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 set in. In order to relieve the symptoms permanently, you often need to use this medication for months or even for more than a year. There are various steroid sprays, all of which have been shown to have a similar effect.

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 you take as tablets or get through an infusion (drip). The steroids in tablets and infusions travel around the whole body. In topical medications like nasal sprays or skin creams, they mostly affect only the area they are applied to.

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

Only few studies have looked into how well antibiotics work in chronic sinusitis. It still isn’t clear how effective these medications are. They only fight bacteria – but sinusitis is typically caused by viruses. Plus, chronic sinusitis is often influenced by other factors as well, such as allergies.

Severe bacterial sinusitis can – in rare cases – lead to complications. That may happen if the infection spreads beyond the sinuses. Then you quickly have to take antibiotics. Doing so can prevent serious complications like meningitis, which is an 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 help you sleep at night. But these decongestant medications may soon have the opposite effect instead: The membranes lining the nose start to swell again after just a few hours. 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.

As well as medication, you can use saline (salt water) solutions to reduce swelling in the mucous membranes and to help loosen the mucus (“snot”). You can get the solution in ready-to-use nasal spray bottles. There are also special nasal irrigation devices that allow you to rinse your sinuses with the solution. Nasal sprays and rinses are available from pharmacies, for instance.

To make the saline solution, you can simply mix tap water with normal table salt or with special packets of salts that are available from pharmacies. 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’re more likely to cause the lining of the nose to become dry and irritated.

You can also heat water and inhale the steam. Some people like to add things like chamomile or peppermint. But there's a lack of good research on the effectiveness of saline solutions and inhaling steam.

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 is better to only use them for a few days because of their possible side effects, such as stomach problems.

Dupilumab, omalizumab and mepolizumab have been approved in Germany for use in adults who have severe chronic sinusitis with nasal polyps. These biologics are used together with steroid medication. Research has shown that using dupilumab relieves the symptoms better than steroid nasal sprays alone. There is also evidence to suggest that omalizumab and mepolizumab can help. According to the research, none of these drugs has severe side effects.

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 – from using medication alone, 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, nasal polyps, and inflamed areas of the mucous membrane lining. 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 if

• steroid sprays and other treatments don't relieve the symptoms enough or
• the inflammation spreads, increasing the risk of complications.

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’s less severe. Then you still have to use medication. Only a few good-quality studies have looked into whether FESS can improve the symptoms over the long term or how effective it is compared with using steroids alone.

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 soon gets better. It may take several weeks for the wounds in the sinuses to heal completely, though. It is important to take good care of the wounds until they have healed. 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 widens 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 is difficult to assess the pros and cons of sinus balloon dilation because there's a lack of good research in this area. The costs of the procedure generally aren't covered by statutory health insurers in Germany.