Steps a Patient with Chronic Sinusitis Goes Thru

For the vast majority of patients with sinus infections, a trip to the primary care doctor's office and a prescription for antibiotics is all that is required. However, for the unfortunate few, several courses of oral antibiotics do not seem to help as much as it should.

In such cases, these patients eventually end up at an ENT office for further evaluation and management.

ASSUMING the patient has bona fide chronic or recurrent sinus infections and not some other medical problem confused for a sinus infection such as trigeminal migraines, these are the typical steps such patients go through in order to address their sinusitis. Keep in mind that some of these steps may be flipped or merged depending on an individual's unique clinical situation.

Step 1:
Endoscopic evaluation of the nasal cavity and if possible, the sinuses. If purulent drainage seen, culture are obtained in order to identify the organism and determine what antibiotics will work best to kill it (known as C&S). More oral antibiotics along with steroids typically prescribed at this stage. Nasal flushes with xlear or chitorhino can be tried especially if plain saline sinus flushes not helpful.

Step 2:
If not already done, allergy testing to evaluate for any allergic triggers that could be contributing or even driving the sinus infections. If allergies present, aggressive allergy medical management is started including medications and allergy shots.

Immunologic testing is also often performed in order to determine if there is some sort of immunodeficiency resulting in the body being unable to fight off infections as well as it should. Such immunologic testing typically evaluates for immunoglobulin (Ig) levels. More rarely, testing may include cellular immune functionality (lymphocytes, B cell memory, etc). If any immunologic dysfunction present, referral to immunology specialist is made.

Step 3:
CT Sinus scan to evaluate the extent of the sinus disease.

Step 4:
If medical management not working, sinus surgery is performed. Intra-operative cultures are obtained.

Step 5:
If sinus infections persist in spite of sinus surgery, more aggressive antibiotic treatment is performed via:

1) Adding antibiotics to the saltwater which is than flushed into the nose twice a day.
2) Injecting a thick gel impregnated with antibiotics and steroids into the sinus cavity filling it up. This will stick around for 2-4 weeks.

Step 6:
Potentially start a workup for potential autoimmune issues that may be contributing to the sinus infections (ie, Wegener's Disease, Churg-Strauss Syndrome, etc).

Step 7:
Ultimately, manage the sinus infections as a chronic illness, just like hypertension or diabetes.