ClinicalReview. Since the lining of the nose. Sinusitis: painful and persistent. Complete your CPD points online. Inside AUTHOR

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1 Complete your CPD points online go to click on online CPD ClinicalReview Inside 34 Sinusitis and allergic rhinitis 35 Management 36 Role of biofilms 38 Similar conditions 39 CPD quiz Sinusitis: painful and persistent Chronic nasal congestion is a common and often frustrating complaint seen in patients attending pharmacies. AUTHOR Dr Maree Simpson is associate professor in pharmacy at Charles Sturt University, Orange Since the lining of the nose and the sinuses is continuous, any inflammation and/ or infection affecting the lining of the nose will affect, to a variable extent, the sinuses and vice versa. Although we speak of sinusitis, most conditions of the nose affect both the nasal cavity and the sinuses. Therefore, to be more correct as we advise our patients we may be better to speak of - or at least conceptualise rhinosinusitis. While there are many potential causes for nasal congestion, the two most commonly presented are allergic rhinitis and sinusitis, either acute or chronic. Sinusitis is defined as an inflammation of the nasal sinuses, situated in the forehead, cheeks and behind but between the eyes. In the Australian Bureau of Statistics 2001 National Health Survey, 10.5 per cent of Australians disclosed chronic sinusitis, with more females than males affected (12.4 per cent v 8.9 per cent). At risk groups Some groups are at particular risk of respiratory tract infections including sinusitis, and this includes people with Down syndrome, in whom impaired immunity contributes to decreased viral and bacterial clearance. In addition, nasal and sinus disease is described as almost universal in those living with cystic fibrosis. This is proposed to reflect the similarity of the mucosa in the upper and lower respiratory tract and the possibility that upper tract infections such as sinusitis may impact on the severity of the condition in the lower respiratory tract. A possibly unexpected link has also been established between chronic sinusitis and arterial hypertension. The link was established in a Canadian National Population Health Survey of 52,992 subjects (25,324 males; 27,668 females) aged between years. Compared to an individual without sinusitis, men with 34 November 2011 PharmacyNews

2 To comment %Table 1 Some useful sites for sinusitis URL Web Address CPqYhc7M5aYCFcSGpAodnkt57A cfm?c=12 shtml Information available Australasian Society of Clinical Immunology and Allergy; Information, symptoms and management HealthInsite, recent relevant information on sinusitis NeilMed Sinus Rinse, product information, online video demonstrating use; links to research and publications summaries and other related products e.g. NasaDock Plus Hamilton s nasal care range, key product information about drops, spray, and baby saline drops Otrivin saline baby, online product use demonstration, links to products for adults and children Flo Saline +Plus, preservative free product information, use in babies and pregnancy, links to other products such as Flo Rapid Relief (xylometazoline) Fess sensitive noses nasal spray, plus links to other Fess products that may assist in the management of sinusitis Bosisto s Nasal Spray, hypertonic saline solution with the fresh fragrance of Bosisto s Eucalyptus plus links to other Bosisto s products Sinus Pot or Neti pot, information and video. Australian manufactured. Researchers and clinicians have proposed that there is a link between allergic rhinitis and chronic sinusitis, especially in the presence of asthma. Source: Websites as disclosed, product information and packaging. sinusitis were just over two per cent more likely to have hypertension, whereas women with sinusitis were four per cent more likely to have hypertension, though this difference was not statistically significant. The mechanism to explain this observed effect has not been clearly elucidated, but the authors propose that the nasal congestion associated with sinusitis may increase airways resistance during sleep similar to that proposed for sleep apnoea. Sinusitis Common presentations of sinusitis include fatigue, headache and/or perceived dental pain, sensation of pressure that worsens on leaning forward, bad breath, perception of an unpleasant odour in the nostril(s), and fever more commonly in an acute attack. Sinusitis is categorised into acute and chronic, with chronic sinusitis identified by persistence greater than three weeks which though it may have a bacterial infection present, is characterised as being a chronic inflammatory condition. Chronic sinusitis has been reported to have a significant impact on quality of life and perceived health status with increased pain, decreased positive mood and energy levels. Commonly reported symptoms of chronic sinusitis include nasal congestion, coloured discharge, and facial pain or feelings of pressure. Acute sinusitis, however, often follows a cold or similar mild infection. A common presentation is sensation of a stuffy nose with sinus pain, sometimes also dental pain, rhinorrhea, and malaise. There are patients in whom neither diagnosis seems entirely appropriate and a diagnostic category of recurrent acute rhinosinusitis is proposed for patients in whom a minimum of four episodes of acute bacterial rhinosinusitis occur in any 12 month interval with no evidence of sinusitis between episodes. This condition has been found to be substantially more common in those patients also living with allergic rhinitis. Differentiating sinusitis In recent years, researchers and clinicians have proposed that there is a link between allergic rhinitis and chronic sinusitis, especially in the presence of asthma, and many of the symptoms overlap to some extent. It has been established that within the group of individuals living with allergic rhinitis for example, 25 per cent experience acute sinusitis and 40 per cent have chronic sinusitis. To add to the differential diagnostic challenge, allergic rhinitis is asserted to be the most common disease in developed nations and so very likely to be seen in community pharmacy. Mucus (colour, amount), the presence or absence of sneezing and itching, recent or frequent history of upper respiratory infections are often helpful in distinguishing between sinusitis and other conditions. Patients with allergic rhinitis are substantially more likely to disclose nasal stuffiness with clear nasal discharge and sneezing or ocular itching. By contrast, patients with chronic sinusitis are > PharmacyNews November

3 ClinicalReview more likely to disclose a history of frequent colds, thick post-nasal drip and headache. Acute management Simple early treatment can include steam inhalations and saline drops, both of which assist in nasal drainage. Table 1 lists some indicative products. Although nasal saline is claimed to improve quality of life and reduce symptoms, there is no consensus as to whether isotonic or hypertonic saline is to be preferred, nor as to whether additions such as various essential oils improve outcomes. Some trials have established a superior anti-inflammatory effect and a greater ability to thin mucus for hypertonic saline, other studies fail to establish any difference between hypertonic and normal saline. This may reflect different outcome measures, different treatment regimens, different gender balance or other factors that may have differed across the various trials. In addition to addressing nasal congestion, pain and related facial discomfort can be uncomfortable and simple analgesics can make patients feel more comfortable. Indeed, the desire for pain relief can often be a precipitating factor for patients to seek help and advice. For significant discomfort, regular dosing of simple analgesics is stated to achieve superior pain management relative to prn. However, for acute sinusitis that does not resolve within a short space of time - e.g. a week - antibiotics may be required and referral to a medical practitioner is advisable. With chronic sinusitis, it s important to address underlying conditions such as allergies. Identification of allergens and avoidance where possible is an important first step in the management of allergies, though intra-nasal steroids and lesser sedating antihistamines may also be required when the allergens cannot be identified or avoided. The role of biofilms Although we often think of bacteria as independent individual organisms, they can also exist in biofilms, essentially communities of bacteria protected by a coat of extrapolymeric substances. Most bacteria evaluated in laboratories for resistance or susceptibility to particular antibiotics Patients may not consider CAMs as needing to be disclosed unless a specific inquiry is made. ACUTE SINUSITIS: If not resolved within a week, antibiotics might be required. exist as individual organisms. However biofilms effectively augment bacterial resistance and contribute to survival. Although these biofilms are quite thin, there are several layers of organisms within them, with conditions further into the biofilm becoming increasingly anaerobic and protected. This can be an issue for antibiotics such as the beta lactams, since these target metabolically active cells. In addition, the biofilms can act as breeding grounds, facilitating exchange of genetic material among bacteria within the biofilm and contributing to the development of resistance and of survival. One study reported that appropriate antibiotics eradicated independently living bacteria in 60 per cent of patients but only 22 per cent of patients with biofilms of the same bacteria. This might be of only academic interest were it not for the fact that studies have identified high proportions of individuals with chronic sinusitis having biofilms in sinus tissue. Although a number of laboratory studies have sought adjunctive therapies to aid in the eradication of bacteria in biofilms, there are few human studies. Mupirocin irrigation of the nasal sinuses and gentian violet (separately) have been demonstrated to successfully eradicate biofilms. Surfactant products have also shown promise and SinuSurf is a surfactant product marketed as facilitating deeper cleansing of the nasal passages. The manufacturer cautions that this product is only ever to be used when mixed according to directions with isotonic saline rinse solution. Complementary and alternative medicines Recent research has established that patients attending an ear, nose and throat physician are more likely than not to be taking or using some form of comple- > 36 November 2011 PharmacyNews

4 ClinicalReview Prompt referral to a medical practitioner is required if orbital cellulitis is suspected or probable, as loss of vision in the affected eye can occur in approximately 10 per cent of patients. DANGERS: Sinusitis can cause substantial morbidity. mentary and alternative medicines (CAMs). Thus when talking with patients, we must remember to ask in a non-judgmental manner about possible use of CAMs. Patients may not consider CAMs as needing to be disclosed unless a specific inquiry is made. Flos magnolia, with the common Chinese name of Xin-yi has a long history of use for rhinitis, sinusitis and headache. The herb is the magnolia flower with an appearance rather like an artist s paint brush. Three species, M. biodii, M. denudate, and M. springer, reportedly appear in the Chinese Pharmacopoaeia against the listing for this herbal product. Although studies have demonstrated biological activity in the anti-inflammatory and anti-allergy areas, there are few clinical trials in humans, and only one for the treatment of sinusitis could be found in a literature search, so additional trials are needed. Sinusitis: an adverse effect Biologic therapies that block tumour necrosis factor alpha such as infliximab, etanercept and adalimimab have been relatively recent additions to the treatment of various inflammatory conditions such as rheumatoid arthritis. More recent additions in this group include golimumab and certolizumab. There have been reports that some patients defence against some infections may be compromised by treatment with these medications and so pharmacists and their patients would already be aware of this possibility. As this discussion centres on sinusitis, it is interesting to note a brief report originating in an arthritis and osteoporosis centre at a university hospital in Ireland. This brief report discussed four cases of newly diagnosed, recurrent sinusitis (diagnosis confirmed by ear, nose and throat specialists) in patients being treated with one of these agents adalimimab. Although causation has not been established by the authors, the sinusitis did resolve on cessation of the medication. The authors note that after resolution of the sinusitis, several of the patients elected to continue with adalimimab therapy. Pharmacists and their staff facing a patient with persistently recurring sinusitis may wish to establish whether any tumour necrosis factor alpha medication is being taken. 38 November 2011 PharmacyNews

5 To comment Complications of sinusitis While sinusitis will often resolve with early self care, it is important to identify signs or symptoms that require prompt consultation. Orbital cellulitis is a rare but serious infection which is reported to be more common in children and more common through winter, possibly reflecting the increased number of sinus and respiratory tract infections. Patients will present with many of the following symptoms: unilateral swelling, sinus pain, headache, difficulty opening the eye, excessive tearing, blurred or double vision, fever and general malaise. An early presentation may centre on the eyelid swelling and discomfort and may seem to suggest allergies and perhaps allergic conjunctivitis. However, careful questioning can assist in differentiating from the bilateral, mild eyelid inflammation and itching with normal visual acuity characteristic of allergic conjunctivitis. Prompt referral to a medical practitioner is required if orbital cellulitis is suspected or probable as loss of vision in the affected eye can occur in approximately 10 per cent of patients. Prophylaxis Sinusitis is a common condition with substantial morbidity, so prevention where possible is preferred. While not every intervention will be applicable to every patient, certain interventions can assist. These include smoking cessation, intranasal steroids, effective asthma management, nasal lavage, influenza and/or pneumococcal vaccines and good hand hygiene to reduce pathogens that may be introduced onto or into the nostrils. Summary Sinusitis, whether acute or chronic, affects a significant proportion of the Australian population, with females being affected more than males. It can cause substantial morbidity and affect quality of life. Individuals with particular disease states have a greater susceptibility to chronic sinus infections including those with Down syndrome, cystic fibrosis, and hypertension. However, identifying the condition can sometimes be challenging as sinusitis shares several symptoms with allergic rhinitis which has been described as the most common disease in the developed world. Careful questioning and discussion with patients can however delineate sinusitis from allergic rhinitis. Many cases of acute sinusitis will resolve with early self care and watchful waiting; however, a proportion will benefit from antibiotics. Patients will often prefer to prevent sinusitis where possible, and a number of strategies may assist. For those who smoke, cessation will frequently assist, while for those with underlying allergies, intranasal steroids or second generation antihistamines may assist. Pharmacists and their staff have an opportunity to contribute to increased quality of life in their patients with sinusitis. Pn How to gain your CPD points This activity has been accredited by the Australian College of Pharmacy as a Group 2 activity for.5 CPD credit. The College is authorised by the Australian Pharmacy Council to accredit CPD activities for pharmacists that may be used as supporting evidence of continuing competence. Accreditation number: PN Members can submit their answers online at To ask about College membership please contact (02) or info@acp.edu.au.? QuiZ Sinusitis 1. Rhinosinusitis may be a more appropriate term to use for upper respiratory tract infections than sinusitis as: A. Nasal congestion is more prevalent than sinusitis B. The linings of the nasal passages and sinuses are continuous and inflammation in one will almost invariably occur in the other C. The two most common presentations of nasal congestion are allergic rhinitis and sinusitis D. There are similarities between the upper and lower respiratory tract mucosae 2. Chronic sinusitis involves which of the following? A. Persistence greater than 3 weeks B. Chronic inflammation C. Significant impact on quality of life D. Coloured discharge and facial pain/pressure 3. Which of the following statements about the management of sinusitis is NOT correct? A. Evidence favouring hypertonic over isotonic nasal preparations is unclear B. Antibiotics may be required if symptoms do not clear within 1 week C. Pain relief can be controlled more effectively on a when required basis D. Identification of allergens is important in the management of chronic sinusitis E. None of the above 4. Why may biofilms play a role in sinusitis? A. The anaerobic environment inside the biofilm can reduce the effectiveness of beta lactams B. Biofilms can act as a breeding ground for resistant bacteria via the exchange of genetic material C. Biofilms can significantly reduce effectiveness of antibiotics on the same bacteria D. Adjunctive therapies such as mupirocin irrigation may augment antibiotics in the management of biofilms 5. Which of the following statements about sinusitis is NOT correct? A. The use of complementary medicines is not supported by human trials B. Patients using immune suppressive biological therapies may be at greater risk of sinusitis C. Sinusitis can lead to severe complications including loss of vision D. Sinusitis prophylaxis can include: smoking cessation, intranasal steroids, pseudoephedrine and good hand hygiene E. None of the above To submit answers, go to click on online CPD PharmacyNews November