Source: Slavin RG, Spector SL, Bernstein IL, et al; American Academy of Allergy, Asthma, and Immunology; the American College
of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol 2005; 116(6
Suppl):S13-47.
Take Home points
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The majority of cases of chronic sinusitis may not be infectious, but rather inflammatory, which impacts the way sinusitis
would be treated. That's just one example of the findings of recently published sinusitis guidelines. The Joint Task Force
on Practice Parameters collaborated on the latest practice parameter update.
"In this update, we point out that repeated courses of antibiotics and repeated operations don't generally help patients with
chronic sinusitis — that it's largely an inflammatory response," said Raymond G. Slavin, MD, MS, FAAAAI, professor of internal
medicine, director of the division of allergy and immunology, St. Louis University School of Medicine, Mo. "Much research
is going on to try and determine the precise driving force for the chronic inflammation that occurs."
The main impetus for this update was the mounting evidence that sinusitis is "very common, sometimes underdiagnosed, sometimes
overdiagnosed, and that it extracts tremendous price – in terms of dollars spent and indirectly in terms of quality of life,"
Dr. Slavin told GERIATRICS. He said since the last update in 1998, many advances in this area of infections have occurred.
New to this parameter was emphasis on how the majority of upper respiratory infections are viral in etiology, not bacterial.
So the taskforce is advising a 10-14 day course of observation before antibiotics are instituted, unless there appears to
be an extremely toxic reaction (eg, fever, pain, and/or purulent drainage).
"Our admonition here was based on the fact that there is an increasing and very alarming incidence of antibiotic resistance
that is developing and that we think it has much to do with antibiotics being given for what is essentially a viral infection,"
Dr. Slavin told GERIATRICS. "Our feeling is that if one tells patients that the majority of cases are viral and that injudicious
use of antibiotics is responsible for the alarming increase in bacterial resistance, maybe patients would understand a bit
better."
The guidelines also point out some newer predisposing factors in sinusitis:
- allergic rhinitis or hay fever, if not well-treated, can progress to sinusitis;
- increasing evidence shows that gastroesophageal reflux disease (GERD) may also predispose to sinusitis;
- most significant: viral upper respiratory tract infections may lead to or augment bacterial sinusitis.
As for sinusitis' relevance to older patients, Dr. Slavin says GERD is "particularly prominent" in this segment of the population,
as is perineal non-allergic rhinitis, which appears to predispose to sinusitis.
He said that in general, older patients typically have higher incidence of dryness of nasal mucosa. "The aging process decreases
mucous production, however, buffered saline nasal sprays are extremely useful for this," he notes.
Regarding primary care application, Dr. Slavin said: "Physicians ought to be vigorous in terms of treatment of rhinitis –
whether allergic or nonallergic. They should recognize that decongestants are very useful and that saline nasal sprays may
be helpful. However, decongestants have to be used carefully in the elderly because of increased side effects, but buffered
saline nasal sprays and cortisone nasal sprays can be useful in combating inflammation of rhinitis that may predispose to
sinusitis," he noted.
That said, he acknowledges that physicians still don't appear to be aware of the benefits of nasal spray use, for example.
"It's a high-tech age. People are turning to expensive sprays, antibiotics, other medications. Something as simple as buffered
saline that you can buy over-the-counter gets neglected," he said.
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