Treating chronic sinusitis

Steroid nasal sprays reduce swelling in the sinuses. If there are nasal polyps, treatment with a steroid nasal spray can shrink them. It usually takes a few days for the full effect of steroid sprays to be felt. In order to relieve the symptoms permanently, you often need to take this medication for several months or even more than a year. There are various steroid sprays, all of which have a similar effect according to the research.

Some people are reluctant to take any medication containing steroids. When used for a long time at a high dose, steroids may indeed have side effects. In particular, they can irritate or dry out the membranes lining the nose. People sometimes have temporary headaches too. Nosebleeds can occur, especially at higher steroid doses. But the side effects are usually mild.

Steroid nasal sprays have far fewer side effects than steroid medications that are taken as tablets or given as an infusion (drip). Topical medications like nasal sprays or skin creams mostly affect only the area they are applied to.

Although steroid tablets are effective too, they are generally only used in exceptional cases due to their side effects. They should not be used for more than three weeks.

Only few studies have looked into the benefits of antibiotics in chronic sinusitis. They weren't able to find out how effective they really are, though. Antibiotics only fight bacteria – but sinusitis is typically caused by viruses, not bacteria. Plus, the inflammation in chronic sinusitis is often influenced by other factors as well, such as allergies.

In rare cases, severe bacterial sinusitis can lead to complications. That may happen if the inflammation spreads beyond the sinuses. Then it's very important to use antibiotics quickly in order to prevent serious complications, like meningitis ( inflammation of the membranes covering the brain and spinal cord).

Decongestant nose drops or nasal sprays aim to soothe the mucous membranes and reduce swelling. This makes it easier to breathe through the nose in the short term – which can make it easier to sleep at night. But these decongestant medications can quickly have the opposite effect as well. After just a few hours, the membranes lining the nose may start to swell again. The more often the medication is used, the stronger this effect is. Because decongestant nasal sprays shouldn't be used for more than a few days in a row, they are not suitable for treating chronic sinusitis.

In addition to medication, you can use saline (salt water) solutions to reduce swelling in the mucous membranes and to help loosen the mucus. You can buy them as ready-to-use nasal sprays in bottles. You can also rinse your sinuses using special nasal irrigation devices. Both are available from pharmacies, for instance.

To make the saline solution, you can simply mix tap water with normal table salt or special packets of salts that are available from pharmacies and drugstores. Hypertonic saline solutions (20 grams of salt per liter, about 5 teaspoons) are somewhat more effective than isotonic saline solutions (9 grams of salt per liter, about 2 teaspoons). But they can also have more side effects: Because they have more salt in them, they are more likely to cause the membranes lining the nose to become dry and irritated.

Heating water and inhaling the steam is another option. Some people like to add things like chamomile or peppermint. But there's a lack of good research on the effectiveness of inhaling steam in this way.

Ibuprofen, acetaminophen (paracetamol) and acetylsalicylic acid (the drug in e.g. Aspirin) can relieve the pain, but won't make the sinusitis go away any faster. It's better to only use them for a few days because of their possible side effects, such as stomach problems.

Biologics are used to reduce inflammation, for example in the treatment of rheumatoid arthritis. The biological drug dupilumab (trade name: Dupixent) was approved in October 2019 for the treatment of severe, chronic sinusitis and nasal polyps in adults. This drug can reduce inflammation in the membranes lining the nose by inhibiting a chemical messenger that promotes inflammation. Dupilumab is used in addition to treatment with a steroid nasal spray. It is injected into the skin once every two weeks. Studies show that this treatment relieves the symptoms better than when the steroid spray is used on its own.

A wide variety of other treatments are available too. In addition to other medications, they include herbal products, acupuncture, infrared light therapy and zinc products. There is no scientific proof that they help in the treatment of chronic sinusitis, though.

If the symptoms are severe and don't improve enough – or for long enough – just from taking medication, some people decide to have surgery.

The procedure most commonly used to treat chronic sinusitis is called functional endoscopic sinus surgery (FESS). This involves inserting a thin tube with tiny instruments attached to it ( endoscope) into the sinuses. The instruments can be used to remove parts of the bone, growths in the membranes lining the sinuses (nasal polyps) and inflamed parts of these membranes. The goal of this procedure is to allow more air to flow through your nose and improve your sense of smell. It is supposed to make it easier for the nasal secretions (fluids) to flow out too. Sometimes doctors may also suggest correcting a deviated nasal septum (where the wall between the two nostrils is bent to one side).

Surgery is considered as an option if steroid sprays and other treatments don't relieve the symptoms enough or if the inflammation spreads and complications are likely. FESS is also supposed to increase the effectiveness of medications or saline solutions by making it easier for them to reach the sinuses.

In many cases, chronic sinusitis doesn't go away after the surgery, but it is less severe. Then you still have to use medication. So far only a few good-quality studies have looked into whether FESS can improve the symptoms over the long term or how effective the operation is compared with using steroids on their own.

Serious complications following FESS are very rare. More common effects include short-term bleeding, inflammation, bruising and a reduced sense of smell. About 5 to 15 out of 100 people have these kinds of side effects. A stuffy nose lasting for several days is common, and scabs may form in the nose, but this gets better quickly. It may take several weeks until the wounds in the sinuses have completely healed, though. It is important to take good care of the wounds until the healing is complete. That includes rinsing your nose with a saline solution and regularly going to see an ENT doctor (ear, nose and throat doctor) to have wound fluids removed from your nose.

This involves inserting a catheter through the nose and slowly inflating a small balloon at the opening of the sinuses. Inflating the balloon stretches the opening of the sinuses and expands the parts of the sinuses that have become narrow. Unlike in FESS, the lining of the sinuses remains intact. It is possible to have this procedure done in an outpatient setting (without a hospital stay).

It's difficult to assess the advantages and disadvantages of sinus balloon dilation because there's a lack of high-quality research in this area. The costs of the procedure generally aren't covered by statutory health insurers in Germany.