Treating acute sinusitis
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Editor, – I appreciate such articles as Professor Wormald's (Aust Prescr 2000;23:39-42). I have been a general practitioner for all of my working life, but I have a particular interest in otorhinolaryngology.
I was slightly irked when I read that antihistamines and antihistamine-pseudoephedrine combinations were downgraded and were considered to be of little use. This attitude to histamine and the allergic processes in the body's defence mechanisms against environmental factors is prevalent today. However, it ignores some basic physiology, pathophysiology and pharmacology. Mucosal cell inflammation, whatever the cause, results in cell damage. This results in the release of histamine and other inflammatory mediators. The pharmacological properties of histamine are numerous, the most significant being inflammation of surrounding tissue and more tissue damage. To ignore this pathological sequence of events when tissue damage occurs is basically erroneous.
When treating acute sinusitis, would it not be of great help to know about how the patient reacts to environmental pollutants. This knowledge could be of great help in recurrent sinusitis. I'll not get into IgE levels in various periods in a person's life, nor the RAST screens (very limited these days), and other tests for allergy. The article says to leave these to the specialists.
When considering the need for antibiotic therapy with or without antihistamine-decongestant medication, I would also look for post-nasal discharge during my examination.
Editor, – The excellent article by Professor Wormald makes no mention of the use of bromhexine as an adjunct to the treatment of sinusitis. Respiratory Medicine1 discusses the use of bromhexine to alter the physical characteristics of the mucus and to give an increase in sputum amoxycillin levels. A number of local general practitioners order this combination and in our practice we recommend the use of bromhexine for milder cases. Could Professor Wormald please comment?
John W.M. Williams
Editor, – I wish to add some facts to Professor Peter John Wormald's article 'Treating acute sinusitis' (Aust Prescr 2000;23:39-42).
Firstly, I would like to re-emphasise the fact that dental infections can cause maxillary sinusitis. Selden referred to such a manifestation as the endo-antral syndrome (EAS).2 This is a pathological condition resulting from the spread of infection from the root canal apices near the maxillary sinus into both the antral and periapical tissues. The degree of sinus involvement is related to the proximity of the involved apex to the sinus.3 Reported frequencies of sinusitis of dental origin vary considerably, between 4.6 and 47.0%.4
Because of these facts, I would like to suggest that patients suffering from maxillary sinusitis be referred to the dental surgeons to rule out dental infection as the source of their problem.
Dr Wei Cheong Ngeow
Department of Oral & Maxillofacial Surgery
Faculty of Dentistry
University of Malaya
Professor P.J. Wormald, the author of 'Treating acute sinusitis', comments:
In reply to Dr Aranjo, I am not aware of any scientific evidence that antihistamines or antihistamine-pseudoephedrine combinations provide any benefit in the management of acute sinusitis.
The study quoted in Mr Williams' letter showed that bromhexine increased the levels of amoxycillin in the sputum significantly and that the clinical outcome in the short term was better in this group of patients. Unfortunately there were one or two problems in the methodology of this study, so these findings would need to be repeated and corroborated before being accepted. In addition, it is unknown whether levels of amoxycillin in nasal mucus would be similarly increased and whether this would have a clinical impact on the outcome of sinusitis. I feel that saline douches would probably afford as much benefit as any other medication regarding the viscosity of mucus.
In response to Dr Ngeow's comment, certainly we do see maxillary sinusitis as a consequence of root canal infections. However, I think the reported frequency of sinusitis due to dental origin would be in the region of less than 5% rather than in the higher range.
- Taskar VS, Sharma RR, Goswami R, John PJ, Mahashur AA. Effect of bromhexeine on sputum amoxycillin levels in lower respiratory infections. Respir Med 1992;86:157-60.
- Selden HS. The endo-antral syndrome: an endodontic complication. J Am Dent Assoc 1989;119:397-8, 401-2.
- Matilla K. Roentgenological investigations into the relation between periapical lesions and conditions of the mucous membrane of maxillary sinuses. Acta Odontol Scand 1965;23 Suppl 42.
- Melen I, Lindahl L, Andreasson L, Rundcrantz H. Chronic maxillary sinusitis. Definition, diagnosis and relation to dental infections and nasal polyposis. Acta Oto-Laryngologica 1986;101:320-7.