FAQs Chronic Sinusitis - Medical Treatments

The term optimal care pathway, in general, outlines critical steps in the patient journey in order to improve patient outcomes based on a standardised pathway of care. For chronic (rhino)sinusitis with nasal polyps this involves early diagnosis, prevention of disease progression, prevention of asthma development, prediction of success of treatment, delivering adequate medical or surgical treatment and for the difficult-to-treat or uncontrolled patients a more personalized treatment aiming at targeting specific infammatory molecules can be required.  

First-line treatment refers to the preferred, best and most efficient treatment for a certain disease and it is the first given after diagnosis is made. First-line treatment for chronic (rhino)sinusitis has been determined by international guidelines and depending on the severity and type of disease consists of nasal saline rinsing, nasal spray with corticosteroids, tablets with corticosteroids, and/or long-term antibiotics.    

Second-line treatment is given when first-line therapy doesn’t work or stops working. For patients with chronic (rhino)sinusitis, surgery is considered a second-line treatment and is indicated when medical treatment fails to control their symptoms. Lately, novel treatments (vaccinations) that target the underlying causes of the disease are under investigation for treatment with chronic (rhino)sinusitis.

Medical therapy is directed towards controlling provoking factors, treating concomitant infections and reducing inflammation or oedema (collections of fluid in between cells) inside the sinuses. Unfortunately, the first-line medical treatment does not "cure"  patients with chronic (rhino)sinusitis. Therefore, daily intake of your medication is crucial and continuation of the medication, even after surgery, is essential to control the disease. In general, it is of utmost importance that the patient remembers to take the spray and should use it daily at the prescribed dose to achieve the maximal benefit from this drug.

Chronic (rhino)sinusitis  is a chronic inflammatory disease that is usually well managed with nasal sprays containing corticosteroids. Unfortunatelly, these sprays can only provide symtomatic relief but cannot cure chronic (rhino)sinusitis. Patients should not forget the chronic nature of their disease and be consistent with their treatment. Moreover, medical treatment is not effective for certain conditions such as the presence of massive nasal polyps, fungal sinusitis and mucoceles (encapsulated collection of secretions).  In these cases, sinus surgery is often advised.

Chronic (rhino)sinusitis has a major impact on patient's overall quality of life. Because of its persistent nature, chronic (rhino)sinusitis can impact work and social life, reduce productivity and can cause sleep impairment. Lately, it has been shown that chronic (rhino)sinusitis can affect proper functioning of the lungs and is a risk factor for late-onset asthma development. Moreover, if left untreated, it may lead to serious complications.

The 'best treatment' for chronic (rhino)sinusitis remains controversial due to the broad spectrum of the disease and multiple underlying factors causing the disease. In practice, first-line treatment includes nasal rinsing with saline and use of nasal sprays containing corticosteroids. In severe cases, a short period of tablets with corticosteroids may be prescribed as well, always in association with nasal sprays with corticosteroids. Tablets with antibiotics for 12 weeks may be also prescribed in cases with persistent coloured nose secretions. If all the above fail to control your symptoms, sinus surgery may be suggested by your doctor.  

The treatment for nasal polyps is the same as for chronic (rhino)sinusitis because patients with nasal polyps are a subgroup (20%) of patients with chronic (rhino)sinusitis. The 'best treatment' for nasal polyps depends on the extent of disease, existing comorbidities like allergy or asthma, and underlying causes of disease. Nasal rinsing with saline (also known as 'nasal douching') and nasal sprays containing corticosteroids are considered first-line treatment for nasal polyps. Long-term tablets with antibiotics or tablets with corticosteroids may be added for some patients. Uncontrolled disease despite the above medical treatment often requires surgery. 

In moderate to severe symptoms of chronic (rhino)sinusitis, either with or without nasal polyps, long-term treatment with antibiotics can be prescribed for around 12 weeks.

Only steroid tablets can give side effects because they enter the blood circulation. Nasal sprays containing corticosteroids are not causing side effects since they are applied locally, without uptake in the blood circulation. Long-lasting intake of tablets with steroids can influence thyroid disease, dysregulate sugar levels -particularly in patients with diabetes-, cause osteoporosis and trigger depressive of agitated feelings.

The nasal decongestant spray only works for a short period by decongesting the mucosa agressively. It should not be used longer than 5 consecutive days. If used over a longer period, it can have adverse effects like additional swelling and irritation of the mucosa and even cause dependance on this medicine.

Short- and long-term use of nasal sprays containing corticosteroids is safe. The uptake of the corticosteroids into the blood circulation after local application (in the nose) is low. Thus it will not supress the hormonal regulation of the body or cause systemic  side effects (outside the nose and sinuses). The chance of local side effects like nose bleeds or septal performation is very low/minimal.

Decongestant sprays or drops should not be used longer than 5 consecutive days. Thereafter the nose might adapt to the medication and result in more swelling of the mucosa. Nasal rinsing with saline is safe and it is very important to get rid of nasal mucus and potential inhaled triggers of chronic (rhino)sinusitis. By 'cleaning' the inner lining of the nose of mucus, before using a nasal steroid spray, the corticosteroids can work better since they reach the inner lining of the nose more directly, without having to go through a layer of mucus first. Nasal sprays with corticosteroids are safe if the prescribed dosages are respected. If multiple steroid medications, for example where a person suffers from asthma as well as chronic (rhino)sinusitis, then the therapeutic regimen needs to be adapted.

In selected patients who have relatives that are affected by high eye pressure, nasal sprays with steroids might trigger development of these eye problems if overused. Generally eye symptoms are rarely caused by nasal sprays containing steroids. If there are doubts, patients should see an ophtalmologist for review.

Resistance of bacteria is mainly caused by 'bad use' of antibiotics like early termination of the treatment or inconsequent intake. Therefore, it is very important to respect the prescription and complete the treatment as discussed with the doctor, even if there is already symptom improvement or relief before. Overuse of antibiotics also contributes to the development of resistance by the bacteria. That is why a nasal swab for analysis in the laboratory should be performed to see which bacteria are present and to what antibiotic they are resistant to.  This is especilly true in acute sinusitis with bacterial infection. Antibiotics are not the first-line therapy for chronic (rhino)sinusitis.

Nasal rinsing with saline is considered a first-line treatment for chronic (rhino)sinusitis. It provides some symptomatic relief by washing the nasal cavities, removing secretions, reducing secretions dripping into the throat and rinsing allergens and irritants. Moreover, the use of nasal rinsing with saline  prior to administration of other nasal medications enables the medication to effectively reach the inner lining of the mucosa of the nose.

Only salt water should be used in nasal lavage (rinsing) and it is recommended that the salt water is sterile. This is especially important after sinus surgery and if the patients regularly suffers from sinus infections. You can sterilise plain water from the tap by boiling it and adding salt. Another option is to buy sterile salt water. It is also recommended that you should clean and ideally also sterilise your nasal lavage bottle at least weekly, by boiling it, using a steamer or a microwave oven. 

A patient should seek advice from a specialist (ear-nose-throat doctor) when symptoms are not well controlled by the treatment given from the general practitioner. We can state that the disease is uncontrolled, when chronic (rhino)sinusitis symptoms are bothersome in completing daily life activities. 

This depends on the health care system in the country where you live. In most parts of Europe, you should first seek help from your general practitioner. You may be referred to an ear-nose-throat (ENT)-doctor if standard treatment does not work. Standard treatment consists of nasal rinsing with salt water and nasal spray with corticosteroids.

Pharmacists are also members of the multidisciplinary team that can offer help in treating chronic (rhino)sinusitis. They have knowledge about different drugs and can give useful advices on how to use nasal sprays. Some pharmacists can also advice you on how to perform nasal rinsing with salt water. The pharmacist will also stress the fact that a consequent use of nasal sprays with corticosteroids is essential to achieve the maximal benefit from this drug. Additionally, counselling about the temporal effects of nasal sprays with corticosteroids can also be giving by the pharmacist. Patients should know that it might take some days before they start to notice the beneficial effects of nasal sprays with corticosteroids  and that the effect is not instantly like for example with decongestive sprays. However, to make a proper diagnosis and to get the follow-up needed, you must also see a doctor and ideally an ear-nose-throat (ENT)-doctor.