalosporin drugs, ceftibuten is considered the most effective. It is classified as a modern third-generation cephalosporin. The drug has high bactericidal activity against the leading pathogens of acute sinusitis, which has been proven in in vitro and in vivo studies. Among oral cephalosporins, it has the highest resistance to beta-lactamases and has high bioavailability (90%). Ceftibuten is able to selectively accumulate in high concentrations in the pathological focus. Thus, the content of the drug in nasal secretion is 46% of its concentration in serum. An undoubted advantage of ceftibuten is the regimen of administration: 1 time per day. The drug is used at 400 mg 1 time per day for 10 days.

Recently, fluoroquinolones with an extended spectrum of activity, effective against S. pneumoniae and H. influenzae, have been released onto the market. In particular, moxifloxacin and levofloxacin belong to such new generation drugs.

Levofloxacin has high activity against the main pathogens of acute sinusitis, including strains resistant to other classes of antibiotics (for example, penicillin-resistant strains of pneumococcus). The drug is characterized by optimal pharmacokinetics, rapid accumulation in the mucous membrane of the paranasal sinuses and concentrations exceeding the minimum inhibitory for potential pathogens.

According to research data, in acute sinusitis in adults, levofloxacin is not inferior in clinical and bacteriological efficacy to amoxicillin + clavulanic acid and clarithromycin, but is characterized by better tolerability, especially from the gastrointestinal tract. Unlike the above-mentioned drugs, levofloxacin is taken once a day but 500 mg for 10 days. It can be used in patients with an allergy to beta-lactam antibiotics. In severe sinusitis and the risk of complications, step therapy can be used: levofloxacin is first administered parenterally, then orally.

Macrolides are currently considered as second-line antibiotics and are mainly used for allergies to beta-lactam antibiotics. Of the macrolides, azithromycin, clarithromycin, and roxithromycin are justified for acute sinusitis, although they are less effective than amoxicillin for eliminating pneumococcus and Haemophilus influenzae. Erythromycin cannot be recommended for the treatment of acute sinusitis, since it has no activity against Haemophilus influenzae and, in addition, causes a large number of undesirable effects from the gastrointestinal tract.

Of the tetracycline group, only doxycycline remains sufficiently effective in the treatment of acute sinusitis, but it cannot be used in children under 8 years of age.

Special mention should be made of such common drugs as co-trimoxazole, lincomycin and gentamicin. In many foreign sources, co-trimoxazole is considered a highly effective drug for the treatment of acute sinusitis.

However, in Ukraine, a high level of resistance of pneumococci and Haemophilus influenzae to this drug has been identified, so its use should be limited. Lincomycin is not recommended for the treatment of acute sinusitis, since it does not act on Haemophilus influenzae, but this drug can be used in exacerbation of chronic sinusitis if there is pressure on osteomyelitis. Gentamicin is not active against S. pneumoniae and H. influenzae, so it is not indicated for the treatment of sinusitis.

Thus, taking into account all of the above, we can propose the following scheme of systemic antibiotic therapy for acute sinusitis, based on the severity of the disease. In the case of a mild course in the first days of the disease, when viral etiology is most likely, antibiotics are not required. If, despite treatment, there is no improvement for more than 10 days or the severity of symptoms progresses, which indirectly indicates the addition of a bacterial infection, then it is advisable to prescribe antibacterial therapy.

It should be noted that Echinacea compositum C can be successfully used as a certain alternative to classical antibiotic therapy for mild cases of the disease.

In moderate cases, the drugs of choice are amoxicillin, amoxicillin + clavulanic acid, and levofloxacin.

Alternative drugs include:

• cephalosporins (cefuroxime, cefaclor);
• macrolides (azithromycin, clarithromycin, roxithromycin);
• tetracyclines (doxycycline).

Medicines used for severe sinusitis:

• inhibitor-protected penicillins (amoxicillin + clavulanic acid, ampicillin + sulbactam) parenterally;
• cephalosporins of II-III generations (cefuroxime, ceftriaxone, cefotaxime, cefoperazone) parenterally;
• in case of allergy to beta-lactam antibiotics - ciprofloxacin or chloramphenicol parenterally.

Anti-inflammatory therapy is aimed primarily at blocking the cascade of mediator reactions that enhance the inflammatory response. This leads to the relief of such main symptoms of inflammation in acute sinusitis as pain, swelling, dilation of the vessels of the mucous membrane of the paranasal sinuses, and excessive exudation. In this regard, anti-inflammatory therapy should be an essential component of the treatment of acute sinusitis.

There are two main directions of systemic anti-inflammatory therapy in general: the use of glucocorticoids and non-steroidal anti-inflammatory drugs. Fenspiride, a new powerful drug for the treatment of sinusitis, occupies a special place. Fenspiride has a pronounced anti-inflammatory effect due to the blockade of H1 histamine receptors, a decrease in the production of pro-inflammatory substances (cytokines, TNF, arachidonic acid metabolites, free radicals). According to the place of its application, fenspiride is designed specifically for the mucous membranes of the respiratory tract and therefore, when choosing systemic anti-inflammatory therapy for acute sinusitis, it has advantages over other anti-inflammatory drugs. Fenspiride reduces edema, hypersecretion of viscous mucus, improves mucociliary clearance. The anti-inflammatory effect of fenspiride allows you to quickly eliminate all the symptoms of rhinosinusitis.

Nonsteroidal anti-inflammatory drugs inhibit prostaglandin biosynthesis, inhibit cyclooxygenase activity, inhibit lipid peroxidation, and affect the kinin system. All this makes them a powerful tool in the complex treatment of acute bacterial inflammation of the paranasal sinuses.

Nonsteroidal anti-inflammatory drugs are divided into two groups according to their mechanism of action:

• active inhibitors of prostaglandin synthesis (ibuprofen, flurbiprofen, diclofenac). They are most active in acute inflammation;
• relatively weak inhibitors of prostaglandin synthesis (indomethicin, piroxicam, phenylbutazone). These drugs are not very active in acute inflammation, but are very effective in chronic inflammation.

Naturally, when treating acute sinusitis, preference is given to drugs of the first group.

Anti-inflammatory therapy allows to break the vicious circle of the process in the sinus with an obturated opening, starting from the initial stages (ventilation and drainage disorders). Glucocorticoids primarily suppress the development of edema due to the effect on inflammation in the proper plate of the mucous membrane, the functions of the anastomoses are restored. In addition, glucocorticoids actively suppress the release of fluid from the vascular bed and the production of mucus, which is considered an important factor in the pathogenetic treatment of acute sinusitis.

Currently, the following glucocorticoid drugs for local use are registered in Ukraine: beclomethasone, budesonide, fluticasone and mometasone.

As an adjuvant therapy for exacerbation of chronic sinusitis, mometzone is recommended for adults and children over 12 years of age at a dose of 2 inhalations (50 mcg) and each nostril 2 times a day (total daily dose 400 mcg). If necessary, the daily dose can be increased to 800 mcg per day in 2 doses (400 mcg 2 times a day). With a decrease in symptoms of the disease, the dose of the drug is recommended to be reduced.

Due to its high efficiency and rapid onset of action, mometasone can be an alternative to previously used drugs for unloading and anti-inflammatory therapy during exacerbation of chronic sinusitis.

Separately, it should be noted that the drug Traumeel S can be prescribed as an anti-inflammatory drug. Its actions are largely associated with an increase in the blood of one of the main anti-inflammatory cytokines - TGF-beta.

Among the mediators of inflammation, histamine occupies one of the leading places, therefore, it is impossible to ignore the issue of the role of antihistamines in the treatment of acute sinusitis. And antihistamines are widely used in the treatment of acute sinusitis, although their prescription is often unjustified. In the case when acute sinusitis develops against the background of allergic rhinitis, antihistamines block histamine H1 receptors and prevent the action of the mediator released from mast cells as a result of the IgE-mediated reaction. In infectious sinusitis, the prescription of these drugs also makes a certain sense, but only in the early "viral" stage, when the blockade of histamine H1 receptors prevents the action of the mediator released by basophils under the influence of various viruses (respiratory syncytial, paramyxovirus). The second-generation antihypamine drug desloratadine also has a pronounced antiallergic and anti-inflammatory effect and can be recommended for the treatment of acute sinusitis in patients with allergic rhinitis.

The complex homeopathic preparations Engystol and Luffel are considered safe to use and effective anti-allergic agents.

At present, enzymes are not used often enough in the treatment of acute sinusitis in Ukraine and are mainly administered by puncture of the paranasal sinuses. In foreign otolaryngology, there is active development and promotion of alternative, pathogenetic methods of treating sinusitis, based primarily on the use of mucolytic, secretomotor and secretolytic drugs.

Mucolytic drugs change the physicochemical properties of the secretion by reducing its viscosity. For this purpose, lubricating agents that reduce tension or enzymes that cause the rupture of disulfide bonds are used.

Secretomotor drugs include drugs that, through various mechanisms, mainly by increasing the motor activity of the ciliated epithelium, increase the effectiveness of mucociliary clearance. Typical representatives of this group are beta2-adrenoreceptor agonists (bronchodilators). Theophylline, benzylamines and essential oils also have a secretomotor effect.

Secretolytic drugs improve mucus evacuation by changing the nature of secretion. Essential oils of plant origin, extracts of various plants, creosote derivatives and synthetic benzylamines, bromhexine and ambroxol have a secretolytic effect by increasing the secretion of the bronchial glands.

For the treatment of acute sinusitis in Ukraine, sufficient experience has been accumulated in the use of the following mucolytic drugs: myrtol, syncrt, acetylcysteine. These drugs are used mainly in the treatment of diseases of the bronchopulmonary system and are not well known to otolaryngologists.

Myrtol is a medicinal product based on essential oils. Myrtol as an essential oil of plant origin is lipophilic. After oral administration, it is absorbed in the small intestine and through the blood enters the paranasal sinuses, where it is partially excreted through the respiratory epithelium.

The secretolytic effect of myrtol is due to the fact that it stimulates goblet cells and serous-mucous glands, which leads to a decrease in the viscosity of the secretion and a decrease in the thickness of its layer on the mucous membrane of the paranasal sinuses.

The secretomotor effect is associated with the stimulation of beta-adrenoreceptors, the activation of the cilia of the ciliated epithelium of the mucous membrane of the paranasal sinuses occurs. As a result, the frequency of the ciliary beat increases and the speed of secretion transport from the paranasal sinuses increases.

Myrtol thus helps improve drainage from the paranasal sinuses in cases of low secretion and stagnation. It improves drainage of the paranasal sinuses and ensures recovery in both acute and chronic sinusitis.

Sinupret has a reflex secretolytic effect, regulating secretion and normalizing the viscosity of mucus, eliminating mucostasis. Sinupret acts on the mucous membrane of the respiratory tract, relieving swelling and inflammation. The drug restores drainage and ventilation of the paranasal sinuses. Sinupret normalizes the protective properties of the epithelium of the respiratory tract by improving the rheological properties of the exudate, and also has immunostimulating activity. The drug has a virustatic effect on influenza, parainfluenza and rhinosyncytial infection viruses, potentiates the effects of antibiotics.

Mucolytic action is also possessed by drugs that reduce surface tension, i.e. affect the gel phase of the discharge and liquefy both sputum and nasopharyngeal secretion. This group includes carbocysteine. The mucolytic and expectorant action is caused by the activation of sialic transferase, an enzyme of goblet cells of the bronchial mucosa. The drug normalizes the quantitative ratio of acidic and neutral sialomucins of bronchial secretion, promotes the regeneration of the mucous membrane, restoration of its structure, activates the activity of the ciliated epithelium, restores the secretion of immunologically active IgA (specific protection) and the number of sulfhydryl groups of mucus components (non-specific protection), improving mucociliary clearance.

The maximum level in the blood serum and in the mucous membrane of the respiratory tract is observed 2-3 hours after oral administration. The required concentration is maintained in the mucous membrane for 8 hours. Carbocysteine is excreted mainly in the urine, partly unchanged, partly as metabolites.

This group of drugs also includes rinofluimucil - an original combination spray, which, in addition to acetylcysteine, includes a sympathomimetic - thiaminoheptane, which has a mild vasoconstrictor effect, without causing excessive dryness of the mucous membrane, acetylcysteine at the same time liquefies the secretion. After the rupture of disulfide bridges, mucus and phlegm lose their ability to be viscous and, absorbing water, can be gently removed by blowing your nose, sneezing, coughing. The drug has an anti-inflammatory effect due to the inhibition of leukocyte chemotaxis. The main advantage of rinofluimucil is that it works on the surface of the mucous membrane, liquefying and reducing the viscosity of mucus, promoting a productive physiological act of cleansing the paranasal sinuses.

There is another combination drug - thiamphenicol glycinate acetylcysteine. The drug has a combined antibacterial and mupolitic effect and is recommended for the treatment of respiratory diseases caused by bacterial flora and accompanied by the formation of thick viscous secretion. The antimicrobial activity of the drug is due to interference in the synthesis of bacterial proteins. Recent studies have shown that due to the association of thiamphenicol and acetylcysteine in one drug compound, the drug retains an unconjugated form and reaches the site of inflammation in a concentration sufficient to create a bactericidal effect. The drug exhibits mucolytic activity against any type of secretion: mucous, mucopurulent, purulent. The drug facilitates the separation of sputum and nasal mucus. In addition to direct mucolytic action, it has powerful anti-oxidant properties and is able to provide protection of the respiratory system from the cytotoxic effect of metabolites during inflammation.

Algorithm for the treatment of acute sinusitis:

• in catarrhal rhinosinusitis, preference should be given to local anti-inflammatory and antibacterial treatment. At the same time, much attention should be paid to unloading therapy aimed at restoring the drainage and ventilation functions of the paranasal sinuses;
• the use of secretomotor and secretolytic drugs is of great importance;
• in acute purulent sinusitis, systemic antibacterial drugs should be prescribed with mandatory consideration of the rules of empirical antibiotic therapy;
• At the same time, it is advisable to prescribe systemic anti-inflammatory drugs;
• unloading and mucolytic therapy should be used as additional treatment methods;
• if the sinus is filled with mucopurulent discharge and its evacuation is difficult despite the applied complex therapy, a puncture of the paranasal sinuses should be performed, and if necessary, several, taking into account the dynamics of the course of the disease,

Surgical treatment of acute sinusitis

Surgical treatment for acute sinusitis is used only in cases of orbital or intracranial complications. In this case, the corresponding sinus(es) that caused the complication is opened.

Further management

Postoperative management of patients after surgical opening of the paranasal sinuses in case of orbital or intracranial complications is characterized by the fact that the wound is not sutured until the pathological process is completely normalized.