Decongestants

Topical decongestants may improve nasal congestion by stimulating the alpha-adrenergic receptors to constrict dilated arteries within the nasal mucosa, improving blood flow, airflow, and ciliary motility within the nasal tract.22 There are a limited number of studies examining oral and topical decongestants in the management of sinusitis. These studies cite improvement of airflow in the nasal passages, but the effects do not extend to the paranasal sinuses.2 There are no current randomized control studies studying decongestant efficacy for ABRS.3

In a small, nonrandomized study examining topical decongestants as monotherapy for ABRS, mucociliary activity was measured in patients given antibiotics along with either fluticasone, oxymetazoline, 3% NaCl or 0.9% NaCl nasal saline, or no treatment. Oxymetazoline did improve mucociliary clearance, but that result was not statistically significant when compared with the other groups.22

A study compared healthy patients with those with chronic sinusitis who were treated with xylometazoline and pseudoephedrine. Through the use of magnetic resonance imaging, the investigators found that xylometazoline was superior in reducing congestion of the nasal mucosa compared to pseudoephedrine; however, neither intervention showed an improvement in the mucosa of the sinuses.23


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In terms of their use in ABRS, both medications carry risks of significant side effects in certain populations. Oral decongestants should be used with caution in vulnerable populations, including those with hypertension or heart disease, while topical decongestant use must be limited to short use (3-5 days) due to risk of rebound congestion and rhinitis medicamentosa.2,3

Antihistamines

Antihistamines have been widely used in treating acute sinusitis; however, they are most effective in treating rhinitis, not sinusitis. The pathophysiology in VRS or ABRS is not related to the release of histamine from mast cells. Because of their anticholinergic properties, antihistamines increase the viscosity of the nasal discharge and diminish mucociliary function, since cilia do not work effectively in dry or sticky nasal mucosa. These effects cause more harm than benefit in treating sinusitis.18 There are currently no data to support antihistamine use for symptomatic relief in acute sinusitis.3

Nasal Saline Irrigation

Although data may be limited, the use of saline solution to irrigate the sinuses might be a missed opportunity for patient symptom relief. One randomized controlled trial found that daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis.24 A review of multiple studies found that overall, saline irrigation is well tolerated and safe with minimal side effects.25 The most established benefit is found in those with chronic sinusitis.26 It can be used alone or as adjunct therapy in the treatment of both allergic and infectious sinusitis through mechanical clearance of mucous, increasing ciliary beat activity, and decreasing inflammation by reducing allergen exposure.3

Nasal douches, neti pots, and sprays are all devices that can be used with saline solutions that vary in concentration (hypertonic or isotonic). The evidence of the most optimal method of nasal saline delivery is limited in the literature. Saline volumes range from 30 mL to 500 ml, with 250 mL considered a reasonable volume for adults.27 A 2016 Cochrane review found that daily 150 mL irrigations with hypertonic saline solution were more beneficial than placebo, although the evidence was of low quality.26 No studies have reported on the most effective frequency.

It is important to educate patients on best practices for keeping the device clean and using safe water — distilled, boiled, or filtered — to prevent the development of primary amebic meningoencephalitis caused by contaminated tap water found in a few states in the United States.28

Evidence-Based Practice Recommendations

Over the last 20 years, many interventions have demonstrated effectiveness in reducing the overuse of antibiotics. Efforts to educate providers and patients on the importance of antibiotic stewardship have shown to be helpful. Provider audits and feedback, financial incentives, and delayed prescribing practices have been well supported in the literature. 

Clinical decision support, such as a “best practice alert” within electronic health records at the point of care, can be an effective tool to decrease unnecessary antibiotic use and improve provider decision making regarding correct antibiotic choices when they are deemed appropriate.29 Providing patients with a symptomatic prescription pad with instruction on how to best manage their symptoms is another possible solution. This allows patients to walk away with something in hand and gives them a plan of action, which helps maintain patient satisfaction.

Another strongly recommended option is to give a “wait and see” prescription with clear instruction for when to use it. Current evidence supports offering watchful waiting as initial management to patients with ABRS regardless of illness severity, whereas earlier guidelines endorsed it an option for those with only mild symptoms.12 Understanding antibiotic prescribing practices in outpatient settings is critical to designing strategies for reducing inappropriate antibiotic use.30 A 2016 recommendation published by the Centers for Disease Control and Prevention, “Core Elements of Outpatient Antibiotic Stewardship,” provides guidance to providers and facility leadership to implement activities to improve antibiotic use.31

Conclusion

The usage of antibiotics is widespread and generally should be discouraged due to potential allergic reactions, antibiotic resistance, and unnecessary cost. Much safer therapies, such as nasal saline irrigation and intranasal corticosteroids, should be utilized since they show promise and have very low likelihood of harm. There is little evidence to support antihistamines, but oral and topical decongestants can be considered and used with caution in select patients to help with symptom relief. Oral corticosteroids are not typically used and are of limited benefit.

Efforts should be taken to improve antibiotic stewardship across all practice sites. Encouraging and supporting providers to give patients educational materials with specific self-care instructions, implementing delayed antibiotic prescribing, using best practice alerts within the electronic medical record, or implementing other interventions that consistently demonstrate effectiveness are critical to help in this effort.

Kelly Holtz, DNP, APRN, CNP is a Family Nurse Practitioner at Mayo Clinic in Rochester, Minnesota. Lorie Schulz, APRN, CNP is a Family Nurse Practitioner at Mayo Clinic in Rochester, Minnesota. Stephanie Ahrens, APRN, CNP is a Family Nurse Practitioner at Mayo Clinic in Rochester, Minnesota.

References

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