ENT Department, University of Ghent, Ghent, Belgium

This newsletter, the final in a 6-part series about the management of upper respiratory infections (URIs), is designed to aid primary care clinicians in the diagnosis and management of acute rhinosinusitis (ARS).

  Diagnosing acute rhinosinusitis

Most cases of ARS are viral and are defined by inflammation of the paranasal sinuses, usually the maxillary and ethmoid sinuses.¹ Patients typically present with nasal congestion, facial pain/pressure, rhinorrhea, postnasal drainage, headache, and cough.¹

Investigators have noted that after viral rhinosinusitis, cilia and ciliated cells are lost; this reaches a peak at about 1 week after infection. Because ciliary action provides the greatest natural defense against ARS,² impaired ciliary function can increase sensitivity to bacterial infection.³

Most often, patient self-care represents the only useful treatment, with the goal of speeding recovery and easing symptoms.⁴ However, if after 5 to 7 days, symptoms worsen or persist for more than 10 days and are moderate or severe, the clinician should evaluate the need for antibiotic therapy for bacterial sinusitis.

To aid primary care clinicians in the management of acute rhinosinusitis in adults, the ENT-section of the European Academy of Allergy and Clinical Immunology has developed the following treatment algorithm³:

  Treatment with over-the-counter medications

Initial treatment for mild ARS may include decongestants for symptomatic relief.³ Additionally, intranasal corticosteroids may be useful in reducing inflammation and improving drainage and aeration.¹ These agents may also improve other symptoms, such as congestion, headache, and facial pain.¹ However, randomized controlled trials have shown varying results and primarily local adverse events (eg, headache, epistaxis), which are generally mild to moderate and similar in occurrence to placebo.⁵ Evidence suggests that application of the topical steroid mometasone furoate twice daily is significantly superior to placebo and amoxicillin at improving symptom scores.³ Other corticosteroids, such as methylprednisolone, budesonide, flunisolide, and fluticasone propionate, have been shown to be efficacious as adjunct therapy.³ However, these agents were not efficacious when used as prophylaxis to prevent recurrence of ARS.³

  Nonmedical and alternative treatments

The following section reviews the medical literature on some nonmedical and alternative herbal therapies your patients may use to relieve their ARS symptoms.

Nonmedical. Rest, drinking plenty of fluids, steaming the nasal cavities (however, high temperature steaming may impair mucociliary clearance), applying a warm compress to the face, rinsing out the nasal passages, and sleeping with the head elevated have been shown to alleviate symptoms.⁴ The efficacy and tolerability of saline irrigation has been demonstrated in randomized controlled trials of chronic sinusitis,^6,7 and may also serve as an effective adjunctive treatment for patients with ARS.⁸

Myrtol oil. Although not commercially available in the United States, a small number of studies have shown that myrtol oil is superior to other essential oils in treating viral rhinosinusitis. One study demonstrated that antibiotic treatment was required by 23% of patients with uncomplicated ARS who had taken myrtol, vs 40% for placebo.³

Cineole. In a small number of studies, cineole (a derivative of eucalyptus) has been shown to be effective in treating viral rhinosinusitis. In one study, patients taking cineole had a mean reduction in symptom score of 6.7 after 4 days and 11.0 after 7 days, compared with 3.6 and 8.0 days, respectively, in the placebo group.⁶ In another study, patients taking cineole reported a mean symptom score of 6.9 after 4 days and 3.0 after 7 days, compared with 12.2 and 9.2, respectively, in the placebo group.⁷ Adverse events, possibly related to cineole, were mild heartburn and exanthema in 2 patients.⁷

Pelargonium sidoides. Previous newsletters [link] have reported on the efficacy of P sidoides in treating upper respiratory infections. Recent studies have shown that P sidoides has antiviral and mucolytic properties, which may be useful in managing symptoms associated with viral rhinosinusitis.⁸ A double-blind, randomized, placebo-controlled, parallel-group multicenter trial showed a mean decrease in sinusitis severity score of 5.5 points in patients taking P sidoides, compared with a mean decrease of 2.5 points in the placebo group.⁹

References

1. Small CB, Bachert C, Lund VJ, et al. Judicious antibiotic use and intranasal corticosteroids in acute rhinosinusitis. Am J Med. 2007;120:289–294.
2. Thomas M, Yawn B, Price D, et al, For the European Position Paper on Rhinosinusitis and Nasal Polyps Group. EPOS primary care guidelines: European position paper on rhinosinusitis and nasal polyps 2007—a summary. Prim Care Respir J. 2008;17:79–89.
3. Fokkens W, Lund V, Mullol J, et al, For the European Position Paper on Rhinosinusitis and Nasal Polyps Group. European position paper on rhinosinusitis and nasal polyps 2007. Rhinology. 2007;(20 suppl):1–136.
4. Mayo Clinic.  Acute sinusitis. October 11, 2008. http://mayoclinic.com/health/acute-sinusitis/DS00170. Accessed March 11, 2009.
5. Demoly P. Safety of intranasal corticosteroids in acute rhinosinusitis. Am J Otolaryngol Head Neck Med Surg. 2008;29:403–413.
6. Tesche S, Metternich F, Sonnemann U, et al. The value of herbal medicines in the treatment of acute non-purulent rhinosinusitis. Eur Arch Otorhinolaryngol. 2008;265:1355–1359.
7. Kehrl W, Sonnemann U, Dethlefsen U. Therapy for acute nonpurulent rhinosinusitis with cineole: results of a double-blind, randomized, placebo-controlled trial. Laryngoscope. 2004;114:738–742.
8. Brazilian Guidelines on Rhinosinusitis. [In Portuguese.] Rev Bras Otorrinolaringol. 2008;74(2 suppl):6–59. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72992008000700002&lng=en&nrm=iso. Accessed April 3, 2009.
9. Bachert C, Schapowal A, Funk P, et al. Treatment of acute rhinosinusitis with the preparation from Pelargonium sidoides EPs 7630: A randomized, double-blind, placebo-controlled trial. Rhinology. 2009;47:51–58.

The Journal of Family Practice ©2009 Dowden Health Media