Acute sinusitis: treatment

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

[1], [2], [3], [4], [5], [6], [7],

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 cavity of the paranasal sinus in accordance with the fundamental principles of purulent surgery. An important factor. Determining the positive value of puncture treatment, consider the possibility of local exposure to antibacterial, anti-inflammatory, antiseptic and enzymatic agents directly on the mucous membrane of the paranasal sinuses.

The puncture of cells of the latticed maze due to the variability of their anatomical structure is considered inadvisable, despite the available publications promoting this method. Trepanopuncture of the frontal sinus is done much less often and only on strict indications.

In the last quarter of the last century, many studies have been devoted to the selection of special multi-compound mixtures for insertion into the paranasal sinuses during their inflammation. Disadvantages of this method are the very rapid spontaneous evacuation of therapeutic substances through natural anastomoses, the inability to strictly dose the substances administered, the lack of standardization of procedures and various medical institutions, the difficult-to-predict interaction of the components of complex mixtures, the lack of information on the effects of the drug directly on the inflamed mucous membrane of the paranasal sinuses. So, the introduction of more than 100 000 units of benzylpenicillin into the maxillary sinus led to a disruption of the transport function of the ciliated epithelium of the fused shell lining the sinus, and indeed it is the mucociliary transport that is considered one of the main mechanisms for evacuating the pathological contents from the sinus.

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

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 repeated repeated rinsing of the sinus, without additional punctures. The absence of a standard catheter for these purposes led to the creation of dozens of variations, ranging from a conventional polyvinylchloride 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. Permanent multi-day irritation of the inflamed mucous membrane with this foreign body can negate all the obvious advantages of the catheterization method,

Using the dialysis method of the paranasal sinuses, they tried to compensate for the shortcomings of a very rapid spontaneous evacuation of complex therapeutic mixtures through natural anastomoses. The principle of the method was that the medicinal mixtures were injected into the sinuses with the help of standard systems for intravenous drip administration of medicinal substances connected with a puncture needle inserted into the sinus or with 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 for him, all the above-mentioned disadvantages of introducing complex medicinal mixtures into the paranasal sinuses are fully characteristic.

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

Having analyzed all the advantages and disadvantages of the method of puncture therapy for acute sinusitis, it is possible to draw certain conclusions. In the presence of a siistically purulent discharge, the puncture of the paranasal sinuses is considered necessary as an obligatory method of treatment. Evacuation of the muco-purulent discharge is a powerful tool for the pathogenetic treatment of acute sinusitis.

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

Possibilities of modern complex pathogenetic pharmacotherapy of acute sinusitis (general and local antibiotic therapy, general and local anti-inflammatory therapy, secretotherapy and secretolithic therapy allow to reduce the number of punctures for treatment.) Under conditions of complex pharmacotherapy, punctures are shown no more than 3-4 times per course of treatment and only with the purpose of evacuation of pathological purulent discharge.

The possibilities of modern pharmacotherapy allow us to abandon the practice of introducing complex 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 formal drugs of systemic action or local drugs specifically designed for endonasal administration.

Medical treatment of acute sinusitis

As already shown, the key link in the pathogenesis of acute sinusitis is the blockade of the anastomoses of the paranasal sinuses as a result of edema of the mucous membrane. In this regard, one of the main directions of symptomatic (and in some sense, pathogenetic) therapy of acute sinusitis is the restoration of the patency of these joints, 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 anastomoses.

Drugs that make it possible to dramatically reduce the edema of the mucous membrane that performs the lumen of the sinus anastomoses, and thereby for a time restore their patency, are vasoconstrictors (decongensants). To some extent, this effect can be achieved using anti-inflammatory drugs systemic (fenspiride) and especially local (fuzafungin) action, as well as secretolitic agents (sinupret, myrtol).

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

The appointment of decongensants is absolutely necessary for acute sinusitis, as these drugs eliminate the swelling of the nasal mucosa as soon as possible, restore nasal breathing and patency of natural sinus holes. However, all vasoconstrictive drugs have their drawbacks and side effects. With long-term topical application of oxymetazoline, naphazoline, etc. Cause "bounce syndrome" and so-called drug rhinitis, so the use of these drugs should be limited to 5-7 days. In this regard, phenylephrine differs favorably from the others. Having a soft mild vasoconstrictor effect due to stimulation of alpha 1-adrenergic receptors, it does not cause a reduction in blood flow in the mucosa of the nasal cavity and paranasal sinuses and, therefore, to a lesser extent disrupts their function. Of great importance is the form of release of the drug. Nasal drops, in the form of which the vast majority of decongensants are released, is almost impossible to dose, since most of the solution introduced 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 a threat of overdose of the drug. In this regard, the use of metered aerosols is considered much more beneficial.

Decongensants for ingestion do not cause the development of drug rhinitis, but during the course of treatment they may appear insomnia, tachycardia, episodes of increasing blood pressure. 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.

Antimicrobials for local effects on mucous membranes can be prescribed in combination with systemic drugs, in some cases also as an alternative treatment for acute sinusitis.

The question of local antibiotic therapy of sinusitis is actively discussed. Clearly, the practice of administering antibiotics to the paranasal sinuses for intramuscular or intravenous administration should be excluded. According to their pharmacokinetics, they are not adapted for these purposes. In addition, the dosage regimen is extremely difficult. The main contraindication is the violation of mucociliary transport in the paranasal sinuses due to the adverse effect of large doses of antibiotic 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 sinuses of the paranasal sinuses and directly affect the pathogen in the focus of inflammation. When filling sinuses with mucous or mucopurulent exudate such contact is impossible.

In the composition of the nose spray isofra enters the antibiotic aminogloidoidnogo series of framicetin, intended for topical application in otorhinolaryngology. The concentration of framicetin, obtained with topical application, obggchivaet 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, as is known, are oriented in their own spectrum of action to the destruction of pathogenic microorganisms of the respiratory tract. In this regard, in pulmonology this group of antibiotics is considered one of the leading in the treatment regimens. In otorhinolaryngology, aminoglycoside antibiotics are rarely used because of 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 a loss of the kolevo-vestibular receptor. In the case of the use of framicetin, there is a unique opportunity to use the entire antimicrobial potential of the aminoglycoside antibiotic directed against the pathogenic microorganisms of the upper respiratory tract, and at the same time not to be afraid of its ototoxic effect, since the drug is not introduced systemically, but exclusively locally. Low systemic absorption of Framicin completely excludes ototoxic effect.

The composition of the nasal spray polidexa includes antibiotics of different classes: neomycin and polymyxin, glucocorticoid drug dexamethasone and vasoconstrictor - phenylephrine. The therapeutic effect of nasal slrei is due to the anti-inflammatory effect of dexamethasone on the mucous membrane of the nasal cavity, the antimicrobial effect of antibiotics of two different groups, covering in its spectrum all major pathogens of the nasal cavity, nasopharynx and paranasal sinuses, and also the vasoconstrictive effect of phenylephrine.

The inhalation preparation bioparoks includes a unique ingredient - fusafungin, 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 bacillus, anaerobic pathogens, mycoplasma and even mold fungi. A strong antibacterial affect is also provided by the activation of interleukin-2, which, in turn, increases the activity of natural killers. In addition to antibacterial action, fusafungin also has a local anti-inflammatory effect due to restriction of production of free radicals and a decrease in the release of inflammatory cytokines. Due to its strong local anti-inflammatory activity, fusafungin can be used not only at the stage of catarrhal sinusitis, but also in the case of the inflammatory block of the sastia as an auxiliary anti-inflammatory local remedy.

In most guidelines for the treatment of acute sinusitis systemic antibiotic treatment is referred to first-line drugs in the treatment of this disease. However, weighty arguments against the routine use of empirically prescribed systemic antibiotics for acute sinusitis are the widespread prevalence of resistant strains of bacteria that cause sinusitis, the inability to pinpoint the exact etiology of sinusitis (bacterial or viral). The presence of allergic reactions, secondary immunodeficiency states, as well as zosiiophilic fungal sinusitis.

The main goal of systemic antibiotic therapy for acute rhinosinusitis is elimination of infection and restoration of sterility of the paranasal sinus. The drug for acute processes in most cases 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 causative agents of acute sinusitis to antibiotics varies considerably in different regions. According to foreign researchers, currently there is a tendency to increase the resistance of pneumococci to benzylpenicillin. Macrolides, and the hemophilic rod - to aminopenicillin.

Streptococcus pneumoniae and Haemophilus influenzae isolated from acute sinusitis retain high sensitivity to aminopenicillins and cephaloslorins: 97% of strains of S. Pneumoniae are sensitive to benzylpenicillin, 100% to ampicillin, amoxicillin, to a combination of amoxicillin + clavulanic acid, cefuroxime, 100% of strains H. Influenzae are sensitive to a combination of amoxicillin + clavulanic acid, 88.9% to ampicillin and cefuroxime. The main problem is the high resistance of pneumococci and hemophilic rods to co-tricmoxazole; a moderate and high level of resistance was noted in 40% of S. Pneumoniae strains and in 22% H, influenzae.

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

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

• activity against S. Pneumoniae and H. Influenzae,
• ability to overcome the resistance of pathogens to the antibiotic;
• good penetration into the mucous membrane of the paranasal sinuses with reaching a concentration above the minimal suppressing for the given pathogen;
• the concentration in the blood serum is maintained above the minimum inhibitory within 40-50% of the time between doses of the drug.

Taking into account typical pathogens and data on resistance to antibiotics, the drug of choice for acute sinusitis is amoxicillin, a semisynthetic antibacterial drug from the group of aminopenicillins. The spectrum of antimicrobial action of amoxicillin and ampicillin is similar, however, 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 equal 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 and capsules - 70%, and the bioavailability of amoxicillin in the form of dispersible tablets reaches 93%, which ensures the maximum effectiveness of the drug. However, due to the minimum "residual" concentration of amoxicillin in the intestine (only 7% of the dose), 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 (a pleasantly tasting suspension with an apricot smell will be obtained), 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 and day, divided into 2-3 doses. If a penicillin-resistant pneumococcal is suspected, the dose of the drug may 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 hemophilic rod and moraxella-amoxicillin + clavulonic acid. It has a broad spectrum of antibacterial action and is active against both amoxicillin-sensitive strains and against strains producing beta-lactamases. Amoxicillin + clavulanic acid, an irreversible inhibitor of beta-lactamases, forms a stable inactivated complex with these enzymes and protects omoxycillin from loss of antibacterial activity caused by production of beta-lactamay both by pathogens and opportunistic microorganisms. It is this combination that provides high activity of this drug against key pathogens of acute sinusitis. It is also possible the appointment of cephalosporins of the 2nd generation (cefuroxime inside). If intramuscular route of administration is preferred, ceftriaxone (1 time and day for 3 days) or ampicillin + sulbactam (150 mg / kg per day for 3-4 injections, for adults 1.5-3 g per day) is used.

With recurrent acute sinusitis, treatment should be started immediately with 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 counting on amoxicillin). For young children, the drug is prescribed as a suspension or dispersible tablets.

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

Among cephalosporin oral preparations, ceftibutene is the most effective. He is referred to the modern third generation cephalosporins. The drug has a high bactericidal activity against the leading pathogens of sinusitis, which is proved in studies in vitro and in vivo. Among oral cephalosporins, it has the greatest resistance to beta-lactamases and has a high bioavailability (90%). Ceftibuten is able to selectively accumulate in high concentrations in the pathological focus. Thus, the content of the drug in the nasal secretion is 46% of its concentration in the serum. Undoubted advantage of ceftibutene is the admission regimen: once a day. The drug is used for 400 mg 1 time per day for 10 days.

Recently, the market began to produce fluoroquinolones with an extended activity spectrum, effective against S. Pneumoniae and H. Influenzae. In particular, to such preparations of new generation carry moxifloxacin and levofloxacin.

Levofloxacin has a high activity against the main causative agents of acute sinusitis, including strains resistant to other classes of antibiotics (for example, penicillin-resistant pneumococcal strains). 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 studies, with acute sinusitis in adults, levofloxacin is not inferior in clinical and bacteriological efficacy to amoxicillin + clavulanic acid and clarithromycin, but is better tolerated, especially from the gastrointestinal tract. In contrast to these drugs, levofloxacin is taken once a day but 500 mg for 10 days. It can be used in patients with allergy to beta-lactam antibiotics. In severe sinusitis and the threat of complications, it is possible to use stepwise therapy: levofloxacin is first administered parenterally, then inside.

Macrolides are now considered as second-line antibiotics, and they are mainly used for allergy to beta-lactam antibiotics. Of macrolides in acute sinusitis, the use of azithromycin, clarithromycin and roxithromycin is justified, although they are less effective for eliminating pneumococcus and hemophilic rods than for 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 from the gastrointestinal tract.

Of the tetracycline group, only doxycycline retains sufficient effectiveness in the treatment of acute sinusitis, but it can not be used in children under 8 years of age.

Especially it should be said about such common drugs as co-trimoxazole, lincomycin and gentamicin. In many foreign sources, co-trimoxazole is referred to as highly effective drugs for the treatment of acute sinusitis.

However, in Ukraine, a high level of resistance of pneumococci and a hemophilic rod to this drug has been revealed, therefore its use should be limited. Lincomycin is not recommended for the treatment of acute sinusitis, since it does not affect the hemophilic rod, but this drug can be used in exacerbation of chronic sinusitis if there is a suspected osteomyelitis. Gentamicin is not active against S. Pneumoniae and H. Influenzae, therefore it is not indicated for the treatment of sinusitis.

Thus, taking into account all of the above, we can suggest the following scheme of systemic antibiotic therapy for acute sinusitis, based on the severity of the course of the disease. With an easy flow in the early days of the disease, when the most likely viral etiology, antibiotics are not required. If, in spite of the treatment, there is no improvement for more than 10 days or the severity of the symptoms progresses, which indirectly indicates the attachment of a bacterial infection, it is advisable to prescribe antibacterial therapy.

It should be noted that as a definite alternative to classical antibiotic therapy for the mild course of the disease, it is possible to successfully use echinacea compositum S.

With a moderate course of drug choice, consider amoxicillin, amoxicillin + clavulanic acid, levofloxacin.

Alternative drugs include;

• cephalosporins (cefuroxime, cefaclor);
• macrolides (azithromycin, clarithromycin, roxitromia);
• tetracyclines (doxycin).

Drugs used for severe sinusitis:

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

Anti-inflammatory therapy is directed, first of all, to the blockade of the cascade of mediator reactions that enhance the inflammatory response. This leads to relief of such basic symptoms of inflammation in acute sinusitis, as pain, edema, vasodilatation of the mucous membrane of the paranasal sinuses, excessive exudation. In this regard, anti-inflammatory therapy should be an indispensable component of the treatment of acute sinusitis.

There are two main directions of systemic anti-inflammatory therapy in general; this is the use of glucocorticoids and non-steroidal anti-inflammatory agents. A special place is occupied by fenspiride - a new powerful tool for the treatment of sinusitis. Fenspiride has a pronounced anti-inflammatory effect, which is due to blockade of H1 receptors of histamine, a decrease in the production of pro-inflammatory substances (cytokines, TNF, arachidonic acid metabolites, free radicals). In the place of its application, fenspiride is designed specifically for mucous membranes of the respiratory tract and therefore, when choosing the means of systemic anti-inflammatory therapy of acute sinusitis has advantages over other anti-inflammatory drugs. Fenspiride reduces edema, hypersecretion of viscous mucus, improves mucociliary clearance. The anti-inflammatory action of fenspiride allows faster elimination of all symptoms of rhinosinusitis.

Non-steroidal anti-inflammatory drugs inhibit the biosynthesis of prostaglandins, inhibit the activity of cyclooxygenase, inhibit lipid peroxidation, 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 the 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 for chronic.

Naturally, in the treatment of acute sinusitis, preference is given to the drugs of the first group.

Anti-inflammatory therapy allows to break the vicious circle process in the sinus with an obturated hole, starting from the initial stages (ventilation and drainage disorders). Glucocorticoids primarily suppress the development of edema due to the effect on the inflammation in the lamina propria of the mucosa, The functions of the joints 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.

At present, such glucocorticoid drugs for topical use as beclomethasone, budesonide, fluticasone and mometasone have been registered in Ukraine.

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

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

Separately, it should be noted the possibility of the appointment as an anti-inflammatory drug Traumeel S. His 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, one of the leading places is histamine, so it is impossible to avoid the issue of the role of antihistamines in the treatment of acute sinusitis. A atigistamine drugs are widely used in the treatment of acute sinusitis, although their appointment is often unreasonable. In the case when acute sinusitis develops against the background of allergic rhinitis, antihistamines block the histamine H1 receptors and prevent the action of the mediator released from mast cells as a result of the IgE-mediated reaction. With infectious sinusitis, the purpose of these drugs also has a certain meaning, but only in the early "viral" stage, when the blockade of H1 receptors of histamine prevents the action of the mediator released by basophils under the influence of various viruses (respiratory syncytial, paramyxovirus). The antihypamine preparation of the second generation desloratadine also has a pronounced anti-allergic and anti-inflammatory effect and can be recommended for the treatment of acute sinusitis in patients with allergic rhinitis.

Safe integrated and homeopathic preparations of ENHYSTOL and luffel are considered to be effective and effective ayatallergic agents.

Currently in Ukraine, enzymes in the therapy of acute sinusitis are not used often enough and are mostly injected with puncture of near-peripodal gyehus. In foreign otorhinolaryngology, active development and propagation of alternative pathogenetic methods for the treatment of sinusitis is based on, first of all, the use of mucolytic, secretory and secretory preparations.

Mucolytic drugs change the physico-chemical secret by reducing its viscosity. To this end, use tension reducers, or enzymes that cause disulfide bonds to break.

Drugs are classified as secretion drugs, which, through various mechanisms, mainly by enhancing the motor activity of the ciliated epithelium, increase the effectiveness of mucociliary clearance. Typical representatives of this group are beta2-adrenergic agonists (bronchodilators). Tefillin, benzylamines and essential oils also have a secretory effect.

Secretolithic drugs improve the evacuation of mucus due to a change in the nature of secretion. Essential oils of plant origin, extracts of various plants, creosote derivatives and synthetic benzylamines, bromhexine and ambroxol have a secretolitic effect through increased secretion of bronchial glands.

For the treatment of acute sinusitis in Ukraine, there is now sufficient experience in the use of the following mucolytic drugs: myrtol, synctrt, acetylcysteine. These drugs are used mainly in the treatment of diseases of the broncho-pulmonary system and are not well known to otolaryngologists.

Myrtol - a medicinal product based on essential oils. Myrtol as an essential oil of vegetable origin is lipophilic. After ingestion through the mouth, it is absorbed into the small intestine and through the blood enters the paranasal sinuses, where it is partially released through the respiratory epithelium.

The secretolitic effect of myrtol is due to the fact that it stimulates the bocaloid 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 secretory effect is associated with stimulation of beta adrenorecentros, 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 collision increases and the rate of transport of the secretion from the paranasal sinuses increases.

Myrtol, thus, contributes to improving the outflow from the paranasal sinuses with low secretion, as well as its stagnation. It improves the drainage of the paranasal sinuses and provides recovery for both acute and chronic sinusitis

Sinupret has a reflex secretory effect, regulating secretion and normalizing the viscosity of mucus, eliminating mucostasis. Sinupret acts on the mucous membrane of the respiratory tract, removing edema and inflammation. The drug restores drainage and ventilation of the paranasal sinuses. Sinupret normalizes the protective properties of the epithelium of the respiratory tract due to the improvement of the rheological properties of the exudate, and also has immunostimulating activity. The drug has a virosostatic effect on influenza viruses, parainfluenza and rhinosin citial infection, potentiates the effects of antibiotics.

Mucolytic action is also possessed by drugs that reduce surface tension, that is, affecting the gel phase of the detachable and diluting both phlegm and nasopharyngeal secretions. This group includes carbocysteine. Mucolytic and expectorant effect is due to the activation of sialic transferase - the enzyme of goblet cells of bronchial mucosa. The drug normalizes the quantitative ratio of acidic and neutral sialomucins to bronchial secretions, promotes regeneration of the mucous membrane, restores its structure, activates the activity of the ciliary epithelium, restores the secretion of immunologically active IgA (specific defense) and the amount of sulfhydryl groups of mucus components (non-specific defense), improving mucociliary clearance.

The maximum level in the blood serum and in the mucous membrane of the respiratory tract is observed 2-3 h after ingestion. The required concentration is retained in the mucosa for 8 hours. Carbocysteine is excreted mainly in the urine, partly unchanged, partly in the form of metabolites.

To the same group of drugs include rhinofluucimil - the original combination spray, which, in addition to acetylcysteine, includes sympathomimetic - thiamine-heptane, which has a mild vasoconstrictive affect, without causing excessive dryness of the mucous membrane, acetylcysteine dilutes the secret. After rupture of disulfide bridges, mucus and sputum lose the ability to be viscous and, absorbing water, can be gently removed by blowing, sneezing, coughing. The drug has an anti-inflammatory effect due to inhibition of leukocyte chemotaxis. The main advantage of rhinofluimucil is that it works on the surface of the mucous membrane, diluting and reducing the viscosity of mucus, contributes to a productive physiological act of cleansing the paranasal sinuses.

There is another combination drug - tiamphenicol glycinate acetylcysteinate. The drug has a combined antibacterial and mu- poitic effect and is recommended for the treatment of respiratory diseases caused by bacterial flora and accompanied by the formation of a thick viscous secretion. Antimicrobial activity of the drug is due to interference in the synthesis of bacterial proteins. Recent studies have shown that due to the associations of thiamphenicol and acetylcysteite in one drug compound, the drug remains unconjugated and reaches the focus of inflammation at a concentration sufficient to create a bactericidal effect. The drug shows 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 possesses powerful apty-oxidant properties and is able to provide respiratory protection against the cytotoxic effect of metabolites in inflammation.

Algorithm for the treatment of acute sinusitis:

• with catarrhal rhinosinusitis should be preferred 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 sinus joints;
• great importance is the use of secretory and secretolitic drugs;
• with acute purulent sinusitis should be prescribed systemic antibacterial drugs with mandatory consideration of the rules of empirical antibiotic therapy;
• it is also desirable to prescribe systemic anti-inflammatory drugs;
• as additional methods of treatment should use unloading and mucolytic therapy;
• when filling the sinus with a mucopurulent discharge and difficulty in evacuating it despite the applied complex therapy, it is necessary to perform a puncture of the paranasal sinuses, and if necessary a few, given the dynamics of the course of the disease,

Surgical treatment of acute sinusitis

Surgical treatment for acute sinusitis is used only in the case of orbital or intracranial complications. In this case, the corresponding sinus (sinuses) is opened, which was the cause of this complication.

Further management

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