How to Treat a Sinus Infection [The right way]

How to Treat a Sinus Infection – The right way!

Woman sick with sinus infection
Learn how to treat a sinus infection the RIGHT way!

 

Sinus infections suck!

I understand what you’re going through.  You start off with your typical cold symptoms:  a little stuffy or runny nose or a sore throat.  For most of your friends, this will be just a few days of feeling sick and then they’re better.  They don’t understand what you’re about to go through.Your nose congestion is going to get worse.  Then you start to feel the fullness behind your eyes and cheeks, the start of a headache, and you know that every virus and bacteria are fighting for their right to party in your sinuses.  And it keeps getting worse.

Soon, your headache will be relentless and worsen with every cough and head movement as well as every bump and hill you go over.  Your sleep will be nonexistent.  And should you bend over to tie your shoe… rage to anyone near you!

But what you do next is what I can help with:

  • What can you do at home to treat your sinus infection?
  • When do you go to the doctor?
  • When do you ask for antibiotics
    ?

 

Treat sinusitis the right way!

It is not complicated to treat a sinus infection, but it is often done incorrectly by both patients and medical providers.  The problem:  treating sinusitis the wrong way can cost you time and money!

Treat sinusitis the wrong way and you’ll be wasting time AND MONEY!

To help, I have put together this “How to Treat a Sinus Infection” guide to help you treat sinusitis the right way and, in doing so, help you save money!

Warning:  This is a long post with a lot of great tips!   

To make your life easier, you can download the post and keep this guide with you.  I promise your “How to Treat a Sinus Infection” pocket guide will be the gift that keep on giving!

Download your “How To Treat a Sinus Infection” pocket guide

 

Before we begin, do you really have a sinus infection?

If you are someone who has had frequent sinus infections, this step may seem ridiculous.  But if you this is relatively new for you, it is important to make sure you have the right diagnosis before you start to treat sinusitis.

I’ve written this post to help you try and sort out your symptoms.  Please take a moment to read through it and make sure you have the right diagnosis (and if you have any questions, feel free to ask me and I’ll be happy to help).

Once you confirm that your diagnosis, we can move on and discuss how to treat a sinus infection.

Treat sinusitis AFTER you have the right diagnosis
First make sure you have the right diagnosis!

How to Treat a Sinus Infection – Step 1

–The Importance of Time–

If I had to go through ONE thing before I lost your attention, it would be the importance of time (symptom duration) in guiding proper treatment.

As a general rule, most sinus infections start off as a viral infection and this viral phase lasts for about 10-14 days.  What this means to you is:

  • For 2 weeks, you need symptomatic treatment only
  • Antibiotics WILL NOT HELP during this time
  • If you see your provider during this time and they give you antibiotics:
    • They will still not help during the viral phase
    • You likely wasted time and money
  • There are some studies that show this phase may be more like 21 days, particularly for children!

 

Best tip for how to treat a sinus infection:  The first 2 weeks are viral and symptomatic treatment is the only way to treat a viral sinusitis.  Antibiotics at this point do NOT help.

Let me answer some of the questions you probably asked yourself you read this:

  • If you have a fever, even a high fever – it does not matter.
    • Both viral and bacterial sinus infections can cause fever.
    • Only duration of symptoms matter in treating a sinus infection

 

  • If you have white mucous, or green mucous, or yellow mucous – it does not matter.
    • Both viral and bacterial sinus infections can cause mucous of all colors
    • Only duration of symptoms matter in treating a sinus infection

 

  • If you have a severe headache or severe sinus pain or pressure – it does not matter.
    • Both viral and bacterial sinus infections can cause severe headaches as well as severe sinus pain or pressure.
    • Only duration of symptoms matter in treating a sinus infection!

 

  • Finally, if you have tooth pain – it does not matter.
    • Both viral and bacterial sinus infections can cause tooth pain.
    • ONLY DURATION OF SYMPTOMS matter in treating a sinus infection

 

I am not writing this in a repetitive manner just to be a jerk.  Also, your symptoms do matter to me from the point of view that I want you to feel better.

But as a generalization there is no magical phrase, symptom or temperature that tells you this is a bacterial infection and in need of antibiotic.  Time is the major deciding factor!  So let me save you time and your money:  start with these viral sinusitis treatments during the first 14 days of your sinus infection.

 

How to Treat a Sinus Infection – Step 2

–Over the Counter Symptom Relief from Viral Infections–

 

Hydration

Yeah, yeah, I know — “drink plenty of fluids” is a doctor cliché.  But when you want to treat a sinus infection, hydration is very important!  Mucous is being made in response to the viral infection but since it is so thick it helps keep your sinuses congested and makes draining difficult (which, in turn, causes your sinus pain and pressure).

Fluids help reduce the thickness of the mucous and help it drain easier!

Thinner mucous helps reduce sinus pain and pressure as well as helps reduce the sore throat you may get when all that mucous drains down your throat (a very unpleasant thought and surprisingly gross to type.  But still, fluids help significantly)!

Guaifenesin (Mucinex, Robitussin, or any generic or derivatives of guaifenesin)

Guaifenesin is a great over the counter medication that that also helps thin the mucous (and helps you clear it out of your body).

It gives you a lot of the same benefits mucous-thinning benefits as hydration – and when you add both together they can do a lot to help reduce your sinus pain and pressure!

Sinus Rinse (like a Neil-Med, Netti-pot or similar rinse)

Graphic showing most people tolerate sinus rinse when treating sinusitis
Treat a sinus infection with a sinus rinse

Sinus rinses are a great addition to help treat a sinus infection… if you can tolerate them.  They are NOT a medication and they just help get all the mucous, debris and other irritants out of your nose!

I add the “if you can tolerate them” because a lot of people would rather eat pieces of broken glass than use a sinus rinse.

Sinus rinses are just one of those things that you will either tolerate or you won’t.  But if you can, then it is a great non-medication to help treat a sinus infection.

Pseudoephedrine (Sudafed, Walphed, etc)

If your nose is really stuffy and congested OR if you have a lot of sinus pain or pressure, then I would recommend adding a decongestant.  In this category, the best is probably real pseudoephedrine!  I’m not talking real like name brand Sudafed because generic is just as good.  But you DO need to get the pseudoephedrine from behind the pharmacy counter.

If you want to get pseudoephedrine:  generic is ok (and what I buy) but make sure you get the “good stuff” behind the pharmacy counter.  Just show your license, promise not to turn it to meth, and then enjoy some sinus pressure relief!

Remember, if you have high blood pressure then pseudoephedrine might raise your blood pressure.  Check with your provider before taking it and keep an eye on your blood pressure.  Or choose one of the blood pressure safe decongestants.

Nasal steroids (Flonase/fluticasone, Nasonex/mometasone, Rhinocort/budesonide, Nasacort/triamcinolone)

Let me save you money on this one:  don’t buy a nasal steroid to treat a sinus infection!

These medications are great for treating allergies and have a good role in treating chronic sinusitis.  But since they can take 4-6 weeks to reach full strength, they are of limited value for treating a sinus infection.

Oxymetazoline (Afrin)

I do NOT recommend this medication for treating a sinus infection.  It can reduce congestion in your nose, but you can only take it for 3 days before it starts causing a potential “nose addiction” to the mediation (known as rhinitis medicamentosa).

Most sinus infections last a lot longer than 3 days so this medication will give you temporary relief for a very, very short amount of time and then set you up for a disappointment later when you need to stop using it.

 

How to Treat a Sinus Infection – Step 3

–Prescription Medications for Viral Infections–

If the over the counter symptoms are not enough but you are still in the viral stage of a sinus infection, there are two prescriptions to help treat a sinus infection:  nasal Atrovent (ipratropium bromide) and Astelin (azelastine).

I tend to save these medications for people who have tried everything else and need something… anything… to help.  They each have a specific purpose and do that purpose well.

But overall, if I you were to ask me if making an appointment and a copay is worth it to get these medications–I’d say no.  The benefits they provide to treat a sinus infection are not that much more than the over the counter treatments.

Nasal Atrovent (ipratropium bromide)

Nasal atrovent is best used for a runny nose, which can often happen at the same time as a sinus infection.  So if you want to treat a sinus infection’s runny nose then consider this medication.  However, it will have limited benefit for a stuffy nose or for sinus pain/pressure.

Astelin (azelastine)

This is a topical antihistamine.  It is AMAZING to use for treating allergies, irritant rhinitis, mixed rhinitis, chronic sinusitis and helps with allergic asthma.  It is also even more impressive when combined with a nasal steroid!

But to treat a sinus infection… it’s just ok.

The problem is that there is minimal if any histamine involved in a sinus infection so while this nose spray might help a little with the runny nose and a little with the stuffy nose, it is not what I would reach for if I had to pick one medication to treat a sinus infection.

Man with bacterial sinus headache
Read below to know when you have a bacterial sinusitis

How to Treat a Sinus Infection – Step 4

–Know when you have a Bacterial Sinus Infection–

If you have had symptoms for longer than 10-14 days you very likely have a bacterial sinusitis.  I’ve heard different descriptions of what actually causes a bacterial sinus infection, but the one that makes the most sense to me is the theory of bacterial transformation.

Bacterial transformation says that usually a viral infection starts the sinus infection and, either because of the persistent mucous environment in your sinuses OR that the viral infection weakened your immune system’s response, a bacteria is then able to take over.

Typically, I tend to think you have a bacterial sinus infection when:

  • You often start to feel better and your viral infection is getting better BUT THEN it starts to get worse again!
  • You have a CHANGE in mucous color/consistency. In this scenario, you may have a white colored mucous at first but then it changes to a green, or a yellow, or if it was one of those and changes to white!  The CHANGE is what is important.
  • Again, time duration lasting longer than 10-14 days.

 

In these cases, I still recommend each and every step above.  It’s great a great way to treat a viral or bacterial sinus infection.  But if you have a bacterial transformation, you often need to add an antibiotic.

THIS is the time to make an appointment with your provider!

 

Pick the right antibiotic treatment for bacterial sinusitis
Pick the right antibiotic the FIRST time!

How to Treat a Sinus Infection – Step 5

–Add an Antibiotic for Bacterial Sinus Infections–

Antibiotics are needed to treat a bacterial sinusitis.  But there are some antibiotics that are good and some that are not good to treat a sinus infection.  I get a lot of consults for people who think they have allergies after an antibiotic failed to clear their symptoms who are NOT allergic, but were actually given the wrong antibiotic.

So here is the best evidence-based antibiotics to treat a sinus infection:

Bacterial sinusitis treatment #1 – Amoxicillin-Clavulanate (Augmentin)

If you are able to take a penicillin, then Augmentin (amoxicillin-clavulanate) is the treatment of choice for a bacterial sinus infection.  It is a penicillin with an antibiotic-resistance fighting component and is what I try to give all my patients if I am able.

The dosing varies based on age as well as resistance in your area, but this should be your go to antibiotic to treat a sinus infection.  It does have one problem:  big pills!

If you have problems swallowing large pills, I’d recommend pricing out the liquid version given to younger children as a first choice and changing antibiotics as a second choice.

Bacterial sinusitis treatment #2 – Doxycycline

If you have an allergy to penicillin then the next alternative is a medication called doxycycline.  It is a great antibiotic and does a good job of treating sinus infection.  For some people it can cause an upset stomach or loose stools, but for the most part it is well tolerated (plus, tiny pills)!

Bacterial sinusitis treatment #3 – Cephalosporins or Clindamycin

If you are allergic to multiple medications then you can consider one of these two alternatives.

Cephalosporins might be an antibiotic class you can ask your provider to try to treat a sinus infection.  But know that 7-10% of people with a penicillin allergy also have a cephalosporin allergy.  Make sure you ask your provider whether or not this is a possible treatment choice for you  (note:  as a general rule, if you are penicillin allergic you should also avoid this class of antibiotic).

Clindamycin is another alternative if you have a lot of allergies.  Clindamycin is a wonderful antibiotic that will destroy your sinus infection.  It might cause an upset stomach, loose stools or a secondary intestinal infection called C. diff (technically, any antibiotic can cause this, but Clindamycin has been associated with it historically).  Still, these are rare complications and this antibiotic WILL treat a sinus infection.

Bacterial sinusitis treatment #4 – Fluoroquinolones (Levofloxacin or Moxyfloxacin)

This class of antibiotics is simply amazing!  They work extremely well for sinuses and are a great choice if you have other medication allergies.  They are typically once a day (as opposed to twice a day), small tablets, and minimal stomach aches or related side effects.

They do have a potential side effect and black box warning of causing spontaneous tendonitis/tendon rupture in a subset of patients (largely those at the extreme of age or who are taking chronic daily prednisone) so you should discuss this with your provider before accepting this antibiotic.  But this antibiotic really does a good job to help you feel better fast!

The only reason it isn’t used sooner in the treatment pathway is that it is a fairly strong antibiotic and, as antibiotic resistance increases, should be saved for those who have no other treatment options.

Bacterial sinusitis treatment #5 – NOT A ZPACK!

I started with the first 4 treatment options to show that almost everyone can take at least ONE type of antibiotic to treat a bacterial sinus infection that is NOT a zpack (azithromycin).

Azithromcin (z-pack) is NOT recommended as empiric treatment for a bacterial sinusitis.

Zpacks / azithromycin is given to patients quite often to treat a sinus infection.  It is a convenient antibiotic and it doesn’t cause a lot of side effects.  And it is WRONG!

The most common causes of bacterial sinusitis are increasingly resistant to this antibiotic.  So if you take it there is a very high chance your sinus infection will NOT be treated.

This isn’t just me ranting against antibiotic resistance.  It is also a financial issue which I cover in more detail below.  What I can tell you is that if I had a sinus infection and needed treatment, I would not take this medication.

Don't use a zpack for treating sinusitis
Yay! I DIDN’T pick a Z-pack! I saved my patients time and money!

How to Treat a Sinus Infection – Step 6

–The Financial Cost of Inappropriate Treatment–

I put this section at the end because back in grade school I was taught to end an argument with a strong closing point (a skill that Emmett has already learned at age 6).  But even if you thought I was full of it up to this point, this should make it a lot more clear:

Note:  For costs, I am estimating everything since America has such screwed up health care pricing that I can’t guess any true price (Canada, I wish I were a part of your system)!  But I’ll be consistent so the comparison will work out correctly:

Proper Treatment

Treatment Individual Cost Total
· Viral treatment OTC meds · Cost of OTC meds ($20) $20
· Viral treatment OTC meds
· See Doctor after 14 days with proper antibiotic
· Cost of OTC meds($20)
· Cost of doctor ($50)
· Cost of correct antibiotic ($20)
$90

 

Improper Treatment

Treatment Individual Cost Total
· Viral treatment OTC meds
· Seeing a doctor to tell you it’s viral
· Cost of OTC meds ($20)
· Cost of doctor ($50)
$70
· Viral treatment OTC meds
· See a doctor and being given an antibiotic when you don’t need it
· Cost of OTC meds($20)
· Cost of doctor ($50)
· Cost of incorrect antibiotic ($20)
$90
· Viral treatment OTC meds
· Seeing a doctor and being given an antibiotic when you don’t need it
· Seeing a doctor back after 14 days when you actually need an antibiotic
· Cost of OTC meds ($20)
· Cost of doctor ($50)
· Cost of incorrect antibiotic ($20)
· Cost of return visit ($50)
· Cost of new antibiotic ($20)
$160
· Viral treatment OTC meds
· Seeing a doctor after 14 days
· Getting the wrong antibiotic
· Seeing a doctor back when it doesn’t work
· Getting a new antibiotic
· Cost of OTC meds ($20)
· Cost of doctor ($50)
· Cost of incorrect antibiotic ($20)
· Cost of return visit ($50)
· Cost of new antibiotic ($20)
$160
· Viral treatment OTC meds
· Seeing a doctor after 14 days
· Getting the wrong antibiotic
· Seeing a doctor back when it doesn’t work
· Being told its an allergy when its an antibiotic failure
· Seeing an allergist (who inappropriately does a full allergy test)
· Getting an appropriate antibiotic
· Cost of OTC meds ($20)
· Cost of doctor ($50)
· Cost of incorrect antibiotic ($20)
· Cost of return visit ($50)
· Cost of allergist ($600)
· Cost of correct antibiotic ($20)
$760*

*And this, America, is why our Healthcare costs so damn much!  Plus the crazy high CEO salaries, the inefficiencies of insurance companies, the lack of proper gate keepers, the monetary reward of doing procedures and not in appropriate diagnosis, and more that I could probably go through but I am kind of tired of this rant.

Treatment thanks to this guide

Treatment Individual Cost Total
· Viral treatment OTC meds · Cost of OTC meds ($20) $20
· Viral treatment OTC meds
· See Doctor after 14 days with proper antibiotic
· Cost of OTC meds ($20)
· Cost of doctor ($50)
· Cost of correct antibiotic ($20)
$90

Again, I know these costs vary.  For some people they don’t have a fixed copay but pay a percentage.  For some people different visits cost different amounts.  For my friends in Canada, the cost is a lot less (man, your country really does have its S&^t together) but WAIT TIME is an issue… so picking the right path will save you time.

 

How to Treat a Sinus Infection – Step 7

–My Approach as an Allergist–

I don’t probably need a step 7, but John Elway (the greatest Denver Bronco of all time) was #7 and as a result all great lists should have 7 points (which is ALSO the number of points in a touchdown+extra point… and John Elway scored 300 touchdowns in his career… so this is another good reason to have a step 7).

So to honor John Elway, here is how I approach chronic sinusitis in my patients:

  • If they call or email me with suspected symptoms, I will give them the exact same list I gave you. No charge (why would there be)?  Just helpful information.
  • If they come to see me during the viral stage, I give them the list I just gave you and will NOT give an antibiotic. BUT if their symptoms last longer than 10-14 days I just call in an antibiotic and don’t double charge.
  • If they are sent to me an as allergy referral I will usually treat the sinus infection without doing additional testing and will pick the right antibiotic the first time. Because why would I contribute to the outrageous cost of healthcare?

 

And that’s pretty much it.  I only type this to show that it really isn’t that hard to provide high quality care WITHOUT jacking up the cost of referrals, doing inappropriate tests or causing unnecessary return visits.

 

Final Thoughts

I know this was a long post.  And fairly boring… I think I fell asleep once typing it.  So if you skimmed through all of it and want a copy to reference in the future you can download it here:

Download your “How To Treat a Sinus Infection” pocket guide

If you stayed awake and thought this was helpful, consider sharing it with your friends.  Or printing it out through the link above and sharing that.  I would love it if I could help everyone treat a sinus infection better, faster, and without unnecessary costs.

 

REFERENCES (from uptodate.com)

Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: Establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg 2004; 131:S1.

Fokkens W, Lund V, Mullol J, European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology 2007; 45:97.

Tan T, Little P, Stokes T, Guideline Development Group. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ 2008; 337:a437.

Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1.

Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72.

King D, Mitchell B, Williams CP, Spurling GK. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev 2015; :CD006821.

Louisiana Department of Health and Hospitals. http://new.dhh.louisiana.gov/index.cfm/newsroom/detail/2332 (Accessed on January 22, 2012).

Zalmanovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev 2013; :CD005149.

Ziment I. Management of respiratory problems in the aged. J Am Geriatr Soc 1982; 30:S36.

Bende M, Fukami M, Arfors KE, et al. Effect of oxymetazoline nose drops on acute sinusitis in the rabbit. Ann Otol Rhinol Laryngol 1996; 105:222.

Spector SL, Bernstein IL, Li JT, et al. Parameters for the diagnosis and management of sinusitis. J Allergy Clin Immunol 1998; 102:S107.

Hwang PH. A 51-year-old woman with acute onset of facial pressure, rhinorrhea, and tooth pain: review of acute rhinosinusitis. JAMA 2009; 301:1798.

Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev 2014; :CD000243.

Lemiengre MB, van Driel ML, Merenstein D, et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev 2012; 10:CD006089.

Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016; 164:425.

Rosenfeld RM. CLINICAL PRACTICE. Acute Sinusitis in Adults. N Engl J Med 2016; 375:962.

Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet 2008; 371:908.

Falagas ME, Giannopoulou KP, Vardakas KZ, et al. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. Lancet Infect Dis 2008; 8:543.

Ahovuo-Saloranta A, Borisenko OV, Kovanen N, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008; :CD000243.

de Ferranti SD, Ioannidis JP, Lau J, et al. Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. BMJ 1998; 317:632.

de Bock GH, Dekker FW, Stolk J, et al. Antimicrobial treatment in acute maxillary sinusitis: a meta-analysis. J Clin Epidemiol 1997; 50:881.

Karageorgopoulos DE, Giannopoulou KP, Grammatikos AP, et al. Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials. CMAJ 2008; 178:845.

Piccirillo JF, Mager DE, Frisse ME, et al. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA 2001; 286:1849.

Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004; 130:1.

Wald ER. Staphylococcus aureus: is it a pathogen of acute bacterial sinusitis in children and adults? Clin Infect Dis 2012; 54:826.

FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. http://www.fda.gov/Drugs/DrugSafety/ucm500143.htm (Accessed on May 26, 2016).

Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol 2009; 67:161.

Ariza H, Rojas R, Johnson P, et al. Eradication of common pathogens at days 2, 3 and 4 of moxifloxacin therapy in patients with acute bacterial sinusitis. BMC Ear Nose Throat Disord 2006; 6:8.

Anon JB, Paglia M, Xiang J, et al. Serial sinus aspirate samples during high-dose, short-course levofloxacin treatment of acute maxillary sinusitis. Diagn Microbiol Infect Dis 2007; 57:105.

Ambrose PG, Anon JB, Owen JS, et al. Use of pharmacodynamic end points in the evaluation of gatifloxacin for the treatment of acute maxillary sinusitis. Clin Infect Dis 2004; 38:1513.

Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am 1999; 83:27.

Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev 2014; :CD008115.

Venekamp RP, Thompson MJ, Rovers MM. Systemic corticosteroid therapy for acute sinusitis. JAMA 2015; 313:1258.

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  • Johnny McCarron says:

    I really like your advice to make sure that you are staying well-hydrated. There are a lot of people that don’t understand the difference that water makes to your health. The last thing you want is to cause your health to continue to deteriorate due to dehydration. Do you have any other tips for dealing with sinuses?

  • Thank you for this. I am absorbing the two-week rule, but have a question. Symptoms started 13 days ago in the form of a run-of-the-mill cold. Cold started to get better on Day 11, so I went for a walk outside (near Sacramento, Calif., where tree pollen count is currently high). Days 12 and 13 were misery, with onset of maxillary sinus pain, fairly bad, on one side only. Is it still viral, given that the pain is on one side only? Can you have a sinus allergy on one side only?

    Also, do I start the two-week count from the onset of the cold or the onset of the sinus misery a couple of days ago?

    Thanks also for the other post on pseudoephedrine and blood pressure. It’s giving the greatest relief but I was hesitant because of the blood pressure issue. Half dose is working fine, and I’ll continue without worry.

    • Amy,

      Sorry for the delay in replying. But I want to give you advice that you can use in the future:

      • As a general rule, 2 weeks is a reasonable time frame. It should start counting from the first symptom.
      • If symptoms last longer than 2 weeks, that is a time to consider bacterial infections
      • But also, I consider bacterial causes if any of these also happen:
      • If there is a change in symptoms (sudden worsening, mucus color change, etc)
      • If you start to improve, then worsen, I think bacterial
      • If other people got you sick, and theirs lasted longer and needed antibiotics… odds are you have the same thing and so I consider bacterial

      I hope this very late advice helps. If not now then in the future.

  • Sylvia Guillen says:

    THANKS for NOTHING! I honestly thought you’d like to know!! Idiit!!

    • Sylvia,

      Sorry you felt that way. I try to do my best and will always look to improve. Thank you for your feedback and comment.

  • Giovanna bruzzo says:

    Well I followed all the first steps , always.. as I’ve had somewhat of chronic reoccurrence w sinus infection.
    And they’ve given all the different types of antibiotics .. n stubborn will not go awayo I have to go more rounds w it..
    Then one day a d prescribed a zpack ,never heard of it, n I was cured ! It’s the only thing that’s ever worked for me.. u just never know everyone is different.

    • Thank you for your reply. Sinus infections are definitely tricky and there is no “one size fits all” approach that will apply to everyone.

      I will also say if you have recurrent sinus infections, always be on the lookout for something that is setting you up for the infections. Typical triggers include seasonal allergies or irritant allergies, structural issues that an ENT may be able to fix, or possibly an immune system problem.

      Thank you for your comment and if I can help more, please let me know.

  • Where does fungal sinusitis fit in to this triage scenario?

    • Charlie,

      Great question.

      Fungal sinusitis is typically described as a thick, “peanut buttery” consistency drainage along with all the sinusitis symptoms. It is some times called allergic fungal sinusitis.

      The primary treatment for this is surgery!

      An ENT will be able to diagnose it and then do a debridement surgery and clean everything out. After that, they will likely take samples and you can find out the type of fungus.

      It is also important afterwards to try and reduce the chance of having recurrent infections. Some ideas for this are:
      – If you have allergies, treat them. And if you are allergic to the fungus, strongly consider allergy shots
      – If you have diabetes, get it under control
      – Make sure the ENT also removes any structural issues (polyps, narrow passages, etc) that may increase chance of infection

      These are a few of the biggest things to do to try and reduce the chance of reinfection. Nothing is 100%, but this is a good step AFTER surgery.

  • Kevin Billings says:

    Thank you for the wonderful information in the article. I have a unique situation I believe. I have atrial fibrillation. I am in sinus rhythm 99.99% of the time. The last time I believe I was out of rhythm was over 5 years ago. But I also know what meds to take and what no to take. I get these headaches in the spring and sometimes in the fall. My family dr believes it is allergies. Never had allergies before and have lived in the same area for over 20 years. I sent a text to my cardiologist and asked him what I could take for a sinus problem I had been having for about 10 days. He said I could take OTC Claritin.. Well, I took one table and 3 hours later I was in the ER and the AFib had kicked in. I spent the night there (about 20 hours and lots of drugs before my heart went back to normal rhythm). So I’m sick and tired to the massive headaches everyday.. My head hurts so bad that my teeth hurt. I have been alternating between Tylenol and Advil for the pain. But I know that is only masking the problem and not a cure. I have read your other article and the Coricidin HBP info. I have been taking that as well with little to no results just as you described. But it is all that the pharmacist will suggest I take. I am going to ask my heart doctor what else he recommends that won’t mess with my heart. Just reaching out to all professionals here to try and get the best advice. Thank you in advance.

    • I’m sorry to hear that the antihistamine kicked off the afib. It is a less common reaction for most people… but definitely caused it for you.

      Hearing this, I would probably prioritize a nose spray as a better treatment option than an antihistamine. Either a nasal steroid (such as fluticasone/Flonase) would provide good topical treatment without any significant absorption into the body. A topical antihistamine nose spray (such as azelastine) would also be ok… again, it is minimally if at all absorbed into the blood stream).

      The other side effect: the nose sprays tend to work better than the tablets anyway! So you’ll be getting better treatment with fewer side effects (and isn’t that both an allergists and a patients perfect scenario?!)

  • Never had sinus problems or allergies before. I’ve had chronic sinusitis since Dec of 2015 after catching the flu. Along with the flu I started getting a “sick smell” like I always have when sick with a cold or flu. Unfortunately this sick smell stayed even after the flu was gone. After a few months of smelling this horrible odor (smelled like infected, sweaty gym socks) I went to my PCP who prescribed Augmentin for 14 days. I took it for 10 days and had to stop due to digestive problems from the meds. It also did absolutely nothing for the sick smell.

    Fast forward to Dec 2017 when I got a prescription for Keflex. Within two days the sick smell was completely gone, but was replaced with a “sweet smell”, which I still have today. I also have been using a Navage nasal rinse device for over 2 years which makes me feel better but doesn’t affect my sense of smell or make the sweet smell go away. Since the Augmentin didn’t do anything, and the Keflex did, I am assuming that different bacteria were targeted, and was wondering if a different antibiotic would be recommended that could target bacteria that these two did not.

    I have no excess mucus, no sinus pain, no tooth pain, and no stuffy nose and can breath through both nostrils. My only symptom has been the nasty sick smell, and then this sweet smell after taking the Keflex, along with very limited sense of smell.

    Thanks for this great post.

    David

    • I’m so happy this has helped. It definitely is possible the bacteria were more susceptible to Keflex. For that reason, it is important to change antibiotic types if one doesn’t work or if you’ve had a recent treatment with one type. But there is a limit to this as well. For you, a single change made a difference and thats great. But if you try a couple types and it doesn’t make a difference, the next step isn’t to try a third antibiotic as much as to check with ENT or possible get a CT sinus to see what is causing a sinusitis that has failed multiple different types of antibiotics.

      For you, though, congratulations. Make sure you pass on this tip to anyone you know who has similar symptoms. You can make a difference in their lives and hopefully save them from the 2 YEARS of symptoms you had to deal with!

  • Hi. I have had long lasting symptoms and have went through a course of amoxil then augmentin then biaxin in about summer 2017 and then was put on prilosec and ranitidine and then astelin and nasonex and this was summer of 2017 and beginning of 2017 and really have no relief but a constant post nasal drip and constant throat clearing and xyzal and singular was added on march 2018 this year
    Never had problems with sinus before don’t think another atb would be helpful at this point

    • Tom, this sounds like a complete pain in the *&^ for you! I’m so sorry you’ve had to deal with it for so long.

      With a history like that, there are two things I think about:
      1). First, this might not be a regular sinus infection but more of a chronic sinusitis. In this case, the best course would be to get a CT scan of the sinuses and then consider ENT if abnormal. Often an ENT will need to do surgery to clear out the sinuses and get them back to healthy if there has been a prolonged sinus infection history (and the good news is the sinuses DO become healthy again after surgery)

      2). It is also possible, but less likely, there is an immune deficiency. Recurrent sinus infections that happen later in life can sometimes be a result of the antibody immune system becoming weaker. This is not the most common cause, but is also easy to check: your primary care can order an immunoglobulin panel (IgG, IgA, IgM) and see if they are low or not.

      Allergies, irritant rhinitis or other common causes should also be treated to create a “healthy nose” which is unlikely the cause of sinus infections, but definitely make them more likely to happen (and as a result, improving them and improving nose health make them less likely to happen).

      I hope this helps and you feel better soon!

  • I have been suffering with a sinus infection for over 3 weeks. I did augmentin for 10 days and it did not do the trick. My doctor says it’s probably viral then or that I should see an ENT. I had one 6 months ago too and was given doxycycline which worked back then. Does this mean I likely need a new antibiotic? The pressure stuck by my ears causes dizziness which if not fun.
    Sinus infections are the worst and stupidest illness ever. This article seriously makes it feel like someone else understands the struggle.

    • I definitely understand the struggle. Also… I get frustrated with how many providers treat sinus infections (I admit, I’m biased: I tend to see a lot of sinus infection sufferers who have tried everything and come to me as a “last ditch” effort. But that has also caused me to create a great sinus workup).

      First, as a general rule: most sinus infections START as viruses. As a result, antibiotics within the first 10-14 days are not necessary. Most antibiotics given during this time will not help the sinus infection since its not bacterial. But if the infection continues longer than this, it likely has undergone a bacterial transformation and antibiotics will help. I’m not sure the timing of you, but if they gave antibiotics first and then called it viral second… I worry they got it backwards.

      Second, sometimes sinus infections get covered by something called a biofilm which makes them more resistant to antibiotics. In this case, usually a course of augmentin or levofloxicin is needed… and usually for 21-28 days! This is often done by ENT, but can be done by anyone!

      Third, if this doesn’t help then a CT scan of the sinus and ENT referral are a good next step.

      My thought for you is maybe they got the viral-bacterial treatment stages backwards OR maybe it is more severe. Either way, ENT is a decent next step.

      In the mean time, you can do a few things to reduce symptoms while waiting for ENT:
      – Consider doing a sinus rinse daily or every other day
      – Consider starting a nasal steroid, such as fluticasone, to help reduce sinus inflammation and open drainage passages
      – Consider adding something like mucinex/guaifenesin to help turn thick mucus into thin mucus and drain it out of the nose

      I hope this helps. If not, send me an email and I’ll be able to better guide you.

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