Sinusitis treatment

Since acute sinusitis is an infectious disease, it is natural that the attention of doctors is primarily focused on antibacterial treatment. However, the inflammatory process in the paranasal sinuses occurs in unusual conditions of a closed cavity, impaired drainage, deterioration of the ciliated epithelium function, and sinus aeration. Unfortunately, pediatricians do not take all this into account in most cases.

That is why we will focus on local treatment, which in a significant number of cases provides a positive effect without the use of antibiotics.

The primary objective is to improve drainage from the sinuses, which is achieved by using vasoconstrictors - decongestants. They eliminate swelling of the nasal mucosa, improving the outflow through natural openings. At the moment, there is a wide range of vasoconstrictors, slightly different in the mechanism of action. The main drugs are widely known: naphazoline (naphthyzinum, sanorin), galazolin, oxymetazoline (Nazivin) in children's doses. Nazivin has an additional advantage - prolonged action (up to 12 hours). It is preferable to use aerosol forms, since the spray is evenly distributed over the mucous membrane of the nasal cavity, this creates a longer and more pronounced therapeutic effect. At the stage of severe rhinorrhea, especially with a purulent nature of the discharge, you should not use oil-based decongestants, since they slightly reduce the function of the ciliated epithelium, worsening the outflow of sinus contents into the nasal cavity. Pay attention to the technique of introducing the drug into the nasal cavity. The child's head should be slightly tilted back and turned to the painful side. If the drug is administered by a doctor under rhinoscopy control, it is better to simply lubricate the area of the middle nasal passage - the semilunar fissure - with a vasoconstrictor.

From the etiopathogenetic point of view, mucoactive drugs that affect the mucociliary clearance system are important. They can be systemic (direct and indirect action) and topical (rinofluimucil).

In recent years, sinus catheters have been successfully used, especially in exudative serous and catarrhal acute sinusitis, allowing for active (due to the creation of negative pressure in the nasal cavity) improvement of drainage without sinus puncture. The old method of treatment by displacement has not lost its significance.

Puncture of the maxillary sinus is used not only for diagnostic purposes (to obtain the opportunity to study the contents), but also for therapeutic purposes. It is performed under local anesthesia with a special needle through the lower nasal passage. Puncture can be performed in early childhood - it is very effective in purulent or complicated forms. A medicinal substance, including an antibiotic, can be administered through a puncture needle. In addition, there are complex drugs, such as flumucil-antibiotic, which acts as an antibacterial agent (thiamphenicol) and a mucoactive agent, officially approved for intrasinusal administration.

Physiotherapy has become widespread in acute sinusitis: UHF, laser irradiation, ultraviolet irradiation of blood, microwave therapy, electrophoresis, phonophoresis, etc. Some authors note a positive effect when using natural preparations (sinupret), homeopathic preparations (we noted, in particular, a good result when using cinnabsin), aromatherapy.

Rational antibiotic therapy for acute sinusitis

In the initial stages of acute sinusitis, the correct choice of a drug effective against the main pathogens, doses and dosing regimen, routes of administration of antibiotics, and determination of the sensitivity of microorganisms to the drugs used are of primary importance.

Pathogens causing acute bacterial sinusitis

H. influenzae	12.5%
S. aureus	3.6%
S.pyogenes	1.8%
M. catarrhalis	1.8%
Anaerobes	14.3%
Other	7.1%
S. pneumoniae + others	7.1%
S. pneumoniae + H. influenzae	3.6%
S. pneumoniae	48.2%

Bacteria that cause acute sinusitis are representatives of the normal microflora of the nasal cavity and nasopharynx, which under certain conditions enter the paranasal sinuses (it is believed that the sinuses are normally sterile). Research conducted since the second half of the 20th century shows that the spectrum of pathogens remains relatively constant, and the main role in the development of the disease is played by Streptococcus pneumoniae and Haemophilus influenzae (50-70%). Much less common are Moraxella catarrhalis, S. pyogenes, S. intermedins, S. aureus, anaerobes, etc.

At the same time, the change in the sensitivity of the main pathogens of acute sinusitis to antibiotics is alarming. Thus, according to foreign researchers, a tendency towards increasing resistance of pneumococci to penicillin and macrolides, and Haemophilus influenzae to aminopenicillins is observed. Domestic data differ from foreign data: in the central part of Russia, S. pneumoniae and H. influenzae, isolated in acute sinusitis, retain high sensitivity to aminopenicillins and cephalosporins. However, high resistance to co-trimoxazole is noted: moderate and high levels of resistance are noted in 40.0% of S. pneumoniae and 22.0% of H. influenzae.

Sensitivity of S. pneumoniae and H. influenzae to antibacterial drugs

Antibiotic	Sensitivity of S. pneumoniae, %	Sensitivity of H. influenzae, %
Penicillin	97	-
Ampicillin	100	88.9
Amoxicillin	100	-
Amoxicillin/clavunate	100	100
Cefuroxime	100	88.9
Ceftibuten	90.9	100
Co-trimoxazole	60.6	77.8

Selecting an antibiotic

The main goal of antibacterial therapy of acute and exacerbation of chronic sinusitis is eradication of infection and restoration of sterility of the affected sinus. The question of the time of initiation of antibacterial therapy is considered important. In the first days of the disease, based on the clinical picture, it can be difficult to distinguish between ARVI, which does not require the prescription of antibacterial drugs, and acute bacterial sinusitis, in which they play a major role in treatment. It is believed that if the signs of ARVI, despite symptomatic treatment, persist without improvement for more than 10 days or progress, then it is necessary to prescribe antibacterial drugs. To determine the specific pathogen and its sensitivity, a puncture of the affected sinus is necessary, followed by a microbiological study of the obtained material. The drug is prescribed in each specific case empirically, based on data on typical pathogens and their sensitivity to antibacterial drugs in the region.

Basic principles for choosing an antibiotic for the treatment of acute sinusitis:

• activity against the main pathogens (primarily against S. pneumoniae and H. influenzae );
• the ability to overcome the resistance of these pathogens to an antibacterial drug, if it is widespread in a given region or population;
• good penetration into the mucous membrane of the sinuses, achieving a concentration above the minimum inhibitory concentration for a given pathogen;
• maintaining serum concentrations above the minimum inhibitory concentration for 40-50% of the time between doses.

Taking into account all of the above, the drug of choice for the treatment of acute sinusitis should be amoxicillin orally. Of all the available penicillins and cephalosporins for oral administration, including cephalosporins of the second and third generations, amoxicillin is the most active against penicillin-resistant pneumococci. It reaches high concentrations in the blood serum and mucous membrane of the paranasal sinuses, exceeding the minimum inhibitory concentration of the main pathogens, rarely causes adverse reactions (mainly from the digestive tract), and is easy to use (taken orally 3 times a day regardless of food intake). The disadvantages of amoxicillin include its ability to be destroyed by beta-lactamases, which can produce Haemophilus influenzae and Moraxella. That is why its alternative (especially in cases of treatment ineffectiveness or recurrent processes) is amoxicillin/clavulanate: a combination drug consisting of amoxicillin and a beta-lactamase inhibitor, clavulanic acid.

Cephalosporins of the II generation - cefuroxime (axetine), cefaclor and III generations (cefotaxime, ceftriaxone, cefoperazoni, etc.) are quite effective in treating acute sinusitis. Recently, fluoroquinolones with an extended spectrum of activity, effective against S. pneumoniae and H. influenzae, have begun to appear. In particular, such drugs include grepafloxacin (fluoroquinolones are contraindicated in childhood).

Macrolides are currently considered as second-line antibiotics, mainly used for beta-lactam allergies. Of the macrolides, azithromycin and clarithromycin are justified for acute sinusitis, but the eradication of pneumococcus and Haemophilus influenzae with their use is lower than with amoxicillin. 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 on the part of the digestive tract.

Of the tetracycline group, only doxycycline remains sufficiently effective in the treatment of acute sinusitis, but it can only be used in adults and children over 8 years of age.

Particular mention should be made of such common drugs as co-trimoxazole (biseptol, septrin and other drugs), lincomycin and gentamicin. In many foreign sources, co-trimoxazole is considered a highly effective drug for the treatment of acute sinusitis. However, a high level of resistance of pneumococci and Haemophilus influenzae has been identified, so its use should be limited. Lincomycin cannot be recommended for the treatment of sinusitis, since it does not act on Haemophilus influenzae, a similar situation is with gentamicin (it is not active against S. pneumoniae and H. influenzae ).

There are some differences in antibacterial therapy for severe and complicated cases of sinusitis. In such a situation, preference should be given to drugs or a combination of drugs that can cover the entire possible spectrum of pathogens and overcome the resistance of microorganisms.

Route of administration of antibacterial drugs

In the vast majority of cases, antibacterial drugs should be prescribed orally. Parenteral administration in outpatient practice should be an exception. In a hospital setting, in case of a severe course of the disease or development of complications, treatment should begin with parenteral (preferably intravenous) administration and then, as the condition improves, switch to oral administration (step therapy). Step therapy involves a two-stage use of antibacterial drugs: first, parenteral administration of antibiotics, and then, when the condition improves as soon as possible (usually on the 3rd-4th day), switch to oral administration of the same or a drug with a similar spectrum of activity. For example, amoxicillin + clavulanate intravenously or ampicillin + sulbactam intramuscularly for 3 days, then amoxicillin/clavulanate orally or cefuroxime intravenously for 3 days, then cefuroxime (axetine) orally.

Duration of antibacterial therapy

There is no single point of view on the duration of antibacterial therapy for acute sinusitis. In different sources, you can find recommended courses from 3 to 21 days. Most experts believe that in a single episode of paranasal sinus infection, antibacterial drugs should be prescribed for 10-14 days.

And finally, about the dosage regimens of antibacterial drugs for acute sinusitis. In addition to the severity of the child's condition, it is necessary, of course, to take into account whether the patient has received antibiotics in the last 1-3 months.

Antibiotic dosing regimen for acute sinusitis that occurs for the first time or in children who have not received antibiotics in the last 1-3 months

Antibiotic	Dose, (mg-kg)/day	Multiplicity	Course (days)	Features of reception
Drug of choice
Amoxicillin	40	3	7	Orally, regardless of food
Alternative drugs
Azithromycin	10	1	3	Orally 1 hour before meals
Clarithromycin	15	2	7	Orally, regardless of food
Roxithromycin	5-8	2	7	Orally 15 minutes before meals

Dosage regimen of antibiotics for acute sinusitis in children who have received antibiotics in the last 1-3 months, who are frequently ill, with a severe course, and also when amoxicillin is ineffective.

Antibiotic

Dose, (mghkg)/day

Multiplicity

Course(days)

Features of reception

Drug of choice

Amoxicillin/clavunate

40 mg (amoxicillin)

3

7

Orally, at the beginning of a meal

Alternative drugs

Cefuroxime (Axetil)	30	2	7	Orally during meals
Ceftriaxone	50	1	3	Intramuscularly
Azithromycin	10	1	5	Orally, 1 hour before meals

It should be especially noted that antibiotics must be prescribed for moderate and severe forms in children under 2 years of age.

In conclusion, I would like to emphasize that systemic antibiotic therapy must necessarily be combined with active local treatment carried out by a specialist. Only in this case can the development of complications, recurrent forms or transition to a chronic process be avoided.

Indications for consultation with other specialists

If there is no effect from the treatment, moderate, severe and complicated forms - consult an otolaryngologist.

Indications for hospitalization

Early childhood, moderate, severe and complicated forms of sinusitis.

Sinusogenic orbital and intracranial complications

The paranasal sinuses surround the orbit with thin walls on all sides. This topography, as well as the common vascular system, predispose to the spread of the inflammatory process to the eye. The main ways of spreading infection to the orbit are contact and vascular. First, the periosteum is involved in the process, then pus accumulates between the bone and the periosteum - a subperiosteal abscess is formed. In some cases, thrombophlebitis occurs, and the infected thrombus spreads through the veins of the orbit - orbital phlegmon occurs. In such cases, the process spreads to the cavernous sinus. Thus, orbital sinusogenic complications can be classified as follows: osteoperiostitis of the orbit, subperiosteal abscess, eyelid abscess, retrobulbar abscess, phlegmon, thrombosis of the veins of the orbital tissue.

Sinusogenic intracranial complications in children are much less common, they are associated with the topography of the frontal sinus, the posterior wall of which is adjacent to the frontal lobe of the brain. At the first stage in such cases, there is an accumulation of pus between the dura mater and the bone wall of the sinus - an extradural abscess. Later, when the dura mater melts, a subdural abscess is formed, which often becomes the cause of diffuse purulent meningitis or an abscess of the frontal lobe of the brain.

Forecast

With early diagnosis and timely treatment, the outcome is usually favorable.