Treatment of sinusitis

Because acute sinusitis is an infectious disease, it is natural that the attention of physicians is primarily drawn to antibacterial treatment. However, the inflammatory process in the paranasal sinuses occurs in unusual conditions of a closed cavity, disturbed drainage, impaired function of the ciliated epithelium, aeration of the sinus. All this, unfortunately, in most cases, pediatricians do not take into account.

That is why, we will stop on local treatment, in a significant part of cases providing a positive effect and without the use of antibiotics.

The paramount task is to improve drainage from the sinuses, this is achieved using vasoconstrictive drugs - decongestants. They eliminate the edema of the nasal mucosa, improving the outflow through natural openings. At the moment, there is a wide choice of vasoconstrictors, slightly different in the mechanism of action. The main drugs are widely known: naphazoline (naphthyzine, sanorin), galazoline, 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. In the stage of pronounced rhinorrhea, especially when the discharge is purulent, it is not necessary to use oil-based anticoestingants, since they slightly decrease the function of the ciliated epithelium, worsening the outflow of sinus contents into the nasal cavity. Attention is also paid to the technique of introducing the drug into the nasal cavity. The head of the child should be slightly thrown back and turned to the sore side. If the drug is administered by a doctor under the control of a rhinoscopy, it is better to simply lubricate the area of the middle nasal passage with a vasoconstrictor - a semilunar gap.

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 (rhinofluimucil).

In recent years, sinus catheters have been successfully used, especially in exudative serous and catarrhal acute sinusitis, to improve drainage without sinus puncture (due to the creation of negative pressure in the nasal cavity). Not lost its value and the old way of treatment by the method of displacement.

The puncture of the maxillary sinus is used not only with the diagnostic (obtaining the possibility of exploring the contents), but also with a therapeutic purpose. It is carried out under local anesthesia with a special needle through the lower nasal passage. Puncture can be carried out in early childhood - with purulent or complicated forms it is very effective. Through the puncture needle, you can enter a drug, including an antibiotic. In addition, there are complex preparations, for example, a fluimycil antibiotic that acts as an antibacterial agent (thiamphenicol) and a mucoactive agent that is officially approved for intraspasal administration.

Widespread in acute sinusitis received physiotherapy: UHF, laser irradiation, ultraviolet irradiation of blood, microwave therapy, electrophoresis, phonophoresis, etc. Some authors note a positive effect with the use of drugs of natural origin (sinupret), homeopathic drugs (we noted, in particular, a good result with the use of cinnabsin), aromatherapy.

Rational antibiotic therapy for acute sinusitis

At the initial stages of acute sinusitis, the correct choice of the drug effective against the main pathogens, the dose and dosage regimen, the way of administration of antibiotics, the sensitivity of microorganisms to the drugs used, is of primary importance.

The causative agents of 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 + other	7.1%
S. Pneumoniae + H. Influenzae	3.6%
S. Pneumoniae	48.2%

Bacteria that cause acute sinusitis are representatives of the usual microflora of the nasal cavity and nasopharynx, which fall under certain conditions in the paranasal sinuses (they believe that the sinuses are normal in the norm). Studies conducted since the second half of the XX century show 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%). It is much less common for Moraxella catarrhalis, S. Pyogenes, S. Intermedins, S. Aureus, anaerobes, etc.

At the same time, the sensitivity of the main pathogens of acute sinusitis to antibiotics is disturbing. So, according to foreign researchers, there is a tendency to increase the resistance of pneumococci to penicillin and macrolides, and the hemophilic rod to aminopenicillins. Domestic data differ from foreign ones: high sensitivity to aminopenicillins and cephalosporins persists in the central part of Russia in S. Pneumoniae and H. Influenzae isolated in acute sinusitis. However, high resistance to co-trimoxazole is noted: a moderate and high level of resistance was noted in 40.0% of S. Pneumoniae and 22.0% of H. Influenzae.

The sensitivity of S. pneumoniae and H. Influenzae to antibacterial drugs

Antibiotic	Sensitivity of S. pneumoniae,%	The 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

Choosing an antibiotic

The main goal of antibiotic therapy of acute and exacerbation of chronic sinusitis is eradication of infection and restoration of sterility of the affected sinus. An important question is the timing of the onset of antibiotic therapy. In the early days of the disease, on the basis of the clinical picture, it is difficult to distinguish ARVI, in which antibacterial drugs are not required, and acute bacterial sinusitis, in which they play a major role in treatment. It is believed that if signs of acute respiratory viral infection, despite symptomatic treatment, persist without improvement for more than 10 days or progress, antibiotic prescription is necessary. To establish the specific pathogen and its sensitivity, a puncture of the affected sinus is necessary, followed by a microbiological study of the resulting material. The purpose of the drug in each specific case is empirical, based on data on typical pathogens and their sensitivity to antibacterial drugs in the region.

Basic principles of the choice of 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 prevalent in a given region or population;
• good penetration into the mucosa of the sinuses with reaching a concentration above the minimum inhibitory concentration for this pathogen;
• Preservation of serum concentration above the minimum inhibitory concentration within 40-50% of the time between drug intake.

Given all of the above, the drug of choice for the treatment of acute sinusitis should be amoxicillin inside. Of all available penicillins and cephalosporins for ingestion, including cephalosporins of II-III 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 minimal inhibitory concentration of the main pathogens, rarely causes undesirable reactions (mainly from the side of the digestive tract), it is convenient to use (taken 3 times a day regardless of food intake). The disadvantages of amoxicillin include its ability to be destroyed by beta-lactamases, which can produce hemophilic rod and morocell. That is why his alternative (especially when treatment is not effective or recurrent) is amoxicillin / clavunate: a combination drug consisting of amoxicillin and a beta-lactamase inhibitor-clavulanic acid.

The cephalosporins II-cefuroxime (aksetin), cefaklor and III generations (cefotaxime, ceftriaxone, cefaperazoni, etc.) possess a sufficiently high efficiency in the treatment of acute sinusitis. Recently, fluoroquinolones with an extended activity spectrum, effective against S. Pneumoniae and H. Influenzae, have appeared. In particular, these drugs include grapafloksatsin (fluoroquinolones are contraindicated in childhood).

Macrolides are currently considered as second-line antibiotics, mainly used for allergy to beta-lactams. Of macrolides in acute sinusitis, the use of azithromycin and clarithromycin is justified, however eradication of pneumococcus and hemophilic rod is lower in their appointment than with amoxicillin. Erythromycin can not be recommended for the treatment of acute sinusitis, since it has no activity against the hemophilic rod and, in addition, causes a large number of adverse events on the part of the digestive tract.

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

Especially it should be said about such common drugs as co-trimoxazole (biseptol, septrin and other drugs), lincomycin and gentamicin. In many foreign sources, co-trimoxazole is referred to as highly effective drugs for the treatment of acute sinusitis. However, a high level of resistance of pneumococci and a hemophilic rod has been identified, and therefore its use should be limited. Lincomycin can not be recommended for the treatment of sinusitis, since it does not affect the haemophilic rod, a similar situation with gentamicin (not active against S. Pneumoniae and H. Influenzae ).

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

The route of administration of antibacterial drugs

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

The duration of antibiotic therapy

A single point of view about the duration of antibiotic therapy for acute sinusitis is not present. In different sources it is possible to find recommended courses from 3 to 21 days. Most experts believe that with a single episode of infection of the paranasal sinus antibacterial drugs should be administered within 10-14 days.

And finally about the dosing regimens of antibacterial drugs for acute sinusitis. In addition to the severity of the child's condition, one should, of course, consider whether the patient has received antibiotics within the last 1-3 months.

Dosing regimen of antibiotics for acute sinusitis, which occurred for the first time, or in children who have not received antibiotics during the last 1-3 months

Antibiotic	Dose, (mg-kg) / day	Multiplicity	Course (days)	Reception Features
The drug of choice
Amoxicillin	40	3	7th	Inside, regardless of food
Alternative drugs
Azithromycin	10	1	3	Inside for 1 h before meals
Clarithromycin	15	2	7th	Inside, regardless of food
Roxithromycin	5-8	2	7th	Inside 15 minutes before meals

Dosage regimen of antibiotics for acute sinusitis in children who received antibiotics for the last 1 -3 months, often ill, with severe course, as well as in the ineffectiveness of amoxicillin.

Antibiotic

Dose, (mghkg) / day

Multiplicity

Course (days)

Reception Features

The drug of choice

Amoxicillin / Clavunate

40 mg (by amoxicillin)

3

7th

Inside, at the beginning of a meal

Alternative drugs

Cefuroxime (axetil)	Thirty	2	7th	Inside with food
Ceftriaxone	50	1	3	Intramuscularly
Azithromycin	10	1	5	Inside, 1 h before meals

Particular mention should be made of the need to prescribe antibiotics for moderate to severe and severe forms for 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 conducted by a specialist. Only in this case it is possible to avoid the development of complications, recurrent forms or transition to a chronic process.

Indications for consultation of other specialists

In the absence of the effect of treatment, moderate, severe and complicated forms - consultation of the otorhinolaryngologist.

Indications for hospitalization

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

Sinusogenous orbital and intracranial complications

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

Sinusogenic intracranial complications in children are met much less often, they are associated with the topography of the frontal sinus, the posterior wall of which is due to the frontal lobe of the brain. At the first stage in such cases, there is a buildup of pus between the dura mater and the sinus bone wall - the extradural abscess. Subsequently, during melting of the dura mater, a subdural abscess is formed, often becoming the cause of diffuse purulent meningitis or an abscess of the frontal lobe of the brain.

Forecast

With early diagnosis and timely treatment, as a rule, it is favorable.