If you’ve ever sought your doctor’s advice for nasty nasal congestion and pressure that you just can’t seem to shake, you’ll want to hear this: New research published earlier this month in the Journal of the American Medical Association showing that common antibiotics like amoxicillin were no better than a placebo when it came to clearing up uncomfortable sinus symptoms.
“This story is just publishing in mainstream media, but for clinicians, it’s actually fairly old news,” said URMC ear, nose and throat specialist Dr. Li Man. “For quite some time now, our current recommendations have been to encourage patients to wait it out a week to 10 days, since symptoms quite often resolve on their own.”
But in the real world, this “sit it out” scenario rarely plays out. “Patients clamor for medication anyway,” Man said. “And doctors too often cave, writing the prescriptions.”
To learn more about what we know – and don’t know – about treating sinus pain and infections, read on.
Scripts: Let’s start off by defining what we mean by a sinus infection. Is it just a cold run amok?
Man: That’s a great question to start with – because to be honest, as practitioners, our working definition is a bit fuzzy.
The strict description, of course, is an infection of one or more sinus cavities. But when it comes to making the diagnosis in clinic, there’s actually a bit of a recipe to it – say, if a patient presents with at least two major symptoms (like facial congestion and pus-like nasal discharge), or perhaps one major symptom plus two minor ones (fever and fatigue), we’d typically classify that as a sinus infection.
Scripts: What causes them?
Man: Our sinuses play a big (sometimes under-appreciated!) role in defending our body against harmful pathogens. Coated in mucus, they act almost like flypaper, catching and filtering out stray allergens, even germs, and essentially “sweeping” them away before they reach the lungs. Unfortunately, sometimes the sinuses can become blocked, filling with fluid that acts as a warm, wet breeding ground for viruses or bacteria – and giving rise to infection.
Amazingly, studies estimate that only 2 percent of viral upper respiratory tract infections develop into bacteria sinus infections. However, since viral colds and sinus infections share many of the same symptoms as bacterial infections, they can be easily confused – which pretty simply explains why antibiotics rarely prove effective (the drugs kill bacteria, but are powerless against non-living materials, like viruses.)
Scripts: So, if they’re worthless the majority of the time, why are they still routinely prescribed?
Man: A big part of it is that patients don’t want to be told to go home and simply wait it out – they want to feel proactive, they want a tangible solution, like a prescription – even if that prescription is futile against fighting their particular infection.
The other part of this is a sheer coincidence of timing; to the untrained eye, antibiotics can actually seem to be highly effective! If you consider that the average patient seeks help after four or five days of discomfort, attends an appointment with his doctor on day six and starts medicine soon after, he might very well be feeling better on day seven or eight – because that’s when the infection is resolving on its own. But he, of course, mistakenly attributes his recovery to the medication – and so he absolutely insists on having another prescription the next time he has an infection. You can see how the science has an uphill battle here.
Scripts: But as a doctor, it’s really important to not prescribe antibiotics willy-nilly, right?
Man: It’s incredibly important. If we’re not judicious about prescribing antibiotics, if we use them too liberally, we encourage the evolution of what we call “super bugs” – that is, bacteria that can evade and outlive even our best medicines. That’s why such prudent “antibiotic stewardship” is so critical – as a community of health care providers, we have to work together to safeguard the good medicines we currently have, so we can ensure that they’ll work when truly needed.
On a more personal front, antibiotics do carry some risks. For instance, in patients whose gastrointestinal tracts harbor a bacteria called C. difficile, a course of antibiotics might be all it takes to rouse a potentially life-threatening bowel infection. For others, it might merely mean the inconvenience of diarrhea. Regardless, when you consider that antibiotics are not entirely risk-free, you quickly see that, like all drugs, we must prescribe them with caution.
Scripts: So, if you’re facing a sinus infection, your doctor may instruct you to wait – and that’s really the best medicine?
Man: It’s not the quick fix most patients are hoping to hear, but yes – “watchful waiting” really is the wise thing to do. If you really want to be proactive, getting extra rest will help to bolster the immune system and drinking extra fluid will help to thin out mucus secretions – no prescription required!
At URMC, our otolaryngologists (ENT physicians) are trained in non-surgical and surgical treatment of diseases of the ears, nose, throat, head and neck, performing hundreds of procedures every year. To learn more or to make an appointment, click here.
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