Jewish World Review Feb. 18, 2003 / 16 Adar I, 5763

GERM WARFARE: THE BATTLE FOR CLEAR NOSES



Fighting off a sinus infection sometimes requires a detailed battle plan requiring physicians and patients to join forces for a lengthy course of treatment.


By Susan J. Landers

http://www.NewsAndOpinion.com | Millions of miserable, drippy-nosed, stuffy-headed and pain-wracked patients shuffle into doctors' offices each year. They are among the multitude of Americans affected by sinusitis, and the number is growing. Sinusitis is considered the most common chronic condition to beset humans.

Yet despite the frequency with which those holes in our heads are prone to harbor infections, diagnosing and treating sinusitis can be very difficult. It can be done. But the best method of attack is not always clear.

Wellington S. Tichenor, M.D., a New York City allergist with his own sinus problems, has been treating people with sinusitis for 20 years. "When I had sinus infections, I felt like life wasn't worth living any more, between the exhaustion, pain and just feeling miserable,'' Dr. Tichenor writes on his Web site.

He readily acknowledges how difficult sinusitis is to treat. But don't give up, he advises patients. "If you're not getting better, it doesn't mean that you're not getting good care, but it may mean you're not getting the very best care. Unfortunately, most doctors don't understand the best way to treat it.''

The painful truth, though, is that many patients and their physicians do give up. "People get to the stage where they have symptoms on and off, they may take courses of antibiotics which may or may not help, and then they say, `Well, I just have to live with this,' '' said Howard M. Druce, M.D., who chairs the sinusitis committee for the American Academy of Allergy, Asthma and Immunology.

A study conducted by Dr. Druce and colleagues revealed that some patients had symptoms for as long as 15 years before they sought help from a sinus specialist.


MISERY'S COMPANY

Sinusitis affects about 32 million adults each year. Sinus infections resulted in 11.7 million visits to physician offices and another 1.2 million outpatient hospital visits in 2000. Rates of sinus infections are highest among women and people living in the South. Overall health-care expenditures attributed to sinusitis in 1996 were estimated at $5.6 billion. The average cost per patient claim for treatment of sinusitis in 1997 was $200.


Sources: National Center for Health Statistics, Agency for Health Care Research and Quality, MEDSTAT Group

The long battle usually begins when patients experience the symptoms and try to self-treat. But this approach often fails to produce lasting results although over-the-counter remedies line the shelves of grocery stores and pharmacies and consumers spend millions on pills, sprays and syrups.

Ultimately, those with sinus problems go to the doctor. And the first difficulty physicians then face is in the diagnosis, because of sinus infections' close resemblance to colds.

There are a variety of opinions on how to properly diagnose. Some physicians say CT (computed tomography imaging) scans are the definitive gold standard to be used in reaching the proper diagnosis, but only after a course of treatment has been tried and failed. Others say they rely on an examination of a patient's nose with an endoscope to make a diagnosis.

And maybe it doesn't matter all that much, because often physicians make decisions based on what they see in front of them -- patients who have had one or more of these symptoms for longer than two weeks: facial pain, nasal discharge and postnasal drip or cough, especially a cough at night.

ACUTE VS. CHRONIC

One thing that does matter is the duration of symptoms. Most physicians who treat sinusitis draw a distinction between acute sinusitis, which lasts about three weeks, and chronic sinusitis, which usually lasts for three to eight weeks but can continue for months or even years.

Primary care physicians are doing a fine job of treating acute sinusitis, said Peter J. Casano, M.D., an otolaryngologist in private practice in Jackson, Miss. It's harder to treat chronic sinusitis.

"Acute sinusitis is more straightforward,'' said Marshall Plaut, M.D., chief of the allergic mechanism section at the National Institute of Allergy and Infectious Diseases. "It is an infectious disease, and it needs to be treated.''

But even with acute sinusitis, the path isn't perfectly clear, Dr. Plaut said. Not everyone agrees that acute sinusitis needs to be treated with antibiotics, even if it is bacterial. And some acute infections are viral.

If that sounds complicated, "When you get to chronic sinusitis, things are even more complex,'' Dr. Plaut said.

"Chronic sinusitis is a totally different animal than acute sinusitis,'' agreed Vincenza Snow, M.D., senior medical associate in the Department of Scientific Policy at the American College of Physicians, American Society of Internal Medicine. As a matter of fact, Dr. Snow, co-author of the internists' guidelines on acute sinusitis, said the difficulty of treating chronic sinusitis leads many internists to send patients to specialists.

As would be expected, specialists, whether allergists or otolaryngologists, follow their own treatment regimens. Dr. Druce, for example, advises against giving only antibiotics. "Because we now understand the physiology and the anatomy of the sinuses better, we know that sinusitis is an infection in a closed cavity. And just giving antibiotics alone is not appropriate.

"We typically give an oral decongestant to shrink the lining of the sinus passages,'' he said. In addition, "We may give a nasal steroid spray, which reduces inflammation at a point where the sinuses drain into the nose. We are very liberal with steam inhalation and saline sprays.''

Dr. Tichenor, too, advocates medical drainage via antibiotics, cortisone nasal sprays, mucous thinners and decongestants.

Otolaryngologists are also more likely to prescribe steroid nasal sprays than are primary care physicians, Dr. Casano said. Primary care physicians may lean more toward the use of decongestants and antihistamines.

Some controversy still surrounds antihistamines, which can promote additional drying of the nasal passages, a no-no, say many. But if allergies are the cause of the infection, then antihistamines are a good choice, say others.

All of the above is a far cry from a past treatment that required pushing a needle through the nose and into the sinus passages to relieve pressure and let the pus out. Although the treatment was effective, the patient found it unnerving, Dr. Druce said. The procedure also posed some risk to the optic nerve if not done skillfully.

The narrowness of the tubes (typically one-sixth of an inch) through which about two quarts of mucous flow each day from the sinuses into the nose makes them very prone to blockage.

"Mucous gets blocked up and then gets infected and causes more inflammation and blockage, so it gets to be a vicious cycle,'' Dr. Tichenor said.

Because it is difficult to get the medicine to the site of the infection, many physicians recommend an extended, three-week minimum course of antibiotics. Other physicians recommend prescribing an antibiotic for no longer than two weeks. Some physicians also recommend trying to determine which antibiotic to use in treatment, while others advise using a broad-spectrum antibiotic.

But all physicians are wary of the problem caused by the inappropriate use of antibiotics and the rise of resistant bacteria.

Fear of fostering antibiotic resistance was one of the reasons that ACP-ASIM wrote treatment guidelines for acute sinusitis. The guidelines recommend physicians advise patients to first use over-the-counter cold remedies and saltwater gargles to relieve symptoms of colds, bronchitis and sinusitis.

As many as 75 percent of antibiotics prescribed each year were associated with upper respiratory tract infections, noted Sandra Fryhofer, M.D., the association president when the guidelines were introduced about two years ago.

The guidelines have helped curb physician's impulses to prescribe antibiotics too quickly, Dr. Snow said. "We were over-enthusiastically treating our patients and then, in the end, not really helping them.''

While all agree that inappropriate use of antibiotics is to be avoided, longer courses of antibiotics are also advocated. "It's thought to be less likely to create antibiotic resistance if you treat to completion than if you partially treat,'' Dr. Casano said. "So it comes down to either don't treat or treat aggressively, not some of this in-between treatment that I see a lot of.''

Dr. Tichenor also fears that short courses of antibiotics might be fostering the resistance. "What patients will often say is, `The doctor put me on 10-days-worth of antibiotics, and I felt better while I was on the antibiotics, but as soon as I stopped, I had a return of symptoms.' ''

"What we will typically do,'' Dr. Tichenor said, "is have patients stay on antibiotics until the symptoms have stopped improving and then continue for a week more. Usually it is a minimum of at least three weeks, and often it is as long as six to eight weeks.''

When patients fail to improve with long and intensive medical therapy, some doctors recommend surgery. "The key is to be sure you have provided patients with prolonged and adequate medical therapy before you even consider surgery,'' Dr. Casano said.

While there are cases where people have anatomical problems that can only be corrected with surgery, the majority of patients with a stubborn infection can be treated medically for months, if such a course seems reasonable, and there has been a sign of improvement, he said.

But surgery is not uncommon. Between 200,000 and 300,000 people each year undergo a procedure to clean and drain the sinus, said Dr. Tichenor, who has had surgery himself.

He noted that while he has been essentially cured by the surgery, he still has occasional episodes of sinusitis. But at least those infections are now easier to treat, he said.

WHAT'S NEW?

Additional new treatments are slow in coming. Despite the common nature of sinusitis, research interest had flagged until about two years ago, when Mayo Clinic published a paper on the possible role played by fungi in chronic sinus infections. The National Institute of Allergy and Infectious Diseases is funding that research, Dr. Plaut said.

The connection between asthma and sinusitis is also being investigated, Dr. Plaut said. Chronic sinusitis occurs frequently in patients with asthma, but what the connection is between the two isn't all that clear, he added.

Another long-recognized connection is that between cystic fibrosis and sinusitis. Researchers at Johns Hopkins University in Baltimore recently found that people who have chronic sinusitis often carry a single copy of the gene that causes CF, leading to the possibility of a genetic cause for some cases.

Although research findings are only dribbling in, the situation is better than it used to be, Dr. Tichenor said. "Up until the Mayo Clinic's research, we had basically thrown up our hands and did surgery for the past 10 years or so, and have been largely unhappy with the surgical results because it doesn't cure the disease, it only opens the holes so people can drain better.''

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